SOPs: Policy and Procedure Templates

GENERAL SOP TEMPLATE

Category:

Procedure No:
XX-XXX-XXX

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval:

Exec. Approval:

(TITLE)

PURPOSE

(Paragraph)

POLICY

Include the following statement in all policies:

This policy will be strictly enforced and a violation of this policy may lead to discipline, up to and including termination.

PROCEDURE

Note: To save the header on the second page, do not copy/paste more than what fits on page 1. Copy paste the remainder of the document starting on page 2.

Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Consent for Treatment and Informed Consent

PURPOSE

In order to safeguard client’s rights and protect the legal interests of [AGENCY NAME].

POLICY

[AGENCY NAME] staff are required to follow this procedure by utilizing the most current authorized consent for treatment [NAME] County Department of Behavioral Health, and to receive proper written authorization for treatment prior to engaging in services with a client. In addition, as Informed Consent, [AGENCY NAME] staff will discuss with clients and guardians conditions of treatment, confidentiality issues, legal mandates or other information as necessary.

PROCEDURE

Consent for Treatment

Consent for treatment is a legal authorization or agreement between a client or client’s legal
representative that they are agreeing to receive treatment and services. see attachment 1. Before
we can provide services to a client, we must first have a signed consent for treatment form. the
consent for treatment is in the intake package and is completed during the intake admission with
other intake paperwork.

If a client is in more than one program, a consent for treatment is required for each program the client is in.

Clients or their legal representative can rescind consent for treatment at any time. services are
voluntary. thus, if a client rescinds consent, we would terminate services immediately and close the
chart.

The consent forms are signed as follows:

• Clients 18 years and older can consent to their own treatment and must sign the consent for
treatment form.
• If a client is conserved, consent for treatment will require the signature of the conservator,
public guardian or private conservator.
o the current letter of conservatorship must be obtained at the time of intake and
submitted with the chart for opening.
o if a client becomes conserved during treatment, the letter of conservatorship must
be obtained and submitted along with a Unicare update form to billing for
processing.
• Clients 12 and older must sign the consent for treatment form along with the parent or guardian.
• Clients under 12 do not need to sign the consent, but it is preferred that they do unless they are
“too young to sign” a parent or legal guardian must sign.
• Parent (s) with legal custody can consent for their children’s treatment.
o if parents are divorced or separated and have joint custody, both parents must sign.
• Legal guardians can consent for treatment.
o court order for guardianship must be obtained at intake and filed in the chart.
• Parents can authorize guardianship to others by signing and notarizing authorization.
typically this is done in a structured format such as the “guardianship authorization.” in this
case, the authorized guardian can sign the consent for treatment. see attachment 2 for a
sample “guardianship authorization” form. ([AGENCY NAME] does not fill out the form or
notarize. This form is attached for information only, though a blank form can be provided to
the parent.)
• For children in foster placement, judges, court commissioners, social workers with a court affidavit
, and parents who retain rights can consent to treatment. (Only judges can consent to medications
for children who are dependents of the court (300s), even if the biological parents still have parental
rights.)
• Wards of the court (w&i code 601 and 602) will require the signature of the court, and a
copy of the current juvenile court disposition must be placed on file. If parents or guardians
still retain legal rights, a guardian with legal custody may sign the consent.
• Emancipated minors can consent to treatment. They must also provide documentation of
emancipation prior to providing consent for treatment.
• Children over the age of twelve can consent to their own treatment if they meet certain conditions stated below, but barring unusual and specific circumstances, you should obtain parent’s
consent as soon as possible.
. A minor 12 years of age or older who, in the opinion of the attending professional, is
mature and intelligent enough to consent to outpatient treatment may do so without
parental consent if one of the following criteria is met:
1. The minor would present a danger of serious physical or mental harm to others or
self without such treatment.
2. The minor has been the alleged victim of incest or child abuse.
3. Primary presenting problem is alcohol or drug abuse.
4. Treatment may continue without parental consent only so long as one of the above
criteria is met or if, in the opinion of the attending professional, parental involvement would be harmful.

If the client’s legal guardian or conservatorship status changes during the course of treatment, new
consent for treatment (and other intake paperwork) must be signed by the new individual with legal
authority. The new paperwork should be submitted to billing along with a Unicare update form. The following people cannot consent for treatment:
• Clients who do not have the mental capacity to give consent cannot consent for their own
treatment. legally, if one does not understand what one is consenting to, one cannot give
informed consent.
• Children under the age of twelve cannot consent for their own treatment.
• Foster parents, social workers without a court affidavit, relatives, and caregivers who are not legal guardians cannot consent to treatment.
• Parents who are not their children’s legal guardians cannot consent to treatment. If staff are unsure who can consent to treatment for a client, they should consult with their manager, and with Quality Assurance if there are further questions.

