Community Behavioral Health Services

Policies & Procedures

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SECTIONS AND TITLES	NUMBER	DATE
Department Philosophy and Organization
Communication
Behavioral Health Services (BHS) Policies/Procedures (CBHS: Administrative Manual Holders, All programs) 1.04-02 BHS Policy and Procedure Development Template Final	1.04-02	4/5/2022
Creating and Revising CBHS Medical Records Forms	1.04-03	2/2009
The Provision of and Reporting of Electroconvulsive Therapy (ECT)	1.04-06	4/5/2022
Quality of Care Reporting, Review and Investigation (CBHS: Administrative Manual Holders, Direct treatment programs)	1.04-4	4/27/2020
Code of Professional Conduct	1.04-07	2/28/2019
Mental Health Services Act (MHSA) Full Service Partnerships (FSP) Flex Fund Protocol	1.04-08	10/26/2017
Management Systems
Program Planning
Short-Doyle/Medi-Cal Provider Certification, Recertification and Change in Status Notification Requirements (CBHS: Administrative Manual Holders, SD/MC Certified Providers)	2.01-2	2/2/2000
Billing Information Systems
Credentialing and Service/Billing Privileges in Specialty Mental Health Services for Mental Health Rehabilitation Specialists & Mental Health Workers Service Billing Privileges Matrix Certification Verification	2.01-3	7/2017
Level of Care Designations/Certifications for AOD Treatment Facilities	2.01-4	12/19/2022
Obtaining Client Information for Billing Purposes	2.03-8	1/21/2014
Fee Policy for Substance Abuse Treatment	2.03-10	12/13/2011
Timely Submission of Documents and Data for Behavioral Health Billing Information Systems	2.03-11	1/2010
Medi-Cal Share of Cost	2.03-12	12/06/2010
Handling of Patient Payments Received in BHS Programs (CBHS: Administrative Manual Holders, Outpatient, Day treatment programs)	2.03-18	8/19/2015
Physician Responsibilities for Medicare/MediCal Reimbursement (CBHS: Administrative Manual Holders, CBHS Assistant Directors, CBHS Direct Treatment Programs)	2.03-26	10/16/1997
Verification of Service Delivery (Administrative Manual Holders, All CBHS Programs, CBHS Program Monitors)	2.03-27	1/21/2014
Overpayments Recovery and Reporting Procedures	2.03-28	3/1/2020
Individual Provider Enrollment, Screening, and Credentialing Standards in Federal Insurance Programs	2.03-29	10/2/2023
Personnel & Staff Development
Use of Interns for Clinical Services (CBHS: Administrative Manual Holders, All programs)	2.06-16	3/1/2016
Use of Stipends for Clients & Family Members	2.06-20	6/17/2020
Multicultural Student Stipend Program (MSSP) Policy	2.06-21	1/9/2023
Facilities
Good Neighbor Policy for Programs (CBHS: Administrative Manual Holders, All programs)	2.07-2	7/31/2009
BHS-IT Mobile Device and Cellular Service Policy and Procedures	2.07-3	9/14/2022
Service Delivery System
Components of System and Relationship
Prescription and Laboratory Svcs for CBHS Patients (CBHS: Administrative Manual Holders, Direct Treatment programs)	3.01-3	5/11/2022
CBHS Clinic Medication Rooms Attachment 1 \| Attachment 2 \| Attachment 3 \| Attachment 4 \| Attachment 5 \| Attachment 6 \| Attachment 7 \| Attachment 8	3.01-4	9/7/2021
Medication Storage, Disposal, and Monitoring in Community Care and Substance Abuse Residential Care Facilities Appendix A - Centrally Stored Medication and Destruction Record Attachment 1 - Medication Room Temperature Log Attachment 2 - Temperature Log for Refrigerator Attachment 3 - Monthly Expired Medication Review Attachment 4 - Medication Destruction Log Attachment 5 - Residential Care Facility Medication Storage – Compliance Checklist	3.01-5	11/2/2022
