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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.0208333333333332; text-align:center; page-break-before:column; margin-left:-18px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">United States of America</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.0208333333333332; text-align:center; margin-left:-18px; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.0208333333333332; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1120 20</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">th<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Street, N.W., Ninth Floor</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.0208333333333332; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Washington, DC 20036-3457</span></p>
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							<p style="margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
									</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">SECRETARY OF LABOR</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span></p>
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							<p style="margin-top:0px; margin-bottom:8px; margin-bottom:0cm; "> </p>
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							<p style="text-align:right; margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant,</span></p>
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							<p style="margin-top:0px; margin-bottom:8px; margin-bottom:0cm; "> </p>
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							<p style="text-align:center; margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v.</span></p>
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							<p style="margin-top:0px; margin-bottom:8px; margin-bottom:0cm; "> </p>
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							<p style="margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS OF WESTWOOD PEMBROKE, INC., UHS OF DELAWARE, INC.,</span></p>
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							<p style="margin-top:0px; margin-bottom:8px; margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
								</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span></p>
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							<p style="text-align:center; margin-bottom:0cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHRC<span>
									</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Docket No. 17-0737</span></p>
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				<p style="margin-top:16px; margin-bottom:8px; line-height:1; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">ON BRIEFS:</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:48px; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Anne R. Godoy, Attorney; Amy S. Tryon,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Attorney; Charles F. James, Counsel for Appellate Litigation;<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Edmund C. Baird</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">, Associate Solicitor of Labor for Occupational Safety and Health; Kate S.<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">O’Scannlain</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">, Solicitor; U.S. Department of Labor, Washington, D.C.</span></p>
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				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; text-indent:1.27cm; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">For the Complainant</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:48px; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Melanie L. Paul,</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; "><span><span></span>
						</span>Esq.;<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Jackson Lewis</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; "><span><span></span>
						</span>P.C.,<span>
						</span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">Atlanta, GA</span></p>
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				<p style="margin-top:0px; margin-bottom:13.333px; line-height:1; text-align:justify; margin-left:48px; text-indent:1.27cm; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">For the Respondent</span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; ">, UHS of Westwood Pembroke, Inc.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; "><span style="mso-tab-count:1">  </span>Jonathan L. Snare, Esq.; Morgan, Lewis & Bockius LLP, Washington, DC</span></p>
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				<p style="margin-top:0px; margin-bottom:16px; line-height:1; text-align:justify; "><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; "><span style="mso-tab-count:1">  </span></span><span style="font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; "><span style="mso-tab-count:1">  </span>For the Respondent, UHS of Delaware, Inc.</span></p>
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				<p style="text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">DECISION</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Before: ATTWOOD, Chair</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">man</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and LAIHOW, Commissioner.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">BY THE COMMISSION:</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS of Westwood Pembroke, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(UHS-WP)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>owns and operates</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Pembroke Hospital,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">psychiatric hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>located</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke, Massachusetts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> UHS of Delaware, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(UHS-DE)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">serves as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the management company for UHS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-WP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>pursuant to a management agreement between the two entities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Following an employee complaint of workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">due to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient aggression<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke H</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, OSHA inspect</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">October<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">11,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2016</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">subsequently<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issued</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>a single citation to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP and UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>alleging a repeat violation of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Occupational Safety and Health Act’s general duty clause, 29 U.S.C. §</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">654(a)(1), for exposing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>physical</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>assaults by patients.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref1" href="#ftn1">1</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Administrative Law Judge Keith E. Bell affirmed the citation as to UHS-WP only, rej</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cting the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary’s claim that the two companies should be treated as a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">single<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and recharacterized the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">general duty clause<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violation from repeat to serious.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Secretary and UHS-WP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">petitioned for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>review of the judge’s decision. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For the following reasons, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find UHS-WP and UHS-DE operated as a single employer and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">affirm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as repeat</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref2" href="#ftn2">2</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">BACKGROUND</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Hospital (Pembroke)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is a 120-bed inpatient psychiatric hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">owned by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which operates<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">three facilities as a single entity under one license: Pembroke, Westwood Lodge, and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Lowell Treatment Center. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP is in turn ultimately owned by Universal Health Services (UHS). </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The other cited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>entity,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which is also owned by UHS, provides</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">management services</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">budget oversight</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hief<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">xecutive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">fficer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(CEO)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hief<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inancial<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">fficer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(CFO)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employed and supervised by UHS-DE.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s Director of Nursing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Risk Manager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>report to UHS-DE employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including Pembroke’s CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">L</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ontrol<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">handles Pembroke’s budget for worker</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>compensation claims and visits the hospital monthly to participate in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aggression reduction team meetings, which are attended by the hospital’s CEO. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is divided into six patient care units</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—four for adults, one for adolescents, and one for geriatric patients—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that each care for approximately<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">15-25<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Registered nurses and Mental Health Associates (MHAs) provide direct patient care<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">over three shifts<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nywhere from one to approximately five</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>MHAs<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are assigned to each unit.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref3" href="#ftn3">3</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> MHAs are responsible for providing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">around the clock care to patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which includes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>completing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wellness and vital checks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>each patient every 15 minutes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(even when they are sleeping)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assisting with personal hygiene and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">housekeeping activities,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lead</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">group activities,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">performing admissions duties for new patients,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and escort</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients outside<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ir</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>units for meetings, fresh air breaks, and meals.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At least one MHA is expected to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">always remain on the unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, although MHAs are also expected to respond to calls for assistance on other units when</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">incidents<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">relating to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>occur</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">MHAs<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are responsible for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monitor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>detect</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when verbal de-escalation or other calming techniques are needed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to address patient aggression,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and to implement those techniques as necessary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ach patient has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a personal de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>plan that list</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ir</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proven or preferred calming</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">DISCUSSION</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To prove a violation of the general duty clause, the Secretary must establish that: (1) a condition or activity in the workplace presented a hazard; (2) the employer or its industry recognized the hazard; (3) the hazard was causing or likely to cause death or serious physical harm; and (4) a feasible and effective means existed to eliminate or materially reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Arcadian Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC 2001, 2007 (No. 93-0628, 2004). The Secretary must also show that the employer knew or, with the exercise of reasonable diligence, could have known of the hazardous condition. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Tampa Shipyards, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 15 BNA OSHC 1533, 1537 (No. 86-0469, 1992).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in affirming the violation,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge erred in finding the Secretary established a feasible and effective means of abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary argues the judge erred in finding that UHS-WP and UHS-DE should not be treated as a single employer and that the violation should not be characterized as repeat.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref4" href="#ftn4">4</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> We turn first to the single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer issue, then to whether a feasible and effective means of abatement has been proven, and last to the violation’s characterization.</span></p>
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			<p class="style_Default style_Default " style="margin-left:72px; text-indent:-1.27cm; line-height:1.5; margin-left:72px; text-indent:-1.27cm; line-height:1.5; ">
				<span style="font-weight:bold; padding-right:20px;">I.</span><span style="font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Single Employer</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The three factors relevant to determining whether separate entities operate as a single employer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for purposes of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">liability under<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Act<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are whether the entities (1) share “a common worksite,” (2) “are interrelated and integrated with respect to operations and safety and health matters,” and (3) “share a common president, management, supervision, or ownership.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">S. Scrap Materials Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC 1596, 1627 (No. 94-3393, 2011). The Secretary bears the burden of establishing the existence of a single-employer relationship.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref5" href="#ftn5">5</a></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "> Loretto</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC 1356, 1358 n.4 (No. 02-1164, 2011)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(consolidated)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 692 F.3d 65 (2d Cir. 2012). </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge found that none of these factors supported finding a single-employer relationship between UHS-WP and UHS-DE. </span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">parties rely</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>heavily</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to support their arguments with respect to each factor.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">23 BNA OSHC at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1359-61</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">692 F.3d at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">77-78</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> In that case,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>both the Commission and the Second Circuit concluded that the cited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>nursing home</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>did not operate as a single employer with its management company</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">primarily because the two entities were not interrelated and integrated as to safety matters. 23 BNA OSHC at 1359-60; 692 F.3d at 77.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary argues</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is distinguishable from this case<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“the record<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[here]<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows that UHS-Pembroke and UHS-DE handled policy and other safety matters at Pembroke Hospital as one company.” </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">I</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n response</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this case is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">closely analogous to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all three</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factors<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">weigh against</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>finding a single-employer relationship and therefore the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Commission should affirm the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">judge’s decision dismissing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the company</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>from the case.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For the reasons set forth below, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">agree with the Secretary and find the record establishes that the two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities operated as a single employer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for purposes of the alleged violation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Common worksite</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">re is no dispute that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">have employees working at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the same</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>worksite</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke. Indeed,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s CEO is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a UHS-DE employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">works onsite full</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">time at Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supervising<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hospital’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and overseeing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">day-to-day operations. Likewise,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">L</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ontrol<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager is regularly present at the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>addressing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">various<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">safety matters including the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>workplace violence hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nevertheless<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">found that UHS-WP and UHS-DE do not share a common worksite</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>because</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE employees were exposed to the cited workplace violence hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. He also relied on the fact that the two entities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>have separate business addresses</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE operates out of Pennsylvania while UHS-WP operates its facilities (including Pembroke) out of Massachusetts.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We agree with the Secretary</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">contention</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on review</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge erred in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>making these findings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. U</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nder</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Commission and relevant circuit court precedent, mutual employee access to a hazard is not a precondition</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to establishing the common worksite factor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">A.C.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Castle</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>v. Acosta</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 882 F.3d 34, 42</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1st Cir. 2018)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the First Circuit rejected the notion that a common business address or headquarters is necessary to find a single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship or “that workers from each entity must be at the site at the time the violation occurred, or directly exposed to the risk.”</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref6" href="#ftn6">6</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> 882 F.3d at 42.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary points out</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>below,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">th</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">facts here are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">distinguishable from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">those in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, where the management<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">company<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">had “no physical presence” at the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inspected<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nursing home</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, was rarely onsite, and was not involved in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>day-to-day operations. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC at 1361. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">noted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">above<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and discussed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in detail below<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the next<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">single-employer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factor,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>has</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>CEO and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s Loss Control Manager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">onsite</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">integrally</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">involved in the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">day-to-day<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">operations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hiring, firing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and managing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as well as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">overseeing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient treatment and care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and addressing the cited workplace violence hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Taylor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC 1083, 1085 (finding single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship where one entity’s employee directed and supervised the work performed by the other entity’s employees).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And although the two entities have different principal addresses and perform their primary work at different locations, the central inquiry is whether they share a common wor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ite</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">A.C.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Castle</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">882</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>F.3d at 42</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(noting that a while a shared headquarters or business address “generally satisfies the common worksite factor” it is not “necessary” to do<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">so and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>requiring such would rewrite the test to mean “common business address”)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">here can be no dispute here that UHS-DE employees work alongside UHS-WP employees on a consistent basis at Pembroke.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For all these reasons</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">we find<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the common worksite<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factor supports finding a single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Interrelation and integration</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We also find<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities are interrelated and integrated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>operations, including safety and health matters. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">According to t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-WP and UHS-DE are distinct businesses, as UHS-WP provides direct patient care at its facilities, while UHS-DE is a management and consulting business</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">found</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>primarily develop</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and set</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>its own budgets.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to safety matters,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">judge merely<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stat</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that “[t]here is no evidence that [UHS-WP] lacked sufficient capital or other resources to address worker health and safet</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y.”</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Turning first<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to operations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">we find that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the record establishes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not only<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">direct<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">involvement in supervising<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and in p</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">roviding patient care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">its control of and influence over the hospital’s budget and finances</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as well as the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">clinical and operational aspects of running the hospital, such as regulatory compliance, licensing, quality<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>clinical care, and clinical programming</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">points to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two key undisputed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">facts demonstrating that UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">manages</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>daily operation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Pembroke: (1)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE employee,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">responsible for hiring, disciplining, and firing hospital staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(2)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">N</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ursing and its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">isk<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager both report to UHS-DE management</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed, a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t the hearing,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Thomas<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Hickey, Pembroke’s CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at the time of OSHA’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>inspection,</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref7" href="#ftn7">7</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">confirmed the extent of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">his duties at the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and his testimony in this regard stands unrebutted</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-top:0px; margin-bottom:8px; text-align:justify; margin-left:48px; margin-right:48px; ">I was responsible for hiring staff, disciplinary actions, firing, maintaining our budget, overviewing the quality of the program, addressing regulatory issues, making sure we were meeting joint commission and [state] standards, working with staff to develop excellent treatment planning and programming for our patients, program development, growing our program, making sure our patient beds were filled,<span>
