REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
May 20, 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 I:
1. Administrative Policy and Procedures Manual
2. Education Development Policy and Procedures Manual
3. Infection Control and Employee Health Policies and Procedures 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 Manuals are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals (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 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 Manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Administrative Policy and Procedures Manual contains 383 policies and procedures, which contain hospital-wide policies and procedures required by regulation or determined by ARMC Administration to pertain to the entire ARMC facility/staff. These policies are important in the delivery of quality services and are necessary to maintain compliance with policy and regulatory bodies. ARMC recommends three new policies, 49 have major revisions, 69 have minor revisions, and 262 were reviewed without any recommended changes.
ARMC completed the 2022-2024 review of the Administrative Manual and recommends the revisions summarized in Attachment A. The review and update of the Administrative Manual is certified in Attachment B. The new policies are in Attachments C, D, and E.
The three new policies consist of the following:
• Policy No. 610.52 v1, Code STEMI - This is a new policy that provides a multidisciplinary, timely, and effective approach to care for patients with Acute Coronary Syndrome (ACS)/ ST Elevation.
• Policy No. 840.05 v1, Electronic Health Record Documentation Requirements Policy - This policy was moved from the 700 Information Management section, and it was previously ADM 700.23. Updated language from Meditech to EHR.
• Policy No. 900.06 v1, Report of Firearms Prohibition - This is a new policy to adhere to the mandated reporting requirement as set forth by Assembly Bill (AB) 1587 Welfare & Institutions Codes (WIC) 8100, 8103, and 8105. All persons who meet the criteria for 72-hour holds are required to be reported on the date of admission to the Department of Justice (DOJ) Bureau of Firearms.
The 49 policies with major revisions consist of the following:
• Policy No. 100.01 v6, Administrative Operations Manuals - Organization and Contents - This policy was renamed and updated to the current structure and contents of the hospital-wide policy manuals.
• Policy No. 100.02 v6, Administrative Operations, Infection Prevention, and Environment of Care Manuals - Approval, Distribution - This policy was renamed and updated to the current approval process and distribution of the hospital-wide policy manuals.
• Policy No. 100.03 v9, Policy and Procedure Manuals - Format, Standards, and Approval Process - This policy was renamed and updated to the current structure and contents of all hospital policy manuals.
• Policy No. 100.04 v6, Department Specific Policy and Procedure Manual: Approval Process - This policy was deleted and combined with Administrative (ADM) policy 100.03 due to similar processes in both policies.
• Policy No. 110.18 v5, Visitors - Injuries to - Updated language from Meditech to EHR.
• Policy No. 110.28 v10, Patient Charity Care - This policy was deleted and combined with ADM 110.29 because charity care is a part of the financial assistance process.
• Policy No. 110.29 v10, Patient Financial Assistance - This policy was updated to combine the Charity and Full Financial forgiveness policies into one. In addition, the section pertaining to public health emergency was added to allow forgiveness of bills when there is a public health emergency.
• Policy No. 110.37 v3, Grants: Search and Identification Process - This policy was revised because it included a grant process that no longer existed and was drafted prior to the creation of the Office of Research and Grants. The updates included adding a new grant intake process along with a grant intake form and a flowchart, which detailed the grant approval process.
• Policy No. 110.39 v3, Grants: Development - This policy was revised to remove outdated information and participants. It was updated to include a recommended timeline and references to the current County Grant Policy and standard operating procedure (SOP).
• Policy No. 110.43 v3, Use of Color-coded Armbands - Updated language from Meditech to EHR.
• Policy No. 110.47 v3, Patient Notification of Adverse Event/Medical Error - This policy was revised due to updates to the reporting structure. Staff must notify the Attending Physician, Administration/Administrator-on-Call, House Supervisor, ARMC Risk Management/Patient Safety, and/or the ARMC Communications Consult Team to coordinate the organizational response and situation management process. The term “sentinel event” was changed to “adverse medical event.” The following references were added: The Joint Commission and California Code of Regulations Title 22, §70972. The definitions of “Adverse Medical Event” and “Sentinel Event” were clarified to align with The Joint Commission definitions of these terms. Also, definitions for the following terms were added: “Medical Error”, “Serious Error”, “Minor Error”, “Near Miss”, “Incident”, “HIPAA”, “Authentic Apology”, and “Disclosure”.
