Standards for public agencies

2020 Edition

Home Care and Support Services (PA-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.
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
  • 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

PA-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.

PA-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.

PA-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.

PA-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.

PA-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

PA-HCS 6.06

The agency 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.