2023 Edition

Adult Guardianship Definition

Purpose

Individuals who receive guardianship services maintain a level of independence and self-determination appropriate to their functional capacity, and are at minimized risk of abuse, neglect, or exploitation.

Definition

Adult Guardianship is the court-appointed responsibility of an organization to make any combination of informed personal and/or financial decisions on behalf of an individual who has been deemed incapacitated by the court.
 
Decision-making authority is limited by the court order and generally falls into one of two categories:
  1. Guardian of the Person: The guardian is granted the authority to make decisions regarding personal matters such as medical, residential, and social service decisions.
  2. Guardian of the Estate: The guardian is granted authority over the individual’s estate or finances.
Total authority to make personal and/or financial decisions on behalf of the individual is known as plenary guardianship; however, guardianship can be as limited as the court sees fit given the individual’s assessed capacity. Limited guardianship allows the court to grant decision making authority only over specific areas of the individual’s life. For example, the guardian may have medical decision-making authority, but the individual retains his or her right to make housing decisions.

Note:Throughout this document, the term individual will be used to refer to the incapacitated person or ward for whom the organization is acting as guardian.


Note:Guardianship services are governed by state law and practice can vary dramatically from state to state. The standards below reflect practices that have been associated with improved client outcomes, but should be interpreted within the context of each state’s guardianship law.


Note:Please see AG Reference List for the research that informed the development of these standards.


Note:For information about changes made in the 2020 Edition, please see the AG Crosswalk.


2023 Edition

Adult Guardianship (AG) 1: Person-Centered Logic Model

The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
NotePlease see the Logic Model Template for additional guidance on this standard.  
1
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.

Logic models have been implemented for all programs and the organization has identified at least two outcomes for all its programs.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one client outcome has been identified for all of its programs; or
  • All but a few staff have been trained on use of therapeutic interventions and training is scheduled for the rest; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
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
  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs; or
  • Several staff have not been trained on the use of therapeutic interventions; or
  • There are gaps in monitoring of therapeutic interventions, as required; or
  • There is no process for identifying risks associated with use of therapeutic interventions; or
  • Policy on prohibited interventions does not include at least one of the required elements.
4
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.,
  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs; or
  • There is no written policy or procedures for the use of therapeutic interventions; or 
  • Procedures are clearly inadequate or not being used; or
  • Documentation on therapeutic interventions is routinely incomplete and/or missing; or
  • There is evidence that clients have been harmed by inappropriate or unmonitored use of therapeutic interventions.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • See program description completed during intake
  • Program logic model that includes a list of outcomes being measured
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel

 

AG 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, organizational, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered);
  5. desired outcomes (i.e. the changes you expect to see in persons served); and
  6. expected long-term impact on the organization, community, and/or system.
Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA’s PQI Tool Kit for more information on developing and using program logic models.  
 
Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:
  1. needs assessments and periodic reassessments;
  2. the state’s approach to guardianship services; and
  3. the best available evidence of service effectiveness. 

 

AG 1.02

The logic model identifies client outcomes in at least two of the following areas:
  1. change in functional status;
  2. health, welfare, and safety;
  3. permanency of life situation;
  4. quality of life;
  5. achievement of individual service goals; and
  6. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

2023 Edition

Adult Guardianship (AG) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of individuals in need of guardianship.
Interpretation: Competency can be demonstrated through education, training, or experience. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.
1
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.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up-to-date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,
  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications, including education, experience, training, skills, temperament, etc.; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • List of program personnel that includes:
    • Title
    • Name
    • Employee, volunteer, or independent contractor
    • Degree or other qualifications
    • Time in current position
  • See organizational chart submitted during application
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files

 

AG 2.01

Guardianship workers are licensed or certified as required by state law, and qualified by:
  1. an advanced degree in a relevant field; or
  2. a bachelor’s degree with two years' relevant experience.
Examples: Relevant degrees or experience include law, social work, accounting, nursing, business, geriatrics, developmental disability, psychology, occupational therapy, and public administration.

 

AG 2.02

Supervisors are licensed or certified as required by state law, and qualified by:
  1. an advanced degree in a relevant field;
  2. a minimum of two years' related experience; and
  3. maintainance of certification from a national certifying body.

 

AG 2.03

The organization has access to professionals with expertise in critical areas, such as financial management, health care, housing, bioethics, and law.
Interpretation: The organization may use members of its staff or board as experts in relevant areas. When the organization does not have needed professionals on staff or on its governing body, it should establish relationships with community stakeholders with a vested interest in the service population to fill this consultative role.

