Department for Community Based Services

Standards of Practice Online Manual

23.1 Ongoing Case Planning

Cabinet for Health and Family Services

Department for Community Based Services
Division of Protection and Permanency
Standards of Practice Online Manual
Chapter 23-APS Ongoing Services and Case Planning
23.1 Ongoing Case Planning

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Legal Authority/Introduction


The SSW offers the adult the necessary protective or preventive services as identified in the adult assessment.  These services are based on the voluntary request for or acceptance of protective services by the adult in need of services, the voluntary request for services by a guardian on behalf of the adult or court ordered protective services, which are specified by the court and defined within the court order.

In order to provide the most comprehensive services to the adult, the SSW is encouraged to participate in local coordination efforts with community partners including, but not limited to local coordinating councils on domestic violence, local coordinating councils on elder maltreatment, multidisciplinary geriatric crisis response and intervention teams, adult fatality review teams or TRIAD's.  Participation will enhance interagency knowledge and cooperation thus enhancing the safety and stability of abused and/or neglected adults.


When providing ongoing case services to an adult the SSW:

  1. Ensures that the DCBS-1B Application for Services form is completed upon opening the case;
  2. Develops a case plan with the adult, caretaker and others as appropriate within thirty (30) calendar days after the approval of the investigative assessment;
  3. Develops the case plan only with the client if the adult chooses not to have a family member involved (i.e. alleged perpetrator); 1 
  4. Documents all identified ongoing services to be provided by the SSW as tasks in the family level objective (FLO) or individual level objective (ILO);
  5. Has personal contact with the adult on at least a monthly basis (every thirty (30) calendar days);
  6. Documents all contacts with the client or on behalf of the client within five (5) working days of the contacts in the case file and in the appropriate TWIST screens, as outlined in SOP 1.4 Documentation;
  7. Establishes with the adult the expectation of such contacts and documents such in the case plan;
  8. With consent of the adult may include the following people in case planning:
    1. Designated regional cabinet staff;
    2. Family members;
    3. Family friends;
    4. Community partners (i.e. medical providers, faith based organization members); or
    5. Other individuals requested by the adult;
  9. Signs the case plan along with the adult and others involved;
  10. Documents in the case record if the adult agrees to the case plan goals and objectives, but chooses not to sign the plan;
  11. Provides a copy of the DPP-154 Protection and Permanency Service Appeal to the victim;
  12. Provides a copy of the DPP-154 to the alleged perpetrator if they are requesting or being provided services;
  13. Must consider confidentiality as a significant concern, since inappropriate access to the case plan might cause risk to the victim.
  14. Updates the case plan every six (6) months or whenever a significant change occurs.

In cases of spouse/partner abuse the SSW:

  1. Addresses the first family level objective (FLO) as physical safety;
  2. Addresses specific behavior surrounding the abuse, neglect or exploitation as the first individual level objective (ILO) when the alleged perpetrator is involved in the case plan;
  3. Reassures the victim that it is their right to have services without designated others involved.


Approves all case plans.

Practice Guidance

  • Adults have the right to choose whom to involve in their individual case planning and should be encouraged to involve friends or family members who have the potential to be helpful in some way.
  • For voluntary cases the SSW identifies protective service needs to the adult based on the most recent adult assessment.
  • If the most recent adult assessment is over thirty (30) days old, a new assessmnet is required prior to the completion of the case plan.
  • Adult’s voluntarily accepting services have the right to self determination and   can decide, with the SSW, which goal and objectives to address in their case plan.
  • The case plan must contain at least one family level objective (FLO) based on the adult assessment.
  • The wording of the FLO is tailored to the adult's view of the problem and reflects their phrasing and terminology.
  • If the adult refuses to accept an FLO based on the highest risk identified on the adult assessment, but agrees to an FLO which is not identified as the highest risk, the case plan is based on the objectives the adult wishes to address.
  • Case plans may contain an individual level objective (ILO) if the adult agrees or chooses to address such individual issues.
  • The ILO addresses personal patterns of behavior that are preventing an individual from achieving the family developmental tasks; however, it is not required that APS case plans contain an ILO due to the voluntary nature of these cases.
  • Tasks are completed for every FLO and ILO established in the case plan to identify what the family, SSW or other parties involved in the case are to complete.
  • There must be at least one task for each objective identified.
  • Ongoing alternate care services provided by the SSW may include: 
    • Protective services referrals to community mental health centers, home health agencies and other resources for:
      • Counseling to help the resident and family members;
      • Adjusting to the placement;
      • Understanding grief and loss issues;
      • Understanding changes in social economic status;
      • Adjusting to loss of functional abilities; and
      • Alleviating conflict;
    • Assistance in budgeting the monthly personal allowance;
    • Explanation of DCBS service responsibility;
    • Education on the aging process and methods for dealing with special needs and behaviors;
    • Assistance in securing information about proper nutrition, medical services, budgeting, and recreational activities;
    • Assistance in arranging special health services;
    • Assistance in arranging transportation for medical and social activities; and
    • Assistance in securing volunteers or community organizations for social activities, outings or other supportive services in the facility.


  1. In those circumstances the excluded person is not included as part of the FLO or ILO and should not sign the case plan.


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