Standards for public agencies

2020 Edition

Adult Day Services (PA-AD) 4: Service Planning and Monitoring

Each person participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
2020 Edition

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Purpose

Individuals who participate regularly in Adult Day Services achieve and maintain an optimal level of well-being, functioning and health, and remain in their preferred community residence.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Service planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-AD 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, 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; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.

Interpretation

Service planning is conducted in such a way that individuals and families retain as much personal responsibility and self-determination as possible and/or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and assuming more responsibility for making decisions. 

PA-AD 4.02

The agency 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 agency 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.

PA-AD 4.03

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 towards 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.

PA-AD 4.04

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