 

AG 2.04

Guardianship workers are trained on, or demonstrate competency in:
  1. financial management;
  2. ethics issues unique to adult guardianship including bioethics and healthcare decision-making;
  3. reporting requirements;
  4. substituted judgment and best-interest standards of decision-making;
  5. local guardianship law including interstate jurisdiction and processes for terminating a guardianship; and
  6. state and federal regulations governing eligibility for public benefits, and appropriate steps to maintain the individual’s eligibility.
Examples: Regarding element f, training regarding eligibility requirements can include income and resource limitations, and transactions or assistance from family members that may disqualify the individual from continuing to receive public benefits, such as rent payment, groceries, or cash. Examples of steps that can be used to maintain eligibility can include  tools designed to spend down assets to within limits, such as the establishment of a special needs trust, or pre-payment of funeral or burial plans.

 

AG 2.05

Employee workloads meet the organization’s established caseload ratios and ensure that workers are able to provide appropriate support and timely decision-making for the individuals on their caseload.
Interpretation: The organization should be able to justify established ratios based on established criteria and demonstrate how it assures appropriate, high quality care is being provided to each client.
 
When an organization assigns teams of professionals to carry out different responsibilities for each case, all full-time, professional staff may be counted when determining the staff-to-client ratio.

 
Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the complexity and status of each case, such as the individual’s living situation, the type of guardianship being provided, or the existence of complex medical conditions;
  2. the size of the geographical area covered;
  3. services provided by other professionals or team members such as bookkeepers, guardian assistants, and volunteers;
  4. other organizational responsibilities;
  5. applicable legal requirements;
  6. the qualifications, competencies, and experience of the worker, including the level of supervision needed; and
  7. service volume, accounting for assessed level of needs of persons served.
2023 Edition

Adult Guardianship (AG) 3: Intake and Assessment

The organization’s intake and assessment practices ensure that individuals receive prompt and responsive access to appropriate services.

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VIEW THE STANDARDS

1
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.
2
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
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
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
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
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.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Screening and intake procedures
  • Assessment procedures
  • Copy of assessment tool(s)
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

AG 3.01

The organization conducts ongoing outreach to the community to:
  1. educate the community about guardianship and guardianship law; and
  2.  inform potential referral sources about the services it provides.
Interpretation: If the organization does not develop and distribute its own informational materials, it should refer individuals to appropriate community resources where the information can be obtained, such as the National Guardianship Association and the state's guardianship association.
 

Interpretation: Information on available services should include whether or not the organization has the capacity to take on guardianship responsibilities in emergency situations.
Examples: The type of information distributed may vary based on the needs of the community and can include general information on state guardianship laws, the process for establishing a guardianship, the benefits and consequences of transferring decision-making authority to a guardian, and a list of appropriate community resources. 

Examples: Providers who typically come in contact with the identified service population include providers serving youth with developmental disabilities who are transitioning to the adult system, law enforcement officers, adult protective services, state Area Agencies on Aging, long-term care Ombudsman Programs, banks, housing courts, utility companies, local houses of worship or community centers, residential service providers, and hospitals.

 

AG 3.02

Individuals are evaluated at intake to ensure that:
  1. guardianship is the least restrictive alternative that will still effectively meet the indivdiual’s needs;
  2. the level of guardianship is appropriate to the individual's assessed capacity; and
  3. there is no appropriate family member or friend who could assume the guardianship role.
Interpretation: Although the court will have made the initial determination regarding the appropriateness of guardianship, the organization should still conduct its own evaluation of whether the level and type of guardianship is appropriate, and whether there are less restrictive alternatives that would meet the individual’s needs. If the court has erred or missed pertinent information, the organization can return to the court, request a less restrictive appointment, and suggest possible alternatives to guardianship. 
 
An organization should be seen as the guardian of last resort; meaning, an organization should only be appointed as the guardian of an individual when it has been determined that no family member or friend is willing, able, or suitable to act as guardian.
Examples: Possible alternatives to guardianship include, but are not limited to: powers of attorney, representative payee programs, support services provided by community providers, and informal support systems.

 

AG 3.03

When determining its capacity to serve as guardian, the organization considers the:
  1. organization’s established staff-to-client ratio and current staff workloads;
  2. appropriateness of the court order; and
  3. qualifications and skill level of staff.

 

AG 3.04

When the organization determines it does not have the capacity to serve as an individual’s guardian, the individual is connected to a more appropriate service system or resource.
Examples: An organization might not have the capacity to serve as an individual’s guardian if the initial referral was inappropriate such as when the individual in question has particular health needs that the organization is not equipped to accommodate.

