REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
October 20, 2026
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 D:
1. Nutrition Service Policy and Procedure Manual
2. Primary Care Clinics 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 Manuals are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Division 5, Chapter 1, 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 improves County government operations and provides 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 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, of which two policies have major revisions that are needed due to updates to care and to further align with best practices.
Nutrition Services recommends the revisions summarized in Attachment A.
The two policies with major revisions consist of the following:
• Policy No. 700.00 v4 Serving Temperatures - Added reheating temperature when hot foods fall below the standard temperature.
• Policy No. 900.00 v10 Manual of Clinical Nutrition - Added Moderately Thick and Mildly Thick Liquid consistencies and oral gratification diet. Updated description and basics of therapeutic diets.
The Primary Care Clinics Policy and Procedure Manual (PCC Manual) contains policies and procedures regarding quality of patient care within the various primary care clinics. The PCC Manual contains 58 policies, of which 28 policies have major revisions and 28 policies are recommended for deletion. The remaining two policies and the table of contents have minor revisions.
The Department of Ambulatory Care Services completed the 2026 review of the PCC Manual and recommends the revisions summarized in Attachment B. Update of this manual is certified in Attachment C.
The 28 policies with major revisions consist of the following:
• Policy No. 101.00 v7. Mission, Vision, and Scope of Services - Update of policy to reflect current format and workflow and policy name change. The mission and vision is expanded to include the clinic’s scope of services and locations.
• Policy No. 106.00 v6. Communication of Information/Staff Meetings - Update of policy to reflect current format and workflow. Expansion of clinic communication of information to include various methods and frequency.
• Policy No. 108.00 v9. Guidelines for Patient Dismissal - Update of policy to reflect current format, workflow and removal of attachments of sample letters to dismissed patients. It identifies who may make the decision to dismiss a patient. It lists what departments receive patient dismissal notification.
• Policy No. 109.00 v6. Reinstating Dismissed Patients - Update of policy to reflect current format, workflow and removal of attachments of sample letters to reinstated patients. It identifies the medical director as making the decision to reinstate a formerly dismissed patient.
• Policy No. 178.01 v5. Two Way Electrical Communication Use in the Clinics - Update of policy to reflect current format, workflow, and reflect current expectation of the use of the communication device. Remove the section for Federal communication commission rules.
• Policy No. 181.00 v4. Direct Admission to the Hospital - Update of policy to reflect current format and workflow. The practitioner process to admit a clinic patient to the hospital is outlined. The steps include the hospital staff to contact, and the information to be provided to the receiving nurse. Includes actions and documentation necessary if patient refuses transportation. Outlines what to do if hospital bed not available.
• Policy No. 243.00 v7. Orientation and Clinic Competency Assessment - Update of policy to reflect current workflow and format and policy name change. Policy updated to include the current orientation processes and methods of training. Include meeting with management to evaluate progress with the staff during the probationary period.
• Policy No. 322.00 v9. Late Arrival-No Show Appointments - Update of policy to reflect current format and workflow. Section added to list steps to process a patient that is late or does not show up to the appointment. The practitioner makes the decision to see the patient if patient arrives late. It adds methods to contact patient in an attempt to reschedule appointment.
• Policy No. 402.01 v5. Management of Potentially Infectious Patients - Update of policy to reflect current format and workflow. Order of policy rearranged. Designation of patient placement if contagion suspected. Steps outlined for working with environmental services (EVS), add use of signage for doors, and length of time required for room to be empty prior to EVS cleaning room.
• Policy No. 402.02 v4. Cleaning of Patient Rooms and Health Center Environment - Update of policy to reflect current format and workflow with a focus on hazardous spills and waste handling. Add section to include placing signage on the door giving notice room requires decontamination by EVS. Cleaning is deferred to current hospital hazardous spill and waste handling.
• Policy No. 403.00 v8. Handling & Transportation of Clinic Specimens -Update of policy to reflect current format and workflow including preparation of specimens for transport and policy name change. Outline of process and steps to preparing specimens to be collected and transported. Specimens are to have clear identifiable labeling. Specimens collected and sent out are to be logged by patient name and specimen.
• Policy No. 405.00 v5. Utility Systems Failure - Update of policy to reflect current workflow, format, possibility of clinic closure, and removal of previously attached form. Policy updated to include instructions when the clinic must close and re-direction of staff and patients to an available clinic, or patient visits may be rescheduled or changed to virtual visits.
• Policy No. 420.00 v8. Emergency Response Plan - Update of policy to reflect current workflow and format, and policy name change due to the combination of Emergency Response policy 421.01 v6, the Disaster response and the evacuation of patients policy 422.00 v6. The clinic will use emergency services, the hospital’s administration, and command center as outlined for decision-making.
• Policy No. 501.00 v7. Management of Medical Emergency -Update of policy to reflect current workflow and format, and policy name change. Outline response to a medical emergency in the clinic setting. Listing of elements to include with a call to emergency services-911. Staff to perform according to current hospital code blue policy. Listing of items to include with the transport of patient.
• Policy No. 510.00 v6. Tuberculin Test Administration and Interpretation - Update of policy to reflect current workflow and format, and removal of previously attached form. Policy to include the Medical Assistant (MA) to work within their scope of practice. The MA is included with the licensed staff to administer the Tuberculin Test PPD (Purified Protein Derivative). The licensed staff read the test results. The MA and licensed staff receive annual education. Policy reference includes the MA scope of practice.
• Policy No. 525.00 v6. Use of the Elephant Ear Washer - Update of policy to reflect current format, workflow, and correct grammar of policy title. The policy adds the MA to the clinic staff able to perform this task. This is within the scope of practice for the MA. The policy now provides a limit on age of patients that can have this procedure. Ear lavage is not to be performed on anyone under the age of six years. Policy reference includes MA scope of practice.
• Policy No. 526.00 v8. HemoCue - Update of policy to reflect current format, workflow, and procedure steps. Arrangement of procedure steps organized to begin with the daily quality check then to list steps to perform the patient test. Add the instrument operating manual and control solution package insert into the reference section.
• Policy No. 550.00 v2. Afinion HbA1c Analyzer - Update of policy to reflect current format, workflow, and procedure steps to reduce duplicative information. Specific storage temperatures defer to the user manual. Expected results of control solutions are deferred to the manufacturer package insert. Control solution package insert included in reference section. Fingerstick sampling is the method used and venous sampling steps removed as not in clinic practice.
• Policy No. 555.00 v2. LeadCare® II Blood Lead Analyzer - Update of policy to reflect current format, workflow, and procedure steps to streamline. The lab test is explained under the definition section. To reduce the size of the policy, items were removed that were not of major importance to the process. Removed list of materials included in test kit. Specific storage requests are deferred to the user manual. Handling of the control solutions and expected range values are deferred to the package insert. The blood lead reference value (BLRV) is not a static value and the policy defers to the current Centers of Disease Control and Prevention website for the current BLRV when performing quality control on a new kit. The removal of the “limitations” and “interference” sections now defer to the User’s Guide and section.
• Policy No. 563.00 v4. Siemens Clinitek Multistix Urine Testing & Quality Control - Policy updated to reflect current practice and testing performed, and removal of previously attached form. Update clinic staff to use MA instead of Care Assistant. Add the use of quick response (QR) code by manufacturer as company packaging may not include a package insert.
• Policy No. 563.01 v3. Multistix Urine Testing - Update of policy to reflect current format, workflow, and procedure steps. List of tests performed with the strips listed. Licensed staff listed as Licensed Vocational Nurse (LVN) and Registered Nurse (RN). Added a section for the Quality Control (QC) and QC procedure steps. Added the Multistix 10 SG and control solution QR to the reference section. Package inserts are not available and the manufacturers use QR codes on the packaging.
• Policy No. 567.00 v2. Manual Urine Pregnancy Testing and Quality Control -Update of policy to reflect current format, workflow, and procedure steps, and policy name change. Policy not to be limited by one specific manufacturer. Removal of items specific to this product. Storage and stability is deferred to the package insert. Directions of use are referred to the package insert. Reading of results defers to package insert outlining how the test result displays a positive or negative result.
• Policy No. 580.00 v2. Medication Refill Standing Order - Update of policy to reflect current format, workflow, and procedure steps. Pregnancy status has been expanded to include the electronic health record’s method of identification of a pregnant patient. Female patients at 50 years old do not require pregnancy status confirmation. Fasting has been removed as a requirement to laboratory lipid panels. Calcium channel blockers no longer require a serum creatinine or potassium level for refill. Diabetic supplies have been separated from diabetic medications for refill.
• Policy No. 585.00 v6. Medication Handling & Storage - Update of policy to reflect current workflow and format, and policy name change. Combines policy 585.01 v6 with policy 585.00 v6. Medications in the clinic are overseen by both our Pharmacy and our Clinical Leadership. The combined policy outlines both roles under one policy. Pharmacy maintains and stocks the automatic medication dispensing instruments. Licensed nursing staff order medications and immunizations from the pharmacy department. The primary care clinics do not distribute medications. Medication and vaccine expiration dates are monitored by licensed staff and stock is rotated to use expiring products first. Step-by-step process is outlined for licensed staff to mark and isolate expired product and give to pharmacy.