					</span>all of<span><span></span>
					</span>the-- both clinical and operational aspects of running the hospital.<span>
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Hickey also testified, when asked by the judge<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">about the scope of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">management at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the hospital, that:</span></p>
			</div>
			<div>
				<p style="line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">It involves<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a number of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>broad areas. One is regulatory compliance, licensing, it involves quality of clinical care, developing clinical programming, marketing, budget, hiring and firing of staff. I was responsible for hiring medical staff, operating the pharmacy, the whole caboodle of what’s involved in running a free-standing psychiatric facility and out-patient programs as well. Developing new programs, expanding, market share, etc. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Contrary to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assertion<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that clinical and administrative functions<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are kept separate, Dr. Hickey testified that even though his “responsibility was not to make the clinical decisions,” he nonetheless was responsible for “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mak</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">] sure the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[clinical]<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">process happened the way it should.” </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In fact, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">two Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">managers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who work on clinical matters—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">N</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ursing and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">isk<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">report to Pembroke’s CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(a UHS-DE employee)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as well as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE management.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For instance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">isk<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, who</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is tasked with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">review</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>incidents of patient aggression and coordinating</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>an initiative at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to reduce such</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aggression, regularly works with a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">orporate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">linical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employed by</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE. A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nd a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lthough Pembroke’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">edical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector manages patient care and has authority over clinical and staffing decisions,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Hickey had hiring and firing authority</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>over all employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at Pembroke,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">which would include<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">edical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Indeed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Dr. Hickey testified that while<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">admitting a patient is a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">clinical decision made by the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">edical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he participated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as CEO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">decision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding admissions<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">capacity.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also involved in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establishing hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">policy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>through Pembroke’s Board of Advisors, which includes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>managers (the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Risk Manager</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and Director of Nursing)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">corporate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(Pembroke’s CEO and CFO and UHS-DE Group Director)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and is led by UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">V</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ice</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">resident.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Further, UHS-DE drafts the hospital’s Strategic Plan, which is submitted to the Department of Mental Health. The plan describes UHS-DE’s implementation of patient care improvements, such as staff training and retention.</span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:line-through ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as the Secretary asserts,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anagement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">greement between the two entities reflects UHS-DE’s authority over the hospital’s budget and finances. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Contrary to the judge’s conclusion</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>related<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">arguments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">evidence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shows that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE, through its employees who serve as Pembroke’s CEO and CFO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, that</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">develops the hospital’s budget</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which is then reviewed and approved by higher-level UHS-DE employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This is consistent with t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">m</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anagement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">greement,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>which confirms that UHS-DE is responsible for central financial systems at Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, including:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(a) the billing system; (b) the collection system; (c) the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">disbursement system; (d) the payroll system; (e) the insurance claim system; (f) the management information system; and (g) the patient safety improvement system.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> For all these reasons,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">we</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Secretary has shown that the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities have</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">integrated and interrelated operations.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find that the same integration exists<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">safety and health matters.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Again, the record shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE directs safety and health matters through its onsite CEO, who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">participates in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s committees and meetings related to patient aggression and workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reports workplace violence incidents to UHS-DE, and UHS-DE provides detailed comparisons between a benchmark created by UHS-DE and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">various metrics at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>relating to patient aggression, such as the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>rate of restraints</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>injury. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">dditionally,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identif</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">opportunities<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to address<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">makes</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>recommendations<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in that regard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Moreover</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">L</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oss<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ontrol<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">M</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">anager,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Gina Gilmore</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">visits Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">monthly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and attends “aggression reduction” meetings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where she presents analyses of patient aggression data</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and directly interacts with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees regarding worker safety</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Following the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>meetings, she prepares a “loss control summary” in which she compares injuries at Pembroke to targets set by UHS-DE and discusses whether Pembroke will receive a prevention credit to its worker</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>compensation budget if<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">injuries fall below the UHS-DE target. In the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">loss control</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">summary,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Gilmore</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also analyzes data on patient aggression, identifies times when patient aggression is most likely to occur, and specifies corrective action to address such aggression. When injuries to staff occur due to patient aggression, she performs root cause analyses, which involve interviewing hospital staff</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">presents<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s CEO and other hospital managers, including the Risk Manager and Clinical Director,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with the results of these analyses.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Gilmore</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>advises Pembroke on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">safety<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees and identifying and mitigating issues related to patient aggression.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Thus, this case is not like<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>where the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">corporate management<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entity<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>only</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>infrequently and indirectly involved in employee safety and health</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nursing home<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">personnel<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">retained<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">primary responsibility for safety matters. 23 BNA OSHC at 1360. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Rather, as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">asserts,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it is clear<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and UHS-WP “handled safety matters [at Pembroke] as one company.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Compare</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">C.T. Taylor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC at 1083 (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship established where entity assumed responsibility for employee safety on the job<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">by directly intervening in safety matters)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">FreightCar</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Am</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No. 19-0970, 2021 WL 2311871, at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>*6-7</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(OSHRC March 3, 2021) (single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship not established<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where record was unclear</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">if<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">parent was involved in safety at subsidiary’s worksite)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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			<div>
				<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="line-height:1.5; text-align:center; margin-left:0cm; "><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Common president, management, supervision, or ownership</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">judge found that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">last<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factor weighed against a single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship because</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE has its own management structure with a separate CEO, CFO, and management group. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>found that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s CEO has no managerial duties for UHS-DE and that UHS-DE does not provide daily oversight<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">maintains</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">erro</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">neous</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, citing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the parties’ stipulation that UHS<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is the ultimate corporate owner of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both UHS-WP and UHS-DE. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Again, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">points to the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>direct line of management between Pembroke and UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that runs through the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>hospital’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>CEO, who supervises<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and is in turn supervised by UHS-DE employees. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">asserts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>two companies’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>corporate parent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">operates only as a holding company such that there is no shared ownership or management. According to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">role<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is limited to administrative and financial functions while Pembroke controls clinical functions</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">echoes the judge’s finding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in arguing that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, u</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nlike<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the entities in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP and UHS-DE have their own management structure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and employees.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref8" href="#ftn8">8</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reasons</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>already</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">discussed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">above</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, w</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">agree<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">with the Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities are linked<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">through<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s CEO and CFO<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are UHS-DE employees supervised by higher-level UHS-DE<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">managers</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Dr. Hickey testified that as Pembroke CEO, he reported to the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">V</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ice<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">resident and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">roup<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">D</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">irector of UHS-DE. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s CFO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, in turn,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>report</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CEO as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">her<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">immediate supervisor,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egional CFO and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">V</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ice<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">resident<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ve</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>oversight over<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the CFO’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>work.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Evidence of shared management is also found in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Board of Advisors</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—as noted, the Board<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is comprised of both Pembroke and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>UHS-DE employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(including the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">CEO and CFO)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and approves policy changes at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the parties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stipulated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-WP and UHS-DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>share<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>same ultimate corporate parent. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cf. S. Scrap Materials Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC at 1627 (common management<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">factor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">met where</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">entities were owned by same parent company and shared a company<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">president</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but record lacked evidence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“supervision or management at the two subsidiary companies’ scrap yards was shared”);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC at 1359 (“At the time of the violations, LMC and the three affiliates shared the same president, chief executive officer, and chief financial officer. This outward appearance of a common identity gives way, however, . . . because the record shows that on a day-to-day basis, administrative personnel at Loretto</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Oswego operated independently of LMC.”)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as we have already found,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the evidence shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS-DE is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">integrally<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">involved in the day-to-day management of Pembroke, including the hospital’s core function of patient care and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">related<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">safety matters. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See C.T. Taylor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC at 1083 (finding single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">relationship<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">direct management and safety involvement was present between the two entities</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.) In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">short</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">key<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">roles that UHS-DE employees play in managing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>operations, including</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>safety</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at Pembroke Hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lso<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">establish their</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shared management.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">W</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">therefore<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reverse the judge and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>all three factors support finding a single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer relationship<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">existed between UHS-DE and UHS-WP<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the time of the alleged violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<p class="style_Default style_Default " style="margin-left:72px; text-indent:-1.27cm; line-height:1.5; margin-left:72px; text-indent:-1.27cm; line-height:1.5; ">
				<span style="font-weight:bold; padding-right:20px;">II.</span><span style="font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">A</span><span style="font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">batement</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the citation, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary lists<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">several</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed measures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to abate the cited workplace violence hazard and these measures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">address</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">various aspects of hospital operations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">relating to patient care</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as admissions, security, and therapeutics.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref9" href="#ftn9">9</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Prior to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge’s decision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in this case</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">after</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the parties submitted their<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">post-hearing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">briefs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Commission issued its decision in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>another case involving a general duty clause violation,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">A.H. Sturgill Roofing, Inc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., No. 13-0224, 2019 WL 1099857 (OSHRC Feb. 28, 2019)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and held that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citation’s list of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were proposed as alternatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Secretary could only prevail<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in that case<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">if he prove</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that none of them were implemented</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>by the cited employer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 9.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In other words,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Commission held that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementing any one of the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alternatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>would constitute abatement of the alleged violation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge did not address<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in his<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">analysis</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">relied on other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">precedent to conclude<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citation’s listed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measures as a process</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and correctly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acknowledged</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a process-based approach to abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is permitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where the hazard<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alleged<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">under<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">general duty clause<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cannot be abated with a single action.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref10" href="#ftn10">10</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pepperidge Farm, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 17 BNA OSHC 1993 (No. 89-265, 1997) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finding that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“the appropriate response to the hazard<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[alleged under the general duty clause] </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. . . was a process that included actions selected from a menu of alternatives”);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra Health Mgmt., Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, No. 13-1124, 2019 WL 1142920, at *12-13 (OSHRC March 4, 2019) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">considering</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">numerous proposed abatement measures as means of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">materially reducing workplace<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violence hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>alleged under general duty clause</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC Nw. Psychiatric Hosp., LLC, v. Sec’y of Labor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 951 F.3d 558, 564 (D.C. Cir. 2020)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“menu” of abatement options<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>materially reduce<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>alleged under general duty clause</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">invoke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">now claim</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Secretary proposed the abatement measures as alternatives</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the record contains</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>substantial evidence that it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ha</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequately implemented at least some of the measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Secretary cannot prove the abatement element of the alleged violation. The Secretary responds that the proposed abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“would each cumulatively reduce the hazard” such that every<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified in the citation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">should</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>be implemented. According to the Secretary, “each proposed abatement method would help avoid different and separate acts of patient-on-staff violence.” </span></p>