• Policy No. 400.28 v1, Wheelchairs, Management of Hospital Owned - This policy was deleted because its content was better suited in the Environment of Care (EOC) manual. The policy was changed to EOC policy 6015 v1.
• Policy No. 600.02 v5, Interdisciplinary Plan of Care - This policy was updated to include the Nursing Plan of Care to have one comprehensive policy that can be provided to Surveyors when they present to the hospital. Updated language from Meditech to EHR.
• Policy No. 610.01 v8, Surge Management Plan - The policy was renamed and revised to a proactive approach that emphasizes resource distribution during emergencies rather than reacting to surges, ensuring both immediate and ongoing needs are met. Additionally, Attachment A, the Department Specific Response Plan for Overcrowding checklist, was updated to reflect the hospital’s operating census, providing a systematic way to manage overcrowding in line with current patient capacity and demand fluctuations.
• Policy No. 610.05 v5, Emergency Medical Treatment and Labor Act (“EMTALA”) - The policy was renamed and revised to provide a comprehensive explanation of the process of transferring patients and to memorialize the processes.
• Policy No. 610.07 v5, Patient Evaluation - Medical Screening Examination - Updated language from Meditech to EHR.
• Policy No. 610.11 v6, Management of “Unknown” Patients - Updated language from Meditech to EHR.
• Policy No. 610.12 v6, Patient Identification - Updated language from Meditech to EHR.
• Policy No. 610.13 v5, Patient Registration Guidelines - Outpatient Services - Updated language from Meditech to EHR.
• Policy No. 610.23 v4, Safe Patient Handling and Movement - This policy was updated to reflect current patient handling procedures and designated staff roles. Additionally, a Bedside Mobility Assessment Tool was created for nurses.
• Policy No. 610.25 v6, Stroke Response - This policy was deleted, and the stroke response was added to ADM policy 610.26, Code Stroke
• Policy No. 610.26 v6, Code Stroke - This policy was revised to reflect new guidelines and process changes. Updated language from Meditech to EHR.
• Policy No. 610.28 v4, Infection - Sepsis of the Adult Patient - This policy updated SIRS/Sepsis/Severe Sepsis frequency for Intensive Care Unit (ICU), Non-ICU, and Emergency Room (ER) patients and assessment data to the latest guidelines. The policy updated patient/family education provided and staff Education and Orientation Requirements including allied health providers. The policy was revised to include a statement that clarified Code Sepsis is not called in the Emergency Department (ED). The formatting, grammar, and the references were updated. The term “physician” was revised to “practitioner”. Additionally, a procedure was added to address Sepsis for Labor and Delivery.
• Policy No. 610.29 v5, Reconciliation of Medication Profiles - This policy updated Non-admitted patients Invasive Outpatient procedures/Sedation procedures. Updated language from Meditech to EHR.
• Policy No. 610.38 v2, Discharge Planning Activities - This policy was updated to include patients discharging on a legal hold status such as, but not limited to “5150, 5250, and patients on conservatorship.” Updated language from Meditech to EHR.
• Policy No. 610.40 v3, Management of Observation Patients - The policy was revised to define “Observation” as a billing status and add procedures for services not covered as Observation Services.
• Policy No. 610.43 v3, Code Sepsis - This policy removed Data Collection, Performance Improvement (PI), and Discharge After Sepsis and placed it into ADM policy 610.28. The attachment was removed because it was no longer needed due to documentation being tracked in the Electronic Health Record (EHR). The formatting, grammar, and the references were updated. The policy was revised to include a statement that clarified Code Sepsis is not called in the Emergency Department (ED). The term “physician” was revised to “practitioner”. Additionally, updates were made to clarify the medication referenced.
