Policy and Procedure Manual

Policy and Procedure Manual

This Policy & Procedure Manual provides a record of policy decisions and administrative and clinical procedures to guide the provision of behavioral health services administered by Sacramento County staff and contracted service providers. The Behavioral Health Services Director reserves the right to change, modify, or supersede any of the policies and procedures at any time.

Note: Policies and Procedures created by/for the Division of Behavioral Health Services (BHS) as part of the Department of Health and Human Services are still applicable to BHS as a division of the reorganized Department of Health Services.

For additional information regarding policies and procedures, please contact your program coordinator or send an email to bhs-dhs@saccounty.gov.

Cultural Competence and Ethnic Services (CCES)
CCES 01-02 Procedure for Access to Interpreter
CCES 02-01 Implementation of Cultural Competence
CCES 02-01 Attachment A: Cultural Competence Training Checklist

Enhanced Care Management (ECM)
ECM 02 Provider Service Provisions

Mental Health (MH) and Mental Health Access (MH Access)
MH 02-01 Contract Advance
MH 02-05 Quarterly Reports
MH 02-08 Definitions of Common Terms Used in the Service Contracts
MH 02-10 Leased Vehicles
MH 02-12 Corrective Action Plan
MH 02-20 Family Advocate/Partner
MH 02-21 Youth Advocate
MH 4-02 Multi-Agency Collaboration Agreement
MH 04-03 Subacute Placement Referrals
MH 04-06 Crisis Residential Referral and Admission
MH 04-07 Enrollment of Youth in the Wraparound Program
     MH 04-07 Attachment A: Wraparound Referral Form
     MH 04-07 Attachment B: Sacramento County Wraparound Program Payment and Termination Notice Form SC123X
     MH 04-07 Attachment C: Wraparound Reimbursement Rate
     MH 04-07 Attachment D: Wraparound Exception Request
MH 04-08 Level of Care Utilization System
MH 04-09 Use of Wraparound Funds (under revision)
MH 04-10 Child and Family Team
MH 04-11 Prevention Assistance & Re-Housing Services
     MH 04-11 Attachment A: Rent Reasonableness Checklist Certification
     MH 04-11 Attachment B: Maximum Rental Assistance Calculator
MH 04-12 Therapeutic Behavioral Services (under revision)
MH 04-15 Juvenile Justice Competency Remediation
MH 04-19 Level of Intensity Screening Tool

MH 04-20 Assisted Outpatient Treatment Program

MH 04-21 Behavioral Health Bridge Housing (BHBH) Program
MH 05-01 ECT Authorization for Adults with forms
MH 05-02 ECT Authorization for Children
MH Access 02-01 Mental Health Plan's After Hours Response
MH Access 02-02 Access Team Services
MH Access 02-03 Urgent Service Requests
MH Access 02-04 Authorization Requests
MH Access 02-05 Out of County
MH Access 02-06 Notices of Action
MH Access 02-07 Provision of Second Opinions

