PA-OTP 4: Service Planning and Monitoring
Every person participates in the development and ongoing review of a service plan
that is the basis for delivery of appropriate services
A service plan is developed in a timely manner with the full participation of the service recipient
, and expedited service-planning
is available when crisis or urgent need is identified.
Service planning is conducted so that the service recipient retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions.
-centered service plan is developed with the participation of the individualís family and/or significant others when agreed to by the person.
The service plan is based on the assessment, and includes:
- agreed upon goals, including education, vocational, and employment goals, desired outcomes, and timeframes for achieving them;
- recommendations for medical, psychosocial, economic, legal, or other support services and by whom they will be provided; and
- the service recipientís signature.
During the service planning process the agency explains:
- available options;
- how the agency can support the achievement of desired outcomes; and
- the benefits, alternatives, and risks or consequences of planned services.
The service plan addresses, as appropriate:
- unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for support of the individualís informal social network.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of the service goals.
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 review should be adjusted depending upon: issues and needs of persons receiving services and frequency and intensity of services provided.
The worker and service recipient or legal guardian
regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.
Family members and significant others, as appropriate and with the consent of the individual, may be invited to participate in case conferences and may be advised of ongoing progress.
The agency facilitates the participation of family and significant others by, for example, helping arrange transportation or including them in scheduling decisions.