BHS Laboratory Ordering and Results	3.01-6	2/8/2023
JV-220(A)-223	3.01-7	3/14/2017
Conflicts of Interest in Client Referrals -- City Employees (CBHS: Administrative Manual Holders, Civil Service Programs)	3.02-9	2/28/2019
Conflicts of Interest in Client Referrals -- Contract Employees (CBHS: Administrative Manual Holders, Contract Programs)	3.02-10	8/2/2010
Timely Access and Time and Distance Standards for Behavioral Health Providers	3.02-13	10/24/2022
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and Therapeutic Behavioral Services (TBS) Notices	3.02-14	2/28/2019
Cultural and Linguistic Competency Requirement for Behavioral Health Services	3.02-15	5/30/2018
Tuberculosis Screening/Infection/Exposure in Personnel	3.02-17	4/8/2019
Assisted Outpatient Treatment (AOT) Adult Behavioral Health Assisted Outpatient Treatment Authorization to Release Private Health Information Consent for Community Behavioral Health Services Mental Health/Drug and Alcohol Treatment Programs – Assisted Outpatient Treatment Legal Rights Patients' RIghts	3.02-19	10/18/2022
DPH Crisis Intervention Specialist Team	3.02-20	1/10/2017
Medical Emergencies in Ambulatory Behavioral Health Centers	3.02-21	6/6/2023
24/7 Coverage Requirement for Full Service Partnership Programs	3.02-22	7/17/2018
Translation Request Policy	3.02-23	3/1/2019
Interpretation Request Policy	3.02-24	3/1/2019
Medi-Cal Beneficiary Informing Materials Policy	3.02-25	10/13/2020
Behavioral Health Services Medication Use Improvement Committee (MUIC)	3.02-26	6/6/2023
BHS Telehealth Policy	3.02-27	1/1/2024
Naloxone DPH Clearinghouse
Clearinghouse Naloxone Distribution Attachment A - Policies and Procedures Blank Template Attachment B - Staff Naloxone Training Tracker Template	3.01-8	9/22/2021
DPH Clearinghouse Naloxone Distribution FAQ
Patient Education: Naloxone Fact Sheet English \| Spanish \| Chinese \| Korean \| Russian \| Tagalog \| Vietnamese
Patient Education: Fentanyl Test Strips Brochure English
Residential Services
Tuberculosis Screening & Testing for Residential Programs	3.02-12	3/14/2019
Eligibility and Admission
Involuntary Psychiatric Detention and Coordination of Care for Minors (CBHS: Administrative Manual Holders, Children's Programs and Comprehensive Clinics)	3.03-1	4/2/2020
Mental Health Services for San Francisco Foster Children Placed Out-of-County, SB-785	3.03-02	2/28/2019
San Francisco Residency and County-of-Medi-Cal: Eligibility Requirements to Receive San Francisco Behavioral Health Services (CBHS: Administrative Manual Holders, All programs)	3.03-06	3/27/2018
Healthy Workers Membership in SFMHP (CBHS: Administrative Manual Holders, All CBHS Providers)	3.03-14	5/11/2022
Compliance with Charitable Choice Requirements	3.03-17	12/2009
Prior Authorization Policy and Procedures for San Francisco County Children, Youth, & Families System of Care for Intensive Care Coordination/Intensive Home-Based Services and Therapeutic Foster Care	3.03-18	5/10/2023
Psychological Assessment Services	3.03-20	12/19/2022
Concurrent Review Standards for Psychiatric Inpatient Hospital and Psychiatric Health Facility Services	3.03-21	2/22/2023
Authorization of Outpatient Specialty Mental Health Services (SMHS)	3.03-22	4/26/2023
Screening and Transition Tools	3.03-23	3/01/2023
Accessibility of Service
SF Drug Medi-Cal Organized Delivery System Requirements for Years 2022-2026	3.03-19	9/28/2022
3.04-3 Member Grievance Procedure in Compliance with Section 504 and the ADA (updated January 23, 2024)	3.04-3	2/18/2016
Request for Change in Behavioral Health Provider	3.04-07	3/14/2017
Request for Second Opinion by Medi-Cal Beneficiaries Due to Not Meeting Medical Necessity	3.04-08	3/30/2022
San Francisco Continuity-of-Care Requirements for Medi-Cal Specialty Mental Health Services	3.04-09	4/25/2023
Implementing Non-Hospital/Outpatient Specialty Mental Health Services (SMHS) medical necessity criteria to ensure access to care for Medi-Cal beneficiaries FAQ Medical Necessity Questions Related to CalAIM	3.04-10	3/25/2022
No Wrong Door for Mental Health Services FAQ CalAIM No Wrong Door	3.04-11	7/1/2022
Consent for Treatment
San Francisco Continuity-of-Care Requirements for Medi-Cal Specialty Mental Health Services	3.04-09	4/25/2023
Consent for Community Behavioral Health Services (CBHS: Administrative Manual Holders, Adult Direct treatment programs)	3.05-01	1/2008
Consent for Voluntary Behavioral Health Services: MINORS (CBHS: Direct Treatment Programs)	3.05-03	1/10/2012
BHS Psychiatric Medication Consent in Ambulatory Care Translated AOA Informed Medication Consent: English / Spanish / Chinese / Russian / Tagalog / Vietnamese Translated CYF Informed Medication Consent: English / Spanish / Chinese / Russian / Tagalog / Vietnamese	3.05-04	9/12/2017
Release of Client Information
Confidentiality and the Release of Protected Health Information of CBHS Behavioral Health Clients (CBHS: Administrative Manual Holders, Direct treatment programs)	3.06-01	9/26/2011
Release of Information Pursuant to a Subpoena/ Court Order (CBHS: Administrative Manual Holders, Direct treatment programs)	3.06-04	1/18/2011
Restrictions of Psychotherapy Notes and Informal Memory Prompts	3.06-05	2/1/2017
Special Situations Governing the Release of Information- Duty to Warn and Protect Third Parties in Response to a Client Threat (updated Feb 1, 2006, Tarasoff Decision) (CBHS: Administrative Manual Holders, Direct treatment programs)	3.06-09	9/24/2018
Special Situations Governing Release of Information under the Child Abuse and Neglect Reporting Act (CBHS: Administrative Manual Holders, Direct treatment programs)	3.06-11	8/14/2023
Responding to Court Order for Sealing Medical Records (CBHS: Administrative Manual Holders, Direct Treatment Programs)	3.06-12	1/3/2011
Special Situations Governing the Release of Information: Elder and Dependent Adult Abuse Reporting Requirement (CBHS: Administrative Manual Holders, Direct treatment programs)	3.06-13	8/14/2023
Responding to a Family Following Death of a CBHS Client: Grief Intervention and Disclosure of Information	3.06-16	3/1/2019
Professional Staff
Authority for Involuntary Detention for 72-Hour Evaluation and Treatment (CBHS: Administrative Manual Holders, Direct Treatment Programs)	3.07-02	4/27/2023
San Francisco Private Provider Network Selection and Retention (Administrative Manual Holders, Provider Systems Office, Contracts Office, SFMHP Claims Office, Group Providers, QM: Provider Compliance & Support Coordinator	3.07-4	3/23/2017
Clinical Pharmacists General Procedure and Protocol in CBHS Clinics (CBHS: Administrative Manual Holders, Assistant Directors, Direct Treatment Programs)	3.07-5	5/09/2017
Clinical Pharmacists with an Advanced Practice Pharmacist License General Procedure and Protocol in BHS Clinics	3.07-5.1	5/29/2018
Psychiatric-Mental Health Nurse Practitioners General Procedure and Protocol in CBHS	3.07-6	6/6/2023
Standards for Provider and Organizational Disclosures: Obtaining, Reporting and Monitoring	3.07-7	12/21/2022
Safety and Security
Sexual Battery and Assault: Treatment Guidelines for Adult Patients (CBHS: Administrative Manual Holders, Emergency & designated programs, Rape Treatment Services)	3.09-2	10/25/2011
Client Violence in Adult and Older Adult Programs (CBHS: Administrative Manual Holders, All CBHS Programs except Acute Inpatient Services)	3.09-03	9/19/2017
Occupational Bloodborne Pathogen Exposure Plan, PHP/OSH (DPH Policy: applies to all CBHS programs)	n/a	n/a
Charting
CBHS Medical Records Policy (CBHS: Administrative Manual Holders, Direct treatment programs)	3.10-02	12/19/2013
CBHS Medical Record Procedures for Closing Cases (CBHS: Direct treatment programs)	3.10-05	12/10/2013
Security and Retention of Medical Records (CBHS: Administrative Manual Holders, Direct treatment programs - Acrobat file)	3.10-07	7/17/2018
Dividing CBHS Client Medical Records into Multiple Volumes (CBHS: Administrative Manual Holders, Direct treatment programs - Acrobat file)	3.10-10	2/26/2016
Behavioral Health Progress Notes	3.10-11	10/29/2012
Accurate Recording of Client No-Shows	3.10-12	3/2/2017
CANS and PSC-35 Implementation	3.10-13	8/4/2020
Medi-Cal Documentation Requirements Requirements That Remain in Effect Superseded Regulations AOA CalAIM Updates At-A-Glance CYF CalAIM Updates At-A-Glance Adult SUD CalAIM Updates At-A-Glance CYF SUD CalAIM Updates At-A-Glance FAQ CalAIM Documentation Requirements	3.10-14	9/28/2022
Client Rights
Grievance and Appeal System for Behavioral Health Services	3.11-01	4/25/2023
Duties of the County Patients' Rights Advocate and Responsibility for Program Cooperation (Administrative Manual Holders, DMS programs, Short Doyle funded Forensic Programs, and Designated Facilities in San Francisco)	3.11-02	10/18/2022
Issuing Notices of Adverse Benefit Determination to Medi-Cal Beneficiaries Receiving Specialized Mental Health or Drug Medi-Cal Organized Delivery System Services (CBHS: Administrative Manual Holders, Direct treatment programs)	3.11-04	3/30/2022
Provider Problem Resolution and Appeal Process (CBHS: Administrative Manual Holders,SOC, CBHS Contracts Office, CBHS Organizational Providers, Associate Director SOC)	3.12-01	3/23/2017
Advance Medical Directives	3.13-01	3/23/2017
Behavioral Health Services General ADA Policy (updated January 23, 2024)	3.15-01	3/20/2018
Extra-Departmental Relations
ADA Public Meeting Policy	5.00-2	3/20/2018
Conflict of Interest Policy on Interactions Between Community Behavioral Health Services and the Pharmaceutical Industry	5.00-3	4/12/2023

CBHS Electronic Health Record
BHS Electronic Staff Signatures	6.00-01	5/4/2021
CBHS Electronic Prescribing	6.00-02	5/11/2022
BHS Electronic Record Security and Retention	6.00-03	5/4/2021
Electronic Health Record Data Collection Requirements	6.00-04	5/4/2021
Health Record Audit Policy	6.00-05	1/18/2011
Behavioral Health Services EHR Access Control Policy	6.00-06	5/4/2021
BHS Contracted Provider Anti-Virus Policy	6.00-07	5/4/2021
Client Electronic Signature Policy in Ambulatory Care	6.00-08	10/24/2019

Community Behavioral Health Services

Policies & Procedures

SECTIONS AND TITLES

Department Philosophy and Organization

Communication

Management Systems

Program Planning

Billing Information Systems

Personnel & Staff Development

Facilities

Service Delivery System

Components of System and Relationship

Naloxone DPH Clearinghouse

Residential Services

Eligibility and Admission

Accessibility of Service

Consent for Treatment

Release of Client Information

Professional Staff

Safety and Security

Charting

Client Rights

Extra-Departmental Relations

CBHS Electronic Health Record