REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
March 10, 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 Manual, included and summarized in Attachments A through I:
1. Ambulatory Primary Care Clinics Policy and Procedure Manual
2. Mobile Medical Clinic 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 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 Department of Ambulatory Care 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 a total of 59 policies, of which five are new and three have major revisions (two retired policies). These revisions are needed due to updates to care and to further align with best practices. The Table of Contents was revised to reflect the addition of the new policies.
The Department of Ambulatory Care Primary Care Clinics recommends the revisions and additions summarized in Attachment A.
There are three policies with major revisions:
• Policy No. 565.00 v7, Manual Urine Pregnancy Test - Retired. Replaced by new Policy No 567.00 v1. The new policy updates and combines elements of both policies.
• Policy No. 566.00 v6, Manual Urine Pregnancy Test - Quality Control: Retired. Replaced by new Policy No 567.00 v1. The new policy updates and combines elements of both policies.
• Policy No. 700.00 v2, Standing Orders for Care Gap Requirements - Standing orders placed for diagnostic studies and tests. The addition of a fingerstick lead screening has been added for Standing Orders. The lead test satisfies a Value-Based Performance requirement.
There are five new policies. The new policies added to the manual are included in Attachment B through F, and consist of the following:
• Policy No. 515.00 v1, Laboratory Presyncope Episodes - The policy considers potential events and symptoms that may occur during blood draws. This provides standardized actions taken by the phlebotomist and clinic staff to prevent, navigate, and manage potential occurrences.
• Policy No. 550.00 v1, Afinion HbA1c Analyzer - Hemoglobin A1c (HbA1c) tests are performed by Primary Care Clinic (PCC) clinical staff: Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Care Assistant (CA). The testing is performed using the Afinion HbA1c Analyzer. Afinion HbA1c is an in vitro diagnostic test for quantitative determination of glycated hemoglobin (% HbA1c) in human whole blood. The measurement of % HbA1c is recommended as a marker of long-term metabolic control in persons with diabetes mellitus. This test satisfies a Value-Based Performance requirement.
• Policy No. 555.00 v1, LeadCare II Blood Lead Analyzer - The LeadCare® II Blood Lead Analyzer is a Clinical Laboratory Improvement Act (CLIA) -waived device. The CLIA-waived laboratory test is performed according to the manufacturer’s instructions to determine the quantitative measurement of lead in fresh whole blood under the regulations set forth by the CLIA, the Joint Commission, and the State of California Business and Professions Code. Testing is performed in the Primary Care Clinics by clinical staff who have completed the appropriate training and competency: Care Assistants (CAs), Licensed Vocational Nurses (LVN), and Registered Nurses (RN). This test satisfies a Value-Based Performance requirement.
• Policy No. 567.00 v1, Manual Urine Pregnancy Testing and Quality Control - This policy will replace two current PCC policies: PCC 565.00: Urine Pregnancy Test and PCC 566.00 v6 Manual Urine Pregnancy Test - Quality Control. The new policy combines patient testing and the performance of Quality Control. Clinic staff allowed to perform testing has been expanded to include the Medical Assistant. Clinic staff performing the test include the Medical Assistant, the Licensed Vocational Nurse, and the Registered Nurse. The human chorionic gonadotropin (hCG) pregnancy test is a qualitative test detecting the presence of hCG.
• Policy No. 580.00 v1, Medication Refill Standing Order - The policy allows clinic staff to renew current maintenance medications. Medication renewal is subject to a set of criteria that must be met for the medication to be renewed. Medication criteria is based on the type of medication. Criteria may require laboratory tests, vital signs within a set range, and clinic visits within a time frame.
The Mobile Medical Clinic Policy and Procedure Manual (MMC Manual) contains policies and procedures regarding department organization and function, vehicle maintenance, and patient care practices. The MMC Manual contains a total of 27 policies and procedures, of which 18 policies have major revisions (including 12 deletions), and nine policies and the Table of Contents have minor revisions.
The Mobile Medical Clinic Department completed the 2025 review of the MMC Manual and recommends the revisions summarized in Attachment G. Update of this manual is certified in Attachment H.
The 6 policies with major revisions consist of the following:
• Policy No. 105.00 v4, Emergency Evacuation Plan - The policy title was changed to Emergency Evacuation Plan. Verbiage within the policy was revised to align with ARMC’s Emergency Evacuation Plan.
• Policy No. 110.00 v4, Walk-in Visit/Return Visit Appointment/No Show - The policy and procedures section was revised. New language was added, and some existing language was removed to create a better flowing policy.
• Policy No. 116.00 v4, Preparation of Lab Specimens for Transport - The policy procedure section was revised. Some language was removed and added creating a clear step by step process to follow.
• Policy No. 123.00 v4, Management of Reports from Diagnostic Studies - Policy 121.00, Diagnostic Tests-Follow-up of abnormal results is now combined with policy 123.00. Verbiage was revised to include the electronic process.
• Policy No. 124.00 v4, Patient Education - Revised policy and procedure section so that it is more in alignment with ARMC Patient Education policy.
• Policy No. 138.00 Issue 4, Centrifuge-Horizon 6 Flex - The policy has changes to the procedures. The title of the centrifuge was updated to the new Centrifuge.
There are 12 policies that were deleted. The following policies contained outdated position descriptions and processes that are no longer applicable:
• Policy No. 100.00 v4, Mission, Vision and Value-Belief System - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 101.00.
• Policy No. 101.00 v4, Organizational Structure and Function - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 102.00.
• Policy No. 106.00 v4, Medical Direction-Mobile Medical Clinic - The policy is retired. The Medical Director position no longer exists.
• Policy No. 107.00 v5, Referrals - The policy is retired. Refer to ARMC call center referral policies.
• Policy No. 117.00 v4, Handling Biohazard Materials - The policy is retired. It is combined with policy 115.00, Cleaning of Mobile Clinic.
• Policy No. 121.00 v4, Diagnostic Test-Follow-up of Abnormal Results - This policy is retired. It is combined with policy 123.00, Management of Reports from Diagnostic Studies.
• Policy No. 125.00 v4, Telephone Access to Care During Non-Business Hours - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 502.00.
• Policy No. 130.00 v4, New Hire Orientation and Competency Assessment - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy PCC policy 243.00.
• Policy No. 133.00 v5, Hemocue - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 526.00.
• Policy No. 134.00 v5, Multistix Urine Testing and Quality Control - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 563.01.
• Policy No. 136.00 v4, Siemens Clinitek Status Plus Meter Pregnancy Test - This policy is retired. The equipment is no longer utilized.
• Policy No. 137.00 v4, Siemens Clinitek Point-of-Care Urinalysis - The policy is retired. It can now be referenced under Primary Care Clinics (PCC) policy 563.00.
There are nine policies and the Table of Contents that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
On February 24, 2026 (Item No. 9), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment I.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on January 30, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on February 13, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on February 17, 2026.