GLS 4: Service Planning and Monitoring
|
|
Each person or
family 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 resident and expedited service-
planning is available when crisis or urgent need is identified.
Interpretation: Service planning is conducted so that the
service recipient retains as much personal responsibility and self-determination as possible and/or desired. Individuals with limited ability in making independent choices receive help with making decisions 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 recipients’
legal guardians.
A family-centered service plan is developed with the participation of the resident’s family and/or significant others as agreed to by:
- a legal guardian when the resident is a minor; or
- the resident, when he or she is 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 signature of the resident or legal guardian.
The service plan addresses, as appropriate and with the consent of the resident:
- unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for the support of the resident’s 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 service goals and desired outcomes; and
- the continuing appropriateness of the 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 review should be adjusted depending upon: issues and needs of persons receiving services; and frequency and intensity of services provided.
The worker and resident or legal guardian regularly review progress toward achievement of service goals and sign revisions to service goals and plans.
 |
|
Research Note: Literature suggests that involving individuals in regular review of progress enhances their ability to recognize their treatment gains and see themselves as successful. |
 |
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.
Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, or including them in scheduling decisions.