• Policy No. 588.00 v5. Depo-Provera - Update of policy to reflect current workflow and format, and policy name change. Policy shows reorganization of steps to comply with proper format.
• Policy No. 591.00 v4. Immunizations - Update of policy to reflect current workflow and format, and to spell out abbreviations. Added to the Vaccine for Children (VFC) guidelines and list steps of vaccine delivery, administration, handling and documentation.
• Policy No. 593.00 v3. Nurse Advice - Update of policy to reflect current workflow, format, and reference material. Reference material updated to current edition. Separates the duties of licensed staff for the registered nurse and the licensed vocational nurse. Nurse advice is separated by when the patient is present in the clinic and when advice is given by phone.
• Policy No. 700.00 v3. Standing Orders for Value-Based Primary Care - Update of policy to reflect current workflow and format, and policy name change. This policy supports eligible staff to use standing orders approved by the medical executive committee. Eligible staff are outlined as the MA, LVN, and RN. Eligible staff may use standing orders within their scope.
There are 28 policies that were deleted. These policies contained outdated position descriptions and processes that are no longer applicable. These are the deleted policies:
• Policy No. 102.00 v7. Organizational Structure and Function - Retire. Defer to Arrowhead Regional Medical Center (ARMC) Organizational chart.
• Policy No. 112.00 v7. Charge Nurse - Retire. Position no longer exists.
• Policy No. 151.00 v6. Family Health Centers Plan for Provision of Care - Retire. Combined into Policy 101.00 v7 Mission, Vision, and Scope of Services.
• Policy No. 242.00 v4. Conduction of Personal Business - Retire. Defer to Administrative policies and procedures.
• Policy No. 321.00 v7. Appointments Primary Care Centers - Retire. Defer to Call Referral Center.
• Policy No. 382.00 v5. Transfer of Patient Care-Third Year Residents - Retire. Defer to Graduate Medical Education (GME).
• Policy No. 383.00 v7. Audio-Videotaping-Digital Recording - Retire. Defer to Graduate Medical Education (GME).
• Policy No. 403.01 v4. Transportation of Outlying Clinic Specimens - Retire. Packaging of specimens and preparing for transport have been combined into one policy; Policy 403.00 v8.
• Policy No. 403.02 v4. Outlying Clinic Preparation of Lab Specimens for Transport - Retire. Packaging, labeling, & logging of specimens and preparing for transport have been combined into one policy; Policy 403.00 v8.
• Policy No. 421.01 v6. Emergency Response - Retire. Policy combined with 420.00 v8.
• Policy No. 422.00 v6. Evacuation of Patients - Retire. Policy combined with 420.00 v8.
• Policy No. 443.00 v5. Papoose Board - Retire. Defer to standard equipment clean.
• Policy No. 446.00 v5. Endoscope-Fiber Optic-Cleaning Procedure-Manual Cleaning - Retire. Procedure and endoscope no longer exist in the clinics.
• Policy No. 502.00 v5. Access to Care During Non-Business Hours - Retire. Combined with policy 101.00 v7 and defer to Call Referral Center department that handles this issue.
• Policy No. 504.00 v5. Updating Demographic Information - Retire. Defer to Patient Reception department that handles this issue.
• Policy No. 506.00 v6. Preparation for Exam - Retire. Standardized workflow.
• Policy No. 508.00 v5. Discharging Patients from the Family Health Center - Retire. Standardized workflow.
• Policy No. 517.00 v3. Direct Referral of Prenatal Patients from Labor Delivery - Retire. Not a Primary Care process.
• Policy No. 518.00 v3. Prenatal Care - Retire. Not a Primary Care process.
• Policy No. 527.00 v5. Pulse Oximeter - Retired. Standard Equipment.
• Policy No. 528.00 v5. Spirometer - Retire. Not a current practice.
• Policy No. 529.00 v6. Minor Surgical Procedures - Retired. Standard workflow.
• Policy No. 564.00 v6. Siemens Clinitek Urine Pregnancy Test & Quality Control - Retire. Not current practice.
• Policy No. 566.00 v1. LeadCare II Blood Lead Analyzer - Retire. Policy numbered incorrectly. See policy 555.00 v2 LeadCare II Blood Lead Analyzer.
• Policy No. 585.01 v6. Expiration of Medications and Supplies - Retire. Combine with policy 585.00 v6.
• Policy No. 587.00 v4. Rhogam Administration to Family Health Center Patients - Retire. Not current practice.
• Policy No. 590.00 v4. Vaccine Handling - Retire. Combine with policy 591.00 v4.
• Policy No. 633.00 v5. Return to School or Work Certification for Patients - Retire. Not current practice.
There are two policies that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
On September 1, 2026 (Item No. 11), 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 September 16, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on September 25, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on September 28, 2026.