REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 18, 2025
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 E:
1. Neonatal Intensive Care Unit Policy and Procedure Manual
2. Behavioral Health Policy and Procedure 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 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 Neonatal Intensive Care Unit Policy and Procedures Manual (NICU Manual) contain policies and procedures required by regulation or determined by ARMC Administration that pertains to neonatal intensive care unit. The NICU Manual contains 44 policies, of which eight policies have major revisions, 27 policies have minor revisions, and nine policies and the index were reviewed with no changes.
The Neonatal Intensive Care Unit completed the 2023-2025 review of the NICU Manual and recommends the revisions summarized in Attachment A. Update of this manual is certified in Attachment B.
The eight policies with major revisions consist of the following:
• Policy No. 111.14 v9, Safety and Security: Identification of Infant, and Release of Information - Reflects changes on how staff, visitors, and other agencies access the unit and how a newborn’s identity is confirmed when transferred into our unit from another hospital; this ensures patient safety.
• Policy No. 310.02 v6, Orientation to the Neonatal Intensive Care Unit - Updated the training/orientation process for new nurses and clearly explains what skills new nurses need and what nurses who float between units need.
• Policy No. 402.00 v3, Artificial Milk Preparation - Added instructions for preparing powdered milk. Removed adding powdered milk to ready-to-feed formulas.
• Policy No. 416.00 v5, Complete Exchange Transfusion - Explains that Blood Bank will handle mixing blood for transfusion and clarified the roles of the Practitioner (physician) and nurse during the procedure.
• Policy No. 424.00 v3, Skin to Skin Care - Explains how parents are prepared for skin-to-skin care and how they can safely move and care for their baby with a breathing tube, including how to position the baby and check their temperature.
• Policy No. 427.00 v9, Orogastric/Nasogastric Feeding - Explains and updates the use of stomach (gastric) tubes for removing air or fluid and provided clear instructions on selecting the right size tube, measuring, securing, and labeling it. We also improved the feeding procedure and added information about using special tubes and suction methods.
• Policy No. 432.00 v6, Standard of Care, NICU - Explains when and how to change intravenous lines, and how to chart, Updated stomach (gastric) tube placement, updated dietary consultations and case management requirements.
• Policy No. 440.00 v4, Thermoregulation in the Delivery - Clarified steps on how to keep the newborn’s temperature in a safe range and how to check the body temperature during admission and procedures.
There are 27 policies that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
The Behavioral Health Policy and Procedures Manual (BH Manual) contains 153 policies and procedures regarding department organization and function, customer service and unit specific policies and procedures required by regulation or determined by the Behavioral Health Administration and the Behavioral Health Department Leadership team to pertain to the Behavioral Health staff in the delivery of quality patient care services.
The ARMC Behavioral Health Department recommends major revisions to 38 policies (including four deletions) and one new policy. The Table of Contents has a minor revision to reflect the deletion and change in titles of the policies. The revisions are needed to further align with best practices and regulatory guidance and to reflect practice and process for the adolescent units.
The ARMC Behavioral Health Department recommends the revisions summarized in Attachment C.
The 38 policies with major revisions consist of the following:
• Policy No. 100 v8, Scope of Services - Major changes: This policy now allows the Behavioral Health department to serve adolescents between the ages of 13 and 17. The age range is based on the type of programs offered and the qualifications of the staff working in those units. The term “Psychiatric Triage” has been updated to “Psychiatric Emergency Department (ED).” Adolescents and individuals with severe substance use disorders have been added to the populations served. Additionally, the title “Clinical Therapist” has been changed to “Clinical Therapy Department.”.
• Policy No. 202 v5, Transfers to Behavioral Health - Major changes: This version provides detailed instructions for transferring patients from other hospital departments to the Behavioral Health unit. It also outlines the process for moving patients from the Emergency Department to Behavioral Health and vice versa, ensuring smoother and safer transitions for patients.
• Policy No. 203 v8, Patient Movement - Major changes: The updated policy includes procedures for managing adolescents under a 5585 hold, which is used for minors experiencing a mental health crisis. It removes outdated legal references and replaces “Psychiatric Triage” with “Psychiatric Emergency.” It also introduces guidelines for where adolescents on voluntary holds should wait safely within the facility.
• Policy No. 204, v5 Visiting Procedures and Staff Coverage - Major changes: Visiting hours have been adjusted, and the policy now allows minors to receive visits in the adolescent unit when appropriate. These changes aim to support family involvement in care while maintaining safety and structure.
• Policy No. 400 v6, Acuity Staffing Plan - Major changes: Staffing plans have been updated to reflect current needs and now include adolescent inpatient and emergency units. The revised plan ensures that staffing levels are appropriate for the level of care required in each unit.
