are essential if the Grand Jury is to investigate properly and recommend appropriate actions. All complaints are

Recommendations 21

• R00-49
  PROVIDE WATER SOFTENING EQUIPMENT TO ELIMINATE OR REDUCE CORROSIVE PROBLEMS WITH PIPING AND PLUMBING EQUIPMENT.
• R00-50
  UPDATE ENGINEERING SPECIFICATIONS REGARDING THE CORROSIVE EFFECTS OF UNTREATED WATER AND THE NEED TO REPLACE PIPING AHEAD OF SCHEDULE.
• R00-51
  REVIEW EQUIPMENT IN HEAT-PRONE AREAS FOR RELOCATION, IMPROVE VENTILATION, OR PROVIDE COOLING SYSTEMS FOR EACH PIECE OF EQUIPMENT TO ELIMINATE FIRE SPRINKLER SYSTEMS BEING ACTIVATED.
• R00-52
  CONTACT APPROPRIATE COUNTY SAFETY AGENCY FOR PROPER TYPE/KIND OF FIRE EXTINGUISHER AND EYEWASH STATION SIGNS. ARMC CASH COLLECTIONS BACKGROUND As a result of a major embezzlement of cash receipts from the County Medical Center (CMC), the 1996-97 San Bernardino County Grand Jury investigated the Fiscal Services Division and found the management practices, policies, and procedures were not in compliance with County standards. The Grand Jury recommended the County take numerous steps to eliminate future non-compliance and possible embezzlement of funds. In response, the Board of Supervisors and CMC administrators established new and revised management policies and procedures. The 1999-2000 Grand Jury wanted to know if these practices, procedures, and policies were being followed at the new Arrowhead Regional Medical Center (ARMC) and, if so, what steps are being taken to insure their continued compliance. FINDINGS Administrators and supervisors in the ARMC Finance Department stated that their cash collection system at the time of the embezzlement was good but, since then, they have improved procedures to prevent a reoccurrence. At the same time, they commented that a very intelligent person, bent on embezzling, could find a way. A ten-page narrative outlines a step-by-step procedure for the collection, posting, and deposit of receipts, including cash, from all ARMC departments, cafeteria and vending machines. Grand Jury members observed all steps in these procedures from collection to deposit in the safe within the vault. The segregation of duties prohibits any one person from having access to both patient accounts and processing of cash receipts. This was a major factor in the aforementioned embezzlement. New procedures give only four (4) individuals access to the safe. The safe and vault are locked at all times. ARMC’s banking procedure is part of the County’s Consolidated Banking System. When ARMC deposits daily receipts, a coded deposit slip identifying the department is prepared. Receipts are taken by Brink’s Armored Carrier to a Bank of America specialized vault in Ontario. The Ontario location is designed to accommodate armored carriers with maximum security. Deposits start earning interest immediately. County departments are notified and have access to their funds in two (2) days. The Auditor/Controller-Recorder’s office (Supervising Accountant) has ultimate responsibility for reconciling all discrepancies. At the present time ARMC cannot accept credit card payments on accounts. The accountant stated that it could be beneficial and cost effective to do so. RECOMMENDATIONS
• R00-53
  CONTINUE TO CLOSELY MONITOR ARMC COLLECTION POLICIES AND PROCEDURES, ESPECIALLY IN THE AREA OF CASH RECEIPTS. REMAIN CONSTANTLY ALERT FOR IMPROVEMENT IN INTERNAL CONTROLS TO PREVENT ANY POSSIBILITY OF EMBEZZLEMENT.
