AGENDA of Board of Directors for 
Regular Board Meeting 

Wednesday, March 22, 2023 

Location:  5189 Hospital Road, 
Mariposa, CA  95338 

Joseph E.C. Rogers, M.D., Chair, Wendy Ryder-Priola, RN, BSN, Secretary-Treasurer 
Rose Fluharty, MScN, Nicholas Lambert & Suzette Prue, Directors 

Noel Caughman, Legal Counsel, Best Best & Krieger Attorney at Law [Closed Session]

Closed Session 1:00 p.m.

Regular Board Meeting 2:00 p.m.

    1.        Call to order and roll call

    2.        Open Session:  disclosure regarding Closed Session items pursuant to Government Code §54957.7

    3.        CLOSED SESSION

A.     Hearing:  Medical Staff Privileges (Health & Safety Code §32155)

On recommendation from the Medical Executive Committee, the following were granted temporary privileges and submitted today for Board approval:

Michael Ali, MD, Emergency Medicine & Acute, Provisional Staff

Marc Bracy, MD, Emergency Medicine & Acute, Provisional Staff

Allana Bush, FNP, Family Medicine, Allied Health

David Cohen, MD, Teleradiology, Consulting Staff

Samuel Collins, PA, Acute & Emergency Medicine, Allied Health

Kelly Fruth, PA, Family Medicine, Allied Health

Leena Gupta, MD, Acute, Provisional Staff

Eve Hyatt, NP, Acute, Provisional Staff

Janice Hwang, MD, Teleradiology, Consulting Staff

Daniel Ikemiyashiro, MD, Nephrology, Consulting Staff

Crystal Irwin-Warren, DO, Emergency Medicine & Acute, Provisional Staff

Michael Klein, MD, Teleradiology, Consulting Staff

Shahin Laghaee, MD, Gastroenterology, Consulting Staff

Tony Ohn, MD, Emergency Medicine & Acute, Provisional Staff

Zachary Roeder, MD, Teleradiology, Consulting Staff

Atulkumar Roy, MD, Nephrology, Consulting Staff

Rebecca Samet, MD, Emergency Medicine & Acute, Provisional Staff

Claude Schutz, DPM, Podiatry, Consulting Staff

On recommendation from the Medical Executive Committee, the following were granted re-appointment privileges and submitted today for Board approval:

Albert Col, MD, Consulting Staff with Privileges in Dermatology

Ryan Frederiksen, MD, Consulting Staff with Privileges in Teleradiology

Jill Furubayashi, MD, Consulting Staff with Privileges in Teleradiology

Ricardo Garcia-Rivera, MD, Consulting Staff with Privileges in Teleneurology

Arshad Iqbal, MD, Consulting Staff with Privileges in Teleneurology

Archana Lucchesi, MD, Consulting Staff with Privileges in Teleradiology

Kristen Stenger, RDN, Allied Health with Privileges in Dietary/Nutrition

Michael Vecchione, DO, Consulting Staff with Privileges in Teleneurology

Jason Williams, MD, Consulting Staff with Privileges in Teleneurology

On recommendation from the Medical Executive Committee, the following was granted appointment privileges and submitted today for Board approval:

Amit Chaudhari, MD, Consulting Staff with Privileges in Teleneurology

Jennifer Creswell, FNP, Locum Tenen with Privileges in Family Medicine

Adham Kamel, MD, Consulting Staff with Privileges in Teleneurology

Catherine Le, MD, Consulting Staff with Privileges in Teleneurology

Al Montoya, PA, Allied Health with Privileges in Family Medicine

B.     Public Employee Appointment (Government Code § 54957(b))

Title:  Interim Chief Executive Officer

C.     Public Employee Performance Evaluation (Government Code § 54957(b))

Title:  Chief Executive Officer

D.    Conference With Labor Negotiators  (Government Code § 54957.6))

Agency Designated Representative:  HR

Unrepresented Employee:  Chief Executive Officer, Interim Chief Executive Officer

    4.        RECONVENE PUBLIC SESSION

Disclosure on reportable action taken during closed session

                5.        2:00 P.M. Board Meeting

Welcome to our guests—guests may voluntarily sign in if they wish to have their name spelled correctly in the minutes of this organization.

    6.        Public Comments

Persons wishing to speak on any subject not on the agenda may do so at this time.  This legislative body cannot act on or discuss an item that is not on the agenda according to Government Code §54954.2(3).  Persons wishing to comment on an action item are invited to do so when the Board considers that item and when the Chair calls for comments.  Thank you for your participation.

