Standards for public agencies

2020 Edition

Home Care and Support Services (PA-HCS) 7: Care Monitoring

Routine care monitoring ensures delivery of appropriate services.
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
  • Care monitoring procedures
  • Documentation procedures 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-HCS 7.01

Follow-up assessments are based on the physical and cognitive needs of the individual and are conducted by a nurse or other qualified professional: 
  1. in person at least every 30 days for cognitively impaired clients, or clients with other special needs;
  2. in person at least every 60 days for clients who are not cognitively impaired and are receiving personal care aide services;
  3. in person at least every 90 days for clients receiving homemaker services only; and
  4. by phone, in addition to the in-person timeframes listed above, when needed.


The agency is responsible for determining the necessary qualifications for staff conducting assessments.

Fundamental Practice

PA-HCS 7.02

Care providers:
  1. document all interventions and how the person responds;
  2. monitor and document changes in physical, mental, and emotional status and gains of the individual and their caregivers;
  3. respect and note the individual’s choices;
  4. help individuals make independent choices or assume more responsibility for making decisions;
  5. recognize service gaps and alert applicable service providers to unmet needs;
  6. recognize emergency situations and follow procedures to ensure the safety and well being of care recipients; and
  7. report on plan implementation and progress to a supervisor or case manager at least weekly.

PA-HCS 7.03

The care provider and the individual or legal guardian, 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 care plans.
Examples: Reviews may also include other direct care providers and caregivers when possible and appropriate.

PA-HCS 7.04

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


When experienced managers are conducting reviews of their own cases, the manager’s supervisor must review a sample of the manager’s evaluations as per the requirements of the standard.