REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
December 16, 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 Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals, included and summarized in Attachments A through M:
1. Environment of Care Policy and Procedure Manual
2. Facilities Management Policy and Procedure Manual
3. Administrative Policy and Procedure Manual
4. Health Information Management Policy and Procedure Manual
5. Emergency Department 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 Environment of Care Policy and Procedure Manual (EOC Manual) contain policies essential to safety of patients, staff, and visitors at the hospital. The EOC Manual contains 75 policies, of which 16 policies have major revisions, 11 policies and the index have minor revisions, and 48 policies were reviewed with no recommended changes.
The Environment of Care department completed the 2025 review of the EOC Manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The 16 policies with major revisions consist of the following:
• Policy No. 2020 v8, Ergonomic Evaluations and Prescriptions - Email address on attachment updated to current Safety Officer.
• Policy No. 3003 v8, Hospital Security - Made changes to align with the security policy/procedure for incident reporting.
• Policy No. 3006 v8, Infant Security - Removed the registry badge process to align with the current procedure and a revision for securing the building during a Code Pink activation.
• Policy No. 3007 v8, Emergency Department Security - Revised the process for panic alarm activation to align with security policy.
• Policy No. 3009 v8, Code Pink and Code Purple - Infant and Child Abduction - Changes to align with security policy, updated Colton PD dispatch number.
• Policy No. 3010 v8, Code Gray - Irate Person - Updated code gray documentation process to align with security policy.
• Policy No. 3015 v8, Family Health Clinic Alarm Activation Notification Procedure - Two off-site buildings were added to align with the alarm activation process.
• Policy No. 3019 v9, Key and Keypad Code Management - Nursing supervisor approval added for door unlocks to align with the current procedure.
• Policy No. 3020 v1, Wheelchairs, Management of Hospital Owned - This policy was previously Administrative (ADM) 400.28 and has now been relocated to the EOC manual
• Policy No. 4014 v8, Medical Waste Management - Removed line stating medical waste from Family Health Centers (FHCs) is rendered non-infectious before being transported.
• Policy No. 7007 v8, Fire - Evacuation of Patients - A policy that was referenced in this policy underwent a name change. Therefore, the policy name needed to be changed in this policy as well.
• Policy No. 7008 v8, Fire Event Response - A policy that was referenced in this policy underwent a name change. Therefore, the policy name needed to be changed in this policy as well. There was verbiage that needed to be updated to accurately reflect what takes place.
• Policy No. 7020 v8, Fire Prevention - Interim Construction - Verbiage was updated to accurately reflect what takes place.
• Policy No. 7024 v8, Fire Alarm Systems Testing and Inspection - The attachment was incorrect. Therefore, the attachment was updated.
• Policy No. 7038 v8, Fire Extinguisher Inspection - There was verbiage that needed to be updated to accurately reflect what takes place.
• Policy No. 7041 v8, Medical Gas Shut Off - A policy that was referenced in this policy underwent a name change. Therefore, the policy name needed to be changed in this policy as well.
There are 11 policies that contain minor revisions. These policies contain grammatical corrections, removal of unnecessary lines and spaces, and corrections of abbreviations.
The Facilities Management Department Policy and Procedure Manual (FAC Manual) contain policies and procedures regarding the physical environment of the hospital. A total of 88 policies were reviewed, of which 44 policies have major revisions (including three deleted policies), 11 policies and the index have minor revisions, and 33 policies were reviewed with no recommended changes.
The Facilities Management Department completed the 2025 review of this FAC Manual and recommends the revisions summarized in Attachment C. Review and update of this manual is certified in Attachment D.
The 41 policies with major revisions consist of the following:
• Policy No. 1002 v6, Rules and Regulations - Verbiage changes for dress code and updated employee title changes.
• Policy No. 1003 v6, Outside Contractors and Other County Departments Working in the Facility - Updated Vendor procedural changes for Facilities vendors. Update attachment to coincide with updated procedural changes.
• Policy No. 1005 v5, Work Request Operations - Updated employee titles.
• Policy No. 1006 v5, New Employee Orientation - Changes to operations of departmental orientation to add competencies.
• Policy No. 1008 v4, Central Plant - Plant Operator Responsibilities - Updated employee title changes and updates to procedures of recording work orders for staff on shift.
• Policy No. 1009 v5, Central Plant - Humidity Monitoring - Update to state the Central Plant will document notifications given to staff.
