2024 Edition

Housing Stabilization and Community Living Services Definition

Purpose

Individuals and families that use Housing Stabilization and Community Living Services obtain and maintain stable housing in the community, strengthen personal support systems and resources, and enhance life skills and functioning in order to improve overall well-being and live as independently as possible.

Definition

Housing Stabilization and Community Living Services provide temporary or permanent services such as service-enhanced housing, assistance securing safe and stable housing in the community, and supportive services to encourage maximum independence for persons who do not need 24-hour care.

Housing services can be delivered according to a scattered-site housing model, which provides services to individuals and families in individual apartments in multiple locations, or a single-site model, where housing units/apartments/beds are located within the same building or a group of buildings. COA's Housing Stabilization and Community Living Services standards include the following program models: 

Homelessness Prevention programs provide housing identification/relocation and stabilization services (e.g., case management, employment services, counseling, health services, etc.), as well as short- and medium-term rental assistance for individuals and families at imminent risk of becoming homeless. 

Rapid Re-Housing programs help individuals and families exit homelessness and immediately return to permanent housing through move-in and rental assistance. Core program components include: housing identification services, time-limited financial assistance, and case management and supportive services based on individual and family needs. 

Permanent Supportive Housing programs provide long-term affordable housing with ongoing services for individuals and families with high levels of need, including individuals and families experiencing chronic homelessness and those who have a substance use disorder, serious mental illness, intellectual or developmental disability, and/or chronic physical illness or disability.

Recovery Housing provides individuals in recovery with a safe, home-like environment that is free of alcohol and illicit drugs, where they can receive peer support from fellow residents and access additional services, when desired, to promote recovery and prevent relapse. When licensed, clinical staff are providing services directly within the program, recovery homes will be reviewed under Group Living Services (GLS). Recovery housing reviewed under GLS offers 24/7 supervision by paid staff, 24/7 medical oversight of the program by a physician or other qualified medical provider, and 24/7 on-call coverage by clinical personnel. It also tends to be time-limited with residents working towards achieving identified recovery goals and then transitioning to a lower level of support. All other recovery homes will be reviewed under Housing Stabilization and Community Living Services (HSCL).

Single-room Occupancy (SRO) programs provide single-room dwelling units for one individual, and may contain either private or shared food preparation and/or sanitary facilities. SROs serve individuals at risk of or experiencing homelessness, and provide connections to supportive services.

Note:An agency that provides mental health services, employment or vocational services, or child care services as part of its Housing Stabilization and Community Living Services will complete the appropriate service section in addition to the Housing Stabilization and Community Living Services standards.


Note:Though the term “human trafficking” is used throughout this section, there are additional terms that may be utilized, including sex trafficking, commercial sexual exploitation of children (CSEC), domestic minor sex trafficking, and minor prostitution. The term “victim” is commonly used when referring to individuals who have been trafficked to emphasize that they have been coerced and exploited, though the term “survivor” may also be used.


Note:Please see PA-HSCL Reference List for the research that informed the development of these standards.


Note:For information about changes made in the 2020 Edition, please see the HSCL Crosswalk.

2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 1: Person-Centered Logic Model

The agency implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard.  

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, agency, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered); 
  5. desired outcomes (i.e. the changes you expect to see in individuals and families); and
  6. expected long-term impact on the agency, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA Accreditation’s PQI Tool Kit for more information on developing and using program logic models.


Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 

  1. needs assessments and periodic reassessments; 
  2. risks assessments conducted for specific interventions; and
  3. the best available evidence of service effectiveness.
 

PA-HSCL 1.02

The logic model identifies individual and/or family outcomes in at least two of the following areas:
  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

Examples: Common resident outcomes for recovery housing include:

  1. housing stability;
  2. decreased alcohol and illicit drug use;
  3. lower rates of criminal justice involvement;
  4. increased income;
  5. increased employment over time;
  6. improved psychological and emotional well-being;
  7. increased social connectedness; and
  8. improved family functioning.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of individuals and families.
Interpretation: Competency can be demonstrated through education, training, or experience, including lived experience when applicable. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 2.01

Personnel providing case management are qualified by:
  1. a bachelor’s degree in social work or a comparable human service field; or 
  2. at least five years of direct care experience in human services.
NA The agency only provides recovery housing. 
 

PA-HSCL 2.02

Supervisors are qualified by:
  1. an advanced degree in social work or comparable human service field and at least two years of direct experience in service delivery; or
  2. a bachelor’s degree in social work or comparable human service field and four years of direct experience in service delivery.
Interpretation: Appropriate experience and specialized training can compensate for a lack of a bachelor’s degree depending on the program design. For example, in peer-run programs, number of years providing peer support services, in addition to formal trainings and/or certifications, is more critical than level of academic degree.
NA The agency only provides homeless prevention and rapid re-housing services.
 

