Standards for public agencies

2020 Edition

Adult Guardianship (PA-AG) 6: Guardian of the Person

The guardian of the person:
  1. honors the wishes of the individual to the greatest extent possible;
  2. makes informed decisions on behalf of the individual;
  3. promotes improved quality of life and continued development of capabilities; and
  4. monitors the quality and appropriateness of direct services as needed.
NA The agency acts as guardian of the estate only.
2020 Edition

Currently viewing: ADULT GUARDIANSHIP (PA-AG)



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
  • Procedures for ethical decision-making
  • Service monitoring procedures
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


PA-AG 6.01

The individual participates in personal decision-making to the greatest extent possible given his or her assessed capacity for decision-making and subject to the court order.

Fundamental Practice

PA-AG 6.02

The agency has established procedures for ethical decision-making that include the consideration of:
  1. available options;
  2. how each option can support the achievement of desired outcomes;
  3. risks and benefits of each option;
  4. the expressed wishes of the individual as appropriate and subject to the court order;
  5. input from involved parties as appropriate; and
  6. the court order outlining their decision-making authority.
Examples: The guardian can determine the individual’s wishes by considering how the individual has made similar decisions in the past, verbal and non-verbal indicators of preference, or written documentation of the individual’s expressed wishes, such as advance directives that were developed prior to the individual’s loss of decision-making capacity. 
Examples: Involved parties can include close friends and family, doctors, internal ethics committees, the court, attorneys, or religious leaders. 


PA-AG 6.03

To ensure compliance with previously established advance directives, guardianship workers:
  1. provide copies to relevant medical and/or psychiatric service providers; and
  2. store copies in a safe and accessible location.

Fundamental Practice

PA-AG 6.04

Improved quality of life and increased capacity are promoted by:
  1. encouraging relationships and a sense of connectedness;
  2. identifying services and supports that will promote continued growth and improved capacity;
  3. helping the individual to develop a sense of value or purpose; and
  4. regularly re-assessing the individual’s capacity and pursuing termination of guardianship or a change to the court order as appropriate.


PA-AG 6.05

The guardianship worker works with, or on behalf of, the individual to:
  1. arrange for needed or requested services as identified in the guardianship plan;
  2. monitor the quality and appropriateness of services; and
  3. facilitate the initiation or termination of services as appropriate.


The guardian should tailor the type and frequency of service monitoring according to the requirements of the court order, the needs of the individual, frequency and intensity of the services being provided, and frequency of contact with informal caregivers and cooperating providers. 


PA-AG 6.06

The guardianship worker monitors the quality and appropriateness of services by:
  1. directly communicating with current service providers;
  2. attending case conferences as appropriate;
  3. observing the effectiveness of services through regular contact with the individual; and
  4. participating in direct-service planning teams with outside providers.

Fundamental Practice

PA-AG 6.07

The agency ensures each Individual has an emergency response plan that includes, as appropriate:
developing food or emergency kits;
  1. awareness of evacuation procedures at residential facilities where the individual resides;
  2. conducting emergency drills as needed;
  3. inclusion in local or state-wide emergency plans or evacuations; and
  4. search and rescue procedures for individuals with a history of wandering.