2022 Edition

Psychiatric Rehabilitation Services (CA-PSR) 5: Rehabilitation Planning and Monitoring

Each person participates in the development and ongoing review of a rehabilitation plan that is the basis for delivery of appropriate services and supports.


Viewing: CA-PSR 5 - Rehabilitation Planning and Monitoring



Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency. 
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
  • 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
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
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
  • Rehabilitation planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


CA-PSR 5.01

An assessment-based rehabilitation 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 individual’s signature.


Experiences with family rejection and capacity for increasing family acceptance and support should be part of the assessment for family relationships. It should also include culturally appropriate education and guidance to help individuals identifying as part of the LGBTQ community to decrease family rejection and increase family support.


CA-PSR 5.02

The rehabilitation plan addresses, as appropriate:
  1. psychological and emotional needs;
  2. vocational goals;
  3. cultural interests;
  4. development of life skills, including preparation to work or continuation of schooling; and
  5. improvement in the person’s quality of life and necessary skills to remain within the community.

Fundamental Practice

CA-PSR 5.03

The organization determines whether a crisis plan is necessary and, when indicated, engages individuals 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 individuals can implement during a suicidal crisis, as appropriate; and 
  4. specifies interventions that may or may not be implemented in order to help the individual de-escalate and promote stabilisation.


A safety plan includes a prioritized written list of coping strategies and sources of support that individuals who have been deemed to be at high risk for suicide can use. Individuals can implement these strategies 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. 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. 


“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 service recipient 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 individual, crisis plans may reference advanced mental health directives, also known as advanced psychiatric directives.

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 service recipient’s mental health crisis.


CA-PSR 5.04

The worker and a supervisor, or a clinical, service, or peer team, review the rehabilitation plan quarterly, or more frequently depending on the needs of persons served as determined by the service provider and supervisor, to assess: 
  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the 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-PSR 5.05

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.