REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
April 7, 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 Arrowhead Regional Medical Center Administrative Department Policy and Procedure Manual, included and summarized in Attachments A and B.
(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 contain 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 Administrative Policy and Procedure Manual contain a total of 377 policies, of which five had major revisions. These revisions were needed to further align with best practices.
ARMC recommends the revisions summarized in Attachment A.
The five policies with major revisions consist of the following:
• Policy No. 300.03 Issue 17, Organizational Performance Improvement Plan (OPI) 2025 - Title changed to OPI. Made references in the Patient Safety and Quality Committee (PSQC) portion that supports patient/support person (Patient and Family Advisory Council (PFAC) indirectly) and patient/family/visitor equity. Updated references to the 2024-2027 strategic plan and goals.
• Policy No. 610.40 Issue 4, Management of Observation Patients - Updated to include staff who can provide Medicare Outpatient Observation Notice (MOON) form to patients. Replaced the term provider with practitioner. Updated 2023 Centers for Medicare and Medicaid Services (CMS) regulations reference.
• Policy No. 620.05 Issue 9, Pain Assessment and Management - Updated the pain scale that the Newborn Intensive Care Unit uses to the current evidenced based practice model, N-Pass (Neonatal Pain Agitation Sedation Scale). This is for up to three months of age. Removed repeat of “chemically paralyzed patient”. Changed the acceptable term to chart for patient sleeping from “S” to “Asleep”. Updated when a comprehensive pain assessment is completed along with the items that must be documented with that assessment. Clarified how pain medication is ordered along with how range orders are avoided unless ordered with a specific scale. Updated references, formatting, and attachments.
• Policy No. 650.09 Issue 6, Post-Operative/Procedure Care of Intensive Care Unit (ICU) Patients - This policy expanded ICU services to accept patients directly to the ICU from all procedure areas. Previously it was only for traumas.
• Policy No. 690.36 Issue 5, Intravenous Admixture and Administration - Updated policy for current regulations and guidelines (e.g. State Board of Pharmacy, US Pharmacopeia (USP) 797 Sterile Compounding, USP 800 Hazardous Compounding, National Institute for Occupational Safety and Health (NIOSH) Hazardous Drugs) including beyond-use-date time. Updated standard concentrations for common high-risk IV medications such as fentanyl and oxytocin. Updated policy language so that Attachment B will be a sample of the Approved IV Drug List for Nursing in Routine Situations. Specified that the Approved IV Drug List for Nursing in Routine Situations will be updated separately from the policy. Attachment B was updated for current medications, new medications, removal of off-market medications, and to align policy information. Corrections to formatting, approved abbreviations, terminology, and references were also made.
On March 10, 2026 (Item No. 12), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment B.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on March 1, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on March 16, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on March 17, 2026.