	Residential Treatment Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-RTX 4: Service Planning and Monitoring

Each resident participates in the development of a comprehensive, assessment-based service plan that identifies methods and time frames for achieving specific treatment goals and is reviewed and updated, in accord with the type of intervention, client progress, and provider-payer circumstances.

Interpretation: While a service plan may conform to a uniform format, plan content will be individualized through discussion with the resident and, as appropriate, a parent or guardian.

PA-RTX 4.01

An assessment based service plan is developed within one week of admission, and comprehensive plan is developed within 30 days and includes:

service 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.

Interpretation: Crisis stabilization units develop an initial service plan within 24-48 hours of admission. Service planning is conducted so the service recipient retains as much personal responsibility and self-determination as possible. Individuals with limited ability in making independent choices receive help assuming responsibility for making decisions consistent with healthy activities and goal achievement. When the service recipient is a minor, or an adult under the care of a guardian, the agency will follow applicable state laws or regulations requiring involvement of service recipient’s legal guardians.

PA-RTX 4.02

A family-centered service plan is developed with the participation of the resident’s family and/or significant others as agreed to by:

a legal guardian when the resident is a minor;
the person when the resident is an adult not under the care of a guardian.

Interpretation: The service plan addresses, as appropriate, matters that have a direct bearing on safety, a permanent living arrangement, and well-being, including: unmet family service and support needs, family relationships, siblings, other family members in care, and the person’s need for family and informal network support.

PA-RTX 4.03

The service plan includes a diagnosis made using a standardized diagnostic tool and containing:

a diagnostic summary;
a prognosis;
specific treatment modalities to be used, appropriate to the cultural perspective and competencies of the individual; and
the estimated length of treatments and stay.

Interpretation: Standardized diagnostic tools may include the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM), the International Statistical Classification of Diseases and Related Health Problems (ICD), or another comparable standardized diagnostic tool. Individuals in diagnostic settings may receive a working diagnosis while completing a full assessment.

PA-RTX 4.04

Ongoing service goal monitoring, including at least quarterly treatment team review, ensures treatment at an appropriate level and assesses service plan implementation and progress toward achieving service goals and desired outcomes, including the need for continued treatment or changes in service goals.

Interpretation: Service plans are reviewed more frequently for young children, extremely fragile individuals, and as acute needs and contractual requirements dictate. Timeframes for service goal reviews should be adjusted depending upon: issues and needs of persons receiving services; frequency and intensity of services provided; and frequency of contact with informal caregivers and cooperating providers.

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.

QUICK JUMP TO


	PURPOSE: Residential Treatment Services are delivered according to an articulated philosophy that ties individual needs to specific interventions and education, and to achievement of stated goals, such as gains in measurable skills, increased productivity and pro-social behavior, improved functioning, and a stable living arrangement in the community.

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.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	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.


	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".


	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.


	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.


	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.


	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."


	DIAGNOSIS The process by which a social, physical, or mental health problem and its underlying cause are identified and a plan of action formulated toward resolution of the problem. The diagnostic process involves collection and analysis of relevant information. See also ASSESSMENT.


	CLIENT See service recipient.


	MONITORING An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance.


	ACUTE NEEDS Intense conditions of sudden onset and short duration, typically lasting less than 6 months. In the context of substance abuse treatment, those needs that require immediate attention and treatment without which the health of the consumer is at serious risk.


	CAREGIVER The provider of physical, emotional, and social needs to another person, often dependent and unable to provide for his or her own needs. Caregiver is the generic term used for the direct service providers in Community Care and Support Services (CCS).


	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.


	SAMPLE A portion or representative percentage of a greater whole.


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