LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 106.17 Policy Development, Review, Approval, and Distribution
 
Policy Category:  Administrative
Distribution Level:  Directly Operated and Contractors
Responsible Party:  Compliance, Privacy, and Audit Services 
 
Approved by Greg Polk, Chief Deputy Director, on April 17, 2019
 
I.  PURPOSE
 
This policy establishes a centralized and uniform process for development, revision, review, approval, distribution, and maintenance of all Los Angeles County Department of Mental Health (DMH/Department) directly-operated programs and contracted agencies’ policies.

This policy ensures that the policies and supporting procedures are in place to promote Department-wide operational effectiveness, increase efficiency, and achieve compliance with applicable federal, State, and County regulations.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITIONS
 
Distribution Level: An assignment of the entities to which the policy is applicable, namely:
  • Directly-operated programs
  • Directly-operated programs and contracted agencies
Effective Date(s): List of the date(s) pertaining to the current policy.
  • Effective Date: The date the policy is originally issued.
  • Review Date(s): Chronological list of date(s) the policy was reviewed noting with/without revisions.
Policy: Statement(s) of DMH’s position for best practices in support of the Department’s mission, vision, and values.

Procedures: Operational steps or tasks required to comply with policy. Procedures should be consistent with federal, State, and County regulations to ensure DMH is compliant.

Responsible Party: A unit, division, or other pertinent work area responsible for developing, enforcing, periodically reviewing, and updating policy.

Subject Matter Experts: A group of individuals within the Department including, but not limited to, the responsible party identified as having significant professional knowledge and experience in specialized areas to develop and revise DMH policies and procedures.

Workforce Members: Employees, volunteers, interns, trainees, and other persons whose conduct in the performance of their work is under the direct control of DMH, whether or not they are paid by the County.
 
III.  POLICY
 
DMH Policies shall be developed or revised by responsible parties and subject matter experts under the leadership of Discipline Chiefs and in coordination with Compliance, Privacy, and Audit Services (CPAS).

New/revised policies shall be initiated when the Discipline Chiefs, responsible party, or CPAS determines one is needed to maintain compliance with changes in federal, State, or County regulations or best practices.

All policies shall be effective until superseded by another policy, suspended, or deleted upon approval of the Policy Status Change Form.
  • Reviews and updates shall be completed as required due to changes in federal, State, or County regulations or best practices to ensure compliance.
  • In the event a policy is temporarily suspended, Discipline Chiefs shall have executive input on deleting or revising the policy. As appropriate, policies may be deleted.
CPAS shall post and update current policies on the DMH Policies and Procedures Website and maintain an archive of paper policies to be kept for a minimum of 10 years or until the fiscal year cost report is completed, whichever is longer.
 
IV.  PROCEDURES
 
Procedures - Policy Development, Review, Approval, and Distribution
 
V.  AUTHORITY
 
VI.  ATTACHMENTS
 
DMH Policies and Procedures Website: