PA-CM 5: Service Monitoring and Re-Assessment
ensures continuity of service and care and timely adjustments to service provision when the individual’s or family
’s needs and circumstances change.
Service monitoring includes:
- confirmation, usually within one or two working days, that a service has been initiated as scheduled;
- verification, usually within 15 working days, that the service is appropriate and satisfactory;
- follow-up every three months; and
- immediate response to any complaints or problems that develop in the delivery of service or with the person receiving services.
The agency tailors the type and frequency of service monitoring according to the needs of persons receiving services, frequency and intensity of service provided, and frequency of contact with informal caregivers
and cooperating providers.
Every individual participates in a formal re-assessment annually, or more frequently when indicated.
An event-based re-assessment is conducted:
- within five working days of a precipitating event;
- when there is a change in the individual or family’s status or circumstances, or a new issue arises; and
- within 48 hours of notification that hospital or institutional discharge is imminent.
An agency that, due to contractual requirements, is unable to conduct event-based re-assessments according to these timeframes can modify them to meet the needs and goals of the population served.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- the service recipient's progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of agreed upon 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 the review should be adjusted depending upon issues and needs of persons receiving services and frequency and intensity of services provided.
The worker and family regularly review progress toward achievement of agreed upon goals and sign revisions to service goals