Standards for public agencies

2020 Edition

Mental Health and/or Substance Use Services (PA-MHSU) 4: Service Planning and Monitoring

Individuals and their families, as appropriate to the program model and the age and expressed wishes of the person, participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

Interpretation

Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child.
NA The agency provides Diagnosis, Assessment, and Referral Services only.
2020 Edition

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Purpose

Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning and attain recovery and wellness.
Examples: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement can vary given the age and expressed wishes of the person and as permitted by law.

Program model and structure can also impact family involvement. For example, detoxification treatment programs are short-term and primarily focused on withdrawal management; therefore, persons served have limited opportunities to involve family members in the service planning and monitoring process. Furthermore, it may not be appropriate to engage family members due to the service recipient's physical and mental state and treatment progress.
1
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. 
2
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.
3

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.
4
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
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-MHSU 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, 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; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s or legal guardian’s signature.

Interpretation

For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the service recipient. Research has shown that this population is often unsure of which services they are entitled to and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.
Examples: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.

Fundamental Practice

PA-MHSU 4.02

The agency determines whether a crisis plan is necessary and, when indicated, engages persons served and involved family members in crisis and/or safety planning that:
  1. is individualized and centered around strengths; 
  2. identifies individualized warning signs of a crisis;
  3. identifies coping strategies and sources of support that individuals can implement during a suicidal crisis, as appropriate; and 
  4. specifies interventions that may or may not be implemented in order to help the individual de-escalate and promote stabilization.

Interpretation

A safety plan includes a prioritized written list of coping strategies and sources of support that individuals who have been deemed to be at high risk for suicide can use. Individuals can implement these strategies before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings in order to prevent a suicide attempt or possibly death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required. 

Interpretation

“No-suicide contracts,” also known as “no-harm contracts” and other similar terms, should never be used. No-suicide contracts are based on a verbal or written agreement by the service recipient to not engage in self-harm or suicidal acts during a specific timeframe. Research does not support this practice or show that these agreements are effective at preventing suicides, nor have they been found to provide protection against malpractice lawsuits.
Examples: Depending on the needs of the individual, crisis plans may reference advanced mental health directives, also known as advanced psychiatric directives.

Examples: Components of a safety plan can also include: internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction.

Examples: Warning signs for individuals assessed as being at high risk for suicide can include a missed appointment, or significant change in status, and personnel may conduct active outreach and service engagement strategies such as phone calls, text messages, or home visits until contact is made. 

Examples: Safety plans may look different depending on the specific needs of the service recipient. For example, safety plans for survivors of domestic violence may focus on helping individuals prepare for immediate escape, while safety plans for individuals at risk for suicide may address coping strategies and sources of support, such as socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction. Agencies may also provide family members with information on crisis prevention. For example, Mental Health First Aid is a one-day training that can prepare someone to recognize, understand, and respond to a person’s mental health crisis.

PA-MHSU 4.03

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.

Interpretation

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.
NA The agency provides detoxification treatment only.
Examples: Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for individuals with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., individuals receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days. 

PA-MHSU 4.04

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.
NA The agency provides detoxification treatment only.