Standards for public agencies

2020 Edition

Residential Treatment Services (PA-RTX) 19: Transition from the Service System

Residents, and their families and/or legal guardians, as appropriate, participate in planning for transition to the community and are prepared with positive experiences and skills to make a successful move.
NA The agency only operates a crisis stabilization unit, short-term diagnostic center, or detoxification program.
2020 Edition




Residential Treatment Services provide individualized therapeutic interventions and a range of services, including education for residents to increase productive and pro-social behavior, improve functioning and well-being, and return to a stable living arrangement in the community.
Examples: For adolescents, the transition from the service system often coincides with their transition to adulthood. Youth can be supported during their transition to adulthood through individualized planning and preparation that promotes emotional well-being, supportive relationships, access to needed resources, and skill development.
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
  • Transition planning procedures
  • Procedures for assessing independent living skills
  • Independent living skills assessment tool
  • Information provided to residents who are transitioning from the service system
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Residents and their families
  • Review case records

PA-RTX 19.01

The agency works with residents and their families to develop a plan for living in the community.

PA-RTX 19.02

The agency prepares residents, as appropriate to their individualized transition plan, for a successful transition by providing them with information and support regarding:
  1. transfer or termination of custody for youth, as applicable;
  2. their rights and services to which the person may have access as a result of a disability;
  3. access to specialized services and navigating adult-serving systems;
  4. availability of affordable healthcare and counseling;
  5. public assistance and court systems;
  6. child care services; and
  7. support through community volunteers, peers, or persons who have made a successful transition, as appropriate.

PA-RTX 19.03

The agency works with the resident and their family to assess the independent living skills of residents 14 years and older, at regular intervals, using a standardized assessment instrument that includes the following areas:
  1. educational and vocational development;
  2. interpersonal skills;
  3. financial management;
  4. household management; and
  5. self-care.


The first assessment should be completed as soon as possible after residents’ 14th birthdays to establish a benchmark for measuring progress in identified areas. Systematic assessment normally reoccurs at six or twelve month intervals.
NA Residents are not transitioning to an independent living situation.

PA-RTX 19.04

The agency provides residents transitioning to the community with advance notice of the cessation of any health, financial, or other benefits that may occur at transition.

PA-RTX 19.05

During the transition process the agency explores a range of housing options with residents and engages them in an evaluation of the risks and benefits of various living situations.
NA Residents are not transitioning to an independent living situation.
Examples: Options may include the full range of living situations from supported living to fully independent living environments.

PA-RTX 19.06

For every resident transitioning to independence, the agency ensures that basic resources are in place, including:
  1. a safe, stable living arrangement with basic necessities;
  2. a source of income;
  3. affordable health care; and
  4. access to education and career development.
NA Residents are not transitioning to independent living situations.

PA-RTX 19.07

The agency ensures that residents transition from the service system with social supports in place, including, as appropriate, access to:
  1. at least one committed, caring adult;
  2. cultural and community supports; and
  3. positive peer support and mentoring, including peer advocates and peer support programs.

PA-RTX 19.08

The agency assists residents in obtaining or compiling documents necessary to function independently, including, as appropriate:
  1. an identification card or a driver’s license, when the ability to drive is a goal;
  2. a social security or social insurance number;
  3. a resume, describing work experience and career development;
  4. medical records and documentation, including a Medicaid card or other health eligibility documentation;
  5. an original copy of the birth certificate;
  6. bank account access documents;
  7. religious documents and information;
  8. documentation of immigration or refugee history and status, when applicable;
  9. death certificates if parents are deceased;
  10. a life book or a compilation of personal history and photographs, as appropriate;
  11. a list of known relatives, with relationships, addresses, telephone numbers, and permissions for contacting involved parties;
  12. previous placement information and health facilities used, when appropriate; and
  13. educational records, such as high school diploma or general equivalency diploma, and a list of schools attended, when appropriate.
NA Residents are not transitioning to independent living situations.