REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
March 11, 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 Department of Pharmacy Services Policies and Procedures Manual (included and summarized in Attachments A through E).
(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 Manuals 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, along with the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all ARMC Operations, Policy, and Procedure 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 manuals 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 policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Department of Pharmacy Services Policies and Procedures Manual (Pharmacy Services Manual) contains policies and procedures regarding organization and function, customer service and guidelines for the delivery of quality pharmaceutical services. The Pharmacy Services Manual contains 159 policies, including two new policies, nine policies with major changes, four policies were removed, 89 policies and the index have minor changes, and 55 policies have been reviewed with no recommended changes.
ARMC completed the 2022-24 review of the Pharmacy Services Manual and recommends the revisions summarized in Attachment A. Review and update of this manual is certified in Attachment B.
The nine policies with major revisions consist of the following:
• Policy No. 5.34 v1 Procedure for Returning Outpatient Medications to Stock - Policy moved. See 16.16 v1
• Policy No. 5.42 v1 Drug Shortages - Policy moved. See 9.12 v1
• Policy No. 6.3 v6 Handling of Hazardous Drugs - Updated for United States Pharmacopeia (USP) 800: Hazardous Drugs - Handling in Healthcare Settings standards that became applicable November 1, 2023. Includes new Assessment of Risk and Drug Containment information
• Policy No. 6.7 v4 Aseptic Technique - Updated for USP 797: Compounded Sterile Preparations standards that became applicable November 1, 2023. Details clean room aseptic technique.
• Policy No. 6.8 v3 Cleaning, Decontaminating, and Disinfecting Program - Updated for USP 797, including having a designated compounding pharmacist and cleaning process.
• Policy No. 6.9 v2 Cleanroom Attire - Updated for USP 797, including garbing and removal of garb.
• Policy No. 6.10 v4 Sterile Compounding Quality Assurance - Updated for USP 797, including quality assurance testing, beyond-use dating, and processes for drug compounding and storage.
• Policy No. 9.12 v1 Drug Shortages - Formerly 5.42 v1
• Policy No. 16.16 v1 Procedure for Returning Outpatient Medications to Stock - Formerly 5.34 v1
The following four policies were removed as they contained outdated position descriptions and processes that are no longer applicable:
• Policy No. 5.38, Emergency Medications for Staff - Retired or deleted; ARMC does not provide medication to staff.
• Policy No. 16.6 v3, Medication Restock - Optifill - Retired or deleted; the Optifill system has been removed.
• Policy No. 16.7 v1, Optifill Setup - Retired or deleted; the Optifill system has been removed.
• Policy No. 16.10 v1, Quality Assurance - Optifill System - Retired or deleted; the Optifill system has been removed.
The two new policies added to the manual are included in Attachment C and D, and consist of the following:
• Policy No. 5.45 v1, Parenteral Nutrition - Provides for ordering, preparing, distributing, administering, and monitoring of parenteral nutrition.
• Policy No. 9.11 v1, External Supplied Medications - Ensures administered medications at ARMC were acquired from appropriate sources. Medications brought into ARMC from outside pharmacies “white bagging” and/or patients “brown bagging” may pose a risk to patient safety.
There are 89 policies that contain minor revisions. The minor revisions consist of correcting minor grammatical issues and updating references, section names, and specifications of acronyms. The Index was also updated to reflect all the changes made.
On February 11, 2025 (Item No. 10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment E.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on February 4, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on February 14, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on February 19, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on February 21, 2025.