PA-HSCL 2.03

When clinical services are provided on-site, experienced personnel with an advanced degree in social work, psychology, counseling, psychiatry, psychiatric nursing, or other human services, provide: 
  1. case supervision or case consultation;
  2. overall guidance to the program; and
  3. training of direct service and supervisory personnel.
NA Program personnel do not provide clinical services.
 

PA-HSCL 2.04

Personnel who provide peer support:
  1. obtain certification, as defined by their state;
  2. are willing to share their personal recovery stories;
  3. have a job description and clearly understand the role of a peer support worker; and
  4. have adequate support and appropriate supervision, including mentoring and/or coaching from more experienced peers when indicated.
NA The agency does not provide peer support services.

Examples: Peer support staff can have many different job titles that include, but are not limited to, peer support specialist, peer support provider, recovery support specialist, or peer navigator. 
 

PA-HSCL 2.05

Personnel who provide peer support are trained on, or demonstrate competency in:
  1. how to recognize the need for more intensive services and make an appropriate linkage;
  2. established ethical guidelines, including setting appropriate boundaries and protecting confidentiality and privacy;
  3. wellness support methods, trauma-informed care practices, and recovery resources;
  4. managing personal triggers that may occur during the course of their role as a peer support provider; and
  5. skills, concepts, and philosophies related to recovery and peer support.
NA The agency does not provide peer support services.
 

PA-HSCL 2.06

All direct service personnel are trained on, or demonstrate competency in: 
  1. understanding stigma and labeling;
  2. harm reduction; 
  3. recognizing and responding to signs of suicide risk; and
  4. understanding homelessness, including the causes and effects of homelessness, overrepresented and vulnerable populations, impact of homelessness on child development, barriers to exiting homelessness, and service needs.
Interpretation: Personnel that provide homelessness prevention and rapid re-housing services should be trained on or demonstrate competency in the core principles of the program model, including Housing First, rapid re-housing, crisis response, case work, and case coordination.
 

PA-HSCL 2.07

All direct service personnel are trained on, or demonstrate competency in, the special service needs of individuals, including, as appropriate:
  1. individuals coping with substance use and/or mental health issues, including dual diagnosis;
  2. individuals coping with trauma, including how to recognize trauma and appropriate interventions for addressing the acute needs of trauma victims;
  3. individuals with HIV/AIDS;
  4. individuals who identify as lesbian, gay, bisexual, transgender, or gender non-conforming;
  5. individuals who may be the victims of human trafficking or sexual exploitation, including how to identify potential victims;
  6. individuals and families experiencing or at risk of homelessness;
  7. pregnant and parenting mothers and/or fathers with young children;
  8. persons with current or past criminal justice system involvement;
  9. persons with current or past child welfare system involvement;
  10. persons with intellectual and developmental disabilities; and
  11. older adults.
 

PA-HSCL 2.08

Case managers are trained on, or demonstrate competency in:
  1. basic counseling skills;
  2. conducting housing searches;
  3. landlord engagement;
  4. issues related to individuals and families involved with multiple systems;
  5. conducting home visits, including identifying and responding to potential lease issues, as appropriate; and
  6. helping individuals live in the community or transition to independent living.
NA The agency only provides recovery housing.
 

PA-HSCL 2.09

Recovery housing personnel are trained on, or demonstrate competency in:
  1. medication assisted recovery and applicable policies and procedures;
  2. how to identify and report unethical practices including patient brokering or excessive confirmation testing; and
  3. emphasizing peer support and experiential learning in recovery.
Related Standards:
NA The agency does not provide recovery housing.
 

PA-HSCL 2.10

The agency minimizes the number of workers assigned to persons served over the course of their contact with the agency by:
  1. assigning a worker at intake or early in the contact; and
  2. avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
Interpretation: One of the most important aspects of care for victims of human trafficking and other forms of trauma is to be able to develop a consistent, trusting relationship with one staff person who serves as the central coordinator for the full myriad of needed services.
 

PA-HSCL 2.11

Caseloads support the achievement of client outcomes, are regularly reviewed, and generally do not exceed:
  1. 15-18 cases for each direct service provider responsible for counseling services;
  2. 20-30 cases for each direct service provider responsible for case coordination or service navigation; or
  3. an appropriate mix of the above.

Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; 
  3. individuals' needs, service goals, and timelines;
  4. the service model used; and
  5. service volume.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 3: Intake and Assessment

The agency's intake and assessment practices ensure that individuals and families served receive prompt and responsive access to appropriate services.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 3.01

Individuals and families participate in an intake screening within 24 hours of admission and receive information about:
  1. how well their request matches the agency's services; and
  2. what services will be available and when.
Interpretation: For homelessness prevention and rapid re-housing programs, screening is often a collaborative process that occurs within the broader homelessness crisis response system (which may also be known as a Coordinated Entry Process or a Centralized or Coordinated Assessment System). Homelessness prevention and rapid re-housing programs should provide procedural or documentary evidence that demonstrates their role in the screening process.

Interpretation: Matching individuals in recovery to a recovery house that will meet their needs is critical to ensuring resident safety. While this determination will sometimes be made by the referring provider, agencies should have procedures in place to ensure an appropriate match has been made prior to the individual moving in. Individual needs, preferences, and expectations should be considered when assessing the appropriateness of the living arrangement including, but not limited to:
  1. intensity of recovery supports needed or desired (e.g. availability of certified peer specialists, staff qualifications, etc.);
  2. any special needs (e.g. co-occurring mental health diagnoses, mothers with children, veterans, etc.);
  3. geographic preferences;
  4. transportation availability;
  5. chosen recovery pathway (e.g. medication assisted recovery, AA, etc.);
  6. level of medication assisted recovery support needed or desired (e.g. do others in medication-assisted recovery live in the home); and
  7. time in recovery.
Generally, recovery housing should be low barrier, but when it is determined that the recovery home is not going to meet the support needs of the individual, linkages to a more appropriate provider should be offered.
NA Another agency is responsible for screening, as defined in a contract.

Examples: Agencies may collaborate through their community's coordinated entry processes, if available. Coordinated entry provides equal, nondiscriminatory access to appropriate services regardless of where people present for assistance, and connects them to all available community programs and services, as appropriate. Coordinated entry processes provide access to providers delivering a wide range of services, including both homeless-specific programs and services for the general population. Examples include shelters for domestic violence survivors, runaway and homeless youth programs, street outreach services, homelessness prevention programs, emergency shelters, transitional housing, permanent supportive housing, rapid re-housing, programs for veterans, LGBTQ-affirming services and supports, providers of mainstream benefits and services, health and mental health clinics, employment services, and child development programs.
 
Fundamental Practice

PA-HSCL 3.02

Prompt, responsive intake practices:
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. are trauma-informed;
  3. are non-stigmatizing and non-judgmental;
  4. are culturally and linguistically responsive;
  5. give priority to urgent needs and emergency situations;
  6. support timely initiation of services; and
  7. provide placement on a waiting list or linkages to appropriate resources when individuals cannot be served or cannot be served promptly.
Interpretation: To ensure that people who identify as transgender and gender non-conforming are treated with respect and feel safe, service recipient choice regarding their first names and pronouns should be respected and intake forms and procedures should allow individuals to self-identify their gender and receive access to sleeping quarters, bathroom facilities, and shower facilities in accordance with applicable federal and state laws.

Interpretation: Trauma-informed intake practices explore whether a service recipient has been exposed to traumatic events and exhibits trauma-related symptoms and/or mental health disorders. A positive screen indicates that an assessment or further evaluation is warranted. During the screening process, persons served should feel emotionally and physically safe.

Interpretation: Homelessness prevention and rapid re-housing programs should develop screening and intake processes that promote acceptance regardless of income or housing barriers, and implement prioritization criteria when requests for assistance exceed program capacity. Intake should also reflect a Housing First philosophy to ensure that persons are accepted into the program without preconditions.

Examples: Agencies can respond to identified suicide risk by connecting the individual to more intensive services; facilitating the development of a safety and/or crisis plan; or contacting emergency responders, 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotlines, as appropriate.
 
Fundamental Practice

PA-HSCL 3.03

Children and youth receive an age-appropriate intake screening that includes: 
  1. personal and identifying information;
  2. health status, including emergency health needs; and
  3. education status, including enrollment in early childhood education or school.
NA The agency does not serve children and youth.

NA Another agency is responsible for screening, as defined in a contract.
 

PA-HSCL 3.04

Individuals and families participate in an individualized, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes; 
  2. updated as needed based on their needs; and
  3. focused on information pertinent for meeting service requests and objectives.

Interpretation:For programs providing homelessness prevention and rapid re-housing services, information gathered through assessment should focus on the individual’s immediate housing crisis and target the person’s goals, strengths and barriers as they relate directly to obtaining or maintaining housing. Service objectives should be directly related to resolving the housing crisis as quickly as possible.


Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

 

PA-HSCL 3.05

A comprehensive assessment includes, as appropriate:
  1. employment history;
  2. mainstream benefits history;
  3. housing history for the past five years;
  4. housing barriers;
  5. housing goals and preferences;
  6. veteran status;
  7. level of education and education goals;
  8. income and resources;
  9. substance use history;
  10. mental health history, diagnoses, and medications;
  11. intellectual or developmental disability status and history;
  12. family functioning, parental stress, and parenting skills;
  13. a social network inventory, including relationships with family, friends, and/or significant others;
  14. history of childhood victimization and trauma; and
  15. history of adult victimization, including domestic violence and sexual abuse.
Interpretation: Personnel that conduct assessments should be aware of the indicators of a potential trafficking victim, including, but not limited to:
  1. evidence of mental, physical, or sexual abuse; 
  2. physical exhaustion; 
  3. working long hours; 
  4. living with employer or many people in confined area; 
  5. unclear family relationships; 
  6. heightened sense of fear or distrust of authority; 
  7. presence of older male boyfriend or pimp; 
  8. loyalty or positive feelings towards an abuser; 
  9. inability or fear of making eye contact; 
  10. chronic running away or homelessness; 
  11. possession of excess amounts of cash or hotel keys; and 
  12. inability to provide a local address or information about parents. 
Several tools are available to help identify a potential victim of trafficking and determine next steps toward an appropriate course of treatment. Examples of these tools include, but are not limited to, the Rapid Screening Tool for Child Trafficking and the Comprehensive Screening and Safety Tool for Child Trafficking.

Interpretation: In recovery housing, assessments should be driven by the resident and focused on their barriers to recovery, unmet service needs, and strengths and resources. 
 

PA-HSCL 3.06

Children and youth receive a comprehensive, age-appropriate assessment that: 
  1. identifies cognitive, language, motor, behavioral, and social-emotional development needs including those that may require formal screening or evaluation; and 
  2. takes into account involvement in education, child welfare, and/or juvenile justice systems.
Interpretation: To help decrease family rejection and increase family support for youth who identify as LGBTQ, the assessment should include a network inventory of family relationships, experiences with family rejection, capacity for increasing family acceptance and support, and specific culturally appropriate education and guidance.
NA The agency does not serve children and youth.
 

PA-HSCL 3.07

The agency facilitates access to the continuum of services through active collaboration with community resources.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 4: Service Planning and Monitoring

Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 4.01

An assessment-based service plan is developed in a timely manner with the full participation of the individual, 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 signature of persons served.
Interpretation: In the context of homelessness prevention and rapid re-housing programs, service plans should focus on the achievement of housing-specific goals in the shortest amount of time possible and practical, and address barriers to housing retention.

Interpretation: In recovery housing, recovery planning should be driven by the resident and focused on their recovery barriers, service needs, strengths, and resources. Outcome measures of recovery capital that can be the focus of a strengths-based recovery plan include the person’s percieved level of satisfaction or well being as well as measures of personal, social, and community capital including physical health, housing, engagment in meaningful activities, and the presence of social supports.

Unmet service needs can slow the growth of positive recovery capital for individuals in recovery. Examples of common service needs among residents in recovery homes include:
  1. mental health; 
  2. substance use;
  3. legal, including criminal record expungement services;
  4. crisis intervention;
  5. primary care and dentistry;
  6. education and vocational skill development; and/or
  7. housing.
 

PA-HSCL 4.02

The agency works in active partnership with individuals and families to:
  1. assume a service coordination role, as appropriate, when the need has been identified and no other agency 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.
 

PA-HSCL 4.03

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

Interpretation: Quarterly case reviews may not be appropriate in shorter term housing when services are only provided for a few months. In these cases, reviews should be conducted more frequently to confirm progress and the continued appropriateness of the service plan.
 

PA-HSCL 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.
Interpretation: When working with individuals in recovery, the frequency of reviews will vary based on the wishes of the individual and the level of recovery support being provided. For example, individuals new to recovery may have daily meetings with staff to discuss progress, while those with more time in recovery may meet with staff monthly.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 5: Service Components

The agency provides services or supports that meet the immediate needs and wishes of the person and encourage the development of personal support systems, strengths, resources, and independence in community-based, safe, minimally intrusive, and accessible housing.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 5.01

Services are provided in settings that are readily accessible to public transportation, shopping, and community-based services and resources.
 

PA-HSCL 5.02

The agency considers the unique characteristics, needs, and preferences of individuals when grouping people together.

