2022 Edition

Refugee Resettlement Services (CA-RRS) 5: Service Planning and Monitoring

Each person participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate, coordinated services and support.


Generally, children age six and older are to be included in service planning unless there are cultural objections or clinical justifications for not doing so.




Refugees acquire the cross-cultural information, skills, and social support network needed to gain stability, make a positive personal and social adjustment, maintain family connections and well-being, and achieve educational, economic and civic participation goals.
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-RRS 5.01

An assessment-based service plan is developed in a timely manner with the full participation of the 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;
  5. pathways and potential barriers to economic self-sufficiency; and
  6. the individual’s or legal guardian’s signature, as appropriate.


The client should receive a copy or explanation of the signed service plan, sometimes called a service agreement, and other pertinent information. Other pertinent information can include, copies of, or information about, relevant policies, including the organization’s conflict of interest policy and use and protection of client information policy, to allay fears about providing information to service providers.


CA-RRS 5.02

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;
  3. provide referral for services it does not deliver and cannot address through cooperative arrangements;
  4. assist with access to the full array of services to which they are eligible; and
  5. mediate barriers to services within the service delivery system.


CA-RRS 5.03

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of the persons served, to assess: 
  1. service plan coordination and implementation; 
  2. progress toward achieving service goals and desired outcomes; and 
  3. the continuing appropriateness of agreed upon service goals.


When experienced workers conduct reviews of their own cases, the worker's supervisor reviews a sample of the worker's evaluations consistent with the requirements of the standard.


CA-RRS 5.04

The worker and the service recipient, and his or her family when appropriate:
  1. regularly review progress toward achievement of the agreed upon service goals; and 
  2. discuss and sign revisions to service goals and plans.