Group Living Services (CA-GLS) 6: Service Planning and Monitoring
Residents and their families participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and supports.
While a service plan may conform to a uniform format, plan content should be individualized through collaboration with the resident and, as appropriate, a parent or guardian and/or legal advocate based on service needs and program model. Level of family involvement in the service planning process will vary by resident and/or program model.
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
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.
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.
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.
Service planning and monitoring procedures
No On-Site Evidence
Interviews may include:
Residents and their families
Review case records
An assessment-based service plan is developed with the full participation of the resident, and their family when appropriate, and includes:
agreed upon goals, desired outcomes, and timeframes for achieving them;
services and supports to be provided, and by whom;
procedures for expedited service planning when crisis or urgent need is identified; and
the resident’s and/or legal guardian’s signature.
Safety concerns for victims of human trafficking often do not end when they are admitted to residential settings. The organization should work with the victim to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services; maintaining the residence’s location in confidence or restricting access by certain individuals; and linking efficiently to law enforcement, if needed. Psychological safety should also be prioritized as the emotional effects of trauma – mistrust, anxiety, depression, panic disorder, etc. – can be persistent and overwhelming for victims.
If the timelines are not specified by legislation, regulations, and/or contracts, a service plan needs to be completed no longer than 90 days after intake.
Examples: When working with victims of trauma, the organization can facilitate the development of realistic goals in an empowering and trauma-informed manner by building rapport, establishing trust, and promoting physical and psychological safety.
The organization works in active partnership with residents to:
assume a service coordination role, as appropriate, when the need has been identified and no other organization has assumed that responsibility;
ensure that they receive appropriate advocacy support;
assist with access to the full array of services to which they are eligible; and
mediate barriers to services within the service delivery system.
Central coordination of services is one of the most important aspects of care for victims of human trafficking. It provides the opportunity to develop an important, consistent connection with the staff person while the complex myriad of needed services are accessed and coordinated.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of the resident, to assess:
service plan implementation;
progress toward achieving service goals and desired outcomes; and
the continuing appropriateness of the agreed upon service goals.
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.
The worker and individual, and his or her family when appropriate:
review progress toward achievement of agreed upon service goals; and
sign revisions to service goals and plans.
For children and youth, family members and/or legal guardians should always be involved in case conferences and advised of ongoing progress.