Additional Consent:

The consent for treatment is limited to consent for services provided.
Clients/guardians/representatives must sign additional, separate consent forms for the following:
• Medication
• Electronic correspondence
• Outings and waiver of liability form
• Consent to release information

Informed Consent

Informed consent is the requirement and practice of informing clients, parents, guardians, and/or
legal representatives of conditions of treatment, confidentiality issues, legal mandates, and other
necessary information. this can include, but is not limited to:

• Service provider conveys training, qualifications, license status, working under supervision
of a licensed professional, student intern etc.
• Discussion of possible risks and benefits of treatment.
• Client is informed that the provider will make his/her best professional effort to provide
optimal treatment, but a positive outcome cannot be guaranteed.
• Client enters into treatment contract voluntarily.
• Rules of confidentiality are fully explained, including client’s right (even children clients) for confidentiality and the special, sometimes complicated confidentiality issues that arise
when treating a family.
• Limits to confidentiality are fully explained including mandates to report suspected child or dependent adult abuse, duty to warn, danger to self or others, and/or gravely disabled.
• For children of divorced parents, it is explained that consent must be obtained from the parent with legal custody, and if parents have joint custody, both parents must consent to
treatment.
• Client must be mentally capable of providing consent.
• Recognize that a person’s ability to give informed consent may fluctuate over time.
• Client’s decisions must be made based on adequate information.
• Clients must give informed consent prior to audiotaping, videotaping, or permitting
observation.
• If a client’s legal status/guardianship status changes, the client must inform the primary
provider, who must obtain a new consent for treatment and notify the doctor on record. the psychiatrist must obtain new consents for medication.
• Any other information it may be necessary for the client to know so they can make a clear
decision of agreeing to or continuing treatment.

Informed consent should happen at admission or in the first session with client, and any time new
information makes it necessary to update informed consent. It must be documented in a progress
note what information client/guardian/representative was informed on and the client/ guardian/ representative’s stated understanding and response.

Attach your Agency’s Forms:
•
Consent to treatment form

•
Guardianship authorization

Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Equal Access to Shelter, Housing and Services for Transgender and Gender Non-Conforming Clients

PURPOSE

To ensure equal access to shelter, housing and services regardless of actual or perceived gender
identity and/or gender expression.

POLICY

Where appropriate, [AGENCY NAME] will comply with the Department of Housing and Urban
Development’s (HUD) Equal Access Rule and Notice CPD-15-02 on Appropriate Placement for Transgender
Persons in Single-Sex Emergency Shelters and Other Facilities:
(https://www.hud.gov/program_offices/fair_housing_equal_opp/housing_discrimination_and_persons_ide
ntifying_lgbtq#:~:text=HUD's%20Equal%20Access%20Rule%20requires,gender%20identity%2C%20or%20m
arital%20status), and Santa Clara Countywide Quality Assurance Standards for Homeless Housing and
Service Programs:
(https://osh.sccgov.org/sites/g/files/exjcpb671/files/SCC%20CoC%20Quality%20Assurance%20Standards%2
0-%2010.9.20%20-%20HUD%20Mega%20Waiver.pdf).

This policy will be strictly enforced and a violation of this policy may lead to discipline, up to and including
termination.

PROCEDURE

[AGENCY NAME] will adhere to current HUD and [NAME] County regulations/guidelines requiring
that transgender and gender non-conforming clients be sheltered/housed according to their gender of
identification, regardless of physical characteristics.

Single-sex shelter, transitional housing programs, and residential facilities will place clients according to the
gender with which that person identifies. If the client does not identify with either binary gender, the client
shall be placed in a shelter, housing, or residential situation that makes the client feel safest.

Transgender and gender non-conforming clients have access to bathrooms based on their gender
identification, regardless of physical characteristics. Clients who do not identify as male or female should have access to whichever toilet/shower facilities best aligns with their gender identity. Where there are single-use showers and bathrooms in the facility designated for residents, transgender and gender non-conforming residents will be told about them and welcome to use them.

In shelters that separate resident sleeping accommodations by gender, transgender or gender nonconforming clients should be sheltered according to their gender identification, regardless of physical
characteristics.

[AGENCY NAME] policy is to provide quality services in an environment where the needs of persons
served are met and clients’ rights are protected. Such an environment is based on respect for the gender
identity of each person served. Services will be provided in a courteous and affirming manner. [AGENCY NAME] will provide notice and training to all program staff to ensure compliance with written policies
regarding equal access and client intake
Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Medication Education, Consent,
and Training

PURPOSE

To serve as a legal record of the client’s agreement to take psychiatric medication as part of a treatment regimen.

To certify that the client has been informed about the medication as prescribed in the [NAME] County
(SCC) Behavioral Health Services Department (BHSD) “Consent of Outpatient Medication.”

To ensure staff receive ongoing education and training in pharmacology.

POLICY

It is the policy of [AGENCY NAME] to ensure that appropriate education and ongoing training is
provided to the clients, family members, and service providers regarding the practice of prescribing and dispensing medication, the conditions for which medication use is indicated, and the impact the medication may have on an individual’s disability and/or quality of life.

Voluntary clients of SCC BHSD have the right to information regarding medication and have the opportunity to give written consent for medications prescribed.

