2022 Edition

Mental Health and/or Substance Use Services (CA-MHSU) 4: Service Planning and Monitoring

Individuals and their families, as appropriate to the program model and the age and expressed wishes of the person, participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.


Due to the importance of family involvement in achieving positive outcomes for children and youth, service planning and monitoring should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child.
NA The organization provides Diagnosis, Assessment, and Referral Services only.




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.
Examples: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement can vary given the age and expressed wishes of the person and as permitted by law.

Program model and structure can also impact family involvement. For example, due the naure of withdrawal management programs, involving family members in the service planning and monitoring process may not be possible or appropriate.
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-MHSU 4.01

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. 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 person's or legal guardian’s signature.


Generally, children age six and over should be included in service planning, unless there are clinical justifications for not doing so. The organization should have a developmentally appropriate discussion with children about the reason for accessing services and what they can expect to happen during service delivery.
Examples: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.

Fundamental Practice

CA-MHSU 4.02

The organization determines whether a crisis plan is necessary and, when indicated, engages persons served and involved family members in crisis and/or safety planning that:
  1. is individualized and centered around strengths; 
  2. identifies individualized warning signs of a crisis;
  3. identifies coping strategies and sources of support that persons served can implement during a suicidal crisis, as appropriate; and 
  4. specifies interventions that may or may not be implemented to help the individual or family de-escalate and promote stabilisation.


 For individuals who have been deemed to be at high risk of suicide, a safety plan includes a prioritized written list of coping strategies and sources of support that individuals can use before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings in order to prevent a suicide attempt or possibly death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required. 


 For organizations serving children and youth, when safety issues are identified, the organization: 
  1. involves supervisory personnel in reviewing safety concerns and plans; and  
  2. reports safety concerns in accordance with mandated reporting requirements. 


“No-suicide contracts,” also known as “no-harm contracts” and other similar terms, should never be used. No-suicide contracts are based on a verbal or written agreement by the person to not engage in self-harm or suicidal acts during a specific timeframe. Research does not support this practice or show that these agreements are effective at preventing suicides, nor have they been found to provide protection against malpractice lawsuits.
Examples: Depending on the needs of the person, crisis plans may reference advanced mental health directives, also known as advanced psychiatric directives.

Examples: Components of a safety plan can also include: internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction.

Examples: Warning signs for individuals assessed as being at high risk for suicide can include a missed appointment, or significant change in status, and personnel may conduct active outreach and service engagement strategies such as phone calls, text messages, or home visits until contact is made. 

Examples: Safety plans may look different depending on the specific needs of the individual or family. For example, safety plans for survivors of domestic violence may focus on helping individuals prepare for immediate escape, while safety plans for individuals at risk for suicide may address coping strategies and sources of support, such as socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction. Organizations may also provide family members with information on crisis prevention. For example, Mental Health First Aid is a one-day training that can prepare someone to recognize, understand, and respond to a person’s mental health crisis.


CA-MHSU 4.03

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.
NA The organization provides withdrawal management only.
Examples: Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for individuals with suicidal ideation, recent relapse, or those with a recent mental health or substance use related emergency room visit or hospitalization. Individuals with acute or complex needs (e.g., individuals receiving medications for diagnosed symptoms and conditions) or those in a higher level of care such as intensive outpatient may require that their service plan be reviewed and updated every 30 days. 


CA-MHSU 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.
NA The organization provides withdrawal management only.