PA-SH 3: Service Planning and Monitoring
-based service planning
helps shelter residents form a realistic plan for attaining the support and skills needed to return to community life, and securing and maintaining safe, affordable, housing in the community.
Service planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible and/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. When the resident is a minor or an adult with a guardian, the agency should follow state laws or regulations requiring involvement or consent of the resident's legal guardian.
During service planning the agency explains:
- available options;
- how the agency can support the achievement of desired outcomes; and
- the benefits, alternatives, and consequences of planned services.
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 service recipient’s or legal guardian’s signature.
The service plan addresses, as appropriate:
- unmet service and support needs; and
- the need for the support of the resident's informal social network.
Family members and significant others, as appropriate, and with the consent of the individual, are advised of ongoing progress and are invited to participate in case
The worker and resident regularly review progress toward achievement of service goals
and sign revisions to service goals and plans.
Service plans are reviewed at least biweekly by the worker and a supervisor, or a clinical, service, or peer team, to assess:
- service plan implementation;
- the client's progress toward achieving his/her service goals and desired outcomes; and
- the continuing appropriateness of the resident's service goals.
Significant revisions to the service plan are made with the particpation of the service recipient or legal guardian.
Experienced workers may conduct service plan reviews of their own cases. In such cases, the worker's supervisor reviews a sample
of the worker's evaluations
according to the requirements of the standard.