LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 106.17 Policy Development, Review, Approval, and Distribution
 
Policy Category:  Administrative
Distribution Level:  Directly Operated
Responsible Party:  Compliance, Privacy, and Audit Services 
 
Approved by Kimberly Nall, Administrative Director, on Oct 24, 2025
 
I.  PURPOSE
 
This policy establishes a centralized and uniformed process for development, revision, review, approval, distribution, and maintenance of Policies and Procedures (P&P) for all Los Angeles County Department of Mental Health (DMH/Department) directly operated programs.

This policy ensures that the P&P are in place to promote Department-wide operational effectiveness, increase efficiency, and achieve compliance with applicable federal, State, and County regulations.
 
II.  DEFINITIONS
 
Distribution Level: An assignment of the entities to which the policy is applicable, namely:
  • Directly Operated
  • Directly Operated and Contracted
Policy Date(s): List of the date(s) pertaining to the current policy.
  • Effective Date: The date the policy is published.
  • Sunset Date: The date the policy will cease to be effective unless further review action is taken to extend the policy. The sunset date shall be established for three (3) years from the effective date.
Material Changes: Substantial and significant revisions that modify the terms of conditions of employment or the intent of the policy. This does not include changes solely for language enhancement or clarification.

Policy Committee: A recognized committee of Subject Matter Experts made up of a Policy Unit representative and various disciplines dedicated to the development and revision of clinical or administrative P&P.

Policy Committee Chair: The designated DMH executive who oversees the standing Policy Committee meetings.

Policy Manager: The lead of a unit, division, or program responsible for developing, implementing, reviewing, and updating P&P within their area of oversight. 

Subject Matter Experts (SMEs): A group of individuals within DMH including, but not limited to, the Policy Manager identified as having significant professional knowledge and expertise in specialized areas relevant to the development and revision of DMH P&P.

Workforce Members: Employees, volunteers, interns, trainees, and other individuals 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
 
All development and revisions to DMH P&P shall adhere to the established procedures and be coordinated through the Policy Unit.

The development of new policies shall be initiated by SMEs and require approval by a Policy Committee.

Revisions to existing policies shall be initiated by the respective Policy Manager and require approval by a Policy Committee.

Unions will have an opportunity to discuss new and revised policies before they are published within an allocated time frame. Unions may also request to discuss any published policy at any time.

All P&P shall remain effective until the identified sunset date.

All P&P shall be reviewed prior to the sunset date, or earlier as needed, to maintain consistency with applicable federal, State, and County statutes and/or regulations.
 
The Policy Unit shall post approved P&P on the DMH policy platform.
 
IV.  PROCEDURES
 
Procedures - Policy Development, Review, Approval, and Distribution
 
V.  AUTHORITY
 
VI.  ATTACHMENTS