Each youth or family participates in the development and ongoing review of a service plan as the basis for delivery of appropriate services and support.
A service plan is developed in a timely manner with the full participation of the youth and, as appropriate, a parent or legal guardian and an expedited service-planning process is available when crisis or urgent need has been identified.
Interpretation: Service planning is to be conducted so that youth and family members retain as much personal responsibility and self-determination as possible and 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 service recipient is a minor, or an adult under the care of a guardian, the agency should follow applicable state laws or regulations requiring involvement or consent of legal guardians.
An initial service plan is developed with the participant, whenever possible, within 2 days of admission and a comprehensive, individualized service plan is developed within 30 days.
Interpretation: An expedited service-planning process is available when crisis or urgent need has been identified.
During service planning, the agency explains:
The agency addresses permanency planning in the service plan by:
Interpretation: Public and private agency roles in the permanency planning process are defined by state rules, regulations, or contracts. When the agency is not responsible for facilitating permanency planning, it documents attempts to participate in the process.
The service plan is based on the assessment and includes:
A family-centered service plan is developed with the participation of the youth’s family, as agreed to by a legal guardian and youth, when the participant is a minor.
The service plan addresses, as appropriate:
Extended family members, as appropriate and with the consent of the youth, may be invited to participate in case conferences and may be advised of ongoing progress.
Interpretation: The agency facilitates participation by, for example, helping arrange transportation or including family in scheduling decisions.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
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 service plan review should be adjusted depending upon issues and needs of the youth and family, and frequency and intensity of services provided.
The worker and the youth or family regularly review progress toward achievement of agreed upon goals, and sign revisions to service goals and plans.