PA-SA 3: Service Planning and Monitoring
Individuals participate in the development and ongoing review of a service plan
that is the basis for delivery of appropriate services and support.
A service plan is developed in a timely manner with the full participation of the individual receiving services, and expedited service-planning
is available when crisis or urgent need is identified.
Service planning is conducted so that the service recipient
retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions.
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 recipientís signature.
During the service planning process the agency explains:
- available options;
- how the agency can support the achievement of desired outcomes; and
- the benefits, risks, alternatives, and consequences of planned services.
The service plan addresses, as appropriate:
- unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for the support of the individualís informal social network.
The worker and a supervisor, or a clinical, service, or peer team, review the case to assess:
- service plan implementation;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the agreed upon service goals.
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 service plan is reviewed and updated:
- weekly for individuals at high risk for relapse;
- every 30 days for people assessed as having acute needs or during or following a period of relapse; and
- quarterly for all other service recipients.
Timeframes for review should be adjusted depending upon: issues and needs of persons receiving services; and frequency and intensity of services provided.
The worker and the individual or legal guardian
regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.
Family members and significant others, as appropriate, and with the consent of the service recipient, may be invited to participate in case conferences and may be advised of ongoing progress.
The agency facilitates the participation of family and significant others by, for example, helping arrange transportation or including them in scheduling decisions.