REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 1, 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 Manuals, included and summarized in Attachments A through L:
1. Administrative Policy and Procedure Manual
2. Dialysis Services Policy and Procedure Manual
3. Emergency Response Policy and Procedure Manual
4. Health Information Management 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 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, Division 5, Chapter 1, 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 improves 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 Procedure Manual (Admin Manual) contains 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. The Admin Manual is comprised of 378 policies, of which three policies are new, and five policies have major revisions. These revisions were needed to comply with updates to care and to further align with best practices. The table of contents also has a minor revision to reflect the addition of the new policies.
ARMC recommends the revisions summarized in Attachment A.
The new policies added to the Admin Manual are included in Attachments B, C, and D consist of the following:
• Policy No. 600.05 Issue 1, Multidisciplinary Care - This policy was moved from the Nursing Policy and Procedure Manual to the Admin Manual as it delineates responsibilities across multiple departments. The term “provider” was also updated to “practitioner”. The policy title was changed from “Multidisciplinary Rounds” to “Multidisciplinary Care”. The areas within the policy that mentioned rounding language were replaced with collaboration language. Additionally, other specialties were added as needed.
• Policy No. 690.43 Issue 1, Nurse-Driven Titration of Continuous Infusion Medications - This new policy establishes hospital-wide standards for nurse-driven titration and tapering of continuous infusion medications used in critically ill patients. It replaces Pharmacy (RX) Policy No. 5.40 v3, "Titrate and Taper Medication Orders," and incorporates current The Joint Commission Medication Management standards and American Association of Critical-Care Nurses guidance. The policy defines the required elements of titration orders, including starting dose, dose adjustment parameters, maximum dose, and specific clinical goals. It clarifies nursing responsibilities for patient monitoring, reassessment, tapering (weaning), documentation, competency requirements, and patient/family education to ensure safe and consistent administration of titratable continuous infusion medications throughout the organization.
• Policy No. 820.03 Issue 1, School Forms - This policy is for school forms being completed by practitioners which are for internal/ARMC purposes only. The policy specifies the owner of the form, use, and building it in the electronic health record system.
The five policies with major revisions consist of the following:
• Policy No. 110.09 Issue 5, Record and Data Retention Schedule - This policy has been revised to align with the ARMC records retention schedule approved by the Board of Supervisors. A link to access the records retention schedule on the Clerk of the Board website has been added to the policy.
• Policy No. 110.28 Issue 11, Patient Charity Care Policy and Procedure - To comply with AB 2297 and SB 1061, this policy expands the Hospital Fair Billing Program. It also includes updated definitions for various words, including Charity Care, Patient Family, Payment Discount, and High Medical Costs. It also eliminates the consideration of monetary assets for eligibility determination. It clarifies that ARMC may consider health savings accounts when negotiating payment plans and how third-party payments made directly to patients are applied. The policy further clarifies that application deadlines are prohibited. It prohibits liens or sale of any real property owned by the patient and adverse credit reporting. It also adds limitations for when a patient does not have to be reimbursed and requires the individual to apply for other coverage before the discounted program will be utilized.
• Policy No. 110.29 Issue 11, Patient Discount Payment Policy and Procedure - To comply with Assembly Bill 2297 and SB 1061, this policy expands the Hospital Fair Billing Program. Revise the definitions such as Charity Care, Patient Family, Payment Discount, High medical costs. Eliminates the consideration of monetary assets for eligibility determination. Allow hospitals to consider health savings accounts when negotiating payment plans. Clarifies third-party payments made directly to patients are applied. Clarifies that application deadlines are prohibited. Prohibits liens or sale of any real property owned by the patient. Prohibits adverse credit reporting. Adds limitations for when a patient does not have to be reimbursed. Prohibits requiring patients to apply for other coverage before discounted payment will be provided.
• Policy No. 610.06 Issue 7, Transition (Discharge) Planning/Management - Website information for CMS compare was added under Skilled Nursing Facility, Home Health Care, Inpatient Rehab Facilities and Long-Term Care Hospitals. This was updated because Medicare Conditions of Participation require hospitals to provide patients with publicly reported data on quality for each of these agencies.
• Policy No. 900.00 Issue 7, Patient’s Rights - The revised policy contains updated terminology by replacing “physician” with “practitioner/s”. Revised Patient Rights Brochure distribution language to clarify that inpatients receive the brochure at the time consent for treatment is obtained, while outpatients receive it at their initial visit and annually thereafter. Added The Joint Commission, “Rights and Responsibilities of the Individual” to the References section.
The Dialysis Services Policy and Procedure Manual (Dialysis Manual) contain hospital-wide policies and procedures required by regulation or determined as necessary by ARMC Administration regarding the quality of patient care within this specialty. The manual has a total of 224 policies, of which one is a new policy, 14 policies have major revisions, four policies are deleted, 10 policies and the index have minor revisions, and 195 policies were reviewed with no revisions.
The Dialysis Services completed the 2023-2026 review of the Dialysis Manual and recommends the revisions summarized in Attachment E. Update of this manual is certified in Attachment F.
The 14 policies with major revisions consist of the following:
• Policy No. 200.20 v7 Priming a Single Use Dialyzer Utilizing Fresenius 2008T Dialysis Delivery System - The procedure for priming has been changed to follow manufacturer’s instructions.
• Policy No. HDX 200.30 v7 Initiation of Dialysis Using a Graft or Fistula - Brand names removed and dialysis machine set up changed to follow manufacturer’s instructions. Some typographical errors have been corrected as well.
