2022 Edition

Intellectual and Developmental Disabilities Services (CA-IDDS) 4: Service Planning and Monitoring

Person-centered service planning engages persons with developmental disabilities and their team as primary decision makers regarding the services and supports they receive.


Generally, all decisions are made with the informed consent of the individual or guardian. Unless otherwise noted, informed consent is not necessarily written; however, the fact that consent was given should be noted in the individual's case record.




Intellectual and Developmental Disabilities Services support children, youth, and adults to achieve full integration and inclusion in the mainstream, make choices, exert control over their lives, and fully participate in, and contribute to, their communities.
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 staff
    3. Persons served
  • Review case records


CA-IDDS 4.01

The organization works in partnership with the individual, and his or her team according to the wishes of the individual, to develop and implement a plan that enables the fullest and most independent life possible in the community and promotes self-determination.


CA-IDDS 4.02

Individuals with limited ability to make independent decisions receive help from the team in making choices and/or assuming responsibility for making decisions.


CA-IDDS 4.03

An assessment-based service plan is developed in a timely manner with the full participation of persons served, 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. a means for resolving conflicts, and 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 individual’s signature.


CA-IDDS 4.04

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;
  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.  

Fundamental Practice

CA-IDDS 4.05

Service planning for persons with developmental disabilities addresses, as appropriate to the individual:
  1. health and safety issues;
  2. degree of supervision needed;
  3. independent living, social, and daily living skills;
  4. nutritional and dietary needs;
  5. leisure and vocational interests, aptitudes, and need for greater social inclusion;
  6. screening and treatment for co-occurring psychiatric disorders or substance use conditions;
  7. the need for assistive technology, auxiliary aids, and other special accommodations;
  8. positive behaviour support planning;
  9. medication needs;
  10. issues related to adaptive, behaviour, and cognitive functioning, including concrete and abstract reasoning;
  11. specialized supports such as physical, speech, and occupational therapy;
  12. ancillary services;
  13. end of life planning; and
  14. the need for hospice or palliative care.


CA-IDDS 4.06

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on 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.


CA-IDDS 4.07

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.