• Policy No. 2001 v6, General Safety Policy - Small verbiage changes due to employees' title changes.
• Policy No. 2008 v5, Life Safety Rounds - Standard operating procedure (SOP) removed. Verbiage changed to reference EOC Policy 2003.
• Policy No. 2009 v4, Fire Safety Fire Drill Procedure - Verbiage change to procedure to match actual action.
• Policy No. 3001 v5, Fire Safety - Change name of Security Office to Security Command Center.
• Policy No. 3003 v5, Smoke Detector Inspection Procedures - Change name of Security Office to Security Command Center.
• Policy No. 3004 v6, Fire Extinguisher Inspection Sheets - Update title to ARMC Safety Technician. Add verbiage to clarify inspection and due dates labeled on extinguisher tags.
• Policy No. 3006 v5, Fire Alarm Pull Station Test - Verbiage was changed to clarify how to properly activate a fire alarm pull station.
• Policy No. 3009 v5, Kitchen Hood Fire Extinguishing System - Add verbiage to ensure proper function of gas and electrical shut offs as part of procedure.
• Policy No. 3010 v5, Fire Alarm System Testing and Inspections - Change Security Communication Center to Security Command Center.
• Policy No. 3011 v3, Facilities Management Departmental - Fire Event Response - Remove specifics about Security Departments response per their policy.
• Policy No. 3012 v4, Interim Life Safety Measure (ILSM) - Add verbiage for fire door failure per TJC requirements.
• Policy No. 4001 v5, Hazardous Materials Handling - Update contact in policy to EOC Hazard Waste chapter lead. Update process on inventory tracking.
• Policy No. 4002 v3, Hazardous Materials Storage - Remove parts of procedure referring to the storage area as that is not under the Facilities department’s scope. It is covered by Environmental Services (EVS) and EOC.
• Policy No. 5002 v6, Facilities Management Equipment Management Plan - Removal of a process step that is not needed.
• Policy No. 5003 v6, Inventory and Inspection of New Equipment - Removal of Verbiage that does not pertain to Facilities Management.
• Policy No. 5011 v3, Ice Machines - Care and Maintenance, Safe Storage and Dispensing- Change Procedure to follow manufacture guidelines.
• Policy No. 6004 v6, Weekly Tests of Emergency Diesel Generators - Changed offices that are notified before testing.
• Policy No. 6007 v6, Management of Utility System Failure - Changed point of contact.
• Policy No. 6008 v6, Outside Vendor Assistance - Added employee’s title.
• Policy No. 6010 v5, Communication System Failure - Removed other departments’ responsibilities during failure.
• Policy No. 6011 v5, Elevator Failure - Passenger Evacuation - Changed procedure for resetting elevators.
• Policy No. 6019 v6, Medical Gas System - Nitrous Oxide Failure - Employee title change.
• Policy No. 6022 v6, Plumbing System Failure and Flooding Procedure - Removed bathroom limits.
• Policy No. 6023 v5, Vertical Lifts Failure (Including Dumbwaiters, Cart Lifts) - Added verbiage to notify Facilities Manager in the event of a failure.
• Policy No. 6024 v6, Water Distribution System Failure - Removed distribute reserve water from policy.
• Policy No. 6025 v6, Central Plant - Preventative Maintenance - Changes to employee’s title and added verbiage that department uses manufacturer guidelines for Preventative Maintenance.
• Policy No. 6026 v6, Central Plant - Routine Rounds - Corrected equipment name in policy.
• Policy No. 6027 v6, Electrical Distribution Annual Check - Changed to correct voltage.
• Policy No. 6031 v5, Utilities Management User Training - Changes to employee title.
• Policy No. 6033 v5, Safe Use of Electrical Equipment - Removed verifying electrical equipment each time a patient is moved into the area.
• Policy No. 6034 v4, Training Outline for the Handling, Storage, and Transport of Compressed Gas Cylinders - Removed department directors’ responsibility of policy.
• Policy No. 6037 v4, Arrowhead Regional Medical Center - Water Supply and Distribution Systems - Changes to report location.
• Policy No. 7001 v5, Performance Improvement Plan - Changed annual review reporting from multiple committees to Hospital Administration.
• Policy No. 7002 v4, Quality Improvement - Changed PM scheduling from Biomed to Facilities. Removed level 5 from equipment risk assessment. Using only levels 1-4.
