PS 4: Service Planning and Monitoring
Individuals participate in the development and ongoing review of service plans
that are the basis for delivery of appropriate services and support.
A service plan is developed within an appropriate timeframe with the full participation of the service recipient
, and expedited service planning
is available when crisis or urgent need is identified.
Service planning is to be 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 can receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipientsí legal guardians
The service plan is based on the assessment and includes:
- agreed upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided and by whom; and
- the service recipientís signature.
During service planning the organization explains:
- available options;
- how the organization can support the achievement of desired outcomes; and
- the benefits, alternatives, and risks or consequences of planned services.
Individuals are helped to explore the potential benefits and any concerns about involving family
members and significant others, including the birth father, in service planning and provision.
When the individual wishes and it is appropriate, family members and significant others, including the birth father, are invited to participate in case
conferences and advised of ongoing progress.
The organization can facilitate the participation of family and significant others by, for example, helping arrange transportation or including them in scheduling decisions.
The provider and service recipient regularly review progress toward achievement of agreed upon goals and sign revisions to service goals
The provider and a supervisor, or a clinical, service, or peer team, review the case at designated milestones during the pregnancy to assess:
- service plan implementation;
- progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of the agreed upon goals.
Interpretation: Experienced providers may conduct reviews of their own cases. In such cases, the providerís supervisor reviews a sample of the providerís evaluations as per the requirements of the standard.
The organization will define what constitutes a milestone during the pregnancy. Timeframes for service plan review should be adjusted depending upon issues and needs of persons receiving services, and the frequency and intensity of services provided. When providing Pregnancy Options Counseling or Birth Options Counseling, timeframes for service plan review should be adjusted to reflect the length of time counseling services are offered.