It is a client’s right to refuse medication at any time by telling the physician or other member of the
treatment staff of such intentions. Clients cannot be refused other appropriate modalities of treatment solely on the ground that they will not take medication. Refusal to take medication, by itself, does not constitute a ground for initiating involuntary commitment.

The consent process must follow the [NAME] County procedure and includes the distribution of standard Department drug information sheets and the use of a standard consent form.

PROCEDURE

A. Psychiatrists will meet with all persons served and family members, when appropriate, prior to the initiation of any prescribed medications, to provide education regarding the medications that are chosen for use, its intended purpose, side effects, precautions, and risks.

B. Through the use of informed consent, consistent with their scope of practice medical staff will provide the persons served and their family members with education in the following areas:
1) The nature of their illness
2) Biological principles associated with the medications.
3) The risks and side effects of each medication, including long-term side effects.
4) The type(s) of medication being recommended and the intended benefits.
5) Contraindications associated with the medications.
6) Possible adverse interactions between multiple medications and food.
7) Risks associated with pregnancy.
8) The amount (dose and how often dose may be administered) of medication.
9) The importance of taking the medications as they are prescribed.
10) Laboratory monitoring, if appropriate.
11) The rationale for the medications, including the likelihood of improving with or without the medication.
12) Alternative treatment available other than the use of medications.
13) Alternative medications.
14) Signs of relapse and/or non-adherence to medication prescriptions.
15) Potential drug reactions when combining prescription, non-prescription medications or illicit drugs.
16) Instruction on self-administration, when applicable.

C. The treating psychiatrist is required to complete the SCC consent for medication form after the client has received an explanation of the conditions of treatment in a language that the client understands.

The form will also contain specific information in the area of precautions regarding the use of
medications by women of childbearing age, the use of medications during pregnancy, and special
dietary needs and restrictions are associated with the use of the medications.

Psychiatric medication may be administered to minors only with the consent of a parent or legal
guardian, unless the minor has been declared emancipated by the courts. therefore, the legal
guardian must sign the consent when applicable. in the case of clients with an LP’s conservator, the
form must be signed by the client’s legal guardian.

This form must be updated each time a new therapeutic class of medication is ordered.

If a client is unwilling/unable to sign the consent, but desires to take the medication, he/she should
be given the appropriate drug information and a notation should be made at the bottom of the
consent form. Routine attempts to obtain the client’s signature should be made in subsequent visits.

A client may withdraw consent at any time by informing his/her physician. The reason for withdrawal of consent shall be documented in the progress notes, and the physician must discontinue the medication. If the client subsequently consents to resume medication, the physician shall indicate such in the progress note and orders.

Completion of the consent form does not displace the need for the prescriber to write a progress note at each client contact. The consent form shall be permanently filed in the client’s electronic medical health record and chart.

Procedure (continued)

D. The client and their family members will receive ongoing education concerning their medication at a minimum of every 90 days during the quarterly medication review process. As per the medication documentation policy and procedures, a quarterly medication review will be completed every 90 days and will include the following information:

1) The person’s name and ID/social security number.
2) Documentation of the need for continued use of medication.
3) Current medication prescribed.
4) Documentation of any unusual side effects and management strategies for control of side
effects.
5) Documentation of any contraindications associated with the medication.
6) Documentation that all unusual side effects and contradictions have been discussed with the person served.
7) Observations related to continued medication use and the observed behavior of the person served.
8) Signature of physician, credentials, date, and printed name.

E. The treating psychiatrists, qualified and staff licensed to prescribe medications, will maintain
continuing education and training associated with licensure and certification requirements and
maintenance of best practices in the field of psychopharmacology. all staff members involved in
medication services (Psychiatrists, RN, and LPT) will maintain performance objectives on a yearly basis associated with medication treatment guidelines and protocols.

F. staff will receive ongoing education and training in pharmacology.
1) Clinical staff in the adult division will be assigned a Learning Management System course when hired and annually titled [ENTER TITLE].
2) Clinical staff in the children’s division will be assigned a Learning Management System course when hired and every other year, titled [ENTER TITLE]. Additional courses and
course information can be located on the Learning Management System.

Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Medication Services Prescription, Administration, and Documentation

PURPOSE

The purpose of this policy is to ensure that [AGENCY NAME] enforces safe and effective prescribing
and administrating medications and complies with all requirements of federal and state laws and County
policies and procedures, including documentation and risk management.

POLICY

It is the policy of [AGENCY NAME] to ensure that all medications are administered in a safe and timely manner; that all medication administration is documented accurately and that any medication errors are addressed in an effective manner improved service quality and outcome.
The agency will utilize the [NAME] County Medication Treatment Guidelines, protocols and outpatient medication consents which are consistent with current practices in psychopharmacology.

PROCEDURE

A.
Prescribing

1) Medications will only be prescribed by licensed providers (physicians and psychiatric nurse
practitioners) who are lawfully authorized to prescribe for clients of [AGENCY NAME].