• Policy No. HDX 201.00 v7 Termination of Dialysis Treatment - Brand names removed and added verbiage to follow Centers for Disease Control and Prevention (CDC) scrub the hub protocol for accessing catheters.
• Policy No. HDX 413.10 v5 Fresenius Dialysis Delivery System Cleaning and Disinfection - Updated the policy to reflect manufacturer’s guidelines.
• Policy No. HDX 502.00 v5 Central Venous Catheter (CVC) Initiation and Discontinuation of Treatment - Removed brand names.
• Policy No. HDX 502.10 v3 Initiation of Treatment Using a Central Venous Catheter and Single Use Dialyzer - Removed the brand name “Optiflux” from the title, changed electronic medical record to electronic health record, added verbiage to follow CDC scrub the hub protocol for catheter disinfection.
• Policy No. HDX 605.00 v5 Microbial Validation of Stationary Water Treatment Systems After installation or Major Modification/Repair - Updated to reflect manufacturer’s guidelines.
• Policy No. HDX 607.00 v5 Delayed Outpatient Hemodialysis Unit Opening of Greater Than a Week - Updated to reflect manufacturer’s guidelines.
• Policy No. HDX 610.00 v6 Endotoxin Sampling and Analysis: Water - Updated to reflect manufacturer’s guidelines.
• Policy No. HDX 611.00 v6 Bacteria Cultures and Analysis Water and Dialysate - Updated to reflect manufacturer’s guidelines and remove outdated practice.
• Policy No. HDX 613.00 v5 Reverse Osmosis (RO) Water System Filter Maintenance - Updated to reflect manufacturer’s guidelines.
• Policy No. HDX 614.00 v5 Scheduling of Stationary Reverse Osmosis (RO) Related Water System Component Disinfection - Updated to reflect manufacturer’s guidelines and deleted attachments.
• Policy No. HDX 616.00 v5 Reverse Osmosis (RO) Water System Testing and Safety Guidelines - Updated to reflect manufacturer’s guidelines.
• Policy No. HDX 621.00 v5 Portable Reverse Osmosis (RO) Systems Carbon Block Changes - The title was changed from sediment filter to carbon block and the policy was updated to reflect manufacturer’s guidelines.
There is one new policy. The new policy added to the Dialysis Manual is included in Attachment G, and consists of the following:
• Policy No. 722.00 v1 Antibiotic Lock Therapy - This policy was created in conjunction with the pharmacy department and the Infection Preventionist to establish a standardized order set for Antibiotic Lock Therapy (ALT) to salvage Central Venous Catheters with catheter-related bloodstream infections (CRBSIs). ALT is administered as an adjunctive treatment for CRBSIs. It involves instillation of a concentrated antibiotic solution in each lumen of a central venous catheter, allowing it to dwell between uses. It is utilized as a preventive or treatment measure in high-risk patients with long-term central venous catheter access, particularly those undergoing hemodialysis.
There are four policies that were deleted. These policies contain equipment/tools that are no longer used, and one policy is already covered under the epidemiology policy:
• Policy No. HDX 306.00 v3 Phoenix Meter Level I and II Calibration - Equipment is no longer in service.
• Policy No. HDX 306.10 v3 Phoenix Meter Disinfection and Calibration Verification - Equipment is no longer in service.
• Policy No. HDX 306.20 v3 Measuring Conductivity, Temp and or pH Using Phoenix Conductivity Meter - Equipment is no longer in service.
• Policy No. HDX 417.00 v2 Dialyzing Coronavirus Positive Patients In Outpatient Dialysis - The Infection Control Department recommended deleting this policy because its content is already addressed in the Epidemiology Policy.
There are 10 policies that contain minor revisions, consisting of grammatical errors on the subject title and/or in the content.
The Emergency Response Policy and Procedure Manual (Emergency Manual) contains policies essential to the overall response of ARMC in a disaster related event. The Emergency Manual contains ARMC’s Basic Emergency Operations Plan, the Countywide Department Emergency Operations Plan, and policies and procedures outlining ARMC’s emergency response activities to various threats and incidents ensuring patient and staff safety. The manual contains a total of 49 policies, of which three have major revisions, 17 have minor revisions, and 29 were reviewed with no changes.
The Emergency Preparedness Committee completed the 2026 review of the Emergency Manual and recommends the revisions summarized in Attachment H. Review and update of this manual is certified in Attachment I.
The three policies with major revisions consist of the following:
• Policy No. 5000.01 V8, Emergency Operations Plan (EOP) - Updated committee representative roster, updated 2026 Hazard Vulnerability Analysis, clarified EOP activation language, updated disaster volunteer process, updated alternate means of communication, updated multi-year disaster exercise schedule.
• Policy No. 5004 V9, Emergency Communications - Added additional backup communication equipment. Added redundancy during Information Technology/Voice Over Internet Protocol (IT/VOIP) infrastructure disruption.
• Policy No. 5014 V10, Delegation of Responsibilities in Emergencies - Removed from facilities oversight structure. Added section X for Security Department, previously Facilities Management.
There are 17 policies that contain minor revisions, consisting of minor grammatical revisions and updates to emergency contact information.
The Health Information Management Policy and Procedure Manual (HIM Manual) contains 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 one is new. The table of contents has a minor revision to reflect the addition of the new policy.
The Health Information Management department recommends the revisions summarized in Attachment J.
There is one new policy, which is included in Attachment K and consists of the following:
• HIM Policy 375.00 v1 Secure Chat - The new policy is to optimize a specific functionality of the electronic health record system, namely the Secure Chat functionality of the system, including its purpose and roles of the users.
On June 23, 2026 (Item No. 25), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment L.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on July 31, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on August 7, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on August 11, 2026.