	Wilderness and Adventure-Based Therapeutic Outdoor Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-WT 3: Service Planning and Monitoring

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.

PA-WT 3.01

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.

PA-WT 3.02

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.

PA-WT 3.03

During service planning, 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-WT 3.04

The agency addresses permanency planning in the service plan by:

identifying permanency goal(s) and activities or supporting the permanency plan identified by the custodial agency;
reviewing the permanency plan quarterly to assess progress towards agreed upon goals;
providing the youth with age appropriate information about his or her parents and progress toward reunification; and
providing parents or the custodial agent with information, resources, and support for reunification.

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.

NA The agency does not provide out-of-home care for youth in custody of a public agency.

PA-WT 3.05

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 youth’s signature and that of a parent or legal guardian.

PA-WT 3.06

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.

PA-WT 3.07

The service plan addresses, as appropriate:

the unmet service and support needs;
possibilities for maintaining and strengthening family relationships; and
the need for support of the service recipient’s informal social network.

PA-WT 3.08

An interdisciplinary team:

develops a service plan based on the youth’s assessed needs and strengths;
assumes responsibility for coordinating medical, social, psychological, and other evaluations; and
shares the plan with those working directly with the participant.

PA-WT 3.09

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.

PA-WT 3.10

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:

service plan implementation;
progress toward achieving goals and desired outcomes; and
the continuing appropriateness of the 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 service plan review should be adjusted depending upon issues and needs of the youth and family, and frequency and intensity of services provided.

PA-WT 3.11

The worker and the youth or family regularly review progress toward achievement of agreed upon goals, and sign revisions to service goals and plans.

QUICK JUMP TO


	PURPOSE: Youth who participate in Wilderness and Adventure-based Therapeutic Outdoor Services expand individual capabilities, develop self-confidence and insight, ameliorate symptoms, and improve interpersonal skills and relationships.

RELATED FILES


	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.


	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 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.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	PARENTS Parents can include: birth, foster, kinship, and adoptive parents. Please see service standards for more specific information about use of this term.


	CONTRACT A formal written agreement between two or more parties that specifies the services, space, or products to be provided in exchange for some form of compensation. Also known as "purchase of service arrangement."


	OUT-OF-HOME CARE Services for persons living in environments outside of their usual households. Foster Care Services are considered to serve persons in out-of-home care.


	CUSTODY The care, control, and maintenance of a child. The court legally can award custody to an agency in abuse and neglect cases or to parents in divorce, separation, or adoption proceedings. Child welfare departments retain legal custody and control of major decisions for a child in foster care; foster parents do not have legal custody of the children for which they provide care.


	PUBLIC AGENCY An agency under government auspices. A public agency is typically governed and operated by a public entity (e.g., a state, a county, or a department of the federal government. Public agencies seeking accreditation will utilize the Public version of COA's 8th Edition Standards, found at http://www.coastandards.org/standards.php?navView=public.


	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.


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


	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.


	INTERDISCIPLINARY TEAM A group of persons from different professions, disciplines, service areas, organizations, and/or personnel levels who collaborate to make decisions about and provide a range of services for the same consumer or consumer group. The service delivered would not be possible or as efficient if one organization or one professional alone provided the services.


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


	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.


	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.


	SAMPLE A portion or representative percentage of a greater whole.