			</div>
			<div>
				<p class="style_Default style_Default " style="line-height:1.5; text-align:justify; "><span style="font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span style="mso-tab-count:1">  </span></span>We<span>
					</span>agree with the judge<span>
					</span>that the Secretary proposed,<span><span></span>
					</span>and<span><span></span>
					</span>the parties<span><span></span>
					</span>tried,<span><span></span>
					</span>the<span>
					</span>measures<span><span></span>
					</span>listed in the citation<span>
					</span>as a<span>
					</span>process-based approach to abate<span><span></span>
					</span>the cited hazard. Indeed, the Secretary explained in his post-hearing brief that while “each of his proposed abatement measures would have independently provided a material reduction in the hazard of workplace<span>
					</span>violence[,]” it may also be necessary for UHS to “implement[] . . . multiple abatement measures” to satisfy its “duty to remove all preventable instances of the hazard.”  <span><span></span>
					</span>Before the judge, Respondent<span>
					</span>demonstrated<span><span></span>
					</span>the same understanding, referring in<span>
					</span>its<span><span></span>
					</span>joint post-hearing brief to the<span>
					</span>proposed<span>
					</span>measures as “abatement steps” and accusing the Secretary of trying to impose “various abatement methods” through<span>
					</span>a<span>
					</span>general duty clause citation<span>
					</span>to<span><span></span>
					</span>effectively create a workplace violence standard. This<span><span></span>
					</span>supports the Secretary’s position<span>
					</span>on review<span>
					</span>that the parties understood<span>
					</span>the measures were proposed as a process, not as alternatives. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Nat’l</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Realty</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>v. OSHRC</span>, 489 F.2d<span>
					</span>1257,<span>
					</span>1266-67 (D.C. Cir<span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1973</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">) (</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">All</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">preventable forms and instances of hazardous conduct must</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>[]</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>be entirely excluded from the workplace</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.”)</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-style:italic; color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cf. Sturgill</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span>2019 WL 1099857,<span><span></span>
					</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">*9 n.17</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">noting Secretary</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s acknowledgement during oral argument that abatement measures were<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">proposed as<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">alternatives</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span>The Secretary’s approach in this<span>
					</span>regard aligns with the nature<span>
					</span>of<span>
					</span>workplace violence, which<span>
					</span>as alleged here arises in different contexts<span><span></span>
					</span>and conditions<span><span></span>
					</span>at Pembroke, necessitating different abatement<span>
					</span>measures.<span class="style_DefaultParagraphFont style_DefaultParagraphFont style_CommentReference style_CommentReference " style="font-size:12pt; color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-size:8pt; font-size:12pt; "><span><span></span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-style:italic; color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cf. Sturgill</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span>2019 WL 1099857,<span><span></span>
					</span>at *9<span><span></span>
					</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">finding<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">abatement measures to be alternatives where “any one of them would constitute abatement of the alleged violation”);</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">SeaWorld</span>, 748 F.3d 1202 (D.C Cir. 2014)<span><span></span>
					</span>(finding<span>
					</span>two abatement measures proposed as alternatives because if one were implemented, the second would offer no further protection). Indeed, the citation identifies measures that range from preventative to mitigative.<span style="text-decoration:line-through ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Default style_Default " style="line-height:1.5; text-align:justify; text-indent:1.27cm; "> For<span><span></span>
					</span>all<span><span></span>
					</span>these reasons, we<span>
					</span>reject Respondent’s argument and<span>
					</span>find<span>
					</span>that<span>
					</span>to establish the abatement element here,<span><span></span>
					</span>the Secretary need only prove that at least one of the measures<span><span></span>
					</span>he proposed was<span>
					</span>not<span>
					</span>implemented and that the same<span>
					</span>measure<span><span></span>
					</span>is both effective and feasible in addressing the alleged hazard.<span>
					</span><span><span></span>
					</span><span style="font-style:italic; color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Sturgill</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2019 WL 1099857, at *9 (</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">noting</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">where each measure<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is proposed<span>
						</span></span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a “component of a single means of abatement,” the Secretary “need only show a failure to implement one of them”)</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">;</span><span><span></span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Arcadian</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Corp.</span>, 20 BNA OSHC 2001, 2011<span><span></span>
					</span>(No. 93-0628, 2004)<span><span></span>
					</span>(citing<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly Enters. Inc.</span>, 19 BNA OSHC 1161,<span>
					</span>1190<span><span></span>
					</span>(No. 91-3144, 2000) (consolidated) (to establish the feasibility of a proposed abatement measure, the Secretary must “demonstrate both that the<span>
					</span>measure[] [is] capable of being put into effect and that [it] would be effective in materially reducing the incidence of the hazard”) (citations omitted). And<span><span></span>
					</span>given that<span><span></span>
					</span>Respondent<span>
					</span>has taken measures to address<span>
					</span>the<span>
					</span>cited<span><span></span>
					</span>hazard, the Secretary must<span>
					</span>also<span>
					</span>show that<span>
					</span>those measures were<span><span></span>
					</span>inadequate. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">U.S. Postal Serv.</span>, 21 BNA OSHC 1767, 1773-74 (No. 04-0316, 2006);<span>
					</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_Emphasis style_Emphasis " style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cerro Metal Prods. Div., Marmon Grp., Inc.</span><span style="color:WindowText; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 12 BNA OSHC 1821, 1822 (No. 78-5159, 1986)). </span>
				</p>
			</div>
			<div>
				<p class="style_Default style_Default " style="line-height:1.5; text-align:justify; text-indent:1.27cm; ">As discussed below, we agree<span><span></span>
					</span>with the judge that the Secretary established<span>
					</span>Respondent’s failure to adequately implement<span>
					</span>two feasible and effective means of abatement proposed here:<span>
					</span>the provision of personal panic alarms for staff to summon assistance and the provision of adequate equipment to support de-escalation<span><span></span>
					</span>efforts<span><span></span>
					</span>for patients in crisis.<span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref11" href="#ftn11">11</a></span><span><span></span>
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Equipment for summoning assistance</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary propose</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[p]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rovide</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>personal panic alarms for all employees who may work<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in close proximity to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">” and “[p]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rovide</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">training on this equipment and ensure that the equipment is maintained in working order at all times.” </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There is no dispute</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s employees are<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not provide</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">any type of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">panic alarms. Before the judge<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and also</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>on review,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>maintains that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employees were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nonetheless<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">able to adequately summon assistance<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">when faced with patient aggression<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hospital provided</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>them</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">with walkie-talkies and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">access to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an intercom system in every common area. The judge disagreed, finding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(1) walkie-talkies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>were not c</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">onsistently available to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">allow every staff member to carry one; (2) if an employee did not have one, there was only access to one phone (connected to the intercom system) in the middle of each unit; (3) the walkie-talkies were not reliable due to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">technical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">issues</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, such as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">faulty batteries; and (4)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>requiring</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">call</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ou</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t for help or mak</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>such<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">requests<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">through walkie-talkies</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the intercom system</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">meant they<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">could be heard by the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">agitated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which could</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>escalate the situation further. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">agree with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that Pembroke’s reliance on walkie-talkies and the intercom system was inadequate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The evidence shows that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hospital</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">supplied three to four walkie-talkies per unit at the time of the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHA<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inspection<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">but</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not every employee always carried one</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>during their shift</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mployees<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who did carry a walkie-talkie<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">would<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at times<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">forget to return the device<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at the end of their shift<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and leave<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">work</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in their possessio</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n, making the device unavailable for others to use. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even when available, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">estimony from former Pembroke MHA Andrew Santos, former Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egistered<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">N</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">urse Janine Senatore, and Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Director of Nursing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows that the walkie-talkies were not reliably functional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">because<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the batteries would die over time or would not hold a charge;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>also testified that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">static or chatter<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">due to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the device’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shared communication channels<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">made it difficult to decipher a call for help.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for the intercom system, the judge found</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and the record shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>it was n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">either</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>practical<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">or</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>widely used</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">access<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the one phone<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">connected to the system located in the middle of each unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to walk away from a potentially unstable situation to call for help</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>rather than<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">remain with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in crisis</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as Pembroke encouraged</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nd a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">we find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>below, requi</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ring</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees to audibly call for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assistance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">creates the potential to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">further escalate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">an agitated</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient’s distress.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In sum, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that the Secretary established Pembroke’s program was inadequate to address the cited hazard because it failed to provide employees with the means to reliably, timely, and discreetly summon help when confronted with a threat of workplace violence.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">also<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has proven</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">use of personal panic alarms is an effective and feasible means of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addressing the cited hazard</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref12" href="#ftn12">12</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary’s expert witness, Dr. Robert Welch,</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref13" href="#ftn13">13</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">testified<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that access to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">personal<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">panic alarms correlated with significantly lower rates of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employee<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assault</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hospital<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Specifically,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that employees can wear<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">personal panic alarms<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">inconspicuously and silently call for help,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">making the devices<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">more efficient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>reduc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the likelihood of staff becoming victims of patient violence. He explained that personal panic alarms allow employees to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">immediately</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">seek help<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">without<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">audibly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">calling for help over a walkie-talkie or with a loud voice, as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>agitate a distressed patient and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>escalate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>situation.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref14" href="#ftn14">14</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch’s opinion was corroborated by former Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">R</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">egistered<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">N</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">urse Senatore, who testified that she had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effectively<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">used personal panic alarms at other behavioral health hospitals: “They’re just a very immediate system<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for alerting that you need help</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> . . . </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and people come right away. There’s very little lag time.” </span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>disputes the relevance of Dr. Welch’s testimony, arguing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that one</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>study he relied on to support his opinion</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">involved</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>emergency rooms, not psychiatric hospitals. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">But<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in both situations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>medical personnel</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>caring for potentially violent patients in a hospital setting.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Put simply, it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">apparent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from the record that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the face of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient aggression and the potential for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">imminent violence</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">verbally asking or yelling for help<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in the presence of the distressed individual<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">is not equivalent to silently and discreetly summon</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>help via a personal panic alarm. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>all</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>these reasons, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Secretary has established that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failed to maintain<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">equipment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Pembroke employees<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to summon assistance</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when faced with patient aggression</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">providing personal panic alarms is both feasible and effective.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">E</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">quipment for de-escalation</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary also proposes<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that Respondent “[m]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aintain</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>equipment that is sufficient for the implementation of each patient’s individual crisis prevention plan.”</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref15" href="#ftn15">15</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge agreed, finding<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that Pembroke lacked the necessary equipment to implement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">these plans, also known as</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>plans, specifically<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">availability<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">music-playing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>devices. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">does not dispute that Pembroke lacked enough devices to make<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">them</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>immediately available to every patient who wanted or needed one but argues<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hospital had numerous alternative techniques to keep patients calm, and the Secretary has not shown that these other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">me</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">asures</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were ineffective. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Secretary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">maintains<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that Pembroke’s patients specifically identified music as a means of de</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in their plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but it was not consistently available to them</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>due to the limited supply of devices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. The Secretary also argues that regardless of whether other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measures<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">might calm patients, the record<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">clearly<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows that providing sufficient equi</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pment would reduce the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cited<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence hazard.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We agree with the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke lacked sufficient equipment to adequately implement its<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient de-escalation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plans. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pproximately nine out of ten patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">identified listening to music as a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">helping</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>strategy</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">their<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">respective<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, yet</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>time of the inspection, Pembroke supplied</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at most</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>four<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">music-playing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">devices to each unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. This<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>plainly inadequate</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the record</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the adult unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>had sixteen patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, but only three<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">music-playing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>devices,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and that patient conflicts</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>regarding access to the limited number of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">music-playing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">devices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>occurred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>regularly.