Standards for public agencies

2020 Edition

Residential Treatment Services (PA-RTX) 6: Service Planning and Monitoring

Residents and their families participate in the development and ongoing review of a comprehensive service plan that is the basis for delivery of appropriate services and supports.


While a service plan may conform to a uniform format, plan content should be individualized through collaboration with the resident and, as appropriate, a parent, guardian, and/or legal advocate based on service needs and program model. Level of family involvement in the service planning process will vary by resident and/or program model.


When the agency is working with Indian children and families, tribal or local Indian representatives must be included in the service planning process and culturally relevant resources available through or recommended by the tribe or local Indian organizations should be considered when developing the service plan.
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.
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
  • Service planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Residents and their families
  • Review case records

PA-RTX 6.01

Residents participate in the development of an initial service plan within one week of admission and a comprehensive service plan within 30 days.
NA The agency only operates a crisis stabilization unit, short-term diagnostic center or detoxification program.
Note: Service planning timeframes for crisis stabilization units are addressed in PA-RTX 13.04.

PA-RTX 6.02

A comprehensive, assessment-based service plan is developed with the full participation of the resident, 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. procedures for expedited service planning when crisis or urgent need is identified; and
  4. the resident’s and/or legal guardian’s signature.


Safety concerns for victims of human trafficking often do not end when they are admitted to residential settings. The agency should work with the victim to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services; maintaining the residence’s location in confidence or restricting access by certain individuals; and linking efficiently to law enforcement, if needed. Psychological safety should also be prioritized as the emotional effects of trauma – mistrust, anxiety, and depression – can be persistent and overwhelming for victims.
Examples: When working with victims of trauma, the agency can facilitate the development of realistic goals in an empowering and trauma-informed manner by building rapport, establishing trust, and promoting physical and psychological safety.

PA-RTX 6.03

The service plan includes:
  1. specific treatment modalities to be used, appropriate to the cultural perspective and competencies of the individual; and
  2. the estimated length of treatments and stay.

PA-RTX 6.04

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 resident, 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.


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 only operates a crisis stabilization unit, short-term diagnostic center, or detoxification program.
Examples: Service plans may be reviewed more frequently for young children, individuals with specialized care needs, and as acute needs and contractual requirements dictate. Timeframes for service plan reviews may be adjusted depending upon, for example: issues and needs of persons receiving services; changes in residents’ life situations or psychological conditions; frequency and intensity of services provided; and frequency of contact with informal caregivers and cooperating providers.

PA-RTX 6.05

The worker and resident, 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.


For children and youth, family members and/or legal guardians should always be involved in case conferences and advised of ongoing progress.
NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or detoxification program