REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
October 7, 2025
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 following Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals (included in Attachments A through F):
1. Infections Control and Employee Health Policy and Procedures Manual
2. Institutional Review Board Policy and Procedure Manual
3. Post Anesthesia Care Unit 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 Manual 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, 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 Infection Control and Employee Health Policy and Procedure Manual (Infection Control Manual) outlines ARMC’s commitment to preventing the spread of infections by establishing clear guidelines for staff regarding hand hygiene, personal protective equipment use, cleaning and disinfection procedures, waste disposal and other critical infection control practices. These policies and procedures are based on current Centers for Disease Control and Prevention (CDC) recommendations and applicable regulations to safeguard patients and healthcare workers in infection prevention and control in healthcare settings.
The Infection Control Manual contains 65 policies, of which two have major revisions and one has a minor revision. These revisions, as summarized in Attachment A, were needed to further align with best practices and regulatory guidance in preventing and controlling the spread of infections.
The two policies with major revisions consist of the following:
• Policy No. 327 v3, Prevention of Catheter-Associated Urinary Tract Infections - Revised to include language under section V. Obtain urine samples aseptically: If a urinary catheter is present, replace the catheter prior to obtaining a urine specimen if it has been in place for more than 48 hours (unless contraindicated).
• Policy No. 402 v11, Standard and Isolation Precautions - Added Contact Plus and Special isolation categories. Two new isolation categories have been developed from CDC guidelines to address infections that do not align precisely with the signs for contact, droplet, or airborne, or that have additional recommendations.
The minor revision to one policy includes updates to remove obsolete and redundant information.
The Institutional Review Board Policy and Procedure Manual (IRB Manual) is required by federal regulations to ensure that appropriate procedures are in place to protect the rights and welfare of human subjects participating in research. The IRB Manual ensures compliance with these regulations.
The IRB Manual contains 24 policies, all including the index had minor revisions which includes minor format changes and updates to policy numbering.
The Institutional Review Board completed the 2024 review of the IRB Manual, and recommends the revisions summarized in Attachment B. Update of this manual is certified in Attachment D.
The Post Anesthesia Care Unit Policy and Procedures Manual (PACU Manual) contains policies and procedures regarding department organization and function, patient care, and guidelines for the delivery of quality services.
The PACU Manual contains 25 policies, of which 20 and the index have minor revisions to correct grammatical issues and to simplify language to reflect current practice. The five remaining policies were reviewed with no recommended changes.
The Post Anesthesia Care Unit completed the 2025 review of the PACU Manual and recommends the revisions summarized in Attachment C. Update of this manual is certified in Attachment E.
On September 23, 2025 (Item No. 14), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment F.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on September 9, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on September 15, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on September 16, 2025.