• Policy No. 401 v5, Social Work Staffing Plan - Major changes: The age range for patients served by social work has been updated to 13 to 65 years old. Certification hearings have been removed from the list of services provided. The policy now includes the PsyD (Doctor of Psychology) role and adds the 2BHN inpatient unit to the staffing plan.
• Policy No. 402 v5, Patient Assignments - Major changes: This policy clarifies the staff-to-patient ratios, setting a 6:1 ratio for inpatient units and a 4:1 ratio for emergency units. It also requires that at least 50% of the staff be Registered Nurses (RNs). The paper-based patient rounds log has been removed due to the implementation of electronic rounding.
• Policy No. 500 v10, Orientation and Staff Development/Education - Nursing Staff - Major changes: Orientation programs now include training for adolescent units and 5585 holds. The previous Management of Aggressive Behavior (MAB) training has been replaced with a hospital-approved crisis management training program to better prepare staff for handling challenging situations.
• Policy No. 713.01 v7, Hospital Approved Crisis Management Training - Major changes: The policy has been renamed to “Hospital-Approved Crisis Management Training” and now refers to Crisis Prevention & Intervention (CPI) instead of MAB. This change standardizes the language and aligns with current training practices.
• Policy No. 718 v8, Admissions Criteria - Major changes: The policy now includes 5585 holds for adolescents and updates the exclusion criteria. Outdated and inappropriate terms have been replaced with more respectful language, such as using “individuals with intellectual disabilities” instead of “mentally retarded,” and “social or behavioral issues” instead of “community nuisances.”
• Policy No. 800 v5, Environment of Care (EOC) Manual - Major changes: This update reflects changes in leadership roles, replacing the Safety Officer with the Clinical Director II. It also aligns the policy with current Joint Commission (TJC) standards to ensure compliance and safety.
• Policy No. 803 v6, Safety: Patient, Visitor, and Personnel - Major changes: The Assistant Hospital Administrator (AHA) has been replaced with the Clinical Director II. Staff are now instructed to report safety concerns through the Unusual Occurrences Reporting portal instead of using paper forms, streamlining the reporting process.
• Policy No. 806 v5, Code Grey (Stat Call) - Major changes: References to MAB have been updated to reflect the new crisis management training. Leadership roles have also been updated, replacing the Assistant Administrator and AHA with the Clinical Director II to reflect current organizational structure.
• Policy No. 811 v5, Fire Evaluation Plan - Major changes: The fire evacuation plan has been revised to include updated locations, such as the Adolescent Psychiatric Emergency Department. Outdated references, like the area behind the mailroom, have been replaced with current facility areas.
• Policy No. 811.01 v4, Disaster Plan - Major changes: This policy now includes updated department names and abbreviations, such as Behavioral Health (BH) and Clinical Director II. It replaces references to pediatric care with adolescent care and updates evacuation and command center locations to reflect current practices.
• Policy No. 811.02 v2, Emergency Evacuation Plan - All BH Units - Major changes: The evacuation plan has been consolidated for all Behavioral Health units, making it easier to follow. It replaces outdated unit names and exit descriptions with current ones and confirms that all units now share a universal evacuation area.
• Policy No. 1001 v6, Notification of Release to County Mental Health Director Peace Officer - Major changes: This policy now includes requirements for notifying parents or guardians when minors are released from care, especially those under a 5585 hold. It also aligns with Joint Commission standards and reminds providers of their responsibility to inform families.
• Policy No. 1002 v7, Certification Review Hearings - Major changes: Adolescents are now included in the certification hearing process, and the policy requires that parents or guardians be notified. This ensures that minors and their families are informed and involved in legal proceedings related to mental health care.
• Policy No. 1003 v7, Procedure for Handling Allegations of Sexual Familiarity - Major changes: The policy now includes adolescents and references 5585 holds. It also clarifies that nursing staff, rather than Behavioral Health staff, are responsible for transporting patients to the Sexual Assault Response Team (SART) facility.
• Policy No. 1004 v6, Involuntary Patient Advisement - Major changes: This update includes information about 5585 holds for adolescents and revises the related forms and language to ensure clarity and compliance with current standards.
• Policy No. 1005 v6, Involuntary Patients - Major changes: The policy now requires that parents or guardians be notified when minors are placed on involuntary holds. It also includes 5585 holds for adolescents and reminds providers of their duty to inform families.
• Policy No. 1006 v7, Voluntary Patients - Major changes: This version adds requirements for guardian consent when treating adolescents voluntarily. It also states that voluntary patients can be restrained or secluded if they pose a danger. A Roger S. hearing is required if a teen wants to leave care but their guardian disagrees.