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> And while<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke permitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>borrow device</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>from<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each other</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>when needed, availability was neither assured nor immediate.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>In short, regardless of whether<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">other<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">calming techniques</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">listed in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plans were effective</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, i</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">t is</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">nearly impossible</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to reconcile Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’s decision to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provide</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">so few</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">devices</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to each unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">with the fact</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that approximately 90% of its patients requested music as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">their preferred</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>coping strategy. For all these reasons, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the Secretary has established that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementation of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">de</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">escalation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was deficient.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref16" href="#ftn16">16</a></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Turning to the effectiveness and feasibility of providing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">additional<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">listening devices,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">argues<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the Secretary has not shown, through Dr. Welch or otherwise,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">providing more equipment would materially reduce<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the cited hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">We disagree</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> According to Dr. Welch, the use of music as a de-escalation<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">me</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">asure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">result in a significant</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">reduction in the potential for a violent incident:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[I]t’s largely what the patients </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[here] </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. . . identify as their technique, their preferred technique for calming down and de-escalating when they are upset.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">So</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>you</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ve got patients tell[</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">] staff this is what works to help me stay calm and not being able to provide that creates a higher risk situation.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">He also gave an example of how<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">being able to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">provid</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e a patient with a</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>listening device</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assist the staff with<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">de</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">escalat</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a situation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[Y]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ou</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>can say, John you seem upset, would [you] like to listen to music and then maybe we can talk about what’s getting you upset later. You put the headphones on, they walk up and down the hall, you’ve de-escalated the situation right there.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch testified that in his experience, hospitals<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">can readily<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">obtain wireless headphones</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>minimal expense</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref17" href="#ftn17">17</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Three e</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">mployee witnesses confirmed that listening to music helps calm<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">agitated<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients. Former MHA Sherwin testified that as a verbal de-escalation instructor, she<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has observed</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">how</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">aggression, agitation, and pacing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>can be lessened by<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">listening to music:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">So oftentimes you’ll see<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[patients]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">continue to keep pacing for a couple more minutes,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">kind of still agitated, and then slowly within 15 to 20 minutes you can see them start to calm down and deescalate and then be able to have a conversation with staff about what is occurring.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Former Pembroke nurse Libby offered similar testimony, explaining the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">positive<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">effect music has on patients<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in crisis</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">It is a great help. And I realized it even more once I became board certified how much of a role music can be in deescalating a situation. Especially with patients that have a schizophrenic diagnosis. They are hearing voices; it is very helpful.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And former MHA Santos testified that music was “[s]</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">oothing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, calming” and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">confirmed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that he had<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">see</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">n</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">listening to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">music work to calm<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patient</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">who were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">acting<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ag</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">gressive</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and threatening</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Thus, we find that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch’s expert testimony, corroborated by these former Pembroke employees,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shows</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that providing sufficient music equipment would materially reduce the risk of patient assaults by de</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">escalating situations<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in which</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients may become violent. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Based on the foregoing, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">conclude<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that the Secretary has established that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">failed to maintain<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adequate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">equipment<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to summon assistance and implement patient de-escalation plans</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and that the proposed abatement measures in this regard are both feasible and effective. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, we<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">find</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that the Secretary has established the abatement element of the general duty clause violation. As<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">none of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the other prima facie elements</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of the violation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>are in dispute on review, we affirm the citation.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
			</div>
			<p class="style_Normal style_Normal style_ListParagraph style_ListParagraph " style="margin-left:72px; text-indent:-1.27cm; line-height:1.5; margin-left:72px; text-indent:-1.27cm; line-height:1.5; ">
				<span style="font-weight:bold; padding-right:20px;">III.</span><span style="font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Characterization</span></p>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary argues that the judge erred in recharacterizing the general duty clause violation from repeat to serious. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>29 U.S.C. § 666(a) (setting increased penalties for<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">repeatedly violates</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Act’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">requirements)</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Under Commission precedent, a violation is properly characterized as repeat, “if, at the time of the alleged</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> . . . </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violation, there was a Commission final order against the same employer for a substantially similar violation.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Potlatch Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 7 BNA OSHC 1061, 1063 (No. 16183, 1979);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Lake Erie Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 1285, 1289 (No. 02-0520, 2005). The Commission has long held that “similarity of abatement is not the criterion for finding a repeat violation; it is whether the two violations resulted in substantially similar hazards.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Lake Erie Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC at 1289 (citing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Stone Container Corp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 14 BNA OSHC 1757 (No. 88-310, 1990)). To determine whether the hazards are substantially similar, the Commission looks to the circumstances surrounding the violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, e.g.,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Active Oil Serv., Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 1184, 1189 (No. 00-0553, 2005) (finding general duty clause citation violations substantially similar where both involved employee exposure to hazard of asphyxiation in entering fuel tanks to clean).</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In citing the violation here as repeat, the Secretary relies on a 2015 general duty clause citation issued to UHS-WP for exposing employees at its Lowell Treatment Center, an inpatient psychiatric care facility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>also located</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in Massachusetts, “to acts of workplace violence including, but not limited to: verbal threats of assault, physical assaults, choking, punches, kicks, human bites, scratches and/or pulling of hair by patients.” Specifically, the 2015 citation alleged that: </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">From January 1,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2011</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>through December 31, 2014 there have been at least 16 documented cases identified in the OSHA 300 log of employees assaulted on the job by patients resulting in approximately 255 restricted duty days and 730 days away from work.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Additionally</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>there have been at least 38 documented non-recordable cases resulting in a dislocated shoulder, concussion, sprains, strains, contusions, swollen body parts, headaches, human bites, punched in the face, kicked, hit, choked, hair pulled, scratched, bitten, grabbed and thrown by patients. During 2014 there were at least five instances of workplace violence, including an incident on November 30, 2014, when a nurse was punched in the face and knocked out unconscious by a patient, resulting in soft tissue damage to the face and jaw, contusions, swelling, and headaches.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The citation</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>resolved by a settlement agreement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>became a final order in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">April<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2016.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the present citation, the Secretary alleges that Pembroke employees were exposed to assaults by patients in that:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employees including Nurses, Mental Health Associates (MHAs), and Crisis Intervention Specialists (CISs) at UHS of Westwood Pembroke, Inc. (Pembroke Hospital) have suffered serious workplace violence related injuries such as concussion, fracture, strains, contusions, and burns (from hot coffee thrown at face) while performing their job duties, such as attempting to prevent injuries to staff and patients, and during restraint holds.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In rejecting the citation’s repeat characterization, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he judge concluded that the Secretary failed to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">offer sufficient information to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">determine if the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hazards at issue in the two<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">cases<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">substantially similar. He acknowledged</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that the hazards “share some commonality” but found that “the limited information in the record reveals only that the cited workplaces had significant differences related to the hazard” in that some of the abatement measures proposed in the two citations are different. </span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On review,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>adopts the judge’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">rationale</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in claiming that the Secretary failed to establish the two violations are substantially similar</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and relies on the same underlying fallacy—that substantial similarity hinges on abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref18" href="#ftn18">18</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">But</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary need only show</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>employees were exposed to a substantially similar hazard and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">here,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">both violations involve employees exposed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to an almost identical hazard—</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hazard of physical assault by patients at a psychiatric care facility.</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Lake Erie Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC at 1289 (holding that “similarity of abatement is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">not</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the criterion for finding a repeat violation”) (citation omitted) (emphasis added).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The burden<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">therefore<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">shifts to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to rebut the Secretary’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">prima facie<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">showing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>of similarity</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not done</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>so here</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">given that</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>arguments<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">focus almost exclusively on abatement</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref19" href="#ftn19">19</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Manganas</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Painting Co. v. Sec’y of Labor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 273 F.3d 1131, 1135 (D.C. Cir. 2001) (once Secretary has made prima facie showing of substantial similarity, “</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">burden then shifts to the employer to demonstrate that the violations took place under disparate conditions and hazards associated with the separate violations”)</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">citing Potlatch</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 7 BNA OSHC at 1061).</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1.5; text-align:justify; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For all these reasons</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, we affirm the citation as repeat</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and assess the proposed penalty of $2</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">350</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref20" href="#ftn20">20</a></span></p>
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						</span>ORDERED.</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:336px; "><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;">/s/</span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:288px; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Cynthia L. Attwood</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:288px; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">C</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">hair</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">man</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:288px; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;">/s/</span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; text-decoration:underline ;"><span style="mso-tab-count:1">  </span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:288px; text-indent:1.27cm; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Amanda Wood Laihow</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dated:</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">March 3,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2022</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Commissioner</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; text-indent:1.27cm; "><span style="font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-weight:bold; ">OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; "><span style="font-size:10pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">1120 20th Street, N.W., Ninth Floor</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; "><span style="font-size:10pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">Washington, DC 20036-3457</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; margin-left:-48px; "><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:8pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:8pt; "><span style="mso-tab-count:1">  </span>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; "> </p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">SECRETARY OF LABOR,</span></p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "> </p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; text-indent:1.244cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant,</span></p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "> </p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; text-indent:2.514cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">v.</span></p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">OSHRC DOCKET NO. 17-073</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">7</span></p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS OF WESTWOOD PEMBROKE, INC., UHS OF DELAWARE, INC.,</span></p>
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "> </p>
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							<p style="margin-top:7.667px; margin-bottom:0px; line-height:1; text-indent:1.244cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents.</span></p>
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							<p style="margin-top:7.667px; margin-bottom:0px; line-height:1; margin-left:47px; widows:0; orphans:0; "> </p>
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					<td style="vertical-align:top;padding-left:.194cm; padding-right:.194cm; border-left:none, 0, inherit; border-right:none, 0, inherit; border-top:none, 0, inherit; border-bottom:none, 0, inherit; width:8.255cm;">
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							<p style="margin-top:7.667px; margin-bottom:3.467px; line-height:1; widows:0; orphans:0; "> </p>
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				<p style="margin-top:8px; margin-bottom:8px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Appearances:</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Kate</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">O’Scannlain</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Solicitor</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.007cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Labor</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maria S. Fisher, Regional</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.012cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Solicitor</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.046cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Robin Ackermann, Senior Trial Attorney</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ralph<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Minichiello</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, Senior Trial Attorney</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">U.S. Department</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.005cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.011cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Labor, Office</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.005cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">of</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.011cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Solicitor, Boston, MA</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>For</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Complainant</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Melanie L. Paul</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Raymond Perez, II</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Jackson</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.011cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Lewis</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">P.C.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Atlanta,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.005cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">GA</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; margin-left:48px; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Respondents</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-indent:1.27cm; widows:0; orphans:0; "> </p>
			</div>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Before: Keith E. Bell, Administrative</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.004cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Law</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Judge</span></p>
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			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:center; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; text-decoration:underline ;">DECISION</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; letter-spacing:.002cm; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; text-decoration:underline ;"><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; text-decoration:underline ;">AND</span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; letter-spacing:.002cm; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; text-decoration:underline ;"><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; text-decoration:underline ;">ORDER</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:0px; line-height:1; text-align:justify; widows:0; orphans:0; "> </p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Following its receipt of a complaint about workplace violence, OSHA commenced an inspection of UHS of Westwood Pembroke, Inc.’s (“Pembroke’s”) facility located at 199 Oak Street in Pembroke, MA (“Pembroke Hospital”). As a result of this inspection, Pembroke received a Citation and Notification of Penalty (“Citation”) alleging it violated the Occupational Safety and Health Act of 1970,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">29 U.S.C. §§ 651-678 (the “Act”).  The Citation alleges a violation of 29 U.S.C. § 654(a)(1), the provision commonly referred to as the general duty clause, for exposing employees to the hazard of workplace violence in the form of patient on staff aggression.  </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke timely contested the Citation bringing the matter before the Commission.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref21" href="#ftn21">21</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The Secretary of Labor (“Secretary”) filed his initial Complaint on April 27, 2017. He moved to amend his Complaint to add UHS of Delaware, Inc. (“UHS DE”) as a Respondent and to change the classification of the Citation from “serious” to “repeat.” This request was granted in an October 30,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2017</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Order, after which Pembroke and UHS DE together became the Respondents for this matter. </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Subsequently, the Secretary moved again to amend abatement in the Citation and Complaint. This request was uncontested and was approved in a December 13,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2017</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Order. A hearing was held on July 17-20,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2018</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and July 24-25, 2018. </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For the reasons discussed, the Citation is affirmed as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">serious</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and a $12,675 penalty is assessed.</span></p>
			</div>
			<div>
				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Jurisdiction</span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke filed a timely Notice of Contest bringing this matter before the Commission.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref22" href="#ftn22">22</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Stip. 4-6.) Pembroke and its corporate parent, UHS DE, are both employers affecting commerce within the meaning of 29 U.S.C. § 659(c) and both are employers under the Act.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref23" href="#ftn23">23</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Stip. 1, 10-13.) Based upon the record, including the parties’ admission to jurisdiction, the undersigned concludes the Commission has jurisdiction over the parties and the subject matter of this case. (Stip. 1, 4-6.) </span></p>
			</div>
			<div>
