REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
December 3, 2024
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
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 G:
1. Behavioral Health Policy and Procedures Manual
2. Ambulatory Care Services Breathmobile Policy and Procedures Manual
3. Graduate Medical Education Committee Policy and Procedures Manual
(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 Manuals (Manuals) are non-financial in nature.
BACKGROUND INFORMATION
The Manuals 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 Manuals are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these Manuals will 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 Manuals reviewed include the Behavioral Health Policy and Procedure Manual (Behavioral Health Manual), Ambulatory Care Services Breathmobile Policy and Procedure Manual (Breathmobile Manual), and Graduate Medical Education Committee Policy and Procedure Manual (GME Manual).
The Behavioral Health Manual contains 173 policies and procedures regarding department organization and function, customer service, and unit specific policies and procedures required by regulation, or by the Behavioral Health Administration and Behavioral Health Department Leadership team, applicable to Behavioral Health staff in the delivery of quality patient care services. ARMC recommends major revisions to four policies, deletion of 34 policies, and minor revisions to 46 policies. The remaining 89 policies have been reviewed and there are no recommended changes. The Table of Contents was also updated to reflect the deletion and change in titles of the policies.
The four policies with major revisions consist of the following:
• Policy No. 100 v7, Scope of Services - Allows for people over the age of 65 to be evaluated for appropriateness to admit into the Behavioral Health department. This removes the exclusion for admission based solely on age 65 and older. Also removed break down of units as they no longer are applicable to the department.
• Policy No. 713.01 v6, Management of Aggressive Behavior (MAB) - Change of title from Assaultive to Aggressive.
• Policy No. 721 v3, Incoming Transfer Procedure and Log Documentation - Process Change due to presence of Transfer Center.
• Policy No. 1015 v6, Riese Court/Decision Procedure for Medication Competency Hearings - Process change due to following Superior Court calendar and Department of Behavioral Health being responsible for court transportation.
There are 34 policies that were deleted. These policies contained outdated position descriptions and processes that are no longer applicable.
• Policy No. 300 v1, Assistant Hospital Administrator-Behavioral Health Position Description - outdated position description.
• Policy No. 303 v3, Mental Health Nurse II Position Description - outdated position description.
• Policy No. 303.01 v2, Mental Health Nurse II/Charge Nurse Position Description - outdated position description.
• Policy No. 304 v4 Mental Health Nurse I Position Description - outdated position description.
• Policy No. 305 v3, Licensed Vocational Nurse II Position Description - outdated position description.
• Policy No. 306 v3, Licensed Vocational Nurse I Position Description - outdated position description.
• Policy No. 307 v4, Psychiatric Technician I Position Description - outdated position description.
• Policy No. 308 v4 Behavioral Health Clinic Supervisor Position Description - outdated position description.
• Policy No. 309 v4, Clinical Therapist II Position Description - outdated position description.
• Policy No. 310 v4, Clinical Therapist I Position Description - outdated position description.
• Policy No. 311.1 v4, Pre-Licensed Clinical Therapist I Position Description - outdated position description.
• Policy No. 312 v3, Mental Health Clinician I (D) Position Description - outdated position description.
• Policy No. 313 v3, Occupational Therapist II Position Description - outdated position description
• Policy No. 314 v4, Occupational Therapist I Position Description - outdated position description.
• Policy No. 315 v4, Certified Occupational Therapy Assistant Position Description - outdated position description.
• Policy No. 316 v3, Secretary I Position Description - outdated position description.
• Policy No. 317 v1, Office Assistant III Position Description - outdated position description.
• Policy No. 318 v4, Hospital Unit Assistant Position Description - outdated position description.
• Policy No. 320 v3, Verification of License, Certificate and Registration - outdated position description.
• Policy No. 321 v1, Nurse Manager/Nursing Supervisor - Behavioral Health Administration Position Description - outdated position description.
• Policy No. 322 v1, Mental Health Nurse Manager Position Description - outdated position description.
• Policy No. 712 v1, Special Observation Unit (SOU)- no longer applicable.
• Policy No. 712.01 v1, Visitation for Patients on 1:1s/Physical Restraints - no longer applicable.
• Policy No. 730 v3, Consultation and Emergency Medical Care - no longer applicable.
• Policy No. 731 v1, Electroconvulsive Treatment, Psychosurgery, Aversive Conditioning - no longer applicable.
• Policy No. 739 v3, Providing Care for Patient’s Incontinent Episodes - no longer applicable.
• Policy No. 756 v1, Multi Drug Resistant Organism (MDRO), Patient with - no longer applicable.
• Policy No. 759 v1, Patient Abuse - Deleted. Refer to Administrative (ADM) Policy 690.21.
• Policy No. 822 v1, Personal Alarms - no longer applicable.
• Policy No. 906 v1, Patient with Multi Drug Resistant Organism MDRO - no longer applicable.
• Policy No. 1010 v4, Hearing for Jail Hold Patients Description - Deleted. No jail patient in BH.
• Policy No. 1030 v2, Management of Prisoners in the Behavioral Health Unit (BHU)- Deleted. No Prisoners in BHU.
• Policy No. 1100 v5, State Hospital Admission Documents - no longer applicable.
• Policy No. 1103 v1, Handicap Access and Grab Bars - no longer applicable.
Forty-six policies contain minor grammatical revisions and specifications of acronyms.
The Behavioral Health Department completed the 2022-2024 review of the Behavioral Health Manual and recommends the revisions summarized in Attachment A. Update of this manual is certified in Attachment B.
ARMC completed the 2024 review of the Breathmobile Manual and recommends the revisions to all 25 policies, as summarized in Attachment C. Update of this manual is certified in Attachment D. The Breathmobile Manual’s minor revisions consist of updates, formatting, and grammatical corrections. The Table of Contents has also been updated to reflect changes to the titles of some of the policies.
The Graduate Medical Education Committee (GME Committee) is required by the Accreditation Council for Graduate Medical Education (ACGME) who is the accrediting body for all medical residency programs in the United States. ACGME requires the GME Committee to demonstrate effective oversight of ARMC’s residency programs. Part of this oversight requirement includes the implementation of certain institutional polices which are set forth in the GME Manual. The GME Committee has reviewed the GME Manual, which consists of 20 policies, and recommends major revisions to two policies, minor revisions to 17 policies, and updates to the Table of Contents. One of the policies was reviewed with no recommended change.
The GME Committee recommends the revisions to the GME Manual as summarized in Attachment E. Update of this manual is certified in Attachment F.
The two policies with major revisions consist of the following:
• Policy No. 1-011 v3, Resident Supervision Policy - Removed several sections that were too prescriptive for an institution policy.
• Policy No. 1-020 v2 Resident Medical Licensure Policy - Removed several sections due to changes in State law revolving around resident licensure.
The minor revisions to the 17 policies relate to updating the Designated Institutional Official and revising the format for the numbering of the policies in the manual. The Table of Contents was revised to reflect the updated policy numbering.
On November 19, 2024 (Item No.8), the Board accepted and approved the report of review and certification of the Manuals listed in Attachment G.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on November 6, 2024; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on November 8, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on November 8, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on November 14, 2024.