Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
Interpretation: Services needed or requested by individuals and families may include the following:
For all individuals and families: other services needed to maintain and preserve independence or to promote or recover optimum social, psychological, and physical development and functioning.
For individuals, families, and children: mental health or other counseling services, group activity and/or recreation programs, volunteer or employment programs, homemaker services, foster care, intergenerational support services, vocational training, and child care.
For individuals with special needs: counseling, drug and alcohol dependency treatment, transitional living arrangements, residential treatment or other out-of-home placement, education, day treatment or activity programs, nutrition services, vocational training or rehabilitation, and transportation services.
For older adults: mental health or other counseling services, medical and rehabilitative services, escort/transportation services, social programs, volunteer or employment programs, in-home care services, skilled nursing services, senior companion or intergenerational support services, home delivered meals, telephone reassurance services, repair services, day care and respite services, and legal and financial services.
All individuals and families receive:
Note: When the population served is mobile, for example, in the aftermath of a disaster, an integrated service plan and exit plan may be initiated.
A service plan is developed in a timely manner with the full participation of the individual or family, and an expedited service planning process is available when crisis or urgent need has been identified.
Interpretation: Service planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible 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 a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of service recipients' legal guardians.
The service plan is based on the assessment, and includes:
During the service planning process the organization explains:
The service plan addresses, as appropriate:
Case management services: