REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 23, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Clinical Social Work Department Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through D.
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost) Revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manual are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all manuals are reviewed and revised, as necessary, a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The manual and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals improve County government operations and provide for the safety, health, and social service needs of County residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Clinical Social Work Policy and Procedures Manual (Social Work Manual) contains policies and procedures regarding departmental scope of practice, organization, provisions of practice followed by clinical social work staff in providing patient care and/or determined by ARMC Administration as pertaining to the specialty. The Social Work Manual contains 92 policies, of which 47 policies have major revisions (including 34 deletions), 27 policies and the index have minor revisions, and 18 policies were reviewed with no recommended changes.
The Clinical Social Work department completed the 2025 review of the Social Work Manual and recommends the revisions summarized in Attachment A. An update of this manual is certified in Attachment B.
There are 34 policies that were deleted. These policies contained Human Resources position descriptions which are not required in department policies, contained processes that are no longer applicable, and/or were duplications of existing Administrative Policies.
• Policy No. 021 v5, Social Services Manager - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 024 v2, Office Assistant IV - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 025 v4, Office Assistant III - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 026 v1, Supervising Social Service Practitioner - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 027 v2, Social Service Practitioner - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 029 v2, Lead Social Service Practitioner - Delete. Human Resources position descriptions are not required in department policy and procedures.
• Policy No. 031 v3, Staff Assignments - Combined with Clinical Social Work Policy No. 030 Departmental Divisions/Assignments
• Policy No. 032 v3, Burn Unit - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 033 v4, Intensive Care Unit - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 034 v4, Pediatrics - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 035 v6, Medical / Surgical Units - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 037 v5, Emergency Department - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 039 v4, Outpatient Clinics - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 040 v5, Women’s Health-Inpatient / Clinics - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 041 v5, Neonatal Intensive Care Unit - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 042 v4, Outpatient Dialysis - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 045 v2, Stroke Unit - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 046 v2, Palliative Care - Delete. Role of Social Service Practitioner is covered in Clinical Social Work Policy No. 003 Scope of Service.
• Policy No. 90 v4, Department Objectives - Delete. Hospital-wide department Performance Improvements requirements are covered in ADM 300.03 v15 Quality Assurance and Performance Improvement Plan
• Policy No. 91 v6, Annual Reporting Schedule - Delete. Hospital-wide department Performance Improvements requirements are covered in ADM 300.03 v15 Quality Assurance and Performance Improvement Plan
• Policy No. 92 v5, Summary Reports - Delete. Hospital-wide department Performance Improvements requirements are covered in ADM 300.03 v15 Quality Assurance and Performance Improvement Plan
• Policy No. 105 v4, Access to Patient Medical Record - Delete. Process is outlined in Health Information Management Policy No. 321.00 Release of Patient Medical Records/Health Information & ADM Policy No. 810.02 Release of Medical Records Patient Information.
• Policy No. 131 v3, Meal Provisions - Delete. Topic covered in ADM Policy No. 630.02 Patient Nourishment and ADM Policy No. 630.03 Patient Meals.
• Policy No. 132 v5, Shelter / Homeless Referrals - Delete. Policy is a duplication of ADM Policy No. 690.24 Homeless Discharges.
• Policy No. 133 v2, Alcohol / Drug Rehab - Delete. Referral procedures covered under CSW Policy No. 161 Patient Choice.
• Policy No. 134 v5, Domestic Violence - Delete. Referral process covered under CSW Policy No. 161 Patient Choice. Domestic Violence procedures covered under ADM Policy No. 620.04 Reporting of Abuse-Domestic Violence.
• Policy No. 136 v3, Referrals to Behavioral Health - Delete. Referral procedures covered under CSW Policy No. 161 Patient Choice.
• Policy No. 138 v4, Interpreter Services - Delete. Interpreter Services process is covered under ADM Policy No. 900.02 ADA Effective Communication for Dead or Hard of Hearing & ADM Policy No. 900.05 Limited English Proficiency Effective Communication.
• Policy No. 139 v3, Indigent Burial Arrangements / Morgue Referrals - Delete. Morgue visits are covered under ADM Policy No. 690.05 Morgue Placement Viewing and Releasing of Bodies. Details on disposition of fetus are not within Clinical Social Work scope of practice and process is covered under Maternal Child Health Policy No. 5245 Miscarriage Stillbirth and Previable Neonate Care. Referral process for morgue resources is covered under CSW Policy No. 161, Patient Choice.
• Policy No. 141 v3, Safe Surrender of Newborn - Delete. Duplication of ADM Policy No. 690.08 Safe Surrender. ADM policy was updated to include distribution process of packets.
