LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 106.17 Policy Development, Review, Approval, and Distribution
 
  PROCEDURES
  1. Policy Organization
     
    1. Policies are organized by policy group and subject on the Los Angeles County Department of Mental Health (DMH) Policies and Procedures Website.
       
  2. Policy Development and Revision
     
    1. All policies and procedures shall be written as outlined in the DMH Policy Template and DMH Procedures Template.
       
    2. Discipline Chiefs or responsible party shall assign subject matter experts to complete the task of drafting new or revising existing policy and procedures.
       
    3. Assigned subject matter experts are responsible to:
       
      1. Review best practices and current statutory and regulatory requirements in developing new or revising existing policies and procedures;
         
      2. Determine the areas/parties affected by the policy and procedures; and
         
      3. Specify if the policies and procedures are applicable to:
         
        1. Directly-operated programs or
        2. Directly-operated and contracted agencies.
           
          • Policies with an assigned Directly-operated programs and contracted agencies distribution level shall include a statement in the Policy Statement section that contracted agencies/legal entities shall develop their own internal version of policies and procedures consistent with the contractor’s organizational practices and meet the requirements set forth in this policy.
             
  3. Policy review and approval following completion of draft policies and procedures. The responsible party and subject matter experts shall forward the completed drafts to Compliance, Privacy, and Audit Services (CPAS) for final review, editing, formatting, and coordination of review meetings with appropriate parties. 
     
    1. CPAS Responsibilities:
       
      1. Receive draft policies and procedures from the responsible party or designee;
         
      2. Finalize formatting for formal presentation, including assigning policy numbers, verifying logos, and ensuring complete headers (draft policies and procedures need not be fully formatted when submitted to CPAS for review);
         
      3. Review draft policies and procedures to ensure there are no typographical or grammatical errors;
         
      4. Coordinate editing changes with the responsible party to support the completion process;
         
      5. Ensure County Counsel reviews policies and procedures as needed;
         
      6. Ensure DMH Human Resources (DMH-HR) reviews policies and procedures as needed; and
         
        1. DMH-HR shall advise CPAS which policies and procedures are subject to union consultation.
           
      7. Forward completed draft policies and procedures to Discipline Chiefs for final review and signature.
         
    2. DMH-HR Responsibilities
       
      1. DMH-HR shall provide copies of new/revised draft policies and procedures to union representatives and coordinate a timely consultation process. If no feedback or request for a meeting is provided to DMH-HR by the union(s), draft policies and procedures shall continue the review/approval process.
         
      2. DMH-HR shall provide copies of new/revised draft policies and procedures to unions.
         
        1. Final draft policies and procedures shall be sent to the union(s) prior to a union review meeting. If any updates are made prior to the meeting, revised drafts with track changes shall be sent to union(s). If necessary, the review meeting shall be rescheduled to ensure the union(s) has adequate time to review.
        2. Any changes agreed upon shall be coordinated by DMH-HR with CPAS, the responsible party, or both. 
        3. DMH-HR shall notify CPAS regarding outcomes of union reviews.
           
  4. Policy Distribution CPAS shall coordinate the distribution of completed policies and procedures as they are approved by the Discipline Chiefs.
     
    1. Policies and procedures shall be posted on the DMH Policies and Procedures Website.
       
    2. Policy Bulletins shall be distributed by email to workforce members and posted on the DMH Policy Bulletin Updates section to ensure awareness of any new, revised, temporarily suspended, and deleted policies.
       
      1. Policy Bulletins shall be posted quarterly.
         
      2. A “NEW” label shall be added to all new/revised Policy Bulletins.
         
      3. Policy updates shall be presented by CPAS at the Quality Improvement Council (QIC) monthly meeting.
         
  5. Policy Maintenance
     
    1. CPAS shall maintain electronic policies and procedures on the DMH Policies and Procedures Website and a paper copy of enforced policies and procedures in the DMH Master Policy Manual.
       
  6. Policy status changes must be communicated to CPAS via the Policy Status Change Form.
     
  7. Temporarily Suspended: Temporary circumstances may occur that requires a policy and procedures to be suspended until those circumstances cease. In this instance, the policy and procedures shall include a watermark noting that it was suspended with an effective date. The status change shall also be noted in a Policy Bulletin.
     
  8. Deleted: Any policies and procedures no longer needed may be deleted from the website following a formal deletion process completed by the responsible party. A hard copy of deleted policies and procedures shall be kept in the DMH Master Policy Manual maintained by CPAS per current retention requirements. The status change shall also be noted in a Policy Bulletin. 
     
  9. CPAS shall coordinate with the Chief Information Office (CIO) to maintain the most current policies and procedures on the website.
     
  10. CPAS shall monitor the website to verify policies and procedures are current and accessible.