Standards for private organizations

2020 Edition

Wilderness and Adventure-Based Therapeutic Outdoor Services (WT) 5: Service Planning and Monitoring

Youth participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
2020 Edition




Youth who participate in Wilderness and Adventure-based Therapeutic Outdoor Services expand individual capabilities, develop self-confidence and insight, ameliorate symptoms, and improve interpersonal skills and relationships.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
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. Youth or families served
  • Review case records

WT 5.01

An initial service plan is developed with the youth, whenever possible, within 2 days of admission and a comprehensive, individualized service plan is developed within 30 days.

WT 5.02

An interdisciplinary team develops an assessment-based service plan with the full participation of the youth, and their family when appropriate, that 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. signatures from the youth and their parent or legal guardian.

WT 5.03

The organization addresses permanency planning in the service plan by:
  1. identifying permanency goal(s) and activities or supporting the permanency plan identified by the custodial agency;
  2. reviewing the permanency plan quarterly to assess progress towards agreed upon goals;
  3. providing the youth with age appropriate information about his or her parents and progress toward reunification; and
  4. providing parents or the custodial agent with information, resources, and support for reunification.


Public and private agency roles in the permanency planning process are defined by state rules, regulations, or contracts. When the organization is not responsible for facilitating permanency planning, it should document attempts to participate in the process.
NA The organization does not provide out-of-home care for youth in custody of a public agency.

WT 5.04

An interdisciplinary team works in active partnership with youth and their families to:
  1. assume responsibility for coordinating medical, social, psychological, and other evaluations; 
  2. share the service plan with other providers working directly with youth; 
  3. ensure that youth receive appropriate advocacy support;
  4. assist with access to the full array of services to which youth are eligible; and
  5. mediate barriers to services within the service delivery system.

WT 5.05

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of youth, to assess:
  1. service plan implementation;
  2. progress toward achieving 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.

WT 5.06

The worker and youth, and his or her family when appropriate:
  1. review progress toward achievement of agreed upon goals; and 
  2. sign revisions to service goals and plans.