File #: 12168   
Type: Consent Status: Passed
File created: 5/9/2025 Department: Arrowhead Regional Medical Center
On agenda: 5/20/2025 Final action: 5/20/2025
Subject: Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
Attachments: 1. ATT - ARMC - 5-20-25 - Att F - Education (EDU) Manual Summary of Revisions, 2. ATT - ARMC - 5-20-25 - Att H - Infection Control and Employee Health (IC-EH) 2024 Summary of Revisions, 3. ATT - ARMC - 5-20-25 - Att I - ARMC Policy and Procedure Manual Approval List, 4. ATT - ARMC - 5-20-25 - Att A - Administrative (ADM) Policy Procedure Summary of Revisions, 5. R1 - ATT - ARMC - 5-20-25 - Att B -Administrative (ADM) Certification, 6. R1 - ATT - ARMC - 5-20-25 - Att G -Education (EDU) Certification, 7. R1 - ATT - ARMC - 5-20-25 - Att C - ADM 610.52 v1 Code STEMI, 8. R1 - ATT - ARMC - 5-20-25 - Att D - ADM 840.05 v1 Electronic Health Record Documentation Requirements, 9. R1 - ATT - ARMC - 5-20-25 - Att E - ADM 900.06 v1 Report of Firearms Prohibition, 10. Item #17 Executed BAI, 11. Executed Attachment
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...

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