• R00-54
  CONDUCT A STUDY AND, IF FEASIBLE, IMPLEMENT A SYSTEM TO ACCEPT CREDIT CARD PAYMENTS AT THE ARROWHEAD REGIONAL MEDICAL CENTER AND ITS AFFILIATED CLINICS. PUBLIC HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES FOOD PROTECTION PROGRAM BACKGROUND The mission of the Division of Environmental Health Services (DEHS) is to prevent, eliminate, or reduce environmental hazards that could harm the health, safety, and quality of life of the citizens of this County. The Retail Food Protection Program consists of activities required to ensure food provided for human consumption is of good quality, safe, free of adulteration, wholesome, and properly labeled and advertised. The program also strives to ensure food has been produced, stored, and transported under conditions and practices that are safe, clean, and sanitary. The program is responsible for the inspection of all places where food is eaten, processed, sold, or stored (restaurants, markets, food stands, carnivals, schools, nursing homes, etc.) for sanitation and food safety, including manufacturers and wholesalers. The program investigates complaints of suspected food poisoning, unsanitary conditions, and other problems. The program also provides education and training in proper sanitation and food safety techniques to the food workers/servers, operators/managers, and owners of food facilities. The DEHS issues public health permits to all food facilities. The 1997-98 Grand Jury recommended a return to public posting using the “A-B-C” rating system or to a simple placard of certification. Neither of these systems has been implemented. In the response from the Board of Supervisors, it states: “The department is planning to require posting a card or placard at the entry to restaurants that will state that the facility has been inspected and has been issued a permit to operate consistent with Health and Safety Code requirements.” FINDINGS In meetings with the Division Chief and Food Program Manager, the Grand Jury learned that the DEHS has 60 employees to cover over 10,000 establishments in the County. The Food Protection Program has 39 inspectors and each is responsible for about 350 accounts. An inspection usually takes from one to one and one-half hours. A written report is left at the facility. If there are minor violations, the owner is to correct them in a specified length of time, and a re-inspection is required. Any facility receiving less than 60 out of 100 points could be temporarily shut down, depending on the nature of the violation. The DEHS cannot levy a fine to an establishment for repeated noncompliance. Only the environmental court in Redlands can levy monetary fines. If a facility is closed by DEHS, the owner can sue in court. In 1999 DEHS closed 586 miscellaneous facilities. They included restaurants, supermarkets, drug stores, recreational facilities, etc., and a large number of unpermitted establishments (no license or health permit). Two teams of two Grand Jurors each accompanied DEHS inspectors – one team to a restaurant and one to a grocery market. The inspections were unannounced and the owners did not know in advance of the visits. The restaurant was a very busy coffee shop-style facility located near a freeway offramp and catered to truckers and law enforcement personnel. The inspector very carefully and thoroughly inspected all areas of the facility, inside and out, with special attention given to those items that needed follow- up from the previous inspection. He noted much improvement in pest control procedures. The inspection file on this restaurant dated from 1983 and the single-most ongoing problem, repeatedly, has been with maintaining adequate temperature control of both hot and cold foods. This visit was no exception. A worker was asked to adjust temperature controls on food warmers and also refrigerated units. Numerous minor violations were found in the kitchen area, dry storage area, exterior dumpster area, and leaky plumbing. Both restrooms were clean and bright. This restaurant received a score of 56 and was reinspected two weeks later, at which time very good compliance was observed by the inspector. A copy of this re-inspection report was provided to the Grand Jury. No inspection certificate or placard was issued for display. The grocery market was a recently opened independent store in a building that formerly housed a chain supermarket. There were three separate health permits: one each for the deli, bakery, and meat/grocery department. This facility had many violations in all areas, that involved improper temperature control (no thermometers), condemned food that had to be discarded due to contamination, inadequate vector control of flies, improper food storage containers, galvanized cooking utensils, inadequate floor drains, electrical hazards, plumbing problems, etc. The deli scored 36 points, the meat department scored 43, and the bakery scored 87 of a possible 100 points each. None of the employees, including the on-site manager, had the required food handler cards. The inspector gave the owner information for obtaining the cards through the Food Handlers class at San Bernardino Valley College. There was an occasional language problem, and a Grand Jury member acted as an interpreter. The inspection was thorough, in spite of the language barrier. At reinspection, some compliance of previous violations was observed, but the inspector noted new violations. A third inspection was required. A copy of the subsequent inspection report was sent to the Grand Jury. When the Grand Jury questioned why the facilities were not shut down because of their low scores (below 60), the DEHS program manager stated that closure comes only in the event of an immediate and dangerous threat to public health and safety, or when a violation cannot be corrected within a reasonable length of time. RECOMMENDATIONS
• R00-55
  ESTABLISH A PUBLIC NOTIFICATION DISPLAY PLACARD THAT CERTIFIES A FACILITY HAS BEEN INSPECTED AND MEETS COUNTY HEALTH AND SAFETY CODES. SHOW THE DATE OF INSPECTION, EXPIRATION DATE AND SIGNATURE OF THE INSPECTOR. PLACARDS SHOULD ONLY BE ISSUED TO FACILITIES THAT ARE IN COMPLIANCE. THIS RECOMMENDATION IS A MODIFICATION OF THE RECOMMENDATION BY THE 1997-98 GRAND JURY WHICH, TO DATE, HAS NOT BEEN IMPLEMENTED.