				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Background</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; "><span style="mso-tab-count:1">  </span>Corporate Structure</span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke operated three facilities at the time of the inspection: Pembroke Hospital, Westwood Lodge, and Lowell Treatment Center. (Tr. 697; Ex. R-38 at 2.) While each facility was located at a separate address, collectively the sites shared a license and were a single legal business entity. (Tr. 723-24.) Pembroke is a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wholly-owned</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>subsidiary of UHS DE. (Stip. 12.) UHS DE, in turn, is a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">wholly-owned</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>subsidiary of Universal Health Services, Inc. (“UHS”). (Stip. 13.) Thus, UHS owns UHS DE and indirectly owns Pembroke. (Stip. 13; Tr. 752-53.) </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">UHS DE is described as a “management company” for Pembroke. (Tr. 740; Ex. C-27.) At the time of the inspection, Pembroke’s CEO and CFO were both employees of UHS DE.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref24" href="#ftn24">24</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Stip. 10-11; Tr. 598, 693, 757.) UHS DE employees provided oversight for the work of Pembroke’s CEO and CFO. (Tr. 599, 696, 757-58, 1325, 1327-28.) In addition, Gina Gilmore, a Loss Control Manager at UHS DE, handled Pembroke’s budget for workers’ compensation claims and visited the facility every month. (Tr. 549-551.) During these visits, she would meet with Pembroke’s CEO and attend the facility’s Aggression Reduction Team meetings. (Tr. 553-54.) The Director of Nursing, Claire Kent, and the Risk Manager, Stacey Coke Burns, were Pembroke employees but also reported to individuals employed by UHS DE. (Tr. 369-70, 457, 497-98, 502.) </span></p>
			</div>
			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Respondents’ Request for Judicial Notice<span>
					</span></span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In its brief, Respondents assert that the Secretary has pursued general duty clause violations at “several other [UHS] managed hospitals.” (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 3.) Respondents fail to discuss whether these other citations were issued to UHS<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">DE</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or entities affiliated with Pembroke. However, in a footnote elsewhere in the brief, Respondents ask the undersigned to take judicial notice of “other Citations that have been issue to behavioral hospitals.” (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 33.) It requests judicial notice of three specific</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>cases:</span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Secretary of Labor v. BHC Northwest Psychiatric Hospital, LLC d/b/a Brooke Glen Behavioral Hospital</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, (OSHRC Docket 17-0063),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Secretary of Labor v. UHS of Westwood Pembroke, Inc., d/b/a Lowell Treatment Center</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(OSHRC Docket 17-1302 and 17-1304) and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">UHS of Delaware, Inc. (“UHS DE”) and Premier Behavioral Health Solutions of Florida, Inc., d/b/a Suncoast Behavioral Health Center<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(OSHRC Docket 18-0657). </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 33.) The first matter listed concerns BHC Northwest Psychiatric Hospital (“BHC”). Respondents do not explain how or if that entity is affiliated with them. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The undersigned is aware that a matter involving BHC has become a final order of the Commission. However, BHC is appealing the matter and the matter is currently pending before the D.C. Circuit. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC Nw. Psychiatric Hosp</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">LLC d/b/a Brooke Glen Behavioral Hosp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC 1862 (No. 17-0063, 2019) (ALJ),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">argued</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19-1087 (D.C. Cir. Jan. 9, 2020).</span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Federal Rule of Evidence 201(b) permits judicial notice of a “fact” that is not subject to reasonable dispute because it: (1) is generally known within the court’s territorial jurisdiction; or (2) can be accurately and readily determined from sources whose accuracy cannot reasonably be questioned.  Even though Respondents do not discuss their affiliation with BHC, the undersigned can and has reviewed the ALJ’s decision,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">BHC Nw. Psychiatric Hosp. LLC d/b/a Brooke Glen Behavioral Hosp.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC 1862 (No. 17-0063, 2019) (ALJ). However, taking judicial notice of a non-binding decision that is still on appeal is not appropriate. </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for the other two matters highlighted by Respondents, both are active disputes without final determinations. As such, there are no established facts for which judicial notice is appropriate. At the hearing, Respondents did not attempt to offer any evidence regarding the relevance of these matters or how Premier Behavioral Health Solutions of Florida, Inc. is affiliated with them. As a result, the Secretary was deprived of an opportunity to respond to these claims. Further, Respondents assert that UHS DE had only a minimal role at Pembroke Hospital and asks for the entity to be dismissed from this pending matter. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 40.) Asking the undersigned to now undertake a search of other citations issued to behavioral health centers is not the purpose of judicial notice and the late request is denied. </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The undersigned notes that the Secretary offered evidence of another citation issued against Pembroke, the same employer cited in the present matter. That citation, which became a final order on May 27, 2016, is a part of the record before me and has been considered in reaching this decision. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-14 thru C-17.) </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Nature of the Workplace</span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke Hospital is an inpatient psychiatric hospital with six patient care units, serving up to 120 patients at a time.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref25" href="#ftn25">25</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Stip. 2-3; Tr. 290, 373; Ex. R-38 at 1, 8.) Four units focus on adults, one is for adolescents, and the sixth is for geriatric patients. (Tr. 373.) Nurses and Mental Health Associates (“MHAs”) work directly with patients in the units. (Tr. 669, 821-824.) Units always have a registered nurse. (Tr. 380.) </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The MHAs at Pembroke Hospital have many responsibilities, including providing security and fulfilling housekeeping responsibilities. (Tr. 50-52, 96.) The nurse on the unit could not see patients from his or her workstation. (Tr. 58.) So, the MHAs functioned as the “eyes and ears of the nursing staff” and were responsible for monitoring patient behavior, including for signs of aggression or agitation. (Tr. 50.) MHAs searched patient belongings to identify prohibited items that could hurt patients or staff. (Tr. 79, 81, 86.) MHAs conducted these searches alone in small rooms on the unit. (Tr. 79, 81.) MHAs had to make sure certain doors remained locked. They would open and close bathrooms when requested by patients, which might occur fifty times a shift. (Tr. 55, 827.) MHAs also accompanied patients off units for certain meetings, fresh air<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">breaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, and meals.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref26" href="#ftn26">26</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 55-56.) If a patient was unable to leave the unit for meals, an MHA would leave the unit instead and get the patient’s meal. (Tr. 52.) MHAs also left the units for laundry and other housekeeping tasks. (Tr. 50-54, 96.) Consequently, while more than one MHA was assigned to each unit, the staff was often divided between those on the unit and those off the unit. (Tr. 822, 863.)<span>
						</span></span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Prior OSHA Inspections of Pembroke<span>
					</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">About a year before the inspection leading to the Citation before the undersigned, OSHA inspected Pembroke Hospital. (Ex. R-38.) That inspection led to the issuance of a letter on October 2, 2015, which indicates that MHAs were exposed to workplace violence hazards but that “it is not considered appropriate<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">at this time</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to invoke the Section 5(a)(1), the general duty clause of the [Act].”</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref27" href="#ftn27">27</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. R-37 at 2 (emphasis added).) The letter does not state that OSHA considered workplace violence hazards to be outside of the scope of the general duty clause. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 21.) Rather, OSHA exercised its discretion to issue a letter at the end of the investigation.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref28" href="#ftn28">28</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The letter goes on to outline several methods of feasible abatement for workplace violence hazards Pembroke could<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">adopt, but</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>does not demand any specific action.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref29" href="#ftn29">29</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. R-37.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After the letter was issued, OSHA commenced an inspection of Pembroke’s facility in Lowell, MA (the Lowell Treatment Center). After the inspection, the Secretary issued Pembroke a citation for a violation of the general duty clause because it exposed employees to workplace violence in the form of, among other things, patients assaulting staff through punches, kicks, bites, scratches, and hair pulling. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-14, C-15 at 2, R-38 at 2.) While Pembroke initially contested the citation, it subsequently agreed to accept it as issued and agreed to take several abatement actions to address the workplace violence hazards at the Lowell Treatment Center. (Ex. C-15.) </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Current Inspection</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In October 2016, OSHA received another complaint about worker safety at Pembroke Hospital. (Tr. 277; Ex. C-8.) The complaint cites a worker injury following an instance of patient aggression. (Ex. C-8.) This complaint led OSHA to commence another inspection of Pembroke Hospital. (Tr. 277.) OSHA Compliance Safety and Health Officer Salvatore<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Insogna</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>(“CO”) led the investigation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> He first visited the site on October 11, 2016. (Tr. 342.) In addition to the initial complaint triggering the investigation, OSHA received a second complaint on March 27, 2017. (Ex. C-11.) Like the prior complaint, the second one cites employee injuries from workplace violence in the form of assaults by patients against staff. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The CO’s investigation included a review of documents related to employee injuries and illnesses, and interviews with ten or more non-management employees. (Tr. 290-92, 297; Ex. C-68.) When the investigation concluded, the Secretary issued the Citation that is the subject of this litigation. </span></p>
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				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Legal Standard</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Due Process Claims</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents claim that the Citation’s issuance violated due process. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 19.) The Commission ensures that OSHA provides due process by upholding violations of the general duty clause only where the employer or its industry recognized the hazard before the citation was issued. The inquiry is whether the employer or its industry could reasonably foresee an accident capable of causing death or serious injury. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Armstrong Cork Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 8 BNA OSHC 1070, 1074 (No. 76-2777, 1980),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff'd</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 636 F.2d 1207 (3d Cir. 1980) (unpublished). Knowledge of the hazard provides adequate notice to satisfy the requirement of due process. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g., Cape & Vineyard Div. of New Bedford Gas & Edison Light v. OSHRC,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">512 F.2d 1148 (1st Cir. 1975) (finding that actual knowledge of the hazard provides fair notice);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Bethlehem Steel Corp. v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 607 F.2d 871, 875 (3d Cir. 1979) (finding that fair notice is addressed by the requirement that the hazard is recognized);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Babcock & Wilcox Co. v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 622 F.2d 1160, 1164 (3d Cir. 1980) (concluding that either the employer or its industry must be aware of the hazard). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents raise no challenges to how the Secretary defined the hazard here or Pembroke’s recognition of both the hazard and its presence at Pembroke Hospital. Indeed, they stipulated that the “hazard of workplace violence, specifically defined in this case as violence and/or assault by patients against staff, was recognized by [Pembroke].” (Stip. 8.) And they stipulated that the “hazard of workplace violence, specifically defined in this case as violence and/or assault by patients against staff is recognized in the industry.” (Stip. 9.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even if Pembroke had not stipulated to the definition and recognition of the hazard, the record still provides ample support for such findings. </span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Patient attacks on employees routinely occurred at Pembroke Hospital.  (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-8, C-11, C-68.)  One employee indicated he was hit or kicked approximately fifty different times by various patients in his four years working for Pembroke. (Tr. 56-57.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Gen. Dynamics Land Sys</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Div., Inc</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 15 BNA OSHC 1275, 1285 (No. 83-1293, 1991) (accidents put the employer on notice of the hazard), </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "> </span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">985 F.2d 560 (6th Cir. 1993) (unpublished).  Pembroke was aware of these events through accident reports employees could choose to complete after incidents and through the direct knowledge of supervisors, some of whom were exposed to the hazard themselves.  (Tr. 794, 802;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-55, C-56.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Moreover, Pembroke had specific and direct knowledge of the Secretary’s view that the general duty clause applied to the hazard of workplace violence. On May 19, 2015, Pembroke was cited for violating the general duty clause because its employees “were exposed to acts of workplace violence.” (Ex. C-14.) </span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">This citation was issued in 2015 and became a final order on May 27, 2016, months before the commencement of the inspection and issuance of the present citation. (</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-15 thru C-17.) So, Pembroke accepted responsibility for a violation of the general duty clause based upon the presence of the hazard of workplace violence before the investigation leading to the instant Citation commenced.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref30" href="#ftn30">30</a></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> This establishes direct notice of the applicability of the general duty clause to workplace violence hazards at Pembroke’s facilities. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Corbesco</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Inc. v. Sec'y of Labor,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>926 F.2d 422, 428 (5th Cir. 1991) (holding notice is provided through Commission decisions);</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Armstrong</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 8 BNA OSHC at 1073 (finding that the employer itself recognized the hazard because it took an abatement action).</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Besides Pembroke’s direct knowledge, the Secretary provided other evidence that the industry was on notice of the hazard. First, there is no dispute that experts familiar with the industry would take the hazard of workplace violence into account in prescribing a safety program for a behavioral health hospital.  </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Nat’l</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Realty & Constr. Co. v. OSHRC,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>489 F.2d 1257, 1266 (D.C. Cir. 1973).  Experts for both parties recognized that any risk assessment of a facility like Pembroke Hospital would include assessing workplace violence and the hazard would be relevant to any safety program.  (Tr. 903, 915-17, 1455.) Second, OSHA published guidance documents to inform the industry of the hazard and ways to address it. In 2015, it published Preventing Workplace Violence: A Road Map for Healthcare Facilities (“Road Map”). (Ex. C-102.) The Road Map describes the problem of workplace violence in healthcare facilities and provides information on how to identify hazards and respond to risks identified. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Road Map is related to an earlier OSHA publication, Guidelines for Prevention of Violence in Healthcare (“Workplace Violence Guidelines”). (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-97, C-102 at 4.) Neither the Workplace Violence Guidelines nor the Road Map constitute specific standards. At the same time, the documents do not suggest that there is some type of immunity from citation for failing to free a workplace of recognized hazards, as the general duty clause requires. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">These OSHA publications bolster the uncontested point that Pembroke and its industry are aware of the hazard. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Perhaps in recognition of its actual awareness of both the hazard and its presence at Pembroke Hospital, Respondents suggest another due process test. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 20.) They argue the Citation failed to set forth the “specific actions” to be taken so that Respondents can avoid future citations. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Respondents argue they must have notice of the Secretary’s<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">views regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>appropriate abatement before a citation can be issued. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. at 20-21, 23. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents attempt to conflate the due process fair notice requirement, which is driven by Constitutional constraints, with the abatement requirement, which is a statutory interpretation created by binding precedent. The Constitution precludes depriving “any person of life, liberty, or property, without due process of law.” U.S. Const. amend V. The Commission sets forth requirements to ensure that proceedings before the Commission provide due process. For example, the citation must sufficiently define the hazard and the abatement so that the employer can reasonably defend itself. The Secretary must make the employer aware of what he alleges are feasible means of abatement prior to the hearing, but the Commission has not required such information before the issuance of a citation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Erickson Air-Crane Inc.,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>No. 07-0645,</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2012 WL 762001 (O.S.H.R.C, Mar. 2, 2012). In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Erickson</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Secretary proposed various abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">methods</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but the ALJ concluded that none of the proposed methods were feasible. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at *2-3. Nonetheless, the ALJ went on to determine that the hazard could be feasibly abated through some other action. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The parties had neither tried nor consented to try whether that action was feasible. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Commission considered this a due process violation because the pleadings did not put the employer on notice that the alternative abatement method was at issue. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Notice must be given before the record closes as to what is being considered feasible means of abatement. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Commission did not hold that the employer must know before the citation’s issuance what constitutes feasible means of abatement.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref31" href="#ftn31">31</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents cite cases where the parties disputed the presence of a hazard, the employer’s recognition of it, or are otherwise not relevant to the due process issues before me. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 20-21.) Respondents rely on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Asamera</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Oil (U.S.)</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 9 BNA OSHC 1426 (No. 1426, 1980) (consolidated), a non-binding ALJ opinion addressing a specific standard, not the general duty clause, and a non-binding Ninth Circuit decision,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Donovan v. Royal Logging Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 645 F.2d 822 (9th Cir. 1981).</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref32" href="#ftn32">32</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Asamera</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">9 BNA OSHC at 1427 (affirming the ALJ’s decision but according it only “the precedential value of an unreviewed judge’s decision”);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra Health Mgmt., Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC 1838, n.15 (No. 13-1124, 2019) (noting that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Royal Logging</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>is “not relevant precedent” for cases, like the present matter, that cannot be appealed to the Ninth Circuit). Respondents’ reliance on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Davey Tree Expert Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 11 BNA OSHC 1898 (No. 77-2350, 1984) is also misplaced. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 24.) Unlike that case, in this matter, Respondents explicitly chose not to contest the Secretary’s definition of the hazard or Pembroke’s recognition of it.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref33" href="#ftn33">33</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Stips</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 7-9.) Here, Pembroke recognized the hazard of patient on staff violence and knew this hazard was present in its facility. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Stips</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 8-9.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The recognition requirement relates to “knowledge of the hazard, not recognition of the means of abatement.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Kansas City Power & Light Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 10 BNA OSHC 1417, 1422 (No. 76-5255, 1982), citing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Gen. Dynamics Corp., Quincy Shipbuilding Div. v. OSHRC</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 599 F.2d 453 (1st Cir. 1979). </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See also Brock v. L.R.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Willson</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>& Sons, Inc.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">773 F.2d 1377 (D.C. Cir. 1985) (noting in the context of a violation of a specific standard that “The constitution does not require that employers be actually aware that the regulation is applicable to their conduct”). Fair notice challenges to a general duty clause citation fail when the abatement measures are available to and readily knowable by the industry. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">27 BNA OSHC 1851 at n.15. Like the abatement measures in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the abatement measures proposed for Pembroke track the Workplace Violence Guidelines and Road Map as well as those specified in a letter issued to Pembroke after a previous inspection. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>The Secretary set forth specific abatement measures and Respondents were informed of them in advance of the hearing. The Secretary’s Amended Complaint sets forth his proposed abatement and there is no allegation that Respondents were not aware of his proposal well before the hearing. The feasibility of the specific measures discussed herein was tried with the full consent of the parties. (Jt. Pre-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Hr’g</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Stmt. at 16.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly Enters.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">19 BNA OSHC 1161, 1168-69 (No. 91-144, 2000) (consolidated) (excusing a lack of precision in the complaint because, “at the time of the hearing” the Secretary sufficiently specified the alleged hazard). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents then take another tack and argue that because they were not cited after prior inspections, they lacked fair notice they would be cited in the future. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 21-22.) Respondents make this argument without citation to precedent. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">An employer cannot deny the existence of a hazard or its knowledge of it “by relying on the Secretary's earlier failure to cite the condition.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Seibel Modern Mfg. & Welding Corp</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 15 BNA OSHC 1218, 1244 (No. 88-821, 1991). Employers must comply with the Act regardless of whether they have been previously informed that a violation exists. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents claim that the Citation, including the Secretary’s proposed abatement, violates the Constitution is rejected.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref34" href="#ftn34">34</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:48px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Test to Establish a General Duty Clause Violation</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The general duty clause requires every employer to provide its employees with a workplace “free from recognized hazards that are causing or are likely to cause death or serious physical harm.”</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref35" href="#ftn35">35</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> 29 U.S.C. § 654(a)(1). As interpreted by the Commission, to establish a violation of this clause, the Secretary must show: (1) there was an activity or condition in the employer’s workplace that constituted a hazard to employees; (2) either the cited employer or its industry recognized that the condition or activity was hazardous; (3) the hazard was causing or was likely to cause death or serious physical harm; and (4) there were feasible means to eliminate the hazard or materially reduce it. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon Health Care Ctr</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 16 BNA OSHC 1052, 1058 (No. 89-3097, 1993). The evidence must also show the employer knew, or with the exercise of reasonable diligence, could have known of the hazardous condition. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Otis Elevator Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 2204, 2207 (No. 03-1344, 2007).</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Despite agreeing that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">sets forth the test for finding a violation of the general duty clause, Respondents, citing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">National Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, argue that the Secretary must meet various other requirements.