Interpretation: Characteristics and needs that should be considered can include the number of individuals grouped together, age, necessary accommodations, gender, gender identity, and gender expression. Transgender and gender non-conforming people should be given access to sleeping quarters, bathroom facilities, and services based on their preferences and in accordance with applicable federal and state laws.

NA The agency only provides homelessness prevention and rapid re-housing services and does not offer housing services directly to persons served.

Examples: Examples of ways that agencies can meet the grouping needs of transgender and gender non-conforming people can include, but are not limited to:

  1. respecting the individual’s name and pronouns; 
  2. providing gender neutral restrooms where facility structure allows;
  3. having residents use restrooms one at a time;
  4. allowing for single bedroom models; or 
  5. providing LGBTQ+ specific units.
 

PA-HSCL 5.03

Housing services include:
  1. information about community housing options;
  2. assistance obtaining a safe, stable living environment, including housing search support;
  3. assistance applying for rental subsidy or other financial aid programs;
  4. education on tenant rights and responsibilities;
  5. a process to alert service staff when an individuals' rent is overdue and to help prevent rent arrears from mounting; and
  6. tenancy supports.
NA The service population is limited to children and youth for whom living independently is not an option.

Examples: Tenancy supports can help individuals resolve past housing barriers and current housing crises, and avoid accumulating new barriers (e.g. evictions or lease violations). Tenancy supports can assist individuals in understanding the requirements of their lease, budgeting, basic landlord-tenant rights and responsibilities, and conflict avoidance or resolution.
 

PA-HSCL 5.04

The agency provides case management and services that are tailored to the needs and preferences of the individual.
Interpretation: In rapid re-housing programs, persons served should choose when, where, and how often case management meetings occur. Services should be delivered either in the home or in a location of their choosing whenever possible.

Interpretation: Professional case management services may not be provided directly by recovery homes, but residents should receive service navigation and coordination support from staff as appropriate to the needs and preferences of the individual. 
 

PA-HSCL 5.05

The agency encourages social and community integration, independence, and/or housing stability through the development of life skills necessary to:
  1. perform activities of daily living;
  2. manage a household;
  3. manage finances including credit and debt counseling when needed;
  4. maintain personal safety;
  5. access community resources;
  6. pursue educational, occupational, and volunteer opportunities and mainstream benefits;
  7. participate in recreational activities and/or hobbies;
  8. reduce risk-taking behaviors, including practice with decision making and anger management; and
  9. communicate effectively and avoid or resolve conflicts
NA The service population is limited to children and youth for whom living independently is not an option.
 
Fundamental Practice

PA-HSCL 5.06

Health services, provided directly or through referral, include:
  1. routine medical and dental care;
  2. clinical services, including substance use and mental health services;
  3. medication management and/or monitoring;
  4. medical respite care services;
  5. developmentally appropriate information regarding topics including pregnancy prevention, family planning, safe and healthy relationships, and prevention of HIV/AIDS and sexually transmitted diseases; and
  6. harm reduction that aims to prevent behaviors that can have negative outcomes and/or reduce the negative outcomes associated with that behavior.
Interpretation: When an agency does not provide linkages to family planning services because doing so is counter to its mission or beliefs, the agency should disclose this fact and provide individuals with a list of other community providers that offer pregnancy support and education services.

Interpretation: People who identify as transgender may need assistance accessing specialized medical services and should be referred to appropriate providers in the community, as needed.

Examples: Regarding element (f), interventions and goals may vary depending on the behavior that is targeted and the population served, for example preventing pregnancy among youth or reducing harm from continued substance use among adults.
 

PA-HSCL 5.07

Supportive services include, as needed:
  1. crisis intervention;
  2. transportation;
  3. legal assistance;
  4. case advocacy;
  5. parent education and family support;
  6. mainstream benefits enrollment;
  7. help with basic literacy;
  8. help with basic computer literacy; 
  9. educational services, including G.E.D. preparation;
  10. child care; and
  11. social, cultural, recreational, and religious/spiritual activities.
 

PA-HSCL 5.08

Employment and vocational support includes helping individuals:
  1. develop the habits, skills, and self-awareness essential to employability;
  2. write resumes, complete job applications, and prepare for interviews; 
  3. find and access local employment resources and placement options, including on-the-job training;
  4. secure childcare while attending interviews; and
  5. travel to interviews and places of employment.
NA The agency only provides homelessness prevention and rapid re-housing services and does not offer employment and vocational support to persons served.
 

PA-HSCL 5.09

The agency provides time-limited financial assistance to subsidize housing costs.
NA The agency does not provide financial assistance.