                7.        EDUCATION

Anthony Corderio, Imaging Manager

                8.        WRITTEN/VERBAL REPORTS

A.     Chief Nursing Officer (CNO), Lisa Hoyle, report deferred

B.     Chief Human Resources Officer (CHRO), Julie Adair, report attached Exhibit #1

Ø  Labor Union update

Ø  Recruitment efforts

C.     Information Technology (IT), Craig Burchfiel, IT Manager, report attached Exhibit #2

D.    JCFH Foundation, January minutes attached Exhibit #3

E.     Interim Chief Executive Officer (CEO)/Chief Operations Officer (COO), Lynn Buskill, report deferred

Ø  Debrief from incident command regarding the storms

    9.        BOARD DISCUSSION

Explanation of Trade Secrets, Wendy Ryder-Priola, Board Secretary-Treasurer

  10.        DISCUSSION/ACTION ITEM

A.     Letter to the Board & Final Audited Financials 2019-2020, Exhibit #4 & 5

B.     Resolution 7-23 Cancelling the Finance Board meeting of March 29, 2023, Exhibit #6

C.     District Organizational Values, Director Rogers

D.    Director Fluharty’s role as JCFHD board member liaison at JCFH Foundation meetings

E.     Review, discuss, and potentially adopt amendments to the Bylaws for the Board of Directors, see attached Resolution 6-23 Exhibit #7

F.      Discuss and potentially take action to appoint the following board officers: Vice Chairperson, Secretary, and Treasurer in accordance with amended Board Bylaws

Ø  Nomination and election of Vice Chairperson/Secretary (1 year term)

Ø  Nomination and election of Treasurer (1 year term)

G.    Review, Discuss, and potentially adopt a John C. Fremont Board of Directors Public Transparency and Accessibility Policy, see attached Exhibit #8

H.    Discussion and Direction:  Creating a community satisfaction and request survey

I.       Review, discuss and potentially adopt an updated description for the role and duties associated with the position of Clerk of the Board, see attached Exhibit #9

J.        Discuss combining Regular and Finance Board meetings together on one day

K.     Policies & Procedures committee recommends that the following policies & procedures to be adopted and/or affirmed:  Exhibit#10

Ø  Affirmation of Acute P&P

·         N-MS-102 “Acute Daily Census Report”

Ø  Adoption of Imaging P&Ps

·         01-01 “Policies & Procedures General”

·         01-02 “Revisions Updates to Imaging Services Policy & Procedure Manual”

·         01-03 “Scope of Services”

·         01-04 “Imaging Services Department Organizational Chart”

·         01-05 “Duties of the Medical Director of Imaging Services”

·         01-06 “Management Availability”

·         01-07 “Radiologist Availability”

·         01-08 “Use of Imaging Services Equipment by Technologist”

·         01-09 “Non-Radiologist Performing Fluoroscopy Procedures”

·         01-10 “Radiation Physicist Services”

·         01-11a “Use of Outside Imaging Services”

·         01-12 “Hospital Mobile Unit Communications”

·         01-13 “Certification of Technologist”

·         01-14 “Imaging Department Specific Orientation”

·         01-17 “Scheduling of Imaging Examinations”

·         01-18 “Venipuncture and Contrast Injection”

·         01-19 “Emergency Management”

·         02-01 “Scheduling Outpatient Examinations”

·         02-02 “Preparation Outpatient”

·         02-03 “Preparation for ER Inpatient”

·         02-04 FORM “CT Oral Preps”

·         02-05 “Lab Values?

·         02-06 “Venipuncture and Contrast Injection”

·         02-07 “Diagnostic Imaging Contrast Agents”

·         02-08 “Contrast Reaction”

·         02-09 “CT Reaction Box”

·         02-10 “Code Blue in CT Scanner”

·         02-11 “IV Contrast and Dialysis Patients”

·         02-12 “CT Exam for Pregnant Patients”

·         02-13 “Contrast Infiltration”

·         02-14 “CT Tech on Call”

·         02-15 “CT Emergency Shut Off”

·         02-16a “CT Quality Assurance”

·         02-16b “CT Number 2 Attachment”

·         02-17 “Consent for Contrast or Treatment”

·         02-18 “CT Down Time Notification”

·         02-19 “CT Exam Protocols”

·         02-20 “StatRad CT Protocol”

·         02-21 “StatRad Utilization”

Ø  Affirmation of Infection Prevention P&P

·         IP-509 “Employee Illness”

Ø  Adoption of Maintenance P&Ps

·         MN-01 “Air Compressors”

·         MN-02 “HVAC Filters”

·         MN-03 “Auxiliary Generator”

·         MN-04 “Contracts and Agreements”

·         MN-05 “Exterior General Maintenance”

·         MN-06 “Fire Alarms Doors Sprinkler Systems and Smoke Detectors”

·         MN-07 “Forms”

·         MN-08 “Heating”

·         MN-09 “Biohazardous Waste”

·         MN-10 “Maintenance Log”

·         MN-11 “Maintenance Shop”

·         MN-12 “Security”

·         MN-13 “Service Companies”

·         MN-14 “Quarterly Inspections”

·         MN-15 “Refuse Disposal”

·         MN-16 “Emergency Water Supply +attachment”

·         MN-17 “Orientation + checklist”

·         MN-18 “Scales”

·         MN-19 “Lock Out Tag Out”

·         MN-20 “Pest Control”

·         MN-21 “Fire Pull Fire Extinguisher Emergency Exit Access”

·         MN-22 “Surge Protectors + attachment”

Ø  Adoption of Nutrition & Food Services P&P

·         008A “Recommended Storage for Various Foods”

Ø  Affirmation of Pharmacy P&Ps

·         Pharm 2.4 “Disposition of Discontinued, Outdated or Poorly Labeled Medications”

·         Pharm 4.1 “Use of Multi Dose Vials”

·         Pharm 4.2 “Crash Cart Medications + attachment”

·         Pharm 4.16 “Insulin Drip Infusion”

Upon recommendation from the Policies & Procedures and Bylaws committee the changes that were recommended from the January 3, 2023 to Section 6:  Conduit of sensitive information should be reversed back to their original form.

