REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
May 5, 2026
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Administrative Department Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revision of the Arrowhead Regional Medical Center Administrative Policy and Procedure Manual, included and summarized in Attachments A through C.
(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 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 Administrative Policy and Procedure Manual (Admin Manual) contains hospital-wide policies and procedures, which are required by regulation, or determined by the ARMC Administration to pertain to the entire ARMC facility/staff. These policies are important to the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. The Manual is comprised of 377 policies, of which one policy is new, and two policies have major revisions. The table of contents is also updated to reflect the addition of the new policy. The new policy is needed to comply with the California Values Act and guidelines published by the California Attorney General’s Office entitled, “Promoting Safe and Secure Healthcare Access for All: Guidance and Model Policies to Assist California’s Healthcare Facilities in Responding to Immigration Issues.” The major revisions were needed to further align with best practices.
ARMC recommends the revisions summarized in Attachment A.
The new policy added to the manual is included in Attachment B, and consists of the following:
• Policy No. 1000.44 Issue 1, Compliance Program - Immigration Enforcement: This policy provides guidance to ARMC staff on how to respond to immigration enforcement activities at ARMC, as required by Government Code § 7284.8(a) and is consistent with the guidance provided by the California Attorney General’s Office.
The two policies with major revisions consist of the following:
• Policy No. 640.01 Issue 8, Consents - Management of: The policy has been updated to align with CMS revisions and clarification to Hospital Interpretive Guidelines for Informed Consent (CMS Ref: QSO-24-10 guidance for Hospitals). The definition of Informed Consent has been revised and references have been updated.
• Policy No. 670.15 Issue 12, Site - Side Verification and Time Out Procedure: References in the policy to “physician” has been updated to “practitioner.” The policy has also been revised to indicate that site/side verification and time-out should be done on all procedures. The revision also removes a statement that stated that it should be done for elective procedures. The only exception would be in emergency situations that would endanger the patient due to the delay. The revisions also clarified which procedures do not require site marking, such as angiograms, venograms and vascular access sites.
On April 7, 2026 (Item No. 10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on April 10, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on April 13, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on April 14, 2026.