Examples: Financial assistance may cover costs such as:
  1. relocation or moving costs; 
  2. security deposits; 
  3. rent payments; 
  4. utility deposits and/or payments; or
  5. other barriers to housing, such as child care or transportation.
 

PA-HSCL 5.10

The agency establishes strategies for recruiting and retaining landlords in order to maximize housing options for people with tenant screening barriers.
Interpretation: Landlord participation is an essential component to rapid re-housing. Agencies utilizing this model should address potential barriers to landlord recruitment and retention by promoting landlord supports - the incentives offered to landlords for renting to persons served -- including: response to landlord concerns about lease adherence or complaints from other tenants; tenant-landlord mediation; home-based case management; and time-limited financial assistance for move-in costs and rent payments.

NA The agency does not need to recruit landlords because it owns, leases, or manages all of its own housing options.


NA The agency only provides recovery housing.

2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 6: Services for Pregnant and Parenting Families

The agency provides services, either directly or by referral, which support child development and family functioning in a child-friendly and safe environment.
NA The agency does not serve pregnant individuals or families with children.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 6.01

Agencies that serve families house families as a unit and keep sibling or family groups together, when possible.
NA The program does not serve family units, or housing families as a unit is not possible or prohibited by law.

Examples: Allowing families to follow their schedules, routines, and rituals to the greatest extent possible can support family functioning, encourage stability, and minimize stress. 
 

PA-HSCL 6.02

The agency evaluates the educational status and needs of children and youth, and: 
  1. informs youth and parents of their educational rights;
  2. connects children ages 0-5 with early childhood learning programs;
  3. help parents coordinate educational services with relevant school districts;
  4. assists high school students with Free Application for Federal Student Aid and college applications; and
  5. helps children and youth stay current with the curricula.
NA The agency does not serve families with children.

Examples: Agencies can help students stay current with their curricula by, for example, providing time and space for quiet reading and studying or offering assistance with school assignments.
 

PA-HSCL 6.03

The agency meets the developmental needs of children and youth by: 
  1. facilitating connections to early intervention and trauma-specific services, as necessary;
  2. informing parents of age-appropriate developmental milestones; and
  3. sharing age- and developmentally-appropriate parenting skills and techniques with parents.
NA The agency does not serve families with children.
 

PA-HSCL 6.04

When serving families with children the agency provides or arranges for recreational and educational activities that:
  1. are appropriate to children’s ages, developmental levels, and cultures;
  2. encourage play and physical activity; and
  3. are provided in safe, childproofed indoor and outdoor environments.
Interpretation: All toys and equipment must be installed and used according to the manufacturer’s instructions, meet all applicable safety standards, and be appropriate to the children’s ages and developmental levels.
 
Interpretation: Activities should be sensitive to the special needs and self-identities of children and youth.
NA The agency does not serve families with children.

NA The agency only provides homelessness prevention and rapid re-housing services.

Examples: Examples of toys and equipment include: sensory materials, books in the languages spoken by children and youth, art materials, sorting/stacking toys, and gross-motor equipment.
 
Fundamental Practice

PA-HSCL 6.05

Pregnant individuals are provided or linked with specialized services that include, as appropriate: 
  1. pregnancy counseling;
  2. prenatal health care;
  3. genetic risk identification and counseling services;
  4. fetal alcohol syndrome screening;
  5. labor and delivery services;
  6. postpartum care;
  7. mental health care, including information, screening, and treatment for prenatal and postpartum depression;
  8. pediatric health care, including well-baby visits and immunizations;
  9. peer counseling services; and
  10. children’s health insurance programs.
Interpretation: Young people may need more intensive services that are developmentally appropriate for adolescence and early adulthood.
NA The agency does not serve pregnant individuals.
 

PA-HSCL 6.06

The agency provides or refers pregnant and parenting residents to parent education classes or workshops that address:
  1. basic caregiving routines;
  2. child growth and development;
  3. meeting children’s social, emotional, and physical health needs;
  4. environmental safety and injury prevention;
  5. parent-child interactions and bonding;
  6. age-appropriate behavioral expectations and appropriate discipline; 
  7. family planning; and 
  8. establishing a functioning support network of family members or caring adults.
Interpretation: When an agency does not provide linkages to family planning services because doing so is counter to its mission or beliefs, the agency should disclose this fact and provide individuals with a list of other community providers that offer pregnancy support and education services.