 

AG 3.05

The individual participates in an individualized, culturally, and linguistically responsive assessment that:
  1. is completed within established timeframes; 
  2. is updated as needed based on their needs;
  3. is focused on information pertinent for meeting service requests and objectives; and
  4. incorporates information from outside sources, such as those who have worked with the individual in the past, as appropriate to the needs and wishes of the individual.

Interpretation: Re-assessments should be conducted when major events occur that could impact the individual’s service needs, such as discharge from a hospital, major changes in medical condition or mental health status, or when there is a change to the individual’s living situation.

 

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

2023 Edition

Adult Guardianship (AG) 4: Guardianship Planning and Monitoring

Individuals participate in the development and ongoing review of a guardianship plan that is the basis for delivery of appropriate services and support.
1
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.
2
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
  • Active client participation occurs to a considerable extent.
3
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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Guardianship planning and monitoring procedures
  • Procedures for tracking due dates
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Observe system for tracking due dates

 

AG 4.01

An assessment-based guardianship plan is developed in a timely manner with the full participation of the individual, 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; and
  3. opportunities to enhance the individual’s well-being and improve his or her capacity.
Interpretation: Guardianship planning is conducted in such a way that individuals retain as much personal responsibility and self-determination as possible and/or desired. 

 

AG 4.02

The organization works in active partnership with persons served to:
  1. assume a service coordination role, as appropriate, when the need has been identified and no other organization has assumed that responsibility;
  2. ensure that they receive appropriate advocacy support; and
  3. assist with access to the full array of services to which they are eligible.

 

AG 4.03

To mediate barriers to services within the service delivery system, the organization establishes working relationships with community providers including:
  1. adult protective services and other local and state government agencies;
  2. mental health providers;
  3. legal services;
  4. vocational rehabilitation programs;
  5. hospitals and other medical facilities;
  6. home or geriatric care providers;
  7. home security system companies;
  8. local Area Agencies on Aging;
  9. long-term care Ombudsman Programs; and
  10. nursing homes, assisted living, and other residential facilities.

 

AG 4.04

Logs or other records are maintained to track implementation of the guardianship plan, and include:
  1. time spent with the individual and advocating on his or her behalf with service providers;
  2. documentation of the individual’s participation in decision-making;
  3. documentation of decisions made;
  4. initiation or termination of direct services;
  5. reports provided to the court or other regulatory bodies; and
  6. progress towards achievement of desired service goals and outcomes.

 

AG 4.05

The organization has a standardized system for tracking due dates that ensures timely reporting to the court or other government entities, when applicable.
Examples: Entities that may require regular reporting can include the Social Security Administration or the Department of Veterans Affairs.

 

AG 4.06

When appropriate, the guardianship worker makes funeral and burial arrangements that:
  1. respect the individual's expressed desires, culture, heritage, and belief system; and
  2. involve the family to the greatest extent possible and appropriate.
Interpretation: Involvement of the family should include investigating the existence of family plots.

 

AG 4.07

The guardianship worker and a supervisor, or a clinical, service, or peer team, review the case quarterly or more frequently depending on the needs of the individual, to assess:
  1. guardianship plan implementation;
  2. participation of the individual;
  3. progress toward achieving service goals and desired outcomes;
  4. timeliness of court reporting;
  5. frequency of contact; and
  6. the continuing appropriateness of the court order and agreed upon service goals.

 

AG 4.08

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.
2023 Edition

Adult Guardianship (AG) 5: Conflict of Interest

The organization establishes the well-being of individuals as its primary responsibility and eliminates the risk, or appearance, of a conflict of interest.
Interpretation: A conflict of interest exists when an action made on behalf of the individual may be seen as self-serving to the guardianship worker or the organization as a whole, such as when the organization arranges for the individual to live in one of its residential facilities for which it will collect rent or some other form of payment.
1
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.
2
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
  • Active client participation occurs to a considerable extent.
3
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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Adult Guardianship conflict of interest policy
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 
Fundamental Practice

AG 5.01

Whenever possible, the guardianship program:
  1. operates as an independent entity; and
  2. refers individuals to services offered by outside providers.
Interpretation: When the guardianship program is part of a larger organization or entity, it should have the authority to make independent decisions in order to avoid conflicts due to the potentially competing interests of the larger organization or entity. Exceptions to element (b) should be made only when: (1) an appropriate outside service provider is unavailable, and (2) the exception is in the best interest of the individual served. 

 

AG 5.02

When the organization acts as both guardian and direct service provider, reasons for the arrangement should be documented in the case record.

 

AG 5.03

The organization discloses any potential conflict of interest to all involved parties including the court, the individual, and his or her family as appropriate.

 
Fundamental Practice

AG 5.04

The organization only petitions the court for its own appointment as guardian when no other entity is available.