• R00-56
  MONITOR FACILITIES WITH A HISTORY OF REPEATED VIOLATIONS MORE FREQUENTLY. ESTABLISHMENTS THAT ARE CONSISTENTLY IN COMPLIANCE MAY REQUIRE AN ANNUAL INSPECTION ONLY.
• R00-57
  REQUIRE FOOD HANDLER CARDS FOR ON-SITE FOOD ESTABLISHMENT OWNERS AND MANAGERS, AS WELL AS WORKERS AND SERVERS. VERIFY NAMES ON FOOD HANDLER CARDS AGAINST CURRENT PAYROLL RECORDS.
• R00-58
  MAKE AVAILABLE BILINGUAL INSPECTORS, OR INTERPRETERS, AT ALL FACILITIES WHERE ENGLISH IS NOT THE PRIMARY LANGUAGE OR CANNOT BE SPOKEN AND CLEARLY UNDERSTOOD. FULL COMPLIANCE WITH HEALTH CODES CANNOT BE OBTAINED WITHOUT COMPLETE COMPREHENSION IN THEIR LANGUAGE. MEDICAL CARE AVAILABILITY BACKGROUND Within the County’s organizational structure, the Public Health Department and the Department of Behavioral Health are under the administration of the Human Services System, and the Arrowhead Regional Medical Center (ARMC) is directly under the County Administrative Officer. The ARMC opened its new Colton location in early spring 1999 with a license for 373 beds. The ARMC has within its facility a number of “specialty clinics,” with the primary care or Family Practice Clinics being located offsite at multiple locations. With concern for this County’s growing population of medically indigent, homeless, uninsured and under-insured working poor, the Grand Jury researched the availability of free or low-cost medical services. Special focus was on the availability of services for walk-in, urgent-care, and immediate needs. FINDINGS ARMC has been averaging 91 percent of bed capacity. The departments responsible for the delivery of medical care, mental health care, and public health care services are under different administrations and management, expressing different philosophies, and at totally different locations throughout the County. There is duplication of clinic-type facilities, nursing staff, patient appointment staff, and possible lab, x-ray or pharmacy services. There are no “free” or “low-cost” outpatient County clinic services available for the uninsured or under-insured “working poor”. Services available at ARMC’s affiliated Family Practice Clinics are by “pre-scheduled” appointments at a usual and customary fee. While payment schedules can be arranged, a $20 deposit is expected at the time of appointments, with the balance to be billed in approximately 45 days. Currently, when a patient seeks a medical appointment for a particular immediate medical need, a pre-scheduled daytime appointment is made for an amount of time that allows for a full evaluation. Scheduling of lengthy appointments limits the number of patients that can be seen on any given day. There is no “walk-in” or “urgent-care” type of service available daytime or evening, other than the Emergency Room. ARMC Administration advised that this would be the available source for services for an uninsured individual with an immediate need. Emergency Room services are a costly method of delivering walk-in care. RECOMMENDATIONS
• R00-59
  BRING ALL DEPARTMENTS DELIVERING HEALTH CARE SERVICES UNDER ONE ADMINISTRATION AND LEADER- SHIP, FOR A TOTAL PACKAGE OF HEALTH CARE DELIVERY.
• R00-60
  CENTRALIZE CLINIC LOCATIONS WHERE POSSIBLE, WITH THE SHARING OF CLINIC FACILITIES, NURSING STAFF, PATIENT APPOINTMENT STAFF, EQUIPMENT, LABS, X-RAY, AND PHARMACY SERVICES.