Examples: Agencies can tailor how topics are addressed based on the needs of individuals and families. For example, when serving expectant parents or parents of young children, education on environmental safety and injury prevention will typically address topics such as safe practices for sleeping and bathing.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 7: The Rights of Persons Served

The agency respects the rights, dignity, and values of persons served.
NA The agency does not own, lease, or manage any apartments or other community living arrangements.

NA The agency only provides homelessness prevention and rapid re-housing services.
Related Standards:

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 7.01

Individuals are notified in writing of:
  1. items that are discouraged or prohibited; and
  2. any safety procedures the program follows, or consequences that can result, when prohibited items are brought to the residence.
 
Fundamental Practice

PA-HSCL 7.02

Acceptance procedures include:
  1. fair and objective selection criteria; and
  2. written notification regarding reasons for non-acceptance.
 

PA-HSCL 7.03

Persons served are given the opportunity for meaningful voice and choice in program activities and governance including:
  1. participating in the development and enforcement of program rules;
  2. contributing to programming design and decision making; and
  3. sharing feedback including dissatisfaction with aspects of the program.
Interpretation: The agency should have mechanisms in place to receive and respond to resident feedback to ensure their contributions are meaningful. Residents should be informed of how the agency will use their feedback and be made aware of any changes that were made in response to their input.

Examples: The establishment of resident councils is one way to involve individuals in decisions and program design and ensure that they have an opportunity to provide feedback on staff, activities, rules, their overall experience, sense of safety and support, and the living environment.
 

PA-HSCL 7.04

Individuals are permitted to have guests, including overnight guests, as appropriate to the population and type of living situation, and are informed of the guest policy including their responsibility for the behavior of their guests.
 

Examples: In a recovery home, overnight guests may not be permitted or may be limited to the young children of residents.
 
Fundamental Practice

PA-HSCL 7.05

Individuals are notified in writing about circumstances that permit maintenance personnel to enter a room or apartment without the occupant's permission, and receive at least 24-hours’ notice when access is required in non-emergency situations.
 
Fundamental Practice

PA-HSCL 7.06

Searches of a resident’s property are conducted in a trauma-informed manner that respects their rights, dignity, and self-determination and include, as appropriate to the frequency and invasiveness of searches:
  1. communicating policies for searches to residents in writing;
  2. definition and documentation of reasonable cause and assessed risk of harm to self or others;
  3. trained staff; and
  4. an administrative review process including documentation, notification, and the timetable for review.
 
Fundamental Practice

PA-HSCL 7.07

Written policies and procedures regarding eviction and discharge:
  1. are provided at intake;
  2. are clear and simple, avoiding overly rigid and bureaucratic language and rules;
  3. define specific behaviors, conditions, or circumstances that may result in eviction and discharge;
  4. include timely due process provisions; and
  5. describe the conditions or process for re-admittance.
Interpretation: Eviction should be rare and avoided whenever possible.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 8: Recovery Homes

The recovery home provides a safe, supportive, home-like environment that is free of alcohol and illicit drugs. 
NA The agency does not operate recovery housing.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-HSCL 8.01

Indoor and outdoor areas of the recovery home are clean, maintained in good condition, and promote the health and safety of personnel and residents.
 

PA-HSCL 8.02

Recovery homes include:
  1. space to accommodate individual, small, and large group activities;
  2. a common room, dining and/or kitchen area, and space for indoor recreation;
  3. adequately and attractively furnished rooms with a separate bed for each resident, including a clean, comfortable, covered mattress; pillow; and sufficient linens and blankets; 
  4. a non-stacking crib for each infant and toddler that is 24 months or younger that meets safety guidelines, as applicable; 
  5. a sufficient number of private facilities for bathing, toileting, and personal hygiene, that are developmentally appropriate;
  6. access to a telephone, computer, and the internet as permitted, for use by residents and personnel; 
  7. access to laundry facilities;
  8. private areas where residents can meet with family and friends; and
  9. a safe place such as a locker to keep personal belongings and valuables.

Examples: The Consumer Product Safety Commission (CPSC) provides standards to ensure safety for full-size and non-full size cribs.
 

PA-HSCL 8.03

Residents participate actively in:
  1. decorating and personalizing their sleeping area;
  2. food preparation and meal planning; and
  3. contributing to decisions about how to make living areas inviting, comfortable, and reflective of their interests and diversity.
 
Fundamental Practice

PA-HSCL 8.04

The recovery home maintains a supply of opioid overdose reversal medication on-site. 
 

