DTX 4: Service Planning and Monitoring
Each person 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 and expedited service-planning
is available when crisis or urgent need is identified.
Service planning is conducted so that the individual 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. 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
A family-centered service plan is developed with the participation of the individualís family or significant others as agreed to by:
- a legal guardian, when the service recipient is a minor; or
- the person, when an adult not under the care of a guardian.
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 individualís signature.
During service planning the organization explains:
- available options;
- how the organization can support the achievement of desired outcomes; and
- the benefits, alternatives, and consequences of planned services.
The service plan addresses:
- psychological and emotional needs;
- educational and vocational goals;
- social and cultural interests;
- substance use treatment needs; and
- physical health needs.
The service plan addresses, as appropriate and with the consent of the individual:
- the familyís unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for support from the individualís informal social network.
Service planning identifies internal and external service providers, and includes specific referrals
to be made during treatment and aftercare
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the agreed upon 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 individual or legal guardian regularly review progress toward achievement of agreed upon service goals and sign revisions to service goals and plans.
Extended family members and significant others, as appropriate and with the consent of the individual, may be invited to participate in case conferences and advised of ongoing progress.
The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, or including them in scheduling decisions.