Standards for private organizations

2020 Edition

Home Care and Support Services (HCS) 6: Assessment Based Care Planning and Coordination

Individuals and caregivers participate in an assessment, which serves as the basis for a care plan that promotes independent functioning at home and in the community.
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
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are 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
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessment are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
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.,
  • There are 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
  • Assessment procedures
  • Copy of assessment tool(s) including caregiver assessment tool
  • Care planning procedures
  • Procedures that address health and safety issues unique to in-home care and service delivery 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

Fundamental Practice

HCS 6.01

Individuals and caregivers participate in individualized, culturally and linguistically responsive assessments that are:
  1. completed within established timeframes;
  2. focused on information pertinent for meeting service requests and objectives; and
  3. supplemented with information provided by collaborating providers, when appropriate.
Examples: Additional sources of information may enhance assessments when appropriate; for example, physical and occupational therapy services may be involved to determine how to manage or prevent further decline.

HCS 6.02

Assessments identify:
  1. the individual’s view of his or her current health and functioning;
  2. baseline functional, mental, emotional, and physical status information including prescription medication use and recent or progressive functioning to confirm capacity, decline, or progress; and
  3. a caregiver assessment including level of caregiver burden, caregiver health, choice in serving in the caregiver role, and presence of informal support.


All care providers, including those who may not have responsibility for the comprehensive assessment and determination of appropriate level of care, should obtain, at a minimum, information regarding an individual's and/or family's special needs.


The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

HCS 6.03

Professional health and/or social service personnel work with the full participation of the individual and the care team to develop an assessment-based care plan that includes:
  1. specific services to be delivered by the care provider; and
  2. a plan for coordinating services with other providers including nurses, physicians, rehabilitative personnel, and mental health providers, as needed.

HCS 6.04

Professional health and/or social service personnel:
  1. link interventions to service recipient goals; 
  2. assess service appropriateness; 
  3. approve service plans prior to implementation; and 
  4. assist the care provider with plan implementation, as necessary.

HCS 6.05

Prior to beginning services, professional health and/or social service personnel meet with the individual and his or her caregivers in the home to review:
  1. the role of family members in caretaking and related needs;
  2. any current concerns including household and community safety;
  3. specific services to be provided by the care provider;
  4. limits of services provided;
  5. preferences and choices of service recipients that can affect service delivery;
  6. information about advanced directives and crisis planning as appropriate; and
  7. guidelines for resolving differences between service recipient and care providers, including the role of supervisors.

Fundamental Practice

HCS 6.06

The organization addresses health and safety related issues unique to in-home care and service delivery.
Examples: Health and safety issues unique to in-home services include, for example:
  1. off-site supervision;
  2. safety of personnel while off site; and
  3. timely communication and record keeping practices.