 

AG 5.05

All guardianship fees are reported to and approved by the court.
2023 Edition

Adult Guardianship (AG) 6: Guardian of the Person

The guardian of the person:
  1. honors the wishes of the individual to the greatest extent possible;
  2. makes informed decisions on behalf of the individual;
  3. promotes improved quality of life and continued development of capabilities; and
  4. monitors the quality and appropriateness of direct services as needed.
NA The organization acts as guardian of the estate only.
1
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.
2
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
  • Active client participation occurs to a considerable extent.
3
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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Procedures for ethical decision-making
  • Service monitoring procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

AG 6.01

The individual participates in personal decision-making to the greatest extent possible given his or her assessed capacity for decision-making and subject to the court order.

 
Fundamental Practice

AG 6.02

The organization has established procedures for ethical decision-making that include the consideration of:
  1. available options;
  2. how each option can support the achievement of desired outcomes;
  3. risks and benefits of each option;
  4. the expressed wishes of the individual as appropriate and subject to the court order;
  5. input from involved parties as appropriate; and
  6. the court order outlining their decision-making authority.
Examples: The guardian can determine the individual’s wishes by considering how the individual has made similar decisions in the past, verbal and non-verbal indicators of preference, or written documentation of the individual’s expressed wishes, such as advance directives that were developed prior to the individual’s loss of decision-making capacity. 
 
Examples: Involved parties can include close friends and family, doctors, internal ethics committees, the court, attorneys, or religious leaders. 

 

AG 6.03

To ensure compliance with previously established advance directives, guardianship workers:
  1. provide copies to relevant medical and/or psychiatric service providers; and
  2. store copies in a safe and accessible location.

 
Fundamental Practice

AG 6.04

Improved quality of life and increased capacity are promoted by:
  1. encouraging relationships and a sense of connectedness;
  2. identifying services and supports that will promote continued growth and improved capacity;
  3. helping the individual to develop a sense of value or purpose; and
  4. regularly re-assessing the individual’s capacity and pursuing termination of guardianship or a change to the court order as appropriate.

 

AG 6.05

The guardianship worker works with, or on behalf of, the individual to:
  1. arrange for needed or requested services as identified in the guardianship plan;
  2. monitor the quality and appropriateness of services; and
  3. facilitate the initiation or termination of services as appropriate.
Interpretation: The guardian should tailor the type and frequency of service monitoring according to the requirements of the court order, the needs of the individual, frequency and intensity of the services being provided, and frequency of contact with informal caregivers and cooperating providers. 

 

AG 6.06

The guardianship worker monitors the quality and appropriateness of services by:
  1. directly communicating with current service providers;
  2. attending case conferences as appropriate;
  3. observing the effectiveness of services through regular contact with the individual; and
  4. participating in direct-service planning teams with outside providers.

 
Fundamental Practice

AG 6.07

The organization ensures each Individual has an emergency response plan that includes, as appropriate:
developing food or emergency kits;
  1. awareness of evacuation procedures at residential facilities where the individual resides;
  2. conducting emergency drills as needed;
  3. inclusion in local or state-wide emergency plans or evacuations; and
  4. search and rescue procedures for individuals with a history of wandering.
Related Standards:
2023 Edition

Adult Guardianship (AG) 7: Guardian of the Estate

The individual’s estate is managed in an open and transparent manner that:
  1. is consistent with service goals and the individual’s values;
  2. encourages the individual’s involvement to the greatest extent possible;
  3. protects the individual’s assets; and
  4. maintains or improves the individual’s financial standing as appropriate.
NA The organization only acts as guardian of the person.
Note: The terminology used may vary; however, any organization court-ordered to manage an individual’s finances is expected to meet the standards outlined in this section. That includes guardians of the destitute who may only be responsible for managing the individual’s public benefits. Guardian of the estate may also be responsible for managing the individual’s stocks and bonds, paying bills, income and property taxes, real estate, insurance, and maintaining eligibility for public benefits.
 
1
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.
2
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
  • Active client participation occurs to a considerable extent.
3
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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Procedures for:
    1. conducting inventory of client assets
    2. sharing financial information with persons served
    3. Guardian of the Estate financial management
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

AG 7.01

The individual participates in estate planning and financial decision-making to the greatest extent possible given his or her assessed capacity for decision-making and subject to court order.

 

AG 7.02

Upon initiation of guardianship, a thorough inventory of the individual’s assets is conducted to determine:
  1. the type and value of the individual’s assets;
  2. how assets are held, owned or managed;
  3. areas of risk or potential loss; and
  4. what assets should be maintained.
Examples: Assets can include real estate, such as residential or commercial property and personal properties such as investments, insurance, vehicles, and other valuables.

