Standards for Canadian organizations

2020 Edition

Home Care and Support Services (CA-HCS) 7: Care Monitoring

Routine care monitoring ensures delivery of appropriate services.
2020 Edition




Individuals who receive Home Care and Support Services obtain a maximum level of independence, functioning, and health, and extend the time it is possible to live safely at home and in the community.
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
  • Care monitoring procedures
  • Documentation procedures 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

CA-HCS 7.01

Follow-up assessments are based on the physical and cognitive needs of the individual and are conducted by a nurse or other qualified professional: 
  1. in person at least every 30 days for cognitively impaired clients, or clients with other special needs;
  2. in person at least every 60 days for clients who are not cognitively impaired and are receiving personal care aide services;
  3. in-person at least every 90 days for clients receiving homemaker services only; and
  4. by phone, in addition to the in person timeframes listed above, when needed.


The organization is responsible for determining the necessary qualifications for staff conducting assessments.

Fundamental Practice

CA-HCS 7.02

Care providers:
  1. document all interventions and how the person responds;
  2. monitor and document changes in physical, mental, and emotional status and gains of the individual and their caregivers;
  3. respect and note the individual’s choices;
  4. help individuals make independent choices or assume more responsibility for making decisions;
  5. recognize service gaps and alert applicable service providers to unmet needs;
  6. recognize emergency situations and follow procedures to ensure the safety and well being of care recipients; and
  7. report on plan implementation and progress to a supervisor or case manager at least weekly.

CA-HCS 7.03

The care provider and the individual or legal guardian, 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 care plans.
Examples: Reviews may also include other direct care providers and caregivers when possible and appropriate.

CA-HCS 7.04

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


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