2) All medication related-orders shall be documented in writing or electronically ordered and
signed accordingly.

a. Providers, at their discretion, may write or give verbal orders to a licensed medical
support staff who records them in the client’s record.

3) For female clients of childbearing age, providers will discuss the use of medications during
pregnancy and document such discussion prior to prescribing a new medication.

4) Providers will follow all county regulation related to prescribing Controlled Medication.

5) All medications will be electronically ordered through Order Connect.

i. Oral medications will be sent to the pharmacy of the client’s choosing.
ii. Injectable medication prescriptions administered by [AGENCY NAME] will be
electronically ordered through Order Connect to the pharmacy of [AGENCY NAME] choosing.

6) If needed prescriptions may be faxed or called into to the pharmacy and documented as described
above
B. Administering

1)
See residential procedures for Self-Administration Policy (OPS-MED-XXX)

2) Injection medication shall be administered as prescribed by the [AGENCY NAME] providers.
a. If injection is not administered by due date, the prescriber must be notified and a new order
must be obtained to administer the injection.
b. All orders must be documented as described above
3) Prior to administration of an injectable medication that has been transported from the client’s
previous placement facility or provider, a [AGENCY NAME] prescriber must be consulted and at
their discretion order the administration of the medication.
4) Administering sample medications is prohibited.
5) Authorized staff administering injections (physician, RN, or LPT/LVN) will adhere to appropriate
aseptic methods and universal precautions.
6) Injections will be administered in a private setting and on a one-on-one basis.
7) Authorized staff will review the treating psychiatrist’s order prior to administering the injection.
8) All injection medication prescriptions when administered by the Agency will be logged onto the
Centrally Stored Medication Record. All entries must be completed at time of administration.
9) Injections administered by the physician, RN or LPT/LVN will rotate intramuscular injection sites and
document the site of the injection. An assessment of the selected injection site will be done prior to
each injection to assess for any tissue damage and document if tissue damage is observed.

C.
Documentation Requirements

1) All medications prescribed require the completion of the [NAME] County Outpatient Consent
for Medication form. The consent form will provide a guide for a comprehensive overview of the
medication prescribed, its intended purpose, side effects, precautions and risks. The form will also
contain specific information in the area of precautions regarding the use of medications by women
of child-bearing age, the use of medications during pregnancy, and special dietary needs and
restrictions associated with use of the medications.
2) For all medications prescribed, a Progress Note will be completed at the onset of medication
treatment and at every client visit within the designated timeframe. The Progress Note will contain
the following notation in the AVATAR (electronic) system:
a. The client’s name as registered in Unicare/AVATAR
b. Diagnosis to justify the medication being prescribed
c. Date medication prescribed
d. Name of medication
e. Dosage/Strength
f. Route of administration
g. Schedule of administration
h. Acknowledgement of advice of side effects and consent
i. Dates discontinued or changed, with specific reasons for change
j. Next medication follow-up appointment
k. The electronic legal signature of the licensed provider
3) An allergy notation will be placed on the Progress Note for any person served known to have a drug
sensitivity, and will be reviewed and updated by the psychiatrist, RN, or LPT/LPT, as appropriate.
4) In the event of an allergic reaction or other side effect related to the administration of an injectable
medication, the authorized staff administering the injection will notify the prescribing provider and
document the event in a progress note.
5) Providers will document their discussion regarding the client’s needs and preferences for medication
use and determine their overall satisfaction.
6) All injection medication administered by the prescriber, RN or LPT/LPT will be logged on to the
Centrally Stored Medication Record – Medication Dispensing Log with the following information:
a. Date & Time of Administration
b. Medication Name
c. Source of RX
d. Lot # if MDV used (Multi Dose Vial)
e. Dose
f. Route of Administration
g. Staff Signature
7) A progress note documenting the injection will be completed by the RN or LPT within the
designated timeframe.
a. The client’s name as registered in Unicare/AVATAR
b. Date of administration
c. Medication, dosage, injection site
d. Next medication due date
e. Injection refusal or client no show will be reported to the treating psychiatrist and
documented accordingly.

D. Medication

Risk Management will be defined as not following the established policies and procedures
regarding Medication Errors: Administration & Documentation, and other Medication Risk Factors:
Disposal, Storage, and Inventory.
1) Administration and Documentation
a. Incorrect medication
b. Incorrect dose
c. Incorrect amount
d. Incorrect route of administration
e. Incorrect person
f. Incorrect time
g. Medication omitted
h. Incomplete consent form
i. Incomplete Physician prescription order form
j. Medication container mislabeled
2) Storage, Inventory, and Disposal
a. Medication not stored in proper environment (refrigeration)
b. Medication not locked and maintained in a secure manner
c. Medication keys lost
d. Medication count not completed
e. Medication count results in extra or missing medication
f. Inappropriate disposal of syringes and needles
3) All medication errors will be reported in the following manner:
a. The Clinical Incident/Critical Incident Response Reporting procedures will be utilized to
report and fully investigate medication errors and result in organizational quality
improvement activities.
b. The Medical Director and manager in charge of medical services will be immediately
informed of the medication error and will notify the treating psychiatrist when medication
error(s) occur.
c. The client receiving medication services will be informed at the discretion of the psychiatrist
if it is determined through the physician’s clinical judgment that the error impacted the
treatment of the client in any manner.
4) A progress note will be entered into the client’s record when it is determined by the Medical
Director and/or treating medical staff that the medication error resulted in a significant degree of
impact to the client’s care.
5) All medication errors will be discussed with the employee/contractor and his/her Medical Director
or manager and follow the Management Guidebook for supporting the Discipline Process.

