Standards for public agencies

2020 Edition

Adult Guardianship (PA-AG) 4: Guardianship Planning and Monitoring

Individuals participate in the development and ongoing review of a guardianship plan that is the basis for delivery of appropriate services and support.
2020 Edition

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Individuals who receive guardianship services maintain a level of independence and self-determination appropriate to their functional capacity, and are at minimized risk of abuse, neglect, or exploitation.
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. 
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.

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.
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
  • Guardianship planning and monitoring procedures
  • Procedures for tracking due dates
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Observe system for tracking due dates

PA-AG 4.01

An assessment-based guardianship plan is developed in a timely manner with the full participation of the individual, 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; and
  3. opportunities to enhance the individual’s well-being and improve his or her capacity.


Guardianship planning is conducted in such a way that individuals retain as much personal responsibility and self-determination as possible and/or desired. 

PA-AG 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; and
  3. assist with access to the full array of services to which they are eligible.

PA-AG 4.03

To mediate barriers to services within the service delivery system, the agency establishes working relationships with community providers including:
  1. adult protective services and other local and state government agencies;
  2. mental health providers;
  3. legal services;
  4. vocational rehabilitation programs;
  5. hospitals and other medical facilities;
  6. home or geriatric care providers;
  7. home security system companies;
  8. local Area Agencies on Aging;
  9. long-term care Ombudsman Programs; and
  10. nursing homes, assisted living, and other residential facilities.

PA-AG 4.04

Logs or other records are maintained to track implementation of the guardianship plan, and include:
  1. time spent with the individual and advocating on his or her behalf with service providers;
  2. documentation of the individual’s participation in decision-making;
  3. documentation of decisions made;
  4. initiation or termination of direct services;
  5. reports provided to the court or other regulatory bodies; and
  6. progress towards achievement of desired service goals and outcomes.

PA-AG 4.05

The agency has a standardized system for tracking due dates that ensures timely reporting to the court or other government entities, when applicable.
Examples: Entities that may require regular reporting can include the Social Security Administration or the Department of Veterans Affairs.

PA-AG 4.06

When appropriate, the guardianship worker makes funeral and burial arrangements that:
  1. respect the individual's expressed desires, culture, heritage, and belief system; and
  2. involve the family to the greatest extent possible and appropriate.


Involvement of the family should include investigating the existence of family plots.

PA-AG 4.07

The guardianship 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. guardianship plan implementation;
  2. participation of the individual;
  3. progress toward achieving service goals and desired outcomes;
  4. timeliness of court reporting;
  5. frequency of contact; and
  6. the continuing appropriateness of the court order and agreed upon service goals.

PA-AG 4.08

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.