AGENDA of Board of Directors for 
Regular Board Meeting

Wednesday, September 20, 2023

Location:  JCFHD Board Room, 5189 Hospital Road, Mariposa 

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

Mission – To excel in the provision of quality health care services 
Vision – To be the organization of choice for community health care 

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

            Title: Interim Chief Executive Officer

B.     Public Employee Discipline/Dismissal/Release (Government Code 54957)

C.    Conference with Labor Negotiator: Update on Employee Retirement Plan by Julie Adair, Director of Human Resources (Government Code §54957.6)

4.      RECONVENE PUBLIC SESSION

Disclosure on reportable action taken during closed session

5.      2:00 p.m. Call to Order Regular Scheduled Board Meeting

Introduction of 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 agenda item are invited to do so when the Board considers that item and the Chair calls for comments.  Persons will be limited to 3 minutes when addressing the Board. Speaking time may not be granted and/or loaned to another individual for purposes of extending available speaking time unless arrangements have been made in advance for a large group of speakers to have a spokesperson speak on their behalf.  Comments must be kept brief and non-repetitive.  Persons wishing to comment on agenda item are invited to do so when the Board considers that item and the Chair calls for comments.  All questions or comments will be directed to the Board only.  Thank you for your participation.

7.      Announcements /PRESENTATIONS

A.    JCFHDF Black & White Ball, Date is Sat., November 4, 2023 @ 5:30 p.m. Tickets on sale now.

B.     Town Hall scheduled for September 21, 2023, has been cancelled, reschedule to be determined

C.     Mariposa County Supervisor, Rosemarie Smallcombe, County Updates

D.    Hospital Affiliations, Matt Rees, Chief Executive Officer(CEO) of Southern Humboldt Healthcare District, Dr. Rogers 

8.      EDUCATION

A.    Brown Act Training, Rose Fluharty

B.     Grant Orbach of Best Best & Krieger Attorney at Law (BBK), brief overview on when Districts must go to bid and the process, Suzette Prue

            9.      WRITTEN/VERBAL REPORTS 

A.    John C Fremont Healthcare District Foundation, July 2023 minutes

B.     Interim Chief Executive Officer (CEO) Update, Lisa Hoyle, DNP, RN, NEA-BC, FACHE, CPHQ, CPPS, Interim Chief Executive Officer/ Chief Nursing Officer

C.     Craig Burchfiel, Information Technology Manager, Information Technology Update

D.    Roby David, Cardiopulmonary Manager, Cardiolumonary Update

          10.  DISCUSSION/ACTION ITEM   

A.    Bylaws Revision, Approve and Accept, Nick Lambert

B.     Discuss/Approve Revision of USDA Pre-Application, directing Interim Chief Executive Officer, Lisa Hoyle to sign, Gary Hicks

C.     Discuss/Approve Carefusion Solutions, LLC/Pyxis Lease for Acute/Pharmacy

D.    Discuss/Approve Revenue Cycle Proposal from WIPFLi, LLP

E.     Discuss/Approve Business Associate Agreement, Medical Debt Resolution, Inc dba RIP Medical Debt

F.      Resolution #13-23, November and December 2023 Meeting dates to be combined or rescheduled due to holidays

G.    Resolution #14-23, 2024 Meeting Schedule and Renaming of Meetings

H.    ACHD Certification: Information and plan for certification, Rose Fluharty

I.        Discuss and potentially take action to develop a competitive bid process for legal representation of new hospital project, Rose Fluharty

J.       Discuss and potentially take action to develop an RFP process for Owner’s Representative/Property Management for new hospital project, Rose Fluharty

K.    Upon recommendation from Policies & Procedures and Bylaws committee – the following were recommended to be affirmed and/or adopted

Ø  Affirmation of Acute P&Ps

·         N-MS-501 Blood Collection

·         N-MS-607 Care of Patients Valuables

Ø  Affirmation of COVID Protocols

·         COVID Dist Wide COVID-19 Returning to Work and Testing for Healthcare Personnel and Patients