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Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Consent for Treatment and Informed Consent

PURPOSE

[AGENCY NAME] provides timely behavioral health services to clients who meet program eligibility
guidelines for the program to which they are referred. The Referral, Intake, Admission, or Inaccurate Records Correction Process has been standardized across the agency

POLICY

[AGENCY NAME] will follow [NAME] County Behavior Health Services Department requirement that, based on the initial service request date, [AGENCY NAME] will initiate services with clients within 5 business days for Level I and 10 business days for Level II (Specialty Mental Health Services). Additional contractual expectations may apply. Documentation will be complete, accurate, and timely when submitted to the Billing team. When it is incomplete or inaccurate, the documentation will be redirected by Billing to the appropriate person in order to make the necessary corrections.

PROCEDURE

Referrals
1) [AGENCY NAME] receives a referral from a referring party.

a) Referrals are primarily sent through the county care connect portal.
b) Community referrals, such as referrals from schools, parents, faith-based organizations, medical professionals, police departments, self-referrals, other referring agencies, etc., are sometimes given directly to [AGENCY NAME] staff in various programs.
i) All referrals received by individuals at cs must be scanned
ii) Scanned copy must be sent from staff’s email then forwarded to dl-referrals
iii) Include in the subject line: pre-admit request, client last name, client first name initial,
program, u-code
iv) The email must also include (refer to email template from billing):
(a) Client’s full name (first, middle initial, last, and suffix (if applicable)
(b) Cost center
(c) Admitting practitioner (please only use clinicians who have a completed Parcca
Credential
(d) Referral date (if date not provided, the date the email was received will be used)
2) The referral is accessed within the Care Connect portal by the billing team within 24 hours for call center referrals. Referrals that are received by the program are to be forwarded to billing immediately and will be pre-populated within 24 hours.
a) Program manager or designee confirms receipt of the referral with the referring source, if
applicable.
b) Billing team pre-admits all referrals into the Avatar R-Code when they are received.
c) Billing team will open outreach episode, if applicable.
d) Billing team will verify Medi-Cal eligibility for the potential client and generate the Medi-Cal
screen.
e) Program manager or designee reviews the referral to determine if the potential client meets basic
eligibility guidelines based on the specifics of the program contract.
i) Eligibility for services may be determined based on criteria which can include:
(1) Referral received date
(2) Review of Medi-Cal eligibility
(3) Availability of unsponsored funds
f) If accepting referral, the program manager or designee assigns the referral to a practitioner that
coordinates intakes.
g) If transferring referral to another [AGENCY NAME] program:
i) The program managers for both programs will review for eligibility and capacity, as well as
appropriate fit to meet the client’s needs.
(1) Referral information will be provided to the new program.
ii) confirm acceptance with the manager of the new program
iii) the accepting referral manager will resend the referral by email to dl-referrals with:
(a) Client’s full name (first, middle initial, last, and suffix (if applicable)
(b) Cost center
(c) Admitting practitioner (please only use clinicians who have a completed Parcca
credential)
(d) Referral date (if date not provided, the date the email was received will be used)
iv) Follow the process for closing referral in the original program.
h) If not opening the client in the referred cost center, to close the referral:
i) The program manager or designee will interface with the referring party regarding closed
referrals. referrals cannot be returned; please consult the director as needed.
ii) An avatar referral disposition form must be fully completed.
iii) The avatar referral disposition report is saved as a PDF and emailed to the billing manager within 2 business days of the referral close date.
iv) Billing team will close the referral in Avatar within 2 business days of receipt

Reaching Out to Client

1) Practitioner attempts to contact the potential client to discuss intake into the program. Programprogram-specific engagement/assessment process will occur.
a) Every attempted and/or actual contact for the client, referral source, etc. must be recorded on the Avatar Referral Disposition Form as they occur.

Scheduling Intake Appointment

If an intake cannot be scheduled within timely access standards (5 days for level 1 and 10 days for level 2), please consult with your manager.