• Policy No. 620.07 v6, Rapid Response Team - This policy was renamed from Rapid Assessment Team (RAT) to Rapid Response Team.
• Policy No. 640.03 v5, Consent - Antipsychotic Medication - The policy was revised to include patient consent for administering psychotropic medications and their legal implications.
• Policy No. 660.02 v5, Administration of Blood - Lookback - The policy was revised due to updates to the notification structure. The Laboratory Medical Director or designee shall notify the ARMC Risk Management department via the Event Reporting System and the physician will maintain all records. Additionally, the physician shall notify the patient via certified mail. If the physician is unavailable or declines to make the notification, the Laboratory Medical Director will notify the department chair if the attending is unable to provide notification to the patient.
• Policy No. 660.04 v5, Blood and Blood Products: Patient Identification, Requisition and Administration - Updated language from Meditech to EHR.
• Policy No. 670.01 v13, Restraint/Seclusion Guidelines for Non-Violent/Non- Self-Destructive And Violent/Self-Destructive Behavior Management - This policy was updated to include ‘seclusion’ throughout the policy and added ‘risk factors’ to be included in the documentation of the patient’s plan of care. The term “Practitioner” was defined as Physicians, Nurse Practitioners and Physician Assistants. The word “Licensed” was removed from the signature documents to refer to “Practitioner” instead.
• Policy No. 670.04 v5, 12-Lead Electrocardiogram (EKG or ECG) - Updated language from Meditech to EHR.
• Policy No. 670.19 v2, Guidelines for the Administration of Hypertonic Sodium Chloride 23.4% Solution - Updated language from Meditech to EHR.
• Policy No. 670.25 v3, Alcohol Withdrawal: Management of Patient in Telemetry Unit and Intensive Care Unit (ICU) - Updated language from Meditech to EHR
• Policy No. 670.26 v7, Administration of Influenza and Pneumococcal Vaccines - This policy was updated to allow state authorized licensees to administer vaccinations. Patient consent for inpatient vs outpatient was clarified. The references were updated to incorporate guidance from CDC/ACIP. Vaccine specific information was removed because it may change annually. The requirements for age group, education, competency, and standing order were updated to current standards. Attachment A is labeled as a "Sample" due to potential annual change(s). Documentation of the Vaccines section was incorporated into procedures (inpatient vs outpatient). (Note: The standing order form will be updated as needed based on CDC/ACIP vaccine guidance and product availability/formulary.)
• Policy No. 670.30 v2, Ventilator-Associated Events (VAE) Prevention Bundle - This policy was updated to include patient evaluation for Spontaneous Breathing Trail (SBT) and to facilitate Early Mobility. The policy recommends the use of endotracheal tubes with subglottic secretion drainage ports for patients expected to require greater than 48 or 72 hours of mechanical ventilation. Additionally, the references were updated.
• Policy No. 690.21 v4, Abuse: Staff to Patient - The policy revisions included updates to position titles for the House Supervisor, Administrator on Call and/or Administrator, Quality & Accreditation and the Human Resources Officer. Clarified notification path that includes the House Supervisor, Administrator on Call and Administrator, Quality & Accreditation. Definitions for "Alleged" and "Staff” were added to the policy. The definition of a "Dependent Adult" was revised to align with the Title 22 definition. Included the Chief Medical Officer in the notification of an allegation involving a member of the Medical Staff. References to Meditech were removed and grammar was updated. Contact information to send the Abuse Checklist to the Regulatory Compliance Department was added. The following references were added to the policy: Centers for Medicare & Medicaid Services (CMS), California Department of Public Health (CDPH), The Joint Commission and ARMC Policies. Updated language from Meditech to EHR.
• Policy No. 690.22 v3, Laboratory Specimen Labeling and Patient Identification Verification - Updated language from Meditech to EHR.