·         COVID Dist Wide Source Control in the Healthcare Setting

Ø  Affirmation of District Wide Protocols

·         Dist Wide Nursing Reporting of Critical Lab Results

Ø  Affirmation of Emergency Department P&Ps

·         ER 001 Admission of Patients to the Emergency Department

·         ER 007 Elopement Left Without Being Seen

·         ER 008 Patient Leaving Against Medical Advice

·         ER 013 DNR

·         ER 020 Standards of Practice or Care

·         ER 021 Triage

·         ER 023 Assessment of the Trauma Patient

·         ER 024 Age Related Documentation Pediatric

·         ER 038 Patient Presenting with Amputations

·         ER 041 Administration of Blood – please see edits

·         ER 056 Extremity X Ray

·         ER 057 Standard of Care Asthma Patient

·         ER 061 Care of Patient with Stab or Puncture Wounds

·         ER 063 Standard of Care Vaginal Bleeding – please see edits

·         ER 066 Cervical Traction or CSpine Immobilization

·         ER 146 Documentation in the ED Record EMR

·         ER 163 Telephone Triage

·         ER 1012 Restraints

·         ER 2001  Safety

·         ER 2003 Security and Visitors.

·         ER 8116 Cardiac Arrest Code Blue

·         ER 8129 Defibrillation

·         ER 8130  Diarrhea

·         ER 8131  Care of Dying Patient

·         ER 8132 End of Life lssues

·         ER 8133 Emergency Delivery

·         ER 8134 Epistaxis

·         ER 8135 Eye Emergencies

·         ER 8136 Head Injury

·         ER 8138  Hypothermia

·         ER 8139 Hypovolemic Shock

·         ER 8143  Intravenous Therapy

·         ER 8144  Lacerations and or Abrasions

·         ER 8146 Assisting with Lumbar Puncture

·         ER 8152  Patient Under the Influence of Alcohol  - Immediate Intervention

·         ER 8153 Management of Patient Under the Influence of Drugs

·         ER 8155 Orthopedic Emergencies (Extremities)

·         ER 8156  Pediatric Asthma

·         ER 8157  Pediatric Fever

·         ER 8159  Poison Control  Information

·         ER 8161  CMS Reporting and  Documentation  Requirements for Death Associated with Restraint or Seclusion

·         ER 8164 Seizures - Nursing Management

·         ER 8167 Transportation of Emergency Department Patient within the Hospital

·         ER 8170 Vomiting

·         ER 9002 Patient Log

·         ER 9005 Legibility of Medical Record Documentation

·         ER 9006 Unacceptable Abbreviation and Symbol List

·         ER 11002 Blood Glucose Screening

Ø  Affirmation of Environmental Services P&P

·         EVS 2002 Cleaning of the Emergency Department

Ø  Affirmation of Infection Prevention P&P

·         IP-103 Microbiology Reports

·         IP-104 Infection Risk Assessment

·         IP-106 Infection Prevention Chairperson

·         IP-115 Infection Prevention and Control Organizaiton and Function

·         IP-206 Respiratory Hygiene Cough Etiquette

·         IP-301 Reporting Transmissable Infections to Receiving Facility

·         IP-304 Standard Precautions

·         IP-307 Patient Education

Ø  Affirmation of Imaging P&Ps

·         03-01 MRI Safety General Requirements

·         03-02 MR Safe or MR Conditional Equipment

·         03-03 Constraindictions to MRI Scanning

·         03-04 Code Blue in MRI

·         03-05 Fire in or near MRI

·         03-06 Proper Use of Hand Held MRI safe Fire Extinguisher

·         03-07Emergency Medication Box

·         08-01 Ordering Exams

·         08-02 Routine Patient Physical Safety

·         08-03 Provision of Care Treatment and Services Critical Test Results

·         08-04 Scheduling Procedures

·         08-05 patient Refusal of Exam

·         08-06 Provision of Care Treatment and Services Stat Diagnostic Radiological Procedures