PA-HSCL 8.05

Procedures for drug testing include:
  1. collection procedures including whether collection is observed;
  2. timing and frequency of testing including initial testing; ongoing, random point-of-care testing; and confirmation testing when indicated;
  3. potential out-of-pocket costs to the resident;
  4. how test results from outside providers may be used, with resident consent, to reduce the number of tests conducted at the home; and
  5. what will happen if tests come back positive.
Related Standards:
Interpretation: Tests that go beyond what is needed to protect the safety of the resident and the resident’s house mates are unethical and should be avoided. Conversely, increases in drug use or an increase in overdoses may be an indicator that not enough testing is being done. Testing that goes beyond an agency’s own established guidelines should trigger an internal ethics review to determine whether more frequent testing is justified.
 

PA-HSCL 8.06

Policy and procedures regarding relapse:
  1. are designed to protect the health and well-being of the individual and the rest of the residents in the recovery house;
  2. define what protections are in place to prevent relapse;
  3. outline what will happen if relapse occurs;
  4. include timely due process provisions; and
  5. describe the conditions or process for re-admittance if separation from the home is necessary.
Related Standards:
Interpretation: Because research shows that relapse management and support can be central to preventing homelessness, when separation from the home is necessary, the resident should receive information on other providers or programs in the community that may better meet their treatment and support needs. In some cases, programs may hold the bed for a designated period of time while the inidvidual seeks treatment.

Note: See PA-HSCL 7.08 for more information on eviction/discharge.
 

PA-HSCL 8.07

Individuals are offered opportunities to:
  1. participate in and contribute to the recovery community, including giving and receiving peer support; 
  2. engage with and contribute to the local community; and
  3. develop and enhance positive personal and interpersonal skills and behaviors. 

Examples: In regard to element b, ways that residents can contribute to the local community can include school, work, volunteering, and recreation.
 

PA-HSCL 8.08

Individuals, and their families when possible and appropriate, are:
  1. helped to develop social support networks and build healthy, meaningful relationships with caring individuals of their choosing; and
  2. actively connected with self-help/mutual aid groups when desired and appropriate to their request or need for service.
Interpretation: Connections to outside self-help/mutual aid groups should not be limited to providing the time and location for a meeting. Agencies can support the individual’s acclimation to a new group by, for example, discussing meeting protocols and what to expect prior to attending, accompanying them to their first meeting, and encouraging them to make connections with peers while at the meeting.

Examples: Caring individuals may include mentors, community members, friends, classmates, peers, sponsors, siblings, cousins, grandparents, former foster parents, and extended family members.
 

PA-HSCL 8.09

When the organization offers employment to residents, agency policy:
  1. ensures residents are matched with jobs that reflect their goals and interests;
  2. maximizes resident choice, and does not mandate participation; and
  3. prohibits resident exploitation.
Related Standards:
NA The agency does not offer employment opportunities to residents.
2024 Edition

Housing Stabilization and Community Living Services (PA-HSCL) 9: Case Closing and Aftercare

The agency works with persons served and family members, when appropriate, to plan for case closing and, when possible, to develop aftercare plans.
NA The agency provides permanent supportive housing.

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VIEW THE STANDARDS

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-HSCL 9.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of responsibility;
  2. begins at intake; and
  3. involves the worker, persons served, and others, as appropriate to the needs and wishes of the individual or family. 

Examples: In recovery housing, planning for separation early on, before an issue arises, can help ensure individuals have a safe place to go if they must leave the program unexpectedly.
 

PA-HSCL 9.02

Upon case closing, the agency notifies any collaborating service providers, as appropriate.
 

PA-HSCL 9.03

If an individual has to leave the program unexpectedly, the agency makes every effort to identify other service options and link the person with appropriate services.
Interpretation: The agency must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.

Interpretation: To promote safety, recovery housing residents who must be separated from the home should be linked with other housing and/or treatment options that will better fit their service needs and goals. 
 

PA-HSCL 9.04

When appropriate, the agency works with persons served and their family to:
  1. develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and goals and facilitates the initiation or continuation of needed supports and services; or
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.
Interpretation: Case managers in rapid re-housing programs should: 
  1. ensure that all needed referrals have been made;
  2. share information on available community assistance;
  3. provide a “warm handoff” and follow-up for referrals made; and
  4. explain how to access assistance from the program again, if needed.
 

PA-HSCL 9.05

The agency follows up on the aftercare plan, as appropriate, when possible, and with the permission of persons served.
NA The agency has an interagency agreement that does not include aftercare planning or follow-up.

NA The agency only provides homelessness prevention and rapid re-housing services.

Examples: Reasons why follow-up may not be appropriate include, but are not limited to, cases where the person's participation is involuntary, or where there may be a risk to the individual such as in cases of domestic violence.
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