Reading as such, Section 6:  Conduit of sensitive information:  To preserve patient and employee confidentiality, the CEO of the District shall be the sole conduit of all sensitive information between individual Directors, staff, and other parties as required.  Individual Directors are encouraged to bring personal observations or community input about District operations to the CEO.  Any and all inquiries of individual Directors shall be directed to the CEO

Upon recommendation from this committee – an addition of the following to be added to Article V.

Reading as such, Any inappropriate conduct, or sensitive information regarding the CEO, or an individual Director shall be reported to the District's Compliance Officer through the protocol outlined in the JCFHD Compliance Policy.   Directors will be trained during onboarding, and as needed, on the District Compliance Policy.

See attached excerpt from Compliance Plan.  Exhibit # 17

              11.        MINUTES

A.     Approve minutes of the Finance Board meeting of 1/25/2023, Exhibit #11

B.     Accept minutes of the Board Education & Development committee meeting of 2/6/2023, Exhibit #12

C.     Approve minutes of the Special Board meeting of 2/7/2023, Exhibit #13

D.    Approve minutes for the Regular Board meeting of 2/15/2023, Exhibit #14

E.     Accept minutes of the Policies & Procedures and Bylaws committee meeting of 3/15/2023, Exhibit #15

              12.        AGENDA ITEM(S) FOR FUTURE MEETINGS

A.     Interim Chief Executive Officer contract, CHRO Adair, April 19, 2023

B.     Audited Financials 2020/2021, Wes Thew, WIPFLi, LLP

C.     Audited Financial 2021/2022, Wes Thew, WIPFLi, LLP

D.    California Advancing and Innovating Medi-Cal (CalAIM) Rosemarie Smallcombe and/or Baljit Hundal, HHS

E.     Mission, Vision and Values discussion

F.      Focus & Execute, David Sandberg, meeting with new board & new senior team

G.    General Brown Act training, 2+ hours, Annie Branham, Best Best & Krieger, including use of H&S Code 32106 (Trade Secrets) closed session exception, Noel Caughman, Best Best & Krieger, Tentative Date:  April 19, 2023

H.    Compliance education, with Brown Act training

  13.        NEXT MEETING DATES/CALENDAR – Exhibit #16

A.     Board Education & Development committee:  April 12, 2023 @ 10am

B.     Regular Board meeting:  April 19, 2023 @ 2pm

C.     Finance Board meeting:  April 26, 2023 @ 2pm

  14.        ADJOURNMENT

In memory of Kathy Boomer, Elena Hill (Employee’s Aunt), Judy Jones (SNF Resident), Tina Koory (Employee’s Aunt), Charles “Chuck” Armin Veneman (Employee’s Father)

In celebration of the birth of baby Elias Ezekiel Evers to Grandmother Cindy Evers, HRG employee

Regular Board Meetings convene at 2:00 p.m. once each month.  Citizens wishing to schedule matters for Board consideration must contact the Clerk of the board in writing stating the action requested.  Appropriate requests will be scheduled before the Board as time allows.  Deadline for submission of written materials is seven days in advance of meeting.  An original and five copies of all supporting materials must be submitted.

Public Presentations: The law provides the opportunity for the public to be heard on any item within the subject matter jurisdiction of the Board, before or during the consideration of that item by the Board.  For all items, including items not on the agenda, the public presentation time at the start of each meeting is appropriate.  The Chair may set time limits as appropriate to manage the Agenda.  State law does not allow action to be taken on any item not on the Agenda.

In compliance with the Americans with Disability Act, if you require special accommodations to participate in a board meeting, please contact the District at 209-966-3631, x-5101 at least 47 hours prior to the meeting.

This agenda shall be made available upon request in alternative formats to persons with a disability, in compliance with the Americans with Disabilities Act of 1990 (42 U.S.C. §12132) and the Ralph M. Brown Act (California Government Code §54954.2).  Persons requesting special accommodations to participate in a District meeting, please contact the Board Clerk at 209-966-3631, x-5101, during regular business hours, at least 48 hours prior to the time of the meeting.

Pursuant to the Brown Act as codified in Government Code §54957.5, any documents pertaining to a non-closed agenda item distributed to a majority of the Board of Directors in less than 72 hours before a Board meeting shall be available for public inspection.  Said documents shall be available for inspection at the John C. Fremont Healthcare District Administrative Office located at 5189 Hospital Road, Mariposa, California, Monday through Friday, except Holidays, between the hours of 9:00 a.m. and 12:00 p.m.

In compliance with the American Disabilities Act, if you need special assistance to participate in this meeting, please contact the Board Clerk at 209-966-3631, x-5101.

Source: JCF