·         08-07 Patient Safety

·         08-08 Patient Assessment for Imaging Procedures

·         06 01  Radiation Safety Patient and  Employee

·         06 02 Patient Safety

·         06 03 Employee Radiation Safety Guidelines

·         06 04 Radiation Safety

·         06 05 CT Radiation Safety Instructions

·         06 06 Electrical safety  and maintenance

·         06 07 Declaration of pregnancy

·         06 08 Pregnant Staff

·         06 09 Dosimetry of Pregnant Staff

·         06 10 Radiation Exposure Monitoring of Staff

·         06 11  Occupational Dose Limits

·         06 12 Radiation Monitoring Badge

·         06 13 Portable Xray

·         10 01  Annual Equipment Testing

·         10 02 Annual CT Equipment Testing

·         10 03 Lead Apron Testing

Ø  Affirmation of Laboratory P&Ps

·         ABO Grouping

·         Absolute Neutrophil Count

·         Antibody Screen

·         APINH

·         Bacterial Contamination of Platelet Packs

·         BB Alarm Check

·         BB Centrifuge Cleaning

·         BB Computer Downtime

·         Beta-Lactamase Test

·         Bleeding Time

·         Influenza A & B

·         KOH Preparation

·         Lipemic CBC Hemoglobin Correction

·         Loss of Electrical Power

·         M. Cat Butyrate Test

·         Malaria Policy

·         Manual Blood Culture

·         MedTox Drug Screen Controls

·         MedTox Drug Test

·         Advantus

·         Blood Bank Test Index

·         Blood Bank Transfusion Protocols

·         Blood Recipient Arm Band

·         Blood Release

·         Catalase

·         Cell-Dyn 26 Plus Hematology Control

·         Computer Downtime

·         Criteria for Manual Differentials

·         CSF Cell Count

·         Differential Leukocyte Count, Manual

·         Differential Validation

·         Direct Antiglobulin Test

·         Emergency Blood Release

·         Emergency Blood Type Switching

·         Gram Stain

·         H. pylori Sure-Vue

·         H. pylori

·         Hematology Back up Analyzer (Emerald)

·         Hernatology Critical Values

·         Hematology QC

·         Micro_Unexpected Results

·         Microbiology Note

·         Mono Test

·         Platelet Transfusion

·         Power Failure-BB Refrigerator

·         Refrigerator Malfunction

·         Release of Un-Crossmatched Blood

·         Rho  D Typing

·         Routine Crossmatch

·         Serofuge Quality Control

·         Therapeutic Phlebotomy

·         Transfusion Reaction Workup

·         Transfusion Service

·         Microbiology Panic Reports

Ø  Affirmation of Pharmacy P&Ps

·         4.38 Pharmacy Verification of Orders and Emergency Drug Use List

Ø  Affirmation of Physical Therapy P&Ps

·         1901 Supervision of PTA

·         1902 Budget

·         1903 District Department Orientation

·         1904 Staff Continuous Inservice Education and Training

·         1905 Contract Services

·         1907 Description of Services for Physical Therapy

·         1908 Code of Ethics

·         1910 Rehabilitation Services

·         2902 Extended Orientation

·         4901 Supply Management

·         4903 Lifting

·         4904 Therapeutic Exercise

·         4905 Gait Training

·         4906 Transcutaneous Electrical Nerve Stimulation

·         4907 Ultrasound

·         4908 Hydrocollator currently in storage

·         4909 Assistive Devices

·         5901 Designated Exercise Room

Ø  Affirmation of Skilled Nursing Facility Manuals

·         SNF-06 Theft and Loss

Ø  Affirmation of Volunteer Protocols

·         1.12 Purpose & Objectives

           11.  MINUTES

A.    Approve minutes of the Regular Board meeting of May 24, 2023

B.     Approve minutes of the Finance Board meeting of June 28, 2023

C.     Approve minutes of the Finance Board meeting of July 26, 2023

D.    Approve minutes of the Special Board meeting of August 10, 2023

E.     Acceptance minutes of the Policies & Procedures committee meeting of August 23, 2023

F.      Acceptance minutes of the Policies & Procedures committee meeting of August 30, 2023

12.  AGENDA ITEMS FOR FUTURE MEETINGS

A.    Strategic Planning  

B.     Hearing: Quality Management quarterly report, (Health & Safety Code § 32155) Lisa Hoyle, DPN, RN, NEA-BC, FACHE, CPHQ, CPPS, Chief Nursing Officer

C.     Hearing: Compliance quarterly report, (Health & Safety Code § 32155) Colleen Choi, Controller

D.    Hearing: Risk Management quarterly report, (Health & Safety Code § 32155) Lisa Hoyle, DNP, RN, NEA-BC, FACHE, CPHQ, CPPS, Chief Nursing Officer & Julie Adair, Director of Human Resources

            13.  NEXT MEETING DATES

A.    Policies & Procedures and Bylaws committee: TBD

B.     Board Education & Development committee: TBD

C.     Finance Board Meeting: September 27, 2023

D.    Regular Board Meeting: October 18, 2023

E.     Finance Board Meeting: October 25, 2023

F.      If Board Approves on September 20, 2023, November and December Regular and Finance Board Meetings will be held on December 13, 2023

14.  ADJOURNMENT

In memory of Carole Fish (John C. Fremont Hospital Foundation), Doris Minick (Hospice patient) and Ryan McLean (Son of Former JCF Employee)

In Celebration of birth of baby, Athena Marie Lavern, (Baby Girl born at JCF ER)

Proud Parents: Laura Broyles and Luke Pena

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-5106 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-5106, 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