• Policy No. 151 v5, Suspected Adult Abuse - Delete. Duplication of ADM Policy No. 620.02 Elder, Dependent Adult Abuse.
• Policy No. 152 v6, Suspected Child Abuse - Delete. Duplication of ADM Policy No. 620.01 Reporting of Abuse-Children.
• Policy No. 153 v5, Suspected Assault / Domestic Violence - Delete. Duplication of ADM Policy No. 620.04 Reporting of Domestic Violence Abuse.
• Policy No. 182 v4, Medical Transport - Medivan - Delete. Merged with CSW Policy No. 181 Medical Transport.
The remaining 13 policies that had major revisions consist of the following:
• Policy No. 003 v4, Scope of Service - Condensed verbiage. Removing hospital area descriptions, as Social Service Practitioners (SSPs) have the same scope of practice in all areas. Removed On-Call attachment as it’s a Standard of Practice (SOP), not policy. Added verbiage on alignment with State/Accreditation standards. References updated.
• Policy No. 006 v6, Organization and Chain of Command - Condensed verbiage. Removing On-Call attachment, it is a standard of practice, not policy. Updated Leadership chain of command.
• Policy No. 030 v2, Departmental Divisions / Assignments - Renamed and combined Clinical Social Work Policy No. 030 Departmental Divisions/Assignments and Clinical Social Work Policy No. 031 Staff Assignment.
• Policy No. 056 v6, Time and Attendance - Condensed verbiage. Removed duplication of topics addressed in Administrative (ADM) Policies 210.01-210.04.
• Policy No. 070 v7, Staff Orientation - Workflow remains the same. Removed attachments of orientation sheets due to constant change. SOP, not policy.
• Policy No. 081 v6, Weekend and Holiday Protocols / Procedures - Workflow remains the same. Removed attachment (SOP, not policy).
• Policy No. 085 v5, Requests for Legal Counsel - Updated chain of communication, current process and outlined specifics.
• Policy No. 112 v5, Medi-Cal Issues / Referrals - Workflow remains the same. Removed repetitive verbiage and updated outdated verbiage.
• Policy No. 143 v4, Hospital Home Schooling - Workflow remains the same. Updated verbiage and added correct References.
• Policy No. 150 v4, Perinatal Substance Abuse Screening - Workflow remains the same. Verbiage updated, References updated, and clarified Children Family Services process.
• Policy No. 164 v6, Conservatorship / Public Guardian - Workflow remains the same. Attachments updated.
• Policy No. 180 v6, Non-Medical Transport - Workflow remains the same. Verbiage updated. Distribution process is SOP, not policy.
• Policy No. 181 v6, Medical Transport - Titled changed. Merged CSW Policy 181 Medical Transport & CSW Policy 182 Medical Transport-Medivan, as both are related to Medical Transports. No change to the workflow of securing Medical Transport. Verbiage updated. Attachments removed due to varying case by case and level of need.
There are 27 policies that contain minor revisions, consisting of grammatical corrections, condensed duplicated verbiage, chain of command name updates, and corrected abbreviations of disciplines.
The Administrative Policy and Procedure Manual (Administrative Manual) contains hospital-wide policies and procedures, which are required by regulation, or determined by the ARMC Administration to pertain to the entire ARMC facility/staff. These policies are important to the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. The Administrative Manual includes several policies that relate to clinical social work. As part of the Clinical Social Work department’s review of the policies in the Administrative Manual that relate to clinical social work, the department recommends major revisions to five of the 383 policies in the manual.
The major revisions were necessary due to updates to care, updates to attachments, and to clarify certain practices, as follows:
• Policy No. 620.01 v4, Reporting of Child Abuse - No change to workflow. Updated attachments, Practitioner verbiage, clarified Social Service Practitioner method of contact, and submission of forms process.
• Policy No. 620.02 v4, Abuse - Elder, Dependent Adult - No change to workflow. Updated attachments, Practitioner verbiage, clarified Social Service Practitioner method of contact, and submission of forms process.
• Policy No. 620.03 v5, Abuse - Health or Community Care Facility - No change to workflow. Updated attachments, Practitioner verbiage, and clarified Social Service Practitioner method of contact.
• Policy No. 620.04 v3, Abuse - Reporting of Domestic Violence - No change to workflow. Updated attachments, Practitioner verbiage, and name of reporting forms.
• Policy No. 620.08 v5, Safe Surrender of Newborn - No change to workflow. Updated attachments, outlined process, and updated attachment reference.
The department also recommends a minor revision to Policy No. 690-24 v5 to correct the discipline title from “physician” to “practitioner.”
The recommended revisions to the Administrative Manual are set forth in Attachment C.
On September 9, 2025 (Item No. 13), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on August 20, 2025; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on August 29, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on September 3, 2025.