REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
November 4, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Biomedical Engineering Department Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policy and the report of the review and certification of the Arrowhead Regional Medical Center Biomedical Engineering Department 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 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 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 Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Department of Bio-Medical Engineering Policy and Procedure Manual (BME P&P Manual) contains hospital-wide policies and procedures regarding the utilization and safety of equipment throughout the hospital. The BME P&P Manual contains 54 policies, of which one policy has major revisions, 43 policies have minor revisions, and 10 policies and the table of contents were reviewed with no recommended changes.
The Department of Bio-Medical Engineering completed the 2024 - 2025 review of the BME P&P Manual and recommends the revisions summarized in Attachment A. Update of this manual is certified in Attachment B.
The one policy with major revisions consists of the following:
• Policy No. 7001 v8, Preventative Maintenance (PM) - Removed Section lll. A.PM Schedule Extension Allowance. The Joint Commission Standard Environment of Care (EC) 02.04.03 does not allow for preventative maintenance extension allowance.
There are 43 policies that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
On October 21, 2025 (Item No. 6), 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 October 1, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on October 10, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on October 15, 2025.