Standards for public agencies

2020 Edition

Psychiatric Rehabilitation Services (PA-PSR) 5: Rehabilitation Planning and Monitoring

Each person participates in the development and ongoing review of a rehabilitation plan that is the basis for delivery of appropriate services and supports.
2020 Edition




Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency. 
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
  • Rehabilitation planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-PSR 5.01

An assessment-based rehabilitation 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 signature.


Experiences with family rejection and capacity for increasing family acceptance and support should be part of the assessment for family relationships. It should also include culturally appropriate education and guidance to help individuals identifying as part of the LGBTQ community to decrease family rejection and increase family support.

PA-PSR 5.02

The rehabilitation plan addresses, as appropriate:
  1. psychological and emotional needs;
  2. vocational goals;
  3. cultural interests;
  4. development of life skills, including preparation to work or continuation of schooling; and
  5. improvement in the person’s quality of life and necessary skills to remain within the community.

Fundamental Practice

PA-PSR 5.03

The agency determines whether a crisis plan is necessary and, when indicated, engages individuals 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.


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. 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. 


“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.

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 service recipient’s mental health crisis.

PA-PSR 5.04

The worker and a supervisor, or a clinical, service, or peer team, review the rehabilitation plan quarterly, to assess: 
  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the 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-PSR 5.05

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.