Standards for private organizations

2020 Edition

Adult Protective Services (APS) 6: Service Planning and Monitoring

Families participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
NA The organization does not facilitate or monitor service planning.
2020 Edition

Currently viewing: ADULT PROTECTIVE SERVICES (APS)

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Purpose

Adult Protective Services protect vulnerable adults from exploitation, neglect, and abuse.
1
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.
2
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
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
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
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
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
  • Service planning and monitoring procedures
  • Procedures, including criteria, for determining the most beneficial and least intrusive service
  • Data on the timeliness of service plans
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

APS 6.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family and additional service providers when appropriate, and includes:
  1. goals and outcomes for personal safety, stability in living arrangements, and well-being;
  2. services and supports provided to improve care and avoid loss of independence, and by whom;
  3. formal and informal support systems that can aid in safe and appropriate caretaking;
  4. possibilities for maintaining and strengthening family relationships and connections with other informal social networks; 
  5. procedures for expedited service planning when crisis or urgent need is identified; and
  6. the signature of the person served and his or her guardian, as applicable

Interpretation

Individuals with limited ability to make independent choices receive help with making decisions and assuming more responsibility for making decisions.

 

APS 6.02

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;
  3. assist with access to the full array of services to which they are eligible; and
  4. mediate barriers to services within the service delivery system.

 

APS 6.03

The organization provides or recommends the most beneficial and least intrusive service that maintains the individual's safety in the least restrictive environment.

 

APS 6.04

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of persons served, to assess:
  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the agreed upon service goals.

Interpretation

When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.

 

APS 6.05

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.