	Supported Community Living Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

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.

PA-SCL 4.01

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.

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.

PA-SCL 4.02

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.

PA-SCL 4.03

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.

PA-SCL 4.04

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.

PA-SCL 4.05

The worker and individual regularly review progress toward achievement of service goals and sign revisions to service goals and plans.

PA-SCL 4.06

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.

QUICK JUMP TO


	PURPOSE: Individuals and families that use Supported Community Living Services maintain stable residency in the community by developing personal support systems in order to live as independently as possible.

RELATED FILES


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	SERVICE GOALS Broad, issue-oriented statements that reflect the realistic achievements to be accomplished in the short or long term. Goals are achieved through the accomplishment of specific quantifiable objectives.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	SAMPLE A portion or representative percentage of a greater whole.


	EVALUATION The review and assessment of organizational operations, programs and services.