Standards for public agencies

2020 Edition

Adult Protective Services (PA-APS) 6: Service Planning and Monitoring

Families participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
NA The agency does not facilitate or monitor service planning.
2020 Edition




Adult Protective Services protect vulnerable adults from exploitation, neglect, and abuse.
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
  • Service planning and monitoring procedures
  • Procedures, including criteria, for determining the most beneficial and least intrusive service
  • Data on the timeliness of service plans
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-APS 6.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family and additional service providers when appropriate, and includes:
  1. goals and outcomes for personal safety, stability in living arrangements, and well-being;
  2. services and supports provided to improve care and avoid loss of independence, and by whom;
  3. formal and informal support systems that can aid in safe and appropriate caretaking;
  4. possibilities for maintaining and strengthening family relationships and connections with other informal social networks; 
  5. procedures for expedited service planning when crisis or urgent need is identified; and
  6. the signature of the person served and his or her guardian, as applicable


Individuals with limited ability to make independent choices receive help with making decisions and assuming more responsibility for making decisions.

PA-APS 6.02

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-APS 6.03

The agency provides or recommends the most beneficial and least intrusive service that maintains the individual's safety in the least restrictive environment.

PA-APS 6.04

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


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-APS 6.05

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.