2022 Edition

Housing Stabilization and Community Living Services (CA-HSCL) 4: Service Planning and Monitoring

Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.




Individuals and families that use Housing Stabilization and Community Living Services obtain and maintain stable housing in the community, strengthen personal support systems and resources, and enhance life skills and functioning in order to improve overall well-being and live as independently as possible.
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. Persons served
  • Review case records


CA-HSCL 4.01

An assessment-based service 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; 
  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 signature of persons served.


In the context of rapid re-housing programs, service plans should focus on the achievement of housing-specific goals in the shortest amount of time possible and practical, and address barriers to housing retention.


In recovery housing, recovery planning should be driven by the resident and focused on their recovery barriers, service needs, strengths, and resources. Outcome measures of recovery capital that can be the focus of a strengths-based recovery plan include the person’s percieved level of satisfaction or well being as well as measures of personal, social, and community capital including physical health, housing, engagment in meaningful activities, and the presence of social supports.

Unmet service needs can slow the growth of positive recovery capital for individuals in recovery. Examples of common service needs among residents in recovery homes include:
  1. mental health; 
  2. substance use;
  3. legal, including criminal record expungement services;
  4. crisis intervention;
  5. primary care and dentistry;
  6. education and vocational skill development; and/or
  7. housing.


CA-HSCL 4.02

The organization works in active partnership with individuals and families 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;
  3. assist with access to the full array of services to which they are eligible; and 
  4. mediate barriers to services within the service delivery system.


CA-HSCL 4.03

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on program design or the needs of persons served, 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.


Quarterly case reviews may not be appropriate in shorter term housing when services are only provided for a few months. In these cases, reviews should be conducted more frequently to confirm progress and the continued appropriateness of the service plan.


CA-HSCL 4.04

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.


When working with individuals in recovery, the frequency of reviews will vary based on the wishes of the individual and the level of recovery support being provided. For example, individuals new to recovery may have daily meetings with staff to discuss progress, while those with more time in recovery may meet with staff monthly.