PA-SCL 4: Service Planning and Monitoring
Each individual 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 with the full participation of the individual or legal guardian
, within an appropriate timeframe, and an expedited service-planning
process is available when crisis or urgent need has been identified.
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.
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 individual or legal guardian.
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 and with the individual’s consent, the individuals' need for the support of his/her family
and informal social network.
The worker and individual regularly review progress toward achievement of service goals
and sign revisions to service goals and plans.
The worker and a supervisor, or a clinical, service, or peer team, review each case quarterly to assess:
- service plan implementation;
- the individual's progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of agreed upon 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 the review should be adjusted depending upon: issues and needs of persons receiving services and frequency and intensity of services provided.