REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
August 6, 2024
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Nutrition Services 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 Nutrition Services Policy and Procedure Manual, 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 Manuals are non-financial in nature.
BACKGROUND INFORMATION
ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and other appropriate regulations and guidelines. Per CMS and The Joint Commission, all ARMC Operations, Policy, and Procedure 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 and policies 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 policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The Nutrition Services Policy and Procedure Manual (Nutrition Manual) contains policies and procedures regarding nutrition services, assessment, documentation, consultation, and preparation and delivery of quality meal services. The Nutrition Manual contains a total of 90 policies. There are two new policies added, 14 major revisions, 20 policies and the Table of Contents have minor revisions, and 54 policies have been reviewed with no changes.
ARMC completed the 2022 review of Nutrition Manual and recommends the revisions summarized in Attachment A.
The two new policies added to the manual are included in Attachment B, and consist of the following:
• Policy No. 902.01 v1, Nutrition Assessment - Outpatient Dialysis. New policy for nutrition assessment in outpatient dialysis.
• Policy No. 904.03 v1, Outpatient Nutrition Consults. New policy for outpatient nutrition with screening and assessment process. Malnutrition screening tool used for new oncology and infusion patients.
There are 14 policies that contain major revisions consist of the following:
• Policy No. 100.00 v4, Purpose, Objective, & Authority of the Nutrition Services Department - Added the clarification of the nutrition department leadership roles.
• Policy No. 300.00 v6, Dietary Personnel Management:
Section II: Time and Attendance - Updated to our current time clock procedures and outlining employees’ responsibility regarding Kronos.
Section IX: Vacation - Clarified how holidays are awarded.
Section XIII: Chain of Command - Updated to include new leadership positions.
Section XIV: Accidents - Updated to include the new event reporting (RLDatix) system.
• Policy No. 303.00 v10, ADA Registration - Rename to CDR Registration. Replace American Dietetic Association (ADA) with Commission on Dietetic Registration (CDR).
• Policy No. 506.00 v3, Reporting Unusual Occurrence - Revised Meditech to Electronic Medical Record (EMR).
• Policy No. 804.00 v4, Catering Requests and Approval - Updated the policy to match Administrative (ADM) Policy 110.03. Clarified approval language of administrator instead of Compliance. Removed reference fees to outside vendors. Added details regarding when meals are served and when not served.
• Policy 900.00 v9, Manual of Clinical Nutrition - Update Dysphagia Diets to International Dysphagia Diet Standardization Initiative (IDDSI). Removal of infrequently used diets.
• Policy 901.01 v5, Pediatric Nutrition Screening and Assessment - Meditech replaced with Electronic Medical Record (EMR). Updated screening and scoring process.
• Policy 901.02 v8, Neonatal Intensive Care Unit (NICU) and Newborn Nursery Nutrition Screening and Assessment - Meditech replaced with Electronic Medical Record (EMR). Updated screening and assessment process.
• Policy 901.03 v5, Obstetric Nutrition Screening and Assessment - Remove and combine with Policy 901 Nutrition Screening.
• Policy 903.00 v5, Nutrition Documentation - Meditech replaced with Electronic Medical Record (EMR). Meditech procedures replaced with EMR progress note format. Revised documentation format to the Nutrition Care Process (NCP) format.
• Policy 904.00 v4, Consults Nutrition - Renamed policy to Inpatient Nutrition Consults. Combined with Policies 904.01 and 904.02.
• Policy 904.01 v5, Consultation - Enteral Feeding - Combined with Policy 904.00 Consults Nutrition.
• Policy 904.02 v5, Consultation - Total Parenteral Nutrition (TPN) - Combined with Policy 904.00 Consults Nutrition.
• Policy 909.00 v7, Enteral Preparation, Storage, Delivery and Administration - Addition of verifying orders in EMR, preparation procedures of specialized formulas. Removal of Registered Nurse administration process.
The 20 policies with minor revisions consist of minor grammatical revisions.
Review and update of the Nutrition Manual is certified in Attachment C.
On July 23, 2024 (Item No. 9), 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 July 7, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on July 12, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on July 17, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on July 17, 2024.