• Policy No. 690.24 v4, Homeless Discharge - This policy required updates to align with state mandates in Senate Bill 1152: Hospital Patient Discharge Process: Homeless Patients. This included adding a Homeless Determination screening and other required documentation.
• Policy No. 690.27 v5, Critical Value, Read Back Verification of - Updated language from Meditech to EHR.
• Policy No. 690.34 v2, Code Green - Missing/Eloped Patient - The policy revisions expanded patient status and procedures for Conserved, Inmate and/or Custodial.
• Policy No. 700.16 v5, Management of Identity Theft - Updated language from Meditech to EHR.
• Policy No. 700.18 v2, Citrix Access and Appropriate Use Policy - Updated language from Meditech to EHR.
• Policy No. 700.23 v1, Electronic Health Record Documentation Requirements Policy - This policy was deleted because its content was better suited in the 840 Health Information Management Section. The policy was changed to ADM policy 840.05.
• Policy No. 910.08 v4, Donation after Cardiac Death (DCD) - This policy was updated to reflect current OneLegacy guidelines. Additionally, the ethics committee review was removed for each DCD case.
• Policy No. 910.10 v6, Adult-End of Life Care (EOLC) - The policy revisions include an addition of a new comfort care definition and comfort care protocol to allow for evidence-based end-of-life care to those who are not withdrawing life-sustaining measures. Opioid and sedative guidelines for termination of life support were clarified. A standardized sequence and guidance of removal of life-sustaining measures were added. The nursing documentation expectation and guidance for patients who require transfer out of the ICU after withdrawal of life-sustaining measures were updated.
• Policy No. 920.02 v6, Patient’s Rights - Management of Complaints, Grievances - The policy revisions include updates to the process for complaints and grievances pertaining to Medical Staff.
• Policy No. 1000.14 v3, Minimum Necessary Restrictions - Updated language from Meditech to EHR.
The 75 policies with minor revisions include grammatical revisions and updates to roles. The index was also updated to reflect the revisions made to the policies.
The Education Development Policy and Procedures Manual contains education policies and procedures required by regulation or determined by ARMC Administration to pertain to the Education Department staff in the delivery of quality services. ARMC completed the 2021 - 2025 review of the Education Manual and recommends the revisions summarized in Attachment F. The review and update of the Education Manual is certified in Attachment G. The manual contains a total of 31 policies of which five were deleted, 19 have major revisions, and seven policies and the Index have minor revisions.
The five policies deleted consist of the following:
• Policy No. 103.00 V4, Budgetary Mechanism - Deleted - Process is designed by the finance department. It is not specific to the Education Department.
• Policy No. 201.00 V5, Director of Education Role - Deleted - Policy regarding specific position responsibilities is not required. All job duties are reflected in the position description.
• Policy No. 202.00 V4, Nurse Educator Role - Deleted - Policy regarding specific position responsibilities is not required. All job duties are reflected in the position description.
• Policy No. 300.00 V5, Hospital Orientation - Deleted - The policy is a duplicate of Administrative policy 220.02.
• Policy No. 301.00 V6, Nursing Orientation - Deleted - The policy is a duplicate of Nursing Policy 302.00.
The 19 policies with major revisions consist of the following:
• Policy No. 100.00 V7, Scope of Service - Added ostomy nursing consultation and care and diabetes educator for patient education. Removed specific location on ARMC campus as the department has split and staff members have relocated to the Valley building and a new office space.
• Policy No. 104.00 V4, Departmental Staff Meeting, Interdisciplinary Committee Participation, and Communication Mechanisms - Removed Nursing Standards Committee as it is a Department of Nursing meeting not an Education Department meeting. Job titles updated to reflect current titles. Policy No. 105.00 V5, Staff Education - Removed Board of Registered Nursing requirements.
• Policy No. 105.00 V5, Staff Education - Removed specific language about Board of Registered Nursing requirements for continuing education and replaced with following their requirements.