To set-up an intake:
1) Call client/caregiver and provide an overview of the program.
2) Inform the client/caregiver that the appointment will take approximately 2 hours from start to finish.
3) Review Admitting Practitioner’s Avatar scheduler for available appointment times and locations.
Procedure Number:
4) Set up date, time, and location of the appointment. Reserve conference room in Outlook, if needed.
a) All offer dates must be recorded on the Avatar Referral Disposition Form, even if declined.
5) Ask questions about the client’s medical needs:
a) Is the client on any medications? Bring them to the intake.
b) Does the client need an appointment for psychiatric medications?
c) Is the client receiving an injection?
6) Notify the client to bring their Medi-Cal/Medi-Care card to the appointment, because a copy (front and back) will be made.
a) If they don’t have a copy, program staff can support them in obtaining a copy.
7) Verify that Parent/Guardian has signing rights for mental health services and ask for a copy of the legal documents for our medical records if they are not the biological parent. (See SOP-OP-CLI-XXX Consent for Treatment and Informed Consent)
8) Obtain verbal consent from client/caregiver to leave a voicemail message at the number listed in order to provide a reminder call. If consent is not obtained, then a call will be made, but no voicemail message can be recorded.
a) Be sure to capture that verbal consent was given in the Descriptions/Notes section on the Avatar Referral Disposition Form.
9) Explain the importance of attending all appointments, and proactively rescheduling if needed in order to avoid no-shows.

Confirming and documenting intake appointments

Once the intake has been scheduled, the practitioner will do the following:
1) Ensure Avatar referral disposition form is complete, including updated pending status.
2) Add intake to the avatar scheduler for the assigned admitting practitioner.
3) Confirm time/location/room for appointment on Outlook and cc the admitting practitioner.
4) Send pre-pop email to billing team
a) Subject line: pre-pop request, client last name, client first name initial, program, u-code
b) Body of email:
1) Client’s full name (first, middle initial, last, and suffix (if applicable)
2) Cost center
3) Language
4) Admitting practitioner (please only use clinicians that have a
completed Parcca credential)
5) Attending practitioner (please only use clinicians who have a completed Parcca credential)
6) Referral date (if date not provided, the date the email was received
will be used)
5) Billing team will pre-populate the required documentation. Within 2 business days, billing will email the client’s pre-populated documentation to the admitting and attending practitioner, the manager, program admin, and central intake (if ci submitted the pre-pop request).
6) Any request submitted after 4pm will be considered received the next business day.

Intake Appointments

Prepare for intake – the admitting practitioner will print the pre-popped packet (single-sided) & new client packet if the intake is taking place in person, or save them electronically if doing a remote intake.
• Pro tip: complete as much of the documentation in advance when possible (consents, etc.).
o Identify from the referral packet who would be helpful to exchange information with (e.g. previous treatment providers, other agencies involved) so that consents to release can be filled out ahead of time by you and proposed to the client.

Appointment with Client
At the intake, the admitting practitioner will:
1) Introduce themselves, their role, and the program.
2) Provide an overview of the assessment, narrative, and treatment process and timeline.
a) Provide explanation to client about how the attending practitioner will be completing an initial TCP during the next 45 days.
3) Explain how/why services will be provided, including discussion of successful discharge.
4) Discuss the needs of the client/family and service options available for individual, group, family, etc., mention other services if applicable.

Real-Time Opening
An admitting practitioner may request a real-time opening during an intake with a client. A real-time opening is a partial opening of a new client episode in Avatar to allow for timely documentation.

1) Submit “real-time” steps once a client has signed the Consent for Treatment.
a) Email dl-billing real-time & cc Program Manager or designee.
b) Subject line: real-time, client’s last name, client’s first name, and u-code
c) In the body of the email, add the following information:
i) Client’s first name, middle initial, last name, and suffix (if applicable)
ii) Avatar number
iii) Date of birth
iv) Social Security #
v) Program name and u-code
vi) Admitting practitioner (please only use clinicians who have a completed Parcca credential)
vii) Attending practitioner (please only use clinicians who have a completed Parcca credential)
2) Proceed with intake while waiting for real-time confirmation.
3) The admitting practitioner will receive an email confirming when real-time request is completed and will then have access to complete the assessment and other documentation in Avatar.
o Pro tip: you can prepare the email above (i-vii) in advance and send it once the consent for
treatment is signed.
o Real-time will be completed within 15 minutes during normal business hours. Any request
submitted after 4:30 pm will be completed the next business day.
o If you are completing an intake outside of business hours, please connect with billing in
advance.
o Real-times will not be completed after the intake; those intakes will be processed when
intake documents are received.

Intake Packet
When facilitating an intake with the client, the admitting practitioner reviews the pre-populated documents with the individual and/or family/caregiver:
1) There should be a consent to release form, signed by the client or designee, for the emergency contact that the client will identify during the intake.
2) Complete any additional consents to release, as needed.

The following 7 documents will require a wet or electronic signature:
1) Consent for treatment
a. Have the client check the appropriate box for who is receiving services.
b. Obtain client signature and other designee if applicable.
c. The admitting practitioner must sign at the bottom of the page, including their credentials.
2) Assignment of insurance benefits authorizes Medi-Cal to pay [AGENCY NAME] for services.
3) Consents to release client information
a. Complete as many releases of information (ROIs) that are necessary for the coordination of service. This may include teachers, social workers, probation officers, advocates, payees, etc.
b. Include the purpose (e.g. exchange of information, coordinating treatment, integrating treatment with other services).
4) Client handbook acknowledgement form confirms receipt of handbook, which includes notice of
privacy practices. obtain initials for each category and signature.
5) Beneficiary handbook acknowledgement form signed to acknowledge receipt of the handbook.
6) Waiver of liability required release for any client-related transportation.
7) Release for electronic communication requires authorization for email and text information.

