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File #: 13402   
Type: Consent Status: Agenda Ready
File created: 12/8/2025 Department: Arrowhead Regional Medical Center
On agenda: 12/16/2025 Final action:
Subject: Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
Attachments: 1. ATT - ARMC - 12-16-25 - Att I - HIM 374.00 v1 Consents - General, 2. ATT - ARMC - 12-16-25 - Att J - HIM 376.00 v1 Chart Correction - Incorrect Documentation, 3. ATT - ARMC - 12-16-25 - Att K - Emergency Department (ED) 2025 Summary of Revisions, 4. ATT - ARMC - 12-16-25 - Att L - ED 455.00 v1 Procedure Related Deep Sedation (PRDS) or Emergency Departme, 5. ATT - ARMC - 12-16-25 - Att M - ARMC Policy and Procedure Manual Approval List, 6. ATT - ARMC - 12-16-25 - Att A - Environment of Care (EOC) 2025 Summary of Revisions, 7. ATT - ARMC - 12-16-25 - Att B - Environment of Care (EOC) 2025 Certification, 8. ATT - ARMC - 12-16-25 - Att C - Facilities Management (FAC) 2025 Summary of Revisions, 9. ATT - ARMC - 12-16-25 - Att D - Facilities Management (FAC) 2025 Certification, 10. ATT - ARMC - 12-16-25 - Att E - Administrative (ADM) Summary of Revisions, 11. ATT - ARMC - 12-16-25 - Att F - ADM 690.32 v1 - Law Enforcement Weapons, 12. ATT - ARMC - 12-16-25 - Att G - ADM 690.42 v1 - Cannabis for Terminal Illness - Management of, 13. ATT - ARMC - 12-16-25 - Att H -Health Information Management 2025 (HIM) Summary of Revisions
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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 po...

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