• Policy No. 200.00 V8, Organizational Chart - Narrative portion of the policy removed, the organizational chart covers the roles and reporting structure. The title of the policy was updated to reflect the change in the narrative.
• Policy No. 304.00 V4, Continuing Education - Removed reimbursement language as this is part of the memorandum of understanding and the process is delineated in an administrative policy.
• Policy No. 306.00 V5, Education Program Tracking, Reporting, and Maintenance - Removed Education Assistance Proposal language as this is part of the memorandum of understanding and the process is delineated in an administrative policy.
• Policy No. 308.00 V3, Department Role in Patient/Family Education - Removed Closed Circuit Television (CCTV) System language as the CCTV system is no longer in use.
• Policy No. 309.00 V3, Integrating and Coordinating Services With Other Departments - Removed specific agencies and replaced it with a generic term to cover all entities.
• Policy No. 310.00 V3, Selecting Outside Resources For Needed Services - Removed contracting language as this is determined by a different department.
• Policy No. 311.00 V6, American Heart Association (AHA) Classes and Cost - Updated to include online platform and card issuance to electronic Cards.
• Policy No. 312.00 V5, Nursing and Allied Health Student Clinical Rotations - Removed in person meeting requirement for student placement and replaced with online process for requesting placement. Clarified requirements for badges. Updated badge request and approval process.
• Policy No. 313.00 V5, Department Money Transactions - Updated to reflect usage of new receipt and foundation process for deposits.
• Policy No. 400.00 V4, Department Quality Assurance and Performance Improvement (QAPI) - Removed American Heart Association (AHA) specific language and added AHA resources for guidelines. Removed examples of departmental QAPI activities.
• Policy No. 500.00 V3, Patient Privacy - Removed American Heart Association reference. Removed duplicate language found in other policies.
• Policy No. 600.00 V4, Safety Management of the Physical Environment - Removed duplicate language found in other policies. Replaced specific brand names like Sani Cloth and Manikin Wipes with the term germicidal wipes.
• Policy No. 601.00 V3, Disaster Plan - Removed education requirements as they are not applicable to the department. The title "Education Director" has been updated to "Education Services Supervisor," and the title "Secretary" has been changed to "Administrative Assistant."
• Policy No. 602.00 V3, Code Response - Updated code pink and purple to reflect the new location of the department office.
• Policy No. 603.00 V2, Utility System Failure Plan - Specified that the alternative locations for work are determined by need and availability.
• Policy No. 604.00 V2, Emergency Evacuation Plan - Removed duplicate language covered in the Emergency response manual and updated safe evacuation locations.
The seven policies with minor revisions include grammatical revisions and specifications of acronyms.
The Infection Control and Employee Health Policies and Procedures 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. Major revisions are recommended to two policies, and minor revisions are recommended for six policies to further align with best practices and regulatory guidance in preventing and controlling the spread of infections, as set forth on Attachment H.
The two policies with major revisions consist of the following:
• Policy No. 501.00 V10, Pre-Employment and Annual Screenings - Revised to include language that pertains to the implementation of the approved California Department of Public Health program flexibility waiver for the period of February 15, 2024, through February 14, 2027. The flexibility waiver, implemented 07/01/24, limits annual Tuberculosis (TB) testing to Healthcare Personnel (HCP) who might be at increased occupational risk for TB exposure. The CDPH waiver aligns with the 2019 CDC recommendations for TB screening and testing of HCP.
• Policy No. 700.00 V11, Tuberculosis Exposure Control Program - Appendix F: Job Classification/Department Requiring Fit Testing was revised to eliminate fit testing for the Behavioral Health and Security Departments. The revision was made following the completion of a hazard assessment and collaboration with the respective stakeholders.
The six policies with minor revisions include updates to remove obsolete and redundant information.
On May 6, 2025 (Item No. 5), 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 April 25, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on April 28, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on April 30, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on May 1, 2025.