• Policy No. 8001 v3, Department Evacuation - Updated evacuation location.
There are 3 policies that were deleted. These policies contained provisions that no longer pertain to the Facilities department or were duplicated with other current policies.
• Policy No. 2002 v4, Lock out/Tag out Procedure - Duplicate of EOC policy 8001.
• Policy No. 4005 v3, Handling of Radioactive Emergencies - The policy no longer pertains to Facilities Management (FM) department.
• Policy No. 5007 v4, Equipment Management - Orientation and Education - No longer needed. Facilities 5001 covers this topic.
There are 11 policies that contain minor revisions. These revisions include grammatical corrections, removal of unnecessary lines, and corrections of abbreviations.
The Administrative Policy and Procedure Manual (ADM 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 ADM Manual contains a total of 377 policies, of which two had major revisions, two were new, and one had minor revisions. The Index has minor revisions due to the addition of the new policies. These revisions and additions were needed to further align with best practices.
The Administrative Department recommends the revisions summarized in Attachment E.
The two policies with major revisions consist of the following:
• Policy No. 610.06 Issue 7, Transition (Discharge) Planning/ Management - This policy details the multidisciplinary responsibility to assess, develop, implement and evaluate a safe discharge plan for all patients. The policy and attachments are updated to reflect current contacts for all resources.
• Policy No. 610.09 Issue 5, Patient Discharge Lounge - This policy details the guidelines for opening, maintaining, staffing, and closing the patient discharge lounge while on surge. It clarifies the process to move patients to the lounge once they are discharged. It also discusses the types of patients that can be moved to the lounge and what to do if a medical emergency arises.
There are two new policies. These policies are in Attachment F and G. The new policies consist of the following:
• Policy No. 690.32 Issue 1, Law Enforcement Weapons - This policy details a method for preventing acts of violence. To ensure the safety and welfare of patients, visitors, and ARMC Staff, weapons are not to be carried by any employee of the hospital, nor other person outside of those employed and on duty with law enforcement.
• Policy No. 690.42 Issue 1, Cannabis for Terminal Illness - Management of - This policy permits the self-administration of medical cannabis at bedside for an admitted (inpatient) patient with terminal illness. This policy is pursuant to California Senate Bill on “Compassionate Access to Medical Cannabis Act” a.k.a. “Ryan’s Law” (Section HSC 1649.1.).
There is one policy that contains minor revisions. This policy contains updates to the references used and specifications of acronyms.
The Health Information Management Policy and Procedure Manual (HIM Manual) contain department and hospital-wide policies and procedures governed by various regulations, department organization and function, customer service practices, medical record content and retention, release of information, and coding. The HIM Manual contains a total of 37 policies, of which two are new and one has minor revisions. These are needed due to updates to regulation specifically to the Health Insurance Portability and Accountability Act of 1996, and to optimize the features of the electronic health record system. The Index has a minor revision to reflect the addition of the new policies.
The Health Information Management department recommends the revisions summarized in Attachment H.
The two new policies are in Attachment I and J and consist of the following:
• Policy No. 374.00 Issue 1, Consents, General - This policy was needed to build and utilize electronic consents via the electronic health record system (EHR).
• Policy No. 376.00 Issue 1, Chart Correction - Incorrect Documentation - The policy is specific to correct incorrect documentation only past 7 days. The EHR has features that will enable authorized users to correct documentation according to their discipline’s guidelines and EHR module being used.
There is one policy that contains minor revisions, consisting of grammatical corrections and formatting.
The Emergency Department Policy and Procedure Manual (ED Manual) contain hospital-wide policies and procedures regarding quality of patient care within this specialty. The Manual contains 115 policies, which includes one new policy. The index has a minor revision due to the addition of a new policy.
The Emergency Department recommends the revisions summarized in Attachment K.
The one new policy added to the Manual is included in Attachment L, and consists of the following:
Policy No. 455.00 v1, Procedure Related Deep Sedation (PRDS) for Emergency Department Physicians - The new policy was created to provide guidelines for patient management of all procedures where sedatives and analgesics are titrated by Emergency Medicine Physicians that result in deep sedation during procedures per this protocol. The new policy was also needed for compliance with CMS and TJC requirements.
On November 18, 2025 (Item No. 19), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment M.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on November 25, 2025; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on November 25, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on November 25, 2025.