Program-specific documents may be required, including a demographic form, which is not included in the pre-populated documents.

8) Additional documents to discuss and provide to the client
a) SCC provider list
b) Right to make medical decisions brochure

Intake Process
1) Complete the client registration form.
a) Make a copy of Medi-Cal card
i) Can take a photo with the agency phone and send to: [ENTER EMAIL]
b) Document the SSN, if not pre-populated on the registration form
i) If undocumented, use 000-00-0000
2) For clients ages 3-17, have the parent/guardian complete PSC-35
a) Admitting practitioner enters into Avatar
3) For clients ages 18+, complete the dla-20 with the client.
a) Admitting practitioner enters into Avatar
4) Introduce and explain psychiatric services and complete the referral form, if indicated
a) Submit the form to the medical scheduler
5) Complete the relevant sections of the mental health assessment (MHA)
a) Once this is completed, the admitting practitioner will reassign the MHA to the attending
practitioner or other staff on the team
b) explain to the client that the attending practitioner (or other staff on the team) will be complete the MHA.
6) Review information in order to consult with an LPHA for admission diagnosis.

LPHA
The admitting practitioner will need to coordinate and obtain LPHA signatures (within 24 hours following intake) for the following:
1)
Registration form

Completed Chart

After completing the intake process and ensuring that the necessary forms have the appropriate information and signatures:
1) Within two business days after intake admitting practitioner will:
a) scan and attach the following documents to staff’s email:
i) All pre-pop documents as one packet
ii) Avatar referral disposition report
iii) Copy of the referral
iv) Medi-Cal screen
o Pre-pop forms include Medi-Cal screen for the month of referral. if the
admission occurs in a subsequent month, then a new Medi-Cal screen
must be provided.
b) Email complete chart to dl-billing, cc: program admin, and attending practitioner
c) Subject line: electronic opening, client’s last name, client’s first name initial, and u-code
i) The email must also include:
1) Client’s full name (first, middle initial, last, and suffix (if applicable)
2) Cost center
3) Admitting practitioner (please only use clinicians that have a completed parcca credential)
4) Attending practitioner (please only use clinicians that have a completed
Parcca credential)
5) LPHA practitioner
6) Program Manager
7) Program supervisor
8) Open date

2) Billing team will review for accuracy and completeness within two business days
a) If complete and accurate, the billing team will process the opening.
i) Once complete, billing will email the attending practitioner, program manager,
program supervisor, and LPHA, alerting them that the client has been opened in
avatar.
b) If incomplete:
i) The billing team will highlight missing or inaccurate entries and respond to the
originally submitted email including the admitting practitioner, program manager,
program supervisor, and LPHA.
o Add “corrections needed” in the subject line
o A list of corrections will be in the body of the email
ii) Admitting practitioner will make all corrections and email all intake documents to
DL-billing within two business days.

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AI-generated content may be incorrect.
Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

---

SAFETY PLANNING

PURPOSE

To support clients in having a plan available when safety issues arise.

POLICY

It is the policy of [AGENCY NAME] to develop a safety plan with each client (and client’s family/guardian
for children) in the following situations:

• When high risk behaviors are identified
• Significant history of safety needs or concerns are noted
PROCEDURE

The provider will assess for and identify any current or past risks that may warrant the need for a safety plan
at the time a client is admitted into a [AGENCY NAME] program, when a need is identified, or following
a crisis situation.

The provider will discuss the need for a safety plan with the coordinator or manager.

The provider will work with the client and/or client’s family (for children or youth), other team members or
support people (such as teachers, social workers, CASA, mentors, Probation/Parole Officers, etc.), to
develop a safety plan using the [AGENCY NAME] Client Safety Plan Template. (Attachment 1)

A copy of the completed Safety Plan will be provided, unless they refuse, to the client and/or the client’s family
(for children or youth).

Safety plans will be reviewed with the client when there is a critical incident, client goals are reviewed, or
during case conferencing.

Provider will utilize the “Trauma Informed Safe Coping Skills” to support client/support person in identifying
useful interventions. (Attachment 2).

Areas to be addressed on the Safety Plan include:

1. Identifying information: Name, address, contact information, date of birth.
a. If you enter a Correct Name, it will override the legal name on the printed report.

2. Name and contact information of Therapist/Case Manager/Peer Partner, Probation Officer/Parole
Officer, Conservator and/or Social Worker.

3. Team members/support people: People available to support the client, their relationship to the
client and contact information.

4. Anticipated crisis: What the risk is (i.e. suicide, violence/aggression, AWOL, abuse, intimate partner
abuse, substance abuse, etc.).