• R00-61
  OPEN ADDITIONAL OUTPATIENT CLINICS TO PROVIDE SERVICES FOR PATIENTS WITH “WALK-IN,” “URGENT,” OR “IMMEDIATE” NEED, ESPECIALLY IN MORE REMOTE AREAS OF THE COUNTY.
• R00-62
  PROVIDE WALK-IN “SHORT APPOINTMENTS” TO FOCUS ON THE PATIENTS’ CHIEF MEDICAL COMPLAINT, RESERVING FULL EVALUATIONS FOR PRE-SCHEDULED EXAM APPOINTMENTS.
• R00-63
  UTILIZE EXISTING CLINIC FACILITIES FOR “AFTER HOURS” SERVICES.
• R00-64
  DEVELOP PUBLIC INFORMATION PACKETS, NEWSPAPER ARTICLES, AND ADVERTISEMENTS TO ALERT THE PUBLIC TO THE AVAILABILITY OF SERVICES OTHER THAN THE MORE COSTLY EMERGENCY ROOM FOR WALK-IN SERVICES, INCLUDING CLINIC LOCATIONS AND HOURS AVAILABLE. MENTAL HEALTH SERVICES BACKGROUND San Bernardino County provides mental health services through two distinctly separate departments. They work in a collaborative partnership to provide full mental health services to County residents. This Grand Jury has combined the investigation into one report. ● Inpatient Mental Health care is provided at the Arrowhead Regional Medical Center (ARMC) in a separate building on the grounds of the ARMC. The director and his staff are under the ARMC administration. ● Outpatient Mental Health care, including substance abuse services, is provided by the Department of Behavioral Health (DBH) in multiple clinic locations throughout the County. The director of DBH and his staff are under the administration of the Human Services System.
• R00-65
  OPEN A MENTAL HEALTH CRISIS STABILIZATION UNIT (WALK-IN CLINIC) AT THE ARROWHEAD REGIONAL MEDICAL CENTER TO PROVIDE IMMEDIATE PRESCRIPTION RENEWALS AND OTHER EMERGENCY SERVICES NECESSARY TO MAINTAIN AND/OR STABILIZE A CLIENT’S CONDITION.
• R00-66
  UPGRADE OR REBUILD THE GILBERT STREET DEPART- MENT OF BEHAVIORAL HEALTH FACILITIES TO PROVIDE A SAFER, MORE WORKER-FRIENDLY ENVIRONMENT.
• R00-67
  CONTINUE SUPPORTING THE PERINATAL SUBSTANCE ABUSE TREATMENT PROGRAM, PLACING GREATER EMPHASIS IN REDUCING THE PERCENTAGE OF WOMEN FAILING TO REMAIN SUBSTANCE-FREE AND RETURNING TO THE PROGRAM.
• R00-68
  CONTINUE TO ALLOW THE DEPARTMENT OF BEHAVIORAL HEALTH TO CONTROL ITS TRUST FUNDS. THESE FUNDS SHOULD BE HELD IN RESERVE TO PROVIDE NEEDED SERVICES FOR WHICH NO OTHER FUNDING SOURCE IS AVAILABLE.
• R00-69
  IMPLEMENT MORE COST-EFFECTIVE AND EFFICIENT PROCEDURES TO FACILITATE REPAIR, PURCHASE, AND INSTALLATION OF NEEDED ITEMS AT THE RIALTO BEHAVIORAL HEALTH RESOURCE CENTER (BHRC). HUMAN SERVICES COMMITTEE The Human Services Committee reviewed the functional and operational procedures of all departments within the Human Services System, with the exception of the departments of Behavioral Health and Public Health. These two departments were a part of Health Care Services during the early part of our term, and were reviewed by that committee. The Human Services System coordinates the activities of the following County departments: Aging and Adult Services Children’s Services Community Services Jobs and Employment Services Preschool Services Transitional Assistance Veterans Affairs The Human Services System also provides fiscal and technical support to both the Children’s Network and the Children’s Fund. The Human Services Committee established subcommittees to review the function of each of the above departments. All department heads were interviewed. Further interviews were held to investigate compliance with County policies. Suggested areas of concern by previous Grand Juries were considered.