PA-AD 4: Service Planning and Monitoring
Each individual participates in the development and ongoing review of a service plan
that is the basis for delivery of appropriate services and support.
A service plan is developed in a timely manner, with the full participation of the individual, or parent or legal guardian
, and an expedited service-planning
process is available when a crisis or urgent need has been identified.
Service planning is conducted in such a way that individuals and families retain as much personal responsibility and self-determination as possible and/or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and assuming more responsibility for making decisions. When the service recipient
is an adult under the care of a legal guardian, the agency should follow applicable state laws or regulations requiring involvement or consent of service recipients' legal guardians.
The service plan is based on the assessment, and includes:
- service goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom; and
- the signature of the service recipient or his/her legal guardian.
During the service planning process the agency explains:
- available options;
- how the agency can support the achievement of the individual's desired outcomes; and
- the benefits, alternatives, and risks or consequences of planned services.
members and significant others, as appropriate and with the consent of the individual, are advised of ongoing progress and are invited to participate in case
The service plan addresses, as appropriate and with the consent of the service recipient:
- the family’s unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for support of the individual’s informal social network.
The worker and service recipient regularly review progress toward achievement of service goals and sign revisions to service goals and plans.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- the service recipient's progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the individual's service goals.
Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker's supervisor reviews a sample of the worker's evaluations as per the requirements of the standard.
Timeframes for the review should be adjusted depending upon issues and needs of persons receiving services, and frequency and intensity of services provided.