• Policy No. 1007 v6, Leaving Against Medical Advice - Major changes: The policy now includes 5585 holds for adolescents who attempt to leave care against medical advice, ensuring that appropriate legal protections are in place.
• Policy No. 1011 v6, Patients’ Rights - Major changes: This update adds rights for parents, guardians, and family members of adolescent patients. It removes the rule allowing patients to carry $3 in cash and allows staff to inspect mail if there are concerns about contraband. It also includes Roger S. hearings for adolescents.
• Policy No. 1012 v6, Patient Abandonment - Major changes: The policy now includes legal protections for adolescents under PC270.5 and requires guardian involvement in consent decisions. It adds the Adolescent Psychiatric Triage as a location and outlines steps to take if a facility refuses to accept a patient back.
• Policy No. 1013 v6, Seen and Release Individuals - After Hours - Major changes: This policy now includes adolescents as part of the population served and aligns with Joint Commission (TJC) standards. It clarifies that adolescents cannot be released on their own after being seen. A parent or legal guardian must be contacted and give consent before the adolescent can leave the facility. This ensures the safety and proper discharge of minors after hours.
• Policy No. 1018 v5, Patient Safekeeping - Major changes: The policy has been updated to meet TJC standards and now requires that at least two staff members be present when patients are changing into hospital scrubs. This change is intended to protect both patients and staff by ensuring proper observation and accountability during these procedures.
• Policy No. 1021 v6, Clothing Search - Major changes: This update includes TJC standards and requires a minimum of two staff members to be present when a patient changes into scrubs. The term “adolescent triage” has been removed to keep the language more general, using “psychiatric triage” instead. These changes help standardize safety procedures across all patient groups.
• Policy No. 1026 v4, Consent to Use of Psychotropic Medication - Major changes: The policy now includes TJC standards and specifies that parents or legal guardians must provide consent for adolescents to receive psychotropic medications. The consent form has been updated to a new version, and the policy ensures that legal guardians are properly involved in treatment decisions for minors.
• Policy No. 1029 v5, 5150 Validation - Major changes: This version includes updates to meet TJC standards and adds the adolescent triage unit to the policy. It also introduces the 5585 hold for adolescents and includes references to the adolescent psychiatric triage unit. These updates ensure that legal and clinical procedures are clearly defined for both adults and minors in crisis.
• Policy No. 1031 v3, Patient to Patient Assault - Major changes: The policy now includes updates for adolescents and patients under legal conservatorship. It meets TJC standards and includes new requirements for notifying the California Department of Public Health (CDPH) when necessary. The outdated MAB training reference has been replaced with hospital-approved crisis management training. The Department of Health Services is now referred to as the Regulatory Department, which will determine if an incident needs to be reported. The policy also ensures that appropriate notifications are made for incidents involving adolescents and conserved patients.
• Policy No. 1032 v2, Psychotropic Medications, Administration of - Major changes: This update includes TJC standards and changes how emergency medications are handled. Instead of allowing a 24-hour timeframe for administration, the policy now permits only a one-time administration. The requirement to verify 24-hour orders has been removed, as those orders are no longer used.
• Policy No. 1033 v2, Safe Items/Sharps - Major changes: Updated to include TJC standard The policy has been updated to meet TJC standards and now includes the Adolescent Psychiatric Triage unit. However, the term “adolescent psychiatric triage” has been removed from the general language to make the policy more broadly applicable across all units. These changes help ensure safety while maintaining consistency.
• Policy No. 1200 v7, Medical Record - Major changes: This policy has been revised to include the 5585 hold for adolescents in the list of documentation requirements. The issue number has been updated to version 7, and the inclusion of 5585 ensures that adolescent mental health holds are properly recorded in the medical record system.
There are four policies that were deleted. These policies were replaced by new ones and added into a consolidated evacuation procedure policy.
• Policy No. 811.03 v1, Emergency Evacuation Plan - BH Inpatient Units - Major changes: Retired.
• Policy No. 811.04 v1, Emergency Evacuation Plan - 1BHN - Major changes: Retired.
• Policy No. 811.05 v1, Emergency Evacuation Plan - 1BHS - Major changes: Retired.
• Policy No. 813 v3, Patient Locator Flowsheet - Major changes: Retired and replaced by policy 826 v1. Replaces patient locator flowsheet with patient safety checks.
There is one new policy to replace the one that was deleted. This policy is in Attachment D.
• Policy No. 826 v1, Patient Safety Checks - New policy to replace policy 813 v3. Replaces patient locator flowsheet with patient safety checks.
On November 4, 2025 (Item No. 5), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment E.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on October 23, 2025; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on October 24, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on October 28, 2025.