MH Access 02-08 Screening and Transition of Care Tools

Quality Management (QM)
QM 00-01 Uniform Method of Determining Ability to Pay (UMDAP)
QM 00-03 EHR Account Management and Password Protection
QM 00-04 Use of AVATAR Billable and Non-Billable Codes
QM 00-05 Pharmaceutical Company Representatives
QM 00-06 Medication Support Staff Electronic Documentation Requirements
QM 00-07 AVATAR Document Management for Clinical Records
QM 00-08 Deletion of Open & Closed Charges
QM 00-09 Client and Family Billing
QM 00-10 Division of Behavioral Health - Telehealth
QM 01-03 Interpretation Services by Family Members
QM 01-06 Programatic Accessibility aka Physical Accessibility
QM-01-07 Determination for Medical Necessity & Access to Specialty Mental Health Services
QM 01-08 Inpatient Hospitalization Treatment Authorization Requests
QM 02-01 Notice of Adverse Benefit Determination
QM 02-04 Presumptive Transfer (Assembly Bill 1299)
QM 03-01 Problem Resolution
QM 03-04 Nurse Practitioner
QM 03-05 Advance Medical Directive
QM 03-06 Licensure Waiver and Monitoring of Accrued Supervised Hours
QM 03-07 Staff Registration and Credentialing (Click here for Staff Registration and Credentialing Forms)
QM 03-08 Problem Resolution Forms and Brochures Distribution
QM 03-09 Physician Assistant
QM 03-10 Conlan vs. Bonta Claims
QM 03-11 Video and Audio Recordings of Consumers
QM 03-12 Incident Reporting and Breach Notification of Protected Health Information
QM 03-13 License Differential
QM 04-01 Site Certification of Provider Physical Plant
QM 05-01 Credentialing Policy for Network Providers
QM 05-02 Credentialing Policy for Organizational Providers and County Mental Health Programs
QM 05-03 5150 Welfare & Institutions Code Certification & Designatio n
QM 05-04 Day Program Requirements
QM 07-02 Medication Monitoring
QM 07-03 Dispensing “Sample” Medications
QM 07-05 Vital Sign Training for Unlicensed Staff
QM 08-01 Clinical Pathways
QM 08-02 Continuity of Care
QM 09-01 Adverse Incident Reports
QM 09-02 Quality Assessment and Performance Improvement Program
QM 09-03 Continuing Education Requirements
QM 09-05 Electronic Utilization Review/Quality Assurance Activities
QM 10-23 Out of County Authorization, Documentation and Billing Procedure
QM 10-25 Health Questionnaire
QM 10-26 CalAIM Assessment (Mental Health) (Formerly Core Assessment)
QM 10-27 Problem List and Care Planning (Formerly Client Plan)
QM 10-28 Discharge Process
QM 10-29 Mental Status Exam
QM 10-30 Progress Notes (Mental Health)
QM 10-31 Child and Adolescent Needs and Strengths (CANS) Assessment Standards
QM 10-32 Informed Consent for Psychotropic Medication
QM 10-33 Pediatric Symptom Checklist (PSC-35) Standards
QM 10-34 Adult Needs and Strengths Assessment (ANSA) Standards
QM 14-01 Review Process for Implementation of New Clinical Practices
QM 20-01 DHS Claims Certification and Program Integrity
QM 20-03 Deficit Reduction Act False Claims Recovery
QM 20-05 Timely Access
Attachment A - MH Non-Psychiatric SMHS Timeliness Record
Attachment B - MH Psychiatric SMHS Timeliness Record
Attachment C - SUPT Outpatient Timeliness Record
Attachment D - SUPT Opioid Timeliness Record
QM 41-01 Division of Behavioral Health Services Compliance Program
QM 41-03 Division of Behavioral Health Services Code of Conduct
QM 42-01 Division of Behavioral Health Services Compliance Officer
QM 42-02 Division of Behavioral Health Services Compliance Committee
QM 44-01 Division of Behavioral Health Services Issue Reporting

Substance Use Prevention and Treatment (SUPT)
SUPT 01-01 SUPT Overview
SUPT 02-08 Provider Reimbursements
SUPT 02-09 Provider Overpayment
SUPT 02-10 Victims of Trafficking and Violence Protection Act of 2000
SUPT 03-01 DMC-ODS Overview
SUPT 03-02 Distribution of Informing Materials
SUPT 03-03 Timeliness to Services
SUPT 03-05 OTP-NTP Courtesy Dosing
SUPT 03-08 California Assembly Bill 2760 Anti-Overdose
SUPT 03-09 DMC-ODS Medication Monitoring
SUPT 03-10 DMC-ODS Over and Underutilization
SUPT 03-11 Coordination and Continuity of Care
SUPT 03-12 Scope of Practice
SUPT 03-13 DMC-ODS After-Hours Response
SUPT 03-14 Naloxone-Distribution-Project
SUPT 03-15 DMC-ODS Out of Network Single Case Agreements
SUPT 04-01 Prevention Services Overview
SUPT 09-02 Non-Religious Alternatives to 12-Step Programs
SUPT 10-01 Confidentiality and Release of Client Information
SUPT 11-01 Maintenance of Provider Directories
SUPT 11-02 Electronic Health Record and Documentation
SUPT 11-03 Data Reporting

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