 

AG 7.03

The guardian of the estate communicates regularly with the guardian of the person, or any other health care decision-maker, to ensure the financial plan is consistent with service goals. 
Examples: This may include communication within the organization or with outside providers. Some organizations have successfully implemented a checklist system, or similar protocol, for ensuring everyone involved with a particular case is aware of decisions made or work done on behalf of the individual.

 

AG 7.04

Financial information is available to the individual upon request, as appropriate to their assessed capacity to handle such information and in accordance with the court order.

 

AG 7.05

The individual’s income is used to meet his or her identified needs.
Examples: Needs can include:
  1. food, clothing, shelter, and utilities;
  2. health care and prescriptions;
  3. home care, aide services, and housekeeping;
  4. transportation;
  5. insurance;
  6. legal or other professional fees, with court approval;
  7. pre-paid burial arrangements;
  8. social and recreational needs; and
  9. savings.

 
Fundamental Practice

AG 7.06

The organization has procedures governing the management of funds that protect the assets of individuals, including:
  1. an accounting system that accurately tracks all transactions;
  2. authorization and processing of disbursements;
  3. regular, internal audit of client accounts;
  4. an external audit of client accounts conducted at least once every three years;
  5. segregation of duties regarding cash disbursements;
  6. tracking system to notify guardians of key due dates;
  7. separate accounts for each service recipient; and
  8. managing funds in accordance with the Prudent Investor Rule.
Related Standards:
Interpretation: Money can be pooled into one bank account when accounting software has the capacity to manage each account separately, provide adequate documentation of income and expenditures, protect the holdings of each individual, and complies with all applicable contractual obligations.
Examples: Key due dates can include billing due dates, tax deadlines, legal notifications, contractual deadlines or expirations, expiration dates for public benefits; and due dates for submitting accounting reports to regulatory bodies and oversight entities, including the court.

Examples: Authorities that may require regular accounting reports include the courts, the Department of Veterans Affairs, and the Social Security Administration when the guardian has been appointed by the Social Security Administration to serve as a representative payee who manages the individual's Social Security payments.
2023 Edition

Adult Guardianship (AG) 8: Frequency of Contact

Personnel have regular contact with individuals to support the achievement of desired outcomes.
1
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.
2
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
  • Active client participation occurs to a considerable extent.
3
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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Procedures governing frequency of contact
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 
Fundamental Practice

AG 8.01

Guardianship services are available 24 hours a day, seven days a week.
Interpretation: Organizations may utilize a rotating on-call system using pagers or cell phones to ensure someone from the organization is available for after-hour emergencies. This should include methods for accessing client records so on-call staff have access to the summary of authorities granted by the court-order and documentation of work that has been done on the case.

 
Fundamental Practice

AG 8.02

The guardianship worker makes in-person contact with the individual monthly, and more frequently as needed, given the:
  1. individual’s identified needs;
  2. case complexity;
  3. housing situations; and
  4. court mandates or legal requirements.
Interpretation: If contact is not made at least monthly, the reasons for infrequent contact should be documented in the case record. Living in a staffed residential facility or at home with a paid caregiver is not sufficient justification for reducing the frequency of face-to-face contact as the quality or appropriateness of services being provided could be inadequate. The organization must also be able to demonstrate that the standard of care is appropriate, there is no abuse occurring, and the services being provided are effectively meeting the needs of the individual prior to reducing the frequency of contact. In such situations, regular visits to residential facilities or homes and quarterly face-to-face contact with the individual should continue.
2023 Edition

Adult Guardianship (AG) 9: Case Closing

The organization works with persons served and family members, when appropriate, to plan for case closing.
1
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.
2
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
  • 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, the organization terminated services inappropriately; or  
  • Active client participation occurs to a considerable extent; or
  • A formal case closing evaluation is not consistently provided to the public authority per the requirements of the standard.
3
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
  • Services are frequently terminated inappropriately; or  
  • Aftercare planning is not initiated early enough to ensure orderly transitions; or
  • A formal case closing summary and assessment is seldom provided to the public authority per the requirements of the standard; or  
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Case closing procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

AG 9.01

Upon case closing, the organization notifies any collaborating service providers, as appropriate.

 

AG 9.02

When guardianship responsibilities are being transferred, the guardian provides technical assistance and information to ensure the new guardian is prepared to take on the role.
Examples: Guardianship may be transferred to another organization, a different worker or volunteer within the organization, a family member, or a friend or community member.

 

AG 9.03

The guardian makes proper arrangements following the individual’s death, when appropriate and in accordance with the court order.
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