Standards for private organizations

2020 Edition

Adult Guardianship (AG) 4: Guardianship Planning and Monitoring

Individuals participate in the development and ongoing review of a guardianship plan that is the basis for delivery of appropriate services and support.
2020 Edition

Currently viewing: ADULT GUARDIANSHIP (AG)



Individuals who receive guardianship services maintain a level of independence and self-determination appropriate to their functional capacity, and are at minimized risk of abuse, neglect, or exploitation.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Guardianship planning and monitoring procedures
  • Procedures for tracking due dates
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Observe system for tracking due dates

AG 4.01

An assessment-based guardianship plan is developed in a timely manner with the full participation of the individual, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; and
  3. opportunities to enhance the individual’s well-being and improve his or her capacity.


Guardianship planning is conducted in such a way that individuals retain as much personal responsibility and self-determination as possible and/or desired. 

AG 4.02

The organization works in active partnership with persons served to:
  1. assume a service coordination role, as appropriate, when the need has been identified and no other organization has assumed that responsibility;
  2. ensure that they receive appropriate advocacy support; and
  3. assist with access to the full array of services to which they are eligible.

AG 4.03

To mediate barriers to services within the service delivery system, the organization establishes working relationships with community providers including:
  1. adult protective services and other local and state government agencies;
  2. mental health providers;
  3. legal services;
  4. vocational rehabilitation programs;
  5. hospitals and other medical facilities;
  6. home or geriatric care providers;
  7. home security system companies;
  8. local Area Agencies on Aging;
  9. long-term care Ombudsman Programs; and
  10. nursing homes, assisted living, and other residential facilities.

AG 4.04

Logs or other records are maintained to track implementation of the guardianship plan, and include:
  1. time spent with the individual and advocating on his or her behalf with service providers;
  2. documentation of the individual’s participation in decision-making;
  3. documentation of decisions made;
  4. initiation or termination of direct services;
  5. reports provided to the court or other regulatory bodies; and
  6. progress towards achievement of desired service goals and outcomes.

AG 4.05

The organization has a standardized system for tracking due dates that ensures timely reporting to the court or other government entities, when applicable.
Examples: Entities that may require regular reporting can include the Social Security Administration or the Department of Veterans Affairs.

AG 4.06

When appropriate, the guardianship worker makes funeral and burial arrangements that:
  1. respect the individual's expressed desires, culture, heritage, and belief system; and
  2. involve the family to the greatest extent possible and appropriate.


Involvement of the family should include investigating the existence of family plots.

AG 4.07

The guardianship worker and a supervisor, or a clinical, service, or peer team, review the case quarterly or more frequently depending on the needs of the individual, to assess:
  1. guardianship plan implementation;
  2. participation of the individual;
  3. progress toward achieving service goals and desired outcomes;
  4. timeliness of court reporting;
  5. frequency of contact; and
  6. the continuing appropriateness of the court order and agreed upon service goals.

AG 4.08

The worker and individual, and his or her family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and
  2. sign revisions to service goals and plans.