5. Interventions: Possible things the client or support person can do to avert a crisis, stabilize the
situation, and increase safety. See “Trauma Informed Safe Coping Skills.”

a. Proactive: Preventative strategies (i.e. changes to the environment, restraining orders,
rewards/incentives, etc.).

b. Reactive: Strategies to use during or after the crisis to prevent further escalation including
calling support people, initiating relaxation techniques, etc.

6. Current Medications: name, dosage, frequency, psychiatrist name and contact information, primary
care physician name and contact information.

7. Allergies, drug reactions, etc.

8. Other information: Disabilities, health issues, illicit drug use, alcohol abuse, etc.

9. Current address and name of housing program, if needed.

The Safety Plan must be kept in the client’s record (electronic chart). The Safety Plan form will be utilized in
Avatar, which can be exported or printed to provide to the client/family.

Safety Plans will be reviewed and updated regularly, as needed, with client and/or family (for children and
youth).

Safety Planning is an “intervention” and is thus billed according to the service you are providing. For
instance, if you are creating a safety plan at the time of a crisis, the time spent would be billed as part of
your crisis intervention service activity. If a safety plan is created in an individual therapy session, rehab
session, collateral session, etc., it would be identified as an intervention and would be billed as part of that
service activity. If safety planning occurs in a case management session, it would be billed as case
management.

A medical form with a blue mark

AI-generated content may be incorrect.

A paper with text on it

AI-generated content may be incorrect.

A paper with text on it

AI-generated content may be incorrect.
Category:

Procedure No:

Department:

Effective Date:
Month XX, 2014

Mandated For:

Revision Date:
N/A

Mandated For:

Next Review:
Month XX, 2014

Exec. Approval: [SIGNATURE]

Exec. Approval: [SIGNATURE]

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Telehealth Policy and Procedures

PURPOSE

[AGENCY NAME] has established a Telehealth policy in alignment with [NAME] County Behavioral
Health Services Department (BHSD) and California State Department of Health Care Services (DHCS) to
ensure our practices meet standards consistent with the current practice of traditional medical and
behavioral health treatment.
Telehealth is provided to assist with timely access to appropriate outpatient services. State law defines
Telehealth as “the mode of delivering health care services and public health via information and
communication technologies to facilitate the diagnosis, consultation, treatment, education, care
management, and self-management of a patient's health care.

POLICY

Services are provided in the format that will best meet the needs of our clients and families. Face to face
services are the primary format for provision of our behavioral health services, and we also have flexibility
to utilize telehealth and telephone services when it is appropriate to meet our clients’ needs. All clients
should be offered the option of face-to-face services, with the option of in-home, office, or community
locations. It is expected that all staff will be available to provide in-person services for clients as their
position requires.

Telehealth activities will:
- Meet federal and state laws and regulations.
- Be provided and billed under a written agreement and/or in accordance with state and federal
requirements.

Use appropriate equipment that complies with the appropriate technological security standards. Interactive
telecommunications must include, at a minimum, two-way video and audio.

This policy will be strictly enforced and a violation of this policy may lead to discipline, up to and including
Termination

PROCEDURE

A.
Consent

We are required by law to obtain a specific Consent for Telehealth Services. This form is included in all prepopulated intake documents. Informed consent requires that the client be informed of the risks and benefits of telehealth services.

B.
Confidentiality

1. At the start of any telehealth services, you should confirm the client’s identity.
2. You should ask where they are currently located. This allows us to send out emergency services if any safety concerns come up during the session.
3. You should confirm that they are in a safe, confidential space, and inquire if anyone else is in the
room.
4. As a provider, you should only provide telehealth services if you are in a safe and confidential space.
5. You should remind them that for confidentiality/HIPAA compliance, neither you nor the client will record the session.
a. There are exceptions with explicit consent and a plan to safely store and/or destroy the
recording after its intended use. This should be cleared with your Manager and QA.

C.
Safety

If a crisis situation arises, you should assess for safety and attempt to safety plan. If others are present at the location, they may be able to support if clinically appropriate. If you are unable to stabilize the situation remotely and there’s an imminent safety risk, you should contact emergency services and provide them with the client’s location. If appropriate, you can arrange for either you or another provider to go out in person to further evaluate and support.

There are times when telehealth is not an appropriate mode of service for our clients. If your client does not have access to technology, this will not be an appropriate option. Before providing any telehealth services, you should evaluate whether they are appropriate for your client’s clinical needs and personal circumstances. You should use your clinical judgment as to whether the client can fully engage in services in this manner. If you are unsure, please consult with your program leadership. Additionally, telehealth services should not be provided if your client is actively decompensated or actively psychotic. If your client is exhibiting physical symptoms such as slurred speech or disorientation, a face-to-face evaluation should take place. If your client reports suicidal or homicidal ideation, a face-to-face evaluation should take place.

D.
Documentation (Progress Notes)

1. The mode of service and location of service need to be Telehealth.
2. The beginning of each note needs to state, “This session was provided via HIPAA-compliant video
conferencing. The client agreed to be treated via telehealth and provided consent. This writer verified the client’s identity at the beginning of the session. The plan for dealing with an emergency during the session is _________. The client is aware of this plan.