PA-APS 5: Service Planning and Monitoring
Families participate in the development and ongoing review of a service plan
that is the basis for delivery of appropriate services and support.
NA The agency does not facilitate or monitor service planning
Service planning includes, as appropriate:
- the individual;
- family members; and
- additional service providers.
Interpretation: Individuals with limited ability to make independent choices receive help with making decisions and assuming more responsibility for making decisions.
Family members and significant others can be involved in service planning when appropriate and with the consent of the service recipient. The agency can facilitate their participation by, for example, helping arrange transportation and including them in scheduling decisions.
The service plan is based on the assessment and includes:
- goals and outcomes for personal safety, stability in living arrangements, and well-being;
- services to improve care and avoid loss of independence;
- formal and informal support systems that can aid in safe and appropriate caretaking;
- how and by whom services will be provided; and
- the signature of the person served and his or her guardian, as applicable.
The service plan addresses, as appropriate and with the consent of the individual:
- the family’s unmet service and support needs; and
- possibilities for maintaining and strengthening family relationships.
Service plans are completed within timeframes established by the agency.
The worker and a supervisor, or a service or peer team, review the case at least quarterly to assess:
- service plan implementation;
- the appropriateness of safety plans;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the agreed upon service goals, and the need to keep the case open.
Interpretation: Workers should assess the individual’s progress following each visit and review the case when necessary. The case review is sometimes referred to as an administrative review, a supervisory review, a case conference, or a staffing.
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.
The worker and individual or legal guardian
regularly review progress toward achievement of agreed upon service goals and sign revisions to service goals and plans.