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref36" href="#ftn36">36</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Am. Pre-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Hr’g</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Stmt. at 16;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 6, 28-30.) In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">National Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the D.C. Circuit distinguishes between an unrecognized hazard and one, like the situation at hand, that is recognized. 489 F.2d at 1266. Hazard recognition does not automatically trigger liability. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary still must demonstrate “at the hearing” what the employer should have done. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 1266-68. When discussing whether feasible abatement can be found after the hearing, as opposed to beforehand, the D.C. Circuit notes the concept of preventability. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If the conduct resulting in the hazard is something “conscientious experts, familiar with the industry” would take it into account when “prescribing a safety program,” then the Secretary can establish a violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 1266. In the present matter, the testifying experts agree that workplace violence is something facilities like Pembroke Hospital must consider when prescribing a safety program. While the hazard is not entirely preventable, there are steps employers can take to reduce the likelihood of such incidents and the severity of the ones which occur. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC 1841 at n.3 (discussing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">National Reality</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in the context of a general duty clause violation based on workplace violence hazards);</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Armstrong</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 8 BNA OSHC at 1074 (noting that the inquiry into foreseeability is limited to whether the hazard will result in serious injuries or death). </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Presence of a Hazard</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">National Realty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>analyzes what it means for a workplace to be free of a recognized hazard,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and more recent cases apply a four-part test to assess general duty clause violations. Under this framework, the first element the Secretary must prove is that “a condition or activity in the workplace presented a hazard.” 16 BNA OSHC at 1058. The parties stipulated: Employees at the worksite were exposed to the hazard of workplace violence, specifically defined in this case as violence and/or assault by patients against staff, during the six months prior to the issuance of the citation (October 11,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">2016</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to April 7, 2017). (Stip. 7; Tr. 203, 923.) At the hearing, Respondents’ counsel also made plain that they conceded the presence of a hazard to which employees were exposed. (Tr. 194-95.) The Secretary established that employees at Pembroke Hospital were exposed to the hazard of violence and/or assault by patients against staff. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Recognition and Knowledge of the Hazard</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The second element looks at whether the employer or its industry recognized the condition as a hazard. Again, there is no dispute that Pembroke and the behavioral health industry both recognized the hazard of workplace violence in the context of patient on staff violence.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref37" href="#ftn37">37</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Stips</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 8-9;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 1.) As for knowledge of the hazard, establishing this does not require a showing that the employer was<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">actually aware</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>that it was in violation of the Act. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g., Peterson Bros. Steel Erection Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC 1196, 1199 (No. 90-2304, 1993), </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 26 F.3d 573 (5th Cir. 1994). Knowledge is established if the record shows the employer knew or should have known of the conditions constituting a violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Peacock Eng’g Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 26 BNA OSHC 1588, 1592 (No. 11-2780, 2017).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Here, Pembroke had actual knowledge of the hazard’s on-going presence at its workplace. It also knew its employees were exposed to both actual and potential incidents of workplace violence. Pembroke knew patients had the potential to become aggressive towards staff. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 1.) It trained employees about the fact that patients may be assaultive or even homicidal. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-30, R-32.) And it knew that injuries from violence had occurred. Written employee accident reports detailing injuries from violence were provided to management. (Ex. C-3.) Employee injuries were discussed by management at daily meetings. (Tr. 1441-42.) An MHA explained that she repeatedly communicated safety concerns to multiple supervisors, including discussing a violent incident directly with the Director of Nursing, Claire Kent.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref38" href="#ftn38">38</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 853.) Loss control reports provided to Pembroke’s CEO routinely documented many employee injuries and noted the link between the injuries and patient aggression. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-55 thru C-60.) Supervisors were also made aware of occurrences of the hazard through verbal reports and by witnessing assaultive behavior directly. (Tr. 559, 564, 1263, 1268, 1302-3;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-55 thru C-60, R-38, R-39, R-40.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary established recognition and knowledge of the hazard of workplace violence present at Pembroke Hospital. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Serious Physical Harm</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The third element of the test is also met: the cited hazard was causing or was likely to cause death or serious physical harm. A hazard is likely to cause death or serious physical harm if the likely consequence of employee exposure to the hazard would be serious physical harm. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Morrison-Knudsen Co./Yonkers Contracting Co.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">16 BNA OSHC 1105, 1122 (No. 88-572, 1993). The Secretary offered expert testimony on this point.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref39" href="#ftn39">39</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 919;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-66, C-99.) Dr. Robert Welch opined that at the time of the inspection the hazard of workplace violence was causing serious injury at Pembroke Hospital. (Tr. 923-24, 926.) Before reaching his conclusion, Dr. Welch reviewed the employee accident reports and records of OSHA recordable injuries for the two years before the Citation. (Tr. 926.) He identified thirty-two injuries attributable to patient violence over that time. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The incidents included episodes of staff being bit, concussed, head butted, spit at, and suffering hand injuries. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Other record evidence supports Dr. Welch’s conclusions. Pembroke provided training to new employees about risk management. (Tr. 519;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-30.) The training explains that Pembroke’s patients may have the potential for assaultive or even homicidal behavior.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref40" href="#ftn40">40</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-30 at 19, 22.) Pembroke employees reported suffering physical harm<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a result of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patient on staff violence. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-56, C-57, C-58; Tr. 648, 794, 810-11.) The CO reviewed Pembroke Hospital’s records of OSHA recordable injuries and found that a “very substantial majority were workplace violence related.” (Tr. 292.) Injuries to employees constitute at least prima facie evidence that the hazard was likely to cause death or serious injury. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Usery</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>v. Marquette Cement Mfg. Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 568 F.2d 902, 910 (2d Cir. 1977). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s records detail five different employee injuries from violence in one month alone of the inspection period.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref41" href="#ftn41">41</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-56.) KS worked as an MHA on the adolescent unit on both the day and evening shifts. (Tr. 793-94.) She described multiple assaults over the nearly two-year period when she worked for Pembroke Hospital. (Tr. 792-94.) During the inspection period, on November 12, 2016, KS was injured by a patient. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-74; Tr. 794, 803, 857.) The incident occurred on the adolescent unit on a Saturday during the evening shift. (Tr. 794, 853.) KS and another staff member tried to calm an agitated patient verbally, consistent with their training.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref42" href="#ftn42">42</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 795-96.) Their efforts were not successful, and the patient began throwing shampoo bottles and other objects. (Tr. 796.) The patient then proceeded to physically assault KS. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">KS attempted to restrain the patient, but before she could, the patient was able to grab KS’s hair. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The patient pulled with such force as to lift KS’s head and remove chunks of hair. (Tr. 796, 1266.) Another employee, JQ, was also punched in the head as he tried to assist with the restraint. (Tr. 1264-65.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Following the attack, the patient was put on 1:1 observation. (Tr. 801.) 1:1 observation is a staffing arrangement to assign a staff member to stay with a single patient. (Tr. 77-78.) This is typically done<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a result of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>violent or self-injurious behavior and must be approved by a doctor. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> However, not long after this arrangement was put into place, the order for 1:1 observation was removed. KS was concerned by this, particularly because of the severity of the incident and the fact that it was not the first time the patient exhibited violent behavior.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref43" href="#ftn43">43</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 797-98.) She informed the nursing supervisor, Kristin<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Devane</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, of her concerns. (Tr. 814-15; Ex. C-3.) The supervisor did not dispute the concern for violent behavior but indicated there was not enough staff at the time to have the patient on 1:1 observation. (Tr. 815.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">KS completed her shift and returned to work the next day, which was a Sunday. (Tr. 803-4.) Near the end of her shift, a physical conflict developed between two groups of patients. The same patient involved with the attack against KS on the prior day acted as the “ringleader” for one of the factions. (Tr. 804.) When the staff attempted to intervene to protect the patients, the patients began to assault staff. (Tr. 804-5.) Patients kicked staff in their heads, their backs, and their legs. Staff members were punched, scratched, and bitten during the incident. (Tr. 805.) The incident lasted for about two hours before it was appropriately contained. (Tr. 807.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Besides the assaults on November 12 and 13, 2016, KS described another incident which occurred on November 3, 2016. The incident involved a dispute over a music player. Many patients rely on music as a method to calm themselves. Two patients began fighting over an MP3 music player. (Tr. 809.) KS attempted to intervene to restrain the primary aggressor. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> KS sustained a tear to the triangular fibrocartilage complex in her wrist. (Tr. 809, 811.) The injury required emergency treatment and eventual surgery. (Tr. 809-11.) KS still has ongoing numbness in two fingers. (Tr. 811.) Two additional employees assisted with the restraint and were also injured. (Tr. 810.) One of these employees was kicked with enough strength to knock her into the opposite wall. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The assault caused her to suffer cranial nerve damage. (Tr. 810-811.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">KS’s experiences at Pembroke Hospital were not unique. Other employees also described injuries from workplace violence. AS, an MHA, indicated he was hit or kicked approximately 50 times during his four-year employment with Pembroke.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref44" href="#ftn44">44</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 47, 56-57.) He described one instance that occurred during the inspection period. He was about to commence the required search of a newly arrived patient’s belongings. (Tr. 86.) The patient became angry and pushed AS into a wall. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Another nurse recalled multiple assaults, including an incident where a patient nearly tore an employee’s ear off.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref45" href="#ftn45">45</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 217-18; Ex. C-60.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The assaults against staff resulted in multiple employee injuries. (Tr. 805;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-68, C-69.) Employee injuries included concussions, bruises, scratches, and bites. (Tr. 364, 446, 448, 466-67, 805;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-60, C-68, C-69.) Some of the injuries required employees to seek care in an emergency room and some staff injuries persisted for a long time. (Tr. 805, 810-11;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-60, C-68, C-69.) While some injuries are documented in accident reports, the decision to complete an accident report was left to the employees themselves. (Tr. 1273-74.) Further, besides incidents requiring medical attention, there were many more incidents of aggression against employees.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref46" href="#ftn46">46</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 563;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-57, C-58, C-60 at 3, C-61 at 1.) Respondents do not dispute these accounts of routine assault and injury. The Secretary established that the recognized hazard was causing serious physical harm at Pembroke.</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Pembroke’s Abatement Measures Were Inadequate</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As to the fourth element, abatement, the parties agree that under<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Secretary must show there are feasible means to eliminate or materially reduce the hazard. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 6.) However, they disagree as to what constitutes such a showing and whether the Secretary satisfied the requirements in this case.<span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Although the parties cobble together snippets of various cases<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in an attempt to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>create abatement tests suited to their respective positions, the Commission’s decision in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>sets forth a straightforward three prong test to determine whether the Secretary established that there are feasible means to materially reduce a hazard. 27 BNA OSHC at 1849-50. In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which also involved a violation of the general duty clause due to the hazard of workplace violence, the Commission explains that the threshold question is whether the abatement actions the employer took are inadequate. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at n.14, quoting<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">U.S. Postal Serv.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 1767, 1774 (No. 04-0316, 2006).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If the Secretary shows that the employer’s abatement is inadequate, then he must propose abatement measures which can be put into effect, i.e., show that the measures are “feasible.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>at 1849-50. If the measures are feasible, then the Secretary must show the measures will materially reduce the incidence of the hazard, i.e., the Secretary must show the identified measures will be effective. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Turning first to the abatement measures in place at the time of the inspection, Pembroke’s approach to minimizing the hazard centers around training, policies, and procedures. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 24-27.) Pembroke describes its abatement methods for the hazard to include: (1) staffing, (2) written policies, (3) management commitment, (4) employee participation, (5) worksite analysis and hazard identification, (6) hazard prevention and control, (7) training, (8) program evaluation, (9) medical orders, and (10) procedures and equipment for responding to staff calls for assistance. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 2, 24-27.) Collectively, these things constitute Pembroke’s Workplace Violence Prevention Program, which<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>argue appropriately protected staff from patient aggression. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 27.) Respondents concede that their abatement efforts did not eliminate the hazard of workplace violence. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Still, they argue the measures adequately addressed the hazard and the Secretary failed to establish otherwise. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 23.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary finds fault with Pembroke’s existing measures because of the number of workplace violence incidents that continued to occur at the facility. (Sec’y Br. at 52.) While Pembroke cites various policies as part of its Workplace Violence Prevention Program, most are brief, generic, and focus on patient care rather than protecting staff. For example, the one-page Management of Assaultive Behavior policy refers to patient arguments with other patients and visitors, but not arguments with staff. (Ex. R-10.) It calls for patients to be “monitored” for violent behavior and changes related to “assaultive potential” are to be reported to the supervising nurse. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">It does not reference to precautions staff should take. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Similarly, the one-page Patient Observation Rounds checklist has a space for nurses to check a box indicating the patient has the potential for “assaultive or destructive behavior,” but does not specifically refer to staff safety risks or how to address them.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref47" href="#ftn47">47</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. R-17.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, some of the measures called for by the policies were not consistently or thoroughly implemented. There was significant disconnect between the stated policies and what occurred in practice. For example, Pembroke’s Seclusion and/or Restraint Use policy does not require debriefings if a workplace violence incident did not result in a patient being restrained or secluded.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref48" href="#ftn48">48</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. R-12 at 2.) Also, the assessments Pembroke did conduct after workplace violence incidents were often incomplete. (Ex. C-74.) Staffing levels were not considered relevant to the assessment of injuries. (Tr. 513-14.) Even if an employee cited insufficient staffing as a cause of an injury, such information was not included in the analysis. (Tr. 559.) Additionally, although called for by the policies, patient treatment plans were not always updated after a patient had been restrained or secluded. (Ex. R-13.) The December 2016 Massachusetts Department of Mental Health (“DMH”) survey, which overlapped the OSHA inspection period, made recommendations to address shortfalls with Pembroke’s debriefing practices, such as failing to adequately note triggers for violent behavior.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref49" href="#ftn49">49</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 10-11. So, while Pembroke indicated that it conducted root cause analyses of injuries, its program was incomplete. (Tr. 852, 854-58;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-26 at 12, R-12, R-13.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Chevron Oil Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 11 BNA OSHC 1329, 1333 (No. 10799, 1983) (finding employer’s abatement approach inadequate in part because of the lack of accurate measuring and monitoring of data collected through inspections). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch testified in support of the Secretary’s view that Respondents failed to adequately abate the hazard. Dr. Welch practiced medicine as an attending psychiatrist at multiple facilities during his career and his work experience includes training staff about the management of violence in psychiatric care facilities and handling behavioral emergencies. (Ex. C-66; Tr. 915.) Also, he previously served on the Workplace Violence Committee for a healthcare system. (Ex. C-66.) Before offering his opinion at the hearing, Dr. Welch reviewed and analyzed: employee statements, an employee survey focusing on safety, notes from employee interviews, OSHA 300 logs, UHS DE loss control reports, staffing grids and 1:1 staffing information, employee accident reports, photographs of the physical layout of space at Pembroke Hospital, and DMH inspection reports and corrective action plans for the facility. (Tr. 919-20, 922-23, 1143-44.) Dr. Welch also reviewed approximately 60 articles from medical, nursing, and hospital security literature. (Tr. 921-922.) Finally, he surveyed other psychiatric facilities in the same geographic area as Pembroke Hospital to assist with the evaluation of the Secretary’s proposed methods of abatement. (Tr. 920-21.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The abatement measures in place at Pembroke Hospital were inadequate because the Secretary showed: (1) the hazard remains at Pembroke Hospital; (2) staffing was inadequate; (3) employees lacked sufficient means to summon assistance; and (4) Pembroke failed to properly implement patient de-escalation plans.</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Hazard Remains at Pembroke Hospital</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Despite clinical attempts to address patient aggression, the hazard of workplace violence remained prevalent at Pembroke Hospital during the inspection period. All the non-management employees described multiple incidents of workplace violence and Respondents’ records detail additional injuries. Dr. Welch identified “many, many reports” of Pembroke employees documenting their injuries resulting from workplace violence. (Tr. 927.) OSHA 300 and 300A forms for 2016 identified 23 recordable injuries. (Tr. 290-92, Ex. C-68.) From this self-reported information, the CO compared rates of injury at Pembroke Hospital with national averages for psychiatric hospitals.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref50" href="#ftn50">50</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 293.) In comparing injury rates, the CO only considered injuries that resulted in lost work time, restricted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">duties</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or job transfers. (Tr. 291, 293-94.) Pembroke Hospital’s injury rate was approximately two and a half times the national average for psychiatric facilities. (Tr. 293-94, 355, 927.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents point out that the existence of injuries does not establish that its abatement efforts were inadequate. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 27.) While accurate, the presence of a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">higher than average</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>injury rate is relevant to assessing the sufficiency of Pembroke’s program. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">SeaWorld,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">748 F.3d at 1215 (existing safety procedures held inadequate where evidence showed employer’s training and protocols did not prevent continued injuries). Injuries and incidents are not dispositive, but they do lend support to the Secretary’s claim that the abatement methods, as implemented, were inadequate. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Staffing was Inadequate</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">One of Pembroke’s abatement methods was staffing. Both experts agreed that staffing is a way to reduce the hazard of workplace violence in a behavioral health setting. (Tr. 937-40, 942-952, 959-60, 966, 980-81, 1510.) Dr. Welch explained that higher staffing levels mitigate violence and provide a safer working environment. (Tr. 946-47, 952.) He discussed peer reviewed studies that supported his view that adequate staffing reduced the hazard.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref51" href="#ftn51">51</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 950-52, 962, 989;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-94, C-96, C-98, C-100, C-101.) Understaffing is linked to more assaults while higher staff to patient ratio resulted in fewer patients escalating to a point where they became violent and fewer patient emergencies. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-96, C-97, C-98, C-100, C-101; Tr. 980-81.) Pembroke employees working at the site during the inspection period confirmed that, in their experience, insufficient staffing harmed worker safety. (Tr. 90, 329-31, 325-26, 666, 793.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch concluded Pembroke’s staffing was inadequate to manage the risk of workplace violence at Pembroke. (Tr. 939, 1067.) Most shifts at Pembroke had less staff per patient than the national averages for similar facilities. (Tr. 939, 1046-47.) Pembroke does not dispute this, but argues it follows the minimum staffing requirements set by the DMH for patient care. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 13, 26.) The DMH requirements vary with the number of patients (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i.e.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the census) at the facility. (Ex. C-20.) Pembroke uses a document referred to as the “grid” to determine when the census reaches a point that additional hours are needed under the DMH requirements.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref52" href="#ftn52">52</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-20; Tr. 371-72, 387-88, 930-33, 1316.) At a minimum, there is one nurse and one MHA for each unit. (Ex. C-20; Tr. 380.) As the census increases, additional staffing hours may be added. (Tr. 371-72, 387-88; Ex. C-20.) Each additional patient does not automatically trigger an increase in staffing. (Ex. C-20.) The grid is focused on minimum staffing levels per patient for their medical care. (Tr. 931.) In setting the minimum staffing levels, the DMH does not focus on staff safety or workplace violence. (Tr. 931-33.)<span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Besides the individuals “on the grid,” other personnel can assist with workplace violence incidents. (Tr. 475-76.) During the day shift on weekdays, additional support staff and medical personnel are available to prevent and respond to workplace violence situations. (Tr. 475, 819, 1299.) However, not all personnel can respond to a code or request for assistance. (Tr. 1299.) At least one person must<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stay on each unit at all times</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 375-77, 871; Ex. R-17.) The employee assigned to conduct patient checks is limited to that task only. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Further, the number of additional potential responders is not the same on all three shifts. On the evening shift, there is a single “crisis intervention specialist” who can assist units as needed. (Tr. 871, 1233.) The Director of Nursing explained that “a lot of crises” happen on the evening shift. (Tr. 1437.) The crisis intervention specialist is not involved in direct care and tries to be “proactive” to identify problems before they become “huge issues.” (Tr. 473.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">On the night shift, each staff member was responsible for the greatest number of patients. (Tr. 388;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-20, C-78.)</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">There is no crisis intervention specialist and fewer other employees as well. (Tr. 374; Ex. C-78.) For example, by the grid, there only needs to be one nurse per adult unit unless the census for that unit exceeds twenty-three patients.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref53" href="#ftn53">53</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-20.) And, even when the census reaches a point that more staffing hours are required, the grid typically only requires four more hours of care, i.e., an additional employee for only half of the eight-hour shift. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> After the four hours of care are provided, the employee could be sent home, even if additional admissions are anticipated. (Tr. 107-8, 1316.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As with the night shift, on weekends there were fewer employees at the hospital who could respond in the event of a workplace violence incident. There was only one doctor for all 90 patients on weekends. (Tr. 961-62.) There were fewer social workers and case managers as well. (Tr. 960-62.) Patients often were not seen by a psychiatrist, social worker, or case manager until Monday if they were admitted on the weekend. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In fact, 40% of assaults took place on weekends when there was significantly less staff on site.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref54" href="#ftn54">54</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 960.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary contends that Respondents failed to have sufficient staff to abate the hazard of workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref55" href="#ftn55">55</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The evidence reveals that staffing was the overwhelming safety issue for employees and Dr. Welch agreed with employee concerns. (Tr. 306.) According to Dr. Welch, the baseline level of staffing at Pembroke Hospital was both inadequate and significantly below other hospitals he surveyed or worked in. (Tr. 939, 1067-68.) The staff to patient ratios were inadequate to successfully manage the hazard. (Tr. 1067.) Dr. Welch cited multiple occasions during the inspection period when Pembroke fell below its own minimum staffing requirements and employees reported injuries. (Tr. 942.) Studies have found that there is a higher rate of violence and aggression from patients when each staff member is responsible for a higher number of patients. (Tr. 943, 946-47; Ex. C-101.) As discussed in more detail below, the Secretary showed that Respondents’ approach to staffing resulted in an insufficient number of people to accommodate medical orders for 1:1 supervision, to safely address changes in patient acuity, and to handle new patient admissions. (Sec’y Br. at 51, 54, 61.) Pembroke also failed to maintain adequate staffing levels for appropriate de-escalation and for therapeutic activities. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate Staffing for 1:1 Medical Orders</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke argues that one of its methods for addressing the hazard was to allow staff to seek a higher level of observation for certain patients. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 14, 27.) MHAs and nurses could request a doctor to order an MHA to be assigned directly to a particular patient. Doctors could order an MHA to stay within arm’s reach of a single patient. (Tr. 78, 683; Ex. R-11 at 2.) This level of observation is referred to as a 1:1, meaning one employee for one patient. The arrangement permits focused de-escalation and prompt notification of co-workers if a patient starts to become violent. (Tr. 1040-41, 1045, 1125.) While assaultive behavior could support a 1:1 assignment, employee safety was not a specific reason for a patient to be placed on 1:1 observation.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref56" href="#ftn56">56</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1191; Ex. R-11 at 2.) Typically, such arrangements were called for because the patient was injuring themselves. (Tr. 479-80, 1191; Ex. R-11.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary agrees with the importance of 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as a method for both reducing workplace violence incidents and reducing the likelihood such incidents cause serious injuries. (Tr. 1045-46.) He does not call for more 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>or cite issues with Pembroke’s policies addressing 1:1s. Rather, the Secretary’s concern lies with how Pembroke addressed, or failed to address, the need for staff to allow the implementation of orders for 1:1s. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In particular, there</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>was not always enough staff to fill a recommendation for 1:1 staffing. (Tr. 233-36, 453-55, 657, 666, 814-15; Ex. C-78.) Nor did placing a patient on 1:1 supervision typically result in additional staff being assigned to the unit. (Tr. 332, 383, 453, 945-46; Ex. C-38.) Often an MHA was re-assigned from helping a group of patients on the unit to instead focus on a single patient. (Tr. 383, 388-89, 946.) This was particularly the case if more than one patient required 1:1 staffing. (Tr. 332, 383.) Ms. Kent acknowledged it was not a policy to bring an additional staff member in to cover the first 1:1 ordered on a unit. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Typically, it would be covered on the next shift, regardless of when the doctor first ordered it. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">If there was a need to place a second patient on 1:1 observation due to violent behavior, Pembroke generally<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">did not<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">add additional staff. (Tr. 332, 383, 388-89; Ex. C-47.)</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staff reported “tension” between management’s desire to remove a patient from 1:1 observation to improve the staff to patient ratio and the belief of front-line workers that doing so was premature and could result in assaultive behavior. (Tr. 235-36, 664, 657-58.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even with a history of violence, 1:1 observation was not assigned until after a patient was violent towards others or engaged in serious self-injurious behavior at Pembroke Hospital. The potential for violence to employees did not result in additional staff. (Tr. 77-78, 799.) The patient had to demonstrate violence or self-injurious behavior to a sufficient degree before a doctor would order 1:1 observation. (Tr. 77-78.) If a patient previously assaulted medical professionals or others before arriving at Pembroke, that was not sufficient. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> They had to exhibit violent behavior at Pembroke. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">For example, during the inspection period, a patient attempted to punch an MHA in the face. (Tr. 798.) The incident was reported to supervisors. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> A week later, the same patient succeeded in assaulting the MHA. (Tr. 798-99.) Even at that point, the patient was only briefly placed on 1:1 observation for part of a shift. (Tr. 800-1.) According to the MHA, the 1:1 observation was discontinued not because anyone thought the patient no longer needed it, but because there was no female MHA available to fill the role.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref57" href="#ftn57">57</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 801-2.) The same patient was then involved in another violent attack against staff the following day. (Tr. 804-5.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke understood the need for additional staff to implement1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. In 2016, before the latest OSHA inspection commenced, the DMH identified several deficiencies in Pembroke’s approach to staffing. (Ex. C-47.) The DMH found that Pembroke lacked enough staff to allow for emergency coverage.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref58" href="#ftn58">58</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In response to the DMH’s investigation, in December 2016, Pembroke submitted a Plan of Correction to the DMH that called for 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to be handled by additional staff, rather than by reassigning workers from providing care for all patients to caring for a single patient. (Tr. 396, 703-4;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-26, C-38, C-47.) In practice, Pembroke admits that it failed to adhere to its Plan of Correction. (Tr. 332, 736; Ex. C-38.) On multiple shifts during the inspection period, placing a second patient on 1:1 observation did not increase the number of staff members on the unit, despite Pembroke’s commitment in the Plan of Correction.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref59" href="#ftn59">59</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-26, C-38.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary argues that Respondents tried to conceal the number of patients on 1:1 observation to make their staff to patient ratio appear better than it<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was in reality</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref60" href="#ftn60">60</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Sec’y Br. at 31.) Melissa Heron prepared staffing records for production to OSHA. (Tr. 417-19.) The staffing records initially contained the number of patients, the total number of staff, and how many employees were assigned a single patient (i.e., how many were assigned to 1:1 observations). (Tr. 419, 423-24, 887-89; Ex. C-78.) Before turning over the documents, Pembroke removed the information related to 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. (Tr. 417-19, 889.) </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">By removing this information, it</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>could appear that there was adequate staff for all patients and that the units were less acute. (Tr. 887-88, 1054-55.) This perception was corrected when before the hearing, Pembroke provided the removed information to OSHA. (Tr. 417-19, 421-22, 883-84, 887-88; Ex. C-78.) Considering the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">record as a whole, the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Secretary did not establish the editing warranted adverse inferences.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref61" href="#ftn61">61</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch concluded that Pembroke’s approach to staffing was inadequate and left too few employees responsible for too many patients and tasks. The approach of not consistently adding staff when there was a doctor ordered 1:1 observation reduced the effectiveness of Pembroke’s Special Precaution Guidelines, and left staff more vulnerable to the hazard. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate Staffing for Acuity</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke argues that it altered staffing based on a unit’s acuity to address the hazard. In the context of a behavioral health hospital, the “acuity” of a unit refers to the level of activity and risk. (Tr. 1001-2.) Factors influencing the level of acuity include how many patients, staff, and visitors are present, and the condition of the patients. (Tr. 1002-3.) The higher the level of acuity within a unit, the more staff that are needed. (Tr. 576.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In practice, employees explained that increasing staff for acuity did not consistently occur.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref62" href="#ftn62">62</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 132, 307; Ex. C-22.) Dr. Welch evaluated staffing at the facility and agreed with the employees’ view that Pembroke did not sufficiently staff for acuity during the inspection period.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref63" href="#ftn63">63</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1053-54, 1056, 1058.) Pembroke’s claims about increasing staff for acuity were not supported by its records. (Tr. 1055-56.) Although Pembroke took steps to ensure that the minimum level of staffing called for by the grid was met before employees could leave, this requirement did not extend to situations where a unit’s level of acuity required a higher ratio of staff per patient. (Tr. 454.) Pembroke’s goal was to ensure that the base level of staffing for patient care was met, not to have enough staff for purposes of abating the hazard of workplace violence. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Even by the grid, the facility was understaffed for parts of shifts on at least three dates during the inspection period. (Tr. 942; 1443-44.) Injuries from workplace violence incidents were documented on understaffed shifts. (Tr. 942, 960; Ex. C-78.) In one instance, on November 14, 2016, one adult unit was operating for the evening shift with only one nurse and one MHA. There had been a series of assaults in the same unit during prior shifts. Just at the start of the night shift, a patient bit an employee during a restraint. As was always the case on the night shift, there was no crisis intervention specialist who could move onto the unit if the violent behavior continued and only one float employee for all the units. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate staffing harmed preventative actions and responses to violence. Both experts agreed that when staff is available to attend to patients’ initial signs of agitation, verbal intervention alone can be effective at preventing physical violence. (Tr. 947, 1512.) The experts also agreed that having numerous potential responders in the event of behavioral health emergencies aids safety. (Tr. 947-48, 1512.) It facilitates addressing the individual whose behavior started the situation and limits the ability of other patients to take advantage of an employee’s isolation or distraction during a workplace violence incident. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch explained that “at least five people” are required for each behavioral health emergency.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref64" href="#ftn64">64</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 947-48, 1000.) He cited an employee accident report involving a patient who weighed 388 pounds. (Tr. 948.) A situation involving such a large patient could require as many as eight employees to ensure safety for all. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> At times during the inspection period, there were only twelve MHAs for the whole facility. (Ex. C-78.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">KS, a former MHA at Pembroke, explained that she did not feel safe working at Pembroke because routinely there was not enough staff to address the unpredictability of patient behavior. (Tr. 793.) She described one situation during the inspection period that spiraled into a melee. (Tr. 794.) Even after calls for all available staff to respond, there was still not enough support. (Tr. 806, 1482-83.) The situation progressed to a point where some patients started to restrain other patients for the safety of everyone in the unit. (Tr. 794, 807, 856, 948.) KS noted that the situation would have been worse had it not occurred near the end of one shift and the start of the next. (Tr. 806.) Because of this coincidence, some people who had arrived early for their shift could assist with bringing the situation under control. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Had the incident occurred mid-shift such resources would not have been available. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate Staffing for Admissions</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to prior violent incidents, new admissions also impact the acuity of the units.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref65" href="#ftn65">65</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1057-58;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-55, C-101 at 9.) When a patient arrived at Pembroke, a nurse would briefly take vital signs just inside the door to the unit. (Tr. 75.) An MHA would then bring the patient to “a very small room” on the unit.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref66" href="#ftn66">66</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The MHA would continue the admissions process alone in the room with the patient. (Tr. 75, 81.) There were no cameras in the room and only a very small, high window.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref67" href="#ftn67">67</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 88, 512.) The MHA’s assessment included searching the patient and their belongings for contraband,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i.e.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>items that could harm staff or patients. (Tr. 81, 837, 1181-82;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. R-1, R-8.) AS explained that he did not feel safe to be alone with patients at this point in the admissions process. (Tr. 81-82.) First, the patient’s condition was not yet well understood. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Second, the patient and MHA are in the room alone before the contraband search is completed.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref68" href="#ftn68">68</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s Contraband and Restricted Articles policy notes numerous types of objects that could pose a danger to staff. (Ex. R-1.) AS explained that some patients became aggressive during the searches.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref69" href="#ftn69">69</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 81-82.) In addition to contraband a patient may come in with, the room used for the searches also had multiple objects that could be used as projectiles. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The location and size of the room made it difficult to call for help even with a radio. (Tr. 82.) Thus, admissions were one of the “scarier” parts of the job. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After the MHA completed his or her assessment, the new patient moved to the common room where the existing patients were until it was possible to meet with a physician.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref70" href="#ftn70">70</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 91-92, 861-62.) The wait to meet with a physician could take several hours, particularly on weekends, when only one doctor attended the hospital. (Tr. 861-62.) New patients would often become agitated or aggressive after being moved into the common room, particularly if in need of medication,.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref71" href="#ftn71">71</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 79.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Admissions impacted acuity in multiple respects. First, arriving patients were typically distressed and at their sickest. (Tr. 1057.) As they were not fully assessed yet, the practice of having the new patient enter the common room directly increased risk and acuity. (Tr. 1014.) Second, Pembroke did not set separate limits for the number of violent patients being admitted. (Tr. 77.) Often there were multiple admissions of patients with a history of violent behavior during a single shift. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Third, the admission process itself was very time consuming and could occupy both a nurse and an MHA for long periods. (Tr. 1058.) Admitting a patient typically required twenty to thirty minutes of time from an MHA and as much as 90 minutes for the nursing tasks. (Tr. 653-54, 837-38, 1006-7.) In general, according to the Director of Nursing, there were 6.9 admissions per day. (Tr. 1346.) But admissions, both in terms of their number and their timing, varied significantly. (Tr. 863, 1008, 1382, 1436, 1516). Pembroke’s Director of Admissions explained that “every day is very different.” (Tr. 1382.) Sometimes there would be as many as seven admissions to a single unit during a shift. (Tr. 863.) Dr. Welch pointed to another shift during the inspection period with fourteen admissions. (Tr. 1014.) While admitting a patient, the staff member could not focus on de-escalating potentially violent patients and timely intervening to address assaultive behavior towards staff. Fourth, admissions could result in staffing levels that fell below the minimum “floor” required by the grid. (Tr. 455.) Pembroke Hospital had no staff dedicated to handling the admissions tasks. Moreover, it did not consistently staff in anticipation of admissions. (Tr. 242-43, 381-82, 455, 878-79; Ex. C-78.) Rather, the shift would often continue with the same number of employees working despite the number of admissions. (Tr. 878-79.) Additional staff would only be added for the next shift. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Fifth, when there was a high influx of patients, admission tasks had to be performed hastily and sometimes potential weapons were overlooked. (Tr. 837.) This could increase the risk of injury from workplace violence. For these reasons, Dr. Welch concluded that Respondents failed to assign enough staff for admissions and that this increased both the likelihood and potential severity of workplace violence. (Tr. 962, 1056-58.) Admissions increased the number of patients for each staff member and created additional work to assess the newly admitted patients. (Tr. 838-39, 1057-58; Ex. C-55.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents note that discharges reduce the number of patients. Discharges only occurred on the day shift when there already was additional staff who could respond to workplace violence events. In contrast, admissions occurred throughout the twenty-fours and were not evenly distributed. (Tr. 1382, 1014.) Admissions also did not automatically result in increased staff until the next shift, while discharges could result in staff being sent home mid-shift. (Tr. 107-8, 1316.) Staff reductions occurred even when new patients were anticipated but had not yet arrived. (Tr. 107-8, 838-39.) Discharges also impacted the acuity of units. The patients likely to be discharged are, by definition, the healthiest and most stable. (Tr. 1056-57.) The most stable patients were then replaced with the newly admitted, sicker patients. (Tr. 1005, 1056-57.) The patients arriving for admission are “acutely decompensated.” (Tr. 1012.) They may not yet be medicated, and Dr. Welch described it as a “very high-risk time.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary established that Pembroke’s approach to admissions was inadequate.</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate Staff to Verbally De-escalate Patients</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke argues that its use of verbal de-escalation, which included a written policy and training, was adequate. Pembroke’s Management of Aggression policy was a one-page document described by the risk manager as a review for staff about how to manage assaultive behavior. (Tr. 1186-87; Ex. R-10.) But the document does not provide guidance on how to accomplish this. (Ex. R-10.) Instead, it notes that patients will be assessed for assault risk and monitored for behavior. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Changes in behavior or events related to the potential for assaultive behavior are to be reported to the charge nurse, and such reports may alter treatment. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. Staff did receive other training, including being taught a technique called Handle with Care, which the Risk Manager indicated was a method to safely intervene with patients at risk of harming themselves or others.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref72" href="#ftn72">72</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 747, 1188, 1419-20; Ex. R-32.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In addition to the Handle with Care training, Respondents allege that Pembroke also presents a “Workplace Violence Prevention PowerPoint” to employees and indicates that Exhibit R-32 is this presentation. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 7.) At the hearing, Mr. Quinn described Exhibit R-32, not as a Workplace Violence Prevention PowerPoint, but as the “Handle<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Care with the Verbal De-escalation PowerPoint.” (Tr. 1235.) He did not refer to it as workplace violence training and his description matches what is listed on the first page of the document.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref73" href="#ftn73">73</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Ms. Burns, Pembroke’s risk manager, was not asked whether Exhibit 32 constituted Pembroke’s workplace violence training. (Tr. 497.) She testified that, in general, employees were trained about workplace violence, but she did not provide such information to staff. (Tr. 1219-20.) When shown Exhibit C-31, a different collection of PowerPoint slides that uses the phrase “workplace violence,” she could not confirm whether it was used at Pembroke to train employees. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">So, the record does not show that employees were trained on, given, or reviewed Exhibit C-31.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref74" href="#ftn74">74</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch acknowledged that almost all behavioral health hospitals use verbal de-escalation and that it is an appropriate, albeit incomplete, intervention for certain patients. (Tr. 1010.) He did not raise specific issues with Pembroke’s training but explained that Pembroke’s approach to handling workplace violence hazards requires enough staff so employees can promptly identify who is escalating and intervene quickly.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref75" href="#ftn75">75</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Pembroke failed to consistently have enough staff to implement the techniques called for by its Handle<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Care Program. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">So, as implemented, Pembroke’s approach to verbal de-escalation was not sufficiently effective at abating the hazard. (Tr. 1010.) Training could not make up for the lack of adequate staff to handle psychiatric emergencies.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref76" href="#ftn76">76</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-96 at 15.) </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Inadequate Staff for Therapeutic Activities</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch explained that therapeutic group activities are effective at reducing incidents of workplace violence. (Tr. 949, 968-69; Ex. C-101.) Regularly scheduled and predictable activities promote engagement and decrease levels of acuity on the units. (Tr. 820-21, 949-50, 1061-62.) Pembroke recognized the importance of regularly scheduled therapeutic groups.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref77" href="#ftn77">77</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-55, C-57, C-59, R-32.) Its de-escalation training called for increasing structure<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">as a means to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>control crises. (Ex. R-32 at 13.) The Handle<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Care training cites schedules and programs as helpful in avoiding power struggles that can lead to violence. (Ex. R-32 at 22.) Before regulatory visits, Pembroke instructed employees to check to make sure details about groups were written, that groups occurred, and that schedule changes were noted.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref78" href="#ftn78">78</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-1 at 1-2, 4-5, 7-8.) Pembroke also agreed with the DMH’s audit findings that the posted information about groups failed to adequately describe what groups were<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">actually going</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to occur. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-26, R-13, R-29.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Despite this recognition of the importance of making sure groups occurred, groups were regularly canceled due to insufficient staff. (Tr. 221.) KS indicated that at least three times a week a group would be canceled. (Tr. 819.) This most frequently occurred on the evening shift, which had fewer available employees. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Still, even on the day shift, groups were routinely canceled. (Tr. 50, 137.) Groups were canceled because staff was too busy with admissions or because of the need to respond to emergencies. (Tr. 138, 221, 677-78, 820.) There was not enough staff to consistently run the groups and handle the other tasks. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Groups were an “afterthought,” rather than an effective means of abatement. (Tr. 677-78;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-26 at 3, R-13, R-28, R-29.) </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Inadequate Means to Summon Assistance</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke argues that staff could adequately summon additional assistance when needed to prevent or end patient on staff violence. Pembroke’s units often only had three employees. (Tr. 380, 1047; Ex. C-20.) There is no debate that this was insufficient to address all workplace incidents. Staff could verbally announce a “Code Green” to seek assistance in the event of violence or if they anticipated the need for additional support. (Tr. 57; Ex. R-9.) Typically, at least one or two times a day, staff would seek assistance through the Code Green process. (Tr. 827.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Code Greens could also be called over two-way radios (i.e., walkie talkies) if available or by using a phone that could connect to an overhead public address system.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref79" href="#ftn79">79</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 57, 59-60.) Employees were instructed to stay with the patient even when summoning assistance. (Ex. R-9.) However, if the employee did not have a radio, they would need to access the one phone located in the middle of the unit.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref80" href="#ftn80">80</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 59.) There was no phone in the area used for admissions. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The number of two-way radios on each unit varied but there were never more than four.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref81" href="#ftn81">81</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 60-61, 456-57.) Staff who could not access the phone or a radio could verbally request that someone else commence the Code Green process. (Tr. 59.) There was no equipment or procedures to silently alert others of the need for assistance. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Employees discussed various issues with the radios. First, there were not enough to permit every staff member to carry one while working on the units. (Tr. 60-61, 231; Ex. C-78 at 3.) Second, the radios had reliability issues. (Tr. 60.) Problems included static, faulty batteries, and radio airwaves shared with maintenance workers. (Tr. 60, 815.) During fresh air<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">breaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>for patients, a single MHA is responsible for seven patients. (Tr. 56.) At such times, staff must rely on the radio to summon additional assistance. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A nurse described multiple occasions when she attempted to use the radio to call for a Code Green and just heard static or was not able to reach enough employees. (Tr. 221.) Sometimes staff would have to make multiple calls for help with both the radios and through the one phone on the unit<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in order to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>get enough people to respond to the situation. (Tr. 806-7.) One nurse described a situation during the inspection period that continued to escalate as attempts to get assistance were repeatedly made. (Tr. 806, 1482-83.) In short, there was both difficulty in communicating the need for help and then a lack of people who could respond. (Tr. 221, 815.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch concluded that Pembroke lacked an adequate system for employees to summon assistance. (Tr. 1000.) In addition to the problems with the radios and the limited number of phones, there was also no way to silently seek assistance. Staff communications over the radios, verbal calls for assistance, and use of the unit phone could be audible to potential assailants. In contrast, panic alarms allow for discreet requests, which may help to avoid escalating a patient further. (Tr. 1049.) The Secretary established that Pembroke’s approach was inadequate. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Failure to Properly Implement De-Escalation Plans</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">To help manage patient aggression and thereby reduce incidents of workplace violence, Pembroke sought information from patients about activities or interventions that successfully calmed them in the past. (Tr. 512, 1255, 1293;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. R-12, R-18, R-32 at 9.) This information was then used to develop crisis intervention plans for staff to follow<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in order to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>limit patient aggression. (Tr. 512-13.) Staff could augment the information from the patient based on what they observed during treatment. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary does not dispute that Pembroke sought information for de-escalation plans and communicated the findings to staff. His contention is that the facility lacked sufficient equipment to implement one aspect of the plans. Staff were instructed as part of their verbal de-escalation training to employ the calming techniques patients identified. (Ex. R-32.) “Listening to music” is the first option listed in the “helping or comforting strategies” section of the form used for the de-escalation plans and many of the plans called for its use. (Tr. 830, 1434; Ex. R-18.) Dr. Welch and employees reported that music was effective for de-escalating aggressive patients. (Tr. 73-74, 666, 830-31, 962-63, 1064, 1245, 1293, 1306.) However, employees discussed situations where they were unable to allow patients to listen to music because there were too few devices. (Tr. 74, 667.) The insufficient number of music playing devices also led to conflicts among patients.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref82" href="#ftn82">82</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 74-75, 809-10.) The failure to have the equipment necessary to implement the plans rendered the policy ineffective at abating the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Chevron</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 11 BNA OSHC at 1332-33 (finding inspection program to be an inadequate method of abatement because of how it was implemented). </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Pembroke’s Abatement was Inadequate</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s approach to staffing, summoning assistance, and implementing de-escalation plans was inadequate. While Pembroke’s training program was not shown to be deficient, staff training alone is insufficient to abate the hazard.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref83" href="#ftn83">83</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Dr. Welch, supported by research, concluded that to address the hazard, workplace violence programs must include adequate staffing and the use of engineering controls such as maintaining systems to quickly summon assistance. (Tr. 986, 1000.) Despite the abatement measures implemented by Pembroke, the facility continued to experience higher than average injuries. Pembroke failed to appropriately implement the safety measures it had identified to address the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See SeaWorld,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>748 F.3d at 1206, 1215 (finding existing procedures inadequate). The Secretary established that Pembroke’s program was inadequate. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cf. U.S. Postal,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">21 BNA OSHC at 1773-74. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The general duty clause requires employers to “take all feasible steps” to protect against recognized hazards and implement every abatement measure “whenever it is recognized by safety experts as feasible,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">even though it is not of general usage in the industry</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Gen. Dynamics</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 599 F.2d at 464. As discussed below, the Secretary identified currently available engineering and administrative controls that can be feasibly taken and will materially reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pelron</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Corp.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12 BNA OSHC 1833, 1836 (No. 82-388, 1986) (finding that the Secretary may establish that an employer's existing safety procedures were inadequate by demonstrating that there were “specific additional measures” required to abate the hazard). </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:96px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Feasible Means to Abate the Hazard Exist</span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Despite acknowledging it recognized the hazard and arguing it has taken multiple effective steps to abate it, Pembroke claims the hazard is too unpredictable to be abated. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 28-29.) However, its own expert flatly refuted this contention. She explained “there are certainly methods” to reduce the risk of workplace violence. (Tr. 1508.) Dr. Welch concurred with her that there are feasible means to reduce incidents of workplace violence.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref84" href="#ftn84">84</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 934-35.) Unpredictable events do not remove an employer’s obligation to adhere to the general duty clause and address recognized hazards with feasible means of abatement. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">SeaWorld,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">748 F.3d at 1207, 1215;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Armstrong</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 8 BNA OSHC at 1074 (finding the employer’s contention that it should not be found in violation of the general duty clause when it could not foresee the sequence of events that led to injury to be without merit). </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents also criticize the nature of the Secretary’s multi-prong abatement. Yet, when a workplace contains a recognized hazard that is likely to cause death or serious harm, the employer must take “all feasible steps to eliminate or materially reduce the hazard.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Armstrong,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">8 BNA OSHC at 1074, citing</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Gen. Dynamics</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 599 F.2d at 464. Feasible abatement may take the form of a process rather than a single one-time action. In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pepperidge Farm</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17 BNA OSHC 1993 (No. 89-265, 1997),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the hazard could not be abated with a single action, so it was permissible for OSHA to require the employer to engage in a process approach to abatement to determine what action or combination of actions would materially reduce the hazard. 17 BNA OSHC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>2033. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See also Pegasus Tower</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 1190, 1191 (No. 01-0547, 2005) (finding that following a detailed compliance directive was a feasible means of abatement). Similarly, in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra Health</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, several actions were found to be feasible methods for reducing workplace violence hazard.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref85" href="#ftn85">85</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> 27 BNA OSHC at 1849-51. The Secretary does not have to prescribe an action or series of actions that address all situations where the hazard arises. Abatement may still be feasible even if it cannot be used in all situations. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span>Wheeling-Pittsburgh Steel Corp., </span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">10 BNA OSHC 1242, 1245 (No. 76-4807, 1981) (consolidated). </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While not a process<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">per se</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Secretary has set forth multiple abatement methods here.</span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref86" href="#ftn86">86</a></span><span style="font-size:12pt; font-family:Times New Roman; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> He argues that each method is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">feasible and will materially reduce the hazard. (Sec’y Br. at n.7.) The Secretary argues that all these actions should be taken. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">But, if the undersigned concludes that one or more of the methods are not feasible, the Secretary argues that each remaining method is feasible and would materially reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span></p>
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			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Several of the proposed abatement actions relate to maintaining appropriate staffing at the facility:</span></p>
			</div>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Cease efforts to interfere with the issuance of medical orders that specify</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.034cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">required staffing arrangements. </span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">2.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ensure that staffing is sufficient to allow the issuance and implementation of medical orders that specify staffing</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.021cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">arrangements.</span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">3.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maintain staffing that is adequate to safely address changes in patient acuity and new patient admissions. For example, do not decrease staffing levels mid-shift regardless of the timing of patient discharges.</span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">4.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maintain adequate staffing to support therapeutic activity groups and recreation periods, thereby engaging patients in activities that reduce patient agitation and incidents of workplace violence. </span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:11.5pt; font-family:Times New Roman; color:#000000; padding-right:20px;">5.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Provide security staff and/or crisis intervention specialists on all three shifts to assist in preventing and responding to violent</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.012cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">events.</span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Sec’y Br. at 4.) Three actions focus on how and where new patients are admitted. </span></p>
			</div>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Establish a team of nurses and mental health associates (MHAs) that focuses primarily</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.042cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the performance of the tasks associated with the admission and assessment of new patients. This team should not be staffed by employees who are assigned to care for already-admitted</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients.</span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">2.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dedicate a physical area, apart<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from all other units of the hospital,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>to the admission and assessment of new patients. </span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">3.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Do not allow new patients into other units until the tasks associated with admission, including clinical assessments and the provision of medical orders, are complete.</span></p>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The final abatement measures relate to the provision of equipment to summon assistance and implement patient crisis prevention plans:</span></p>
			</div>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Provide personal panic alarms for all employees who may work<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in close proximity to</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>patients, including but not limited to nurses, MHAs, housekeeping staff, and case workers. Provide training on this equipment and ensure that the equipment is</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.03cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">maintained in<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">working order at all</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.005cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">times</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			<p style="margin-left:72px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:72px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">2.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maintain equipment that is sufficient for the implementation of</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.037cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">each patient’s individual crisis prevention</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">plan.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Sec’y Br. at 4.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke does not allege that any of these steps are technologically or economically infeasible. Notably, Respondents argue that Pembroke already complies with some of the abatement methods. Nor does Pembroke allege it lacked the authority or control to implement the proposed abatement measures. Instead, Respondents argue that the Secretary failed to provide enough detail about what constituted adequate abatement and therefore it was deprived of the fair notice of the abatement required. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 21.) In their view, besides showing fair notice of the hazard, the Secretary should also have to prove the employer knew how to materially abate the hazard before the citation was issued. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 21-23.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Discussions of “fair notice” in Commission cases involving alleged violations of the general duty clause typically center on the employer’s notice of an obligation to address a hazard in the workplace, not on whether the employer had notice about how to abate or materially reduce a hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g., Otis,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">21 BNA OSHC at 2206 (discussing fair notice in the context of how the Secretary defined the hazard);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">19 BNA OSHC at 1163 (noting that although the complaint may not have been precise, “at the time of the hearing” the Secretary sufficiently specified the alleged hazard). Having found above that the Secretary provided sufficient notice of the hazard to satisfy the Constitution's due process clause, it is time to assess Respondents’ demand that the Act requires the Secretary to show that employers had fair notice of the required abatement. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The requirement to show feasible means of abatement relates to the Commission’s test for ensuring that the Act does not impose strict liability. The Commission has not articulated the abatement test in the manner Respondents seek. Under the Commission’s test, the abatement prong requires the Secretary to establish the existence of feasible means to eliminate or materially reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See e.g., Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC at 1849 (addressing a violation of the general duty clause for a workplace violence hazard);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Waldon</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC at 1062 (affirming a violation of the general duty clause for a viral exposure risk at a healthcare facility).</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Showing feasibility requires the Secretary to put forth abatement methods that are capable of materially reducing the hazard while also being technologically and economically possible. 27 BNA OSHC at 1849-51. The Secretary does not have to show that the abatement methods would eliminate the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Arcadian Corp</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 20 BNA OSHC 2001, 2011-13 (No. 93-0628, 2004) (finding two of the Secretary’s proposed methods of abatement feasible). Nor is he tasked with showing that the absence of the abatement method was the sole cause of harm. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. His obligation is to show that the proposed abatement is capable of being put into place and effective. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Acme Energy Servs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 23 BNA OSHC 2121, 2127-29 (No. 10-0108, 2012) (finding the abatement prong met because prescribed action would materially reduce the harm, even though it would not eliminate the hazard),<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 542<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F.App’x</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>356 (5th Cir. 2013) (unpublished). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents point to no precedent imposing an obligation on the Secretary to establish an employer’s knowledge of the proposed abatement methods prior to a citation being issued. In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Chevron Oil</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Commission concluded that the Secretary had to show that feasible means to eliminate the hazard exist. 11 BNA OSHC at 1330. It was not the Secretary’s burden to show that the employer or its industry recognized the necessity for proposed safety equipment. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at 1330-31. Instead, the Act requires the Secretary to establish recognition of the hazard and that it can be materially reduced feasibly. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. See also Kansas Cit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">y, 10 BNA OSHC at 1422 (“the recognition element of an employer’s duty under the general duty clause refers to knowledge of the hazard, not recognition of the means of abatement);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">at</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>1849, 1851</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In the present matter, the employer had notice of effective methods of abatement before the Secretary issued the citation. The methodologies proposed here, while tailored for the issues identified at Pembroke Hospital during the inspection, align with the OSHA Road Map and Workplace Violence Guidelines. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-97, C-102.) The Road Map specifically discusses administrative controls to address the hazard, including, assessing patients for violence during admission, ensuring adequate staffing on all units and shifts, and having policies and procedures that minimize stress for patients. (Ex. C-102 at 18-19.) It also discusses engineering controls such as panic buttons. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Besides these publications, a letter sent to Pembroke prior to commencement of the investigation that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lead</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the instant Citation outlines similar approaches to abatement as those the Secretary now seeks. (Ex. R-37.) The letter explains that MHAs are exposed to workplace violence hazards at Pembroke Hospital. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> But, as noted above, the letter states that OSHA elected not to cite the hazard.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref87" href="#ftn87">87</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Still, the letter encourages Pembroke to act and advises that feasible and acceptable means to reduce the hazards of workplace violence at Pembroke Hospital include: (1) modifying admissions process, (2) improving responses to crises, (3)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">making adjustments to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staffing, and (4) providing staff with personal panic alarms:<span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Carefully review admissions to ensure your staff are equipped to handle acute patients who have a history of violent behavior. If an admitted patient has a known history of violent behavior from previous institutions, increase staffing levels for the unit and inform all workers of the potential of violent behavior.</span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Conduct a workplace analysis ... to find existing or potential hazards for assaults and workplace violence. This process should involve record analysis, tracking of injuries, and monitoring trends based on location, shift changes, and staffing levels. </span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Workplace analysis should include review of personnel ability to respond to unit crisis on all shifts. Review the staffing on all shifts to ensure that it reflects the daily acuity of the patient as well [as] patient census and to ensure workers<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">are able to</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>work without putting themselves at risk for a violent assault. </span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Change the present grid to increase staffing levels on the acute units and other units where attacks are occurring. Ensure that extra staff is in place when a patient’s condition requires a<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">one to one</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>watch and when there has been a history of attacks in a unit. An increase in staff levels has the potential to decrease injuries in the workplace. ... .</span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">... A silent button that is carried by staff would provide an additional and immediate way to alert staff, in the event of an escalating situation with a patient and may reduce response times. Ensure that if purchased, all employees are trained and that the panic buttons are maintained and tested according to manufacturer instructions. ...</span></p>
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			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The letter goes on to point Pembroke to the OSHA Workplace Violence Guidelines and indicates the facility can request a free on-site consultation to identify other feasible measures of abatement. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The letter does not provide an obligation independent of the Act to take the specific steps identified therein. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Pembroke was free to adopt different feasible abatement measures to address recognized hazards in its workplace. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Pepperidge Farm, </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17 BNA OSHC at 2032 (employers are free to develop solutions different than what the Secretary proposes to render their workplace “free” of recognized hazards);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Brown & Root, Inc., Power Plant Div.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 8 BNA OSHC 2140, 2144 (No. 76-1296, 1980);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Chevron</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 11 BNA OSHC at 1334, n.16 (emphasizing that the employer could institute “other equally effective methods as long as its alternative methods achieve at least as great a reduction of the hazard”).</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Although the letter did not obligate Pembroke to approach the hazard the way the Secretary suggests, it also did not provide immunity from complying with the Act. When employers know existing safety standards do not adequately address hazards, they must take all feasible steps necessary to protect employees</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">. Int’l Union, United Auto., Aerospace & Agric. Implement Workers of Am., et al. v. Brock</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 815 F.2d 1570, 1577 (D.C. Cir. 1987). “The question is whether a precaution is recognized by safety experts as feasible, and not whether the precaution's use has become customary.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Beverly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC at 1191.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke did not adopt the suggested measures outlined in the letter. The number of employee injuries from the hazard increased from 2015 to 2017. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-68, C-69.) Dr. Welch identified thirty-two employee accident reports attributable to patient on staff violence in the Pembroke records he reviewed. (Tr. 926.) The Secretary showed that Pembroke’s alternative approach to abating the hazard was inadequate. So, rather than a lack of fair notice, this case represents a situation of notice of both the presence of a hazard (something Respondents do not dispute) as well as notice of feasible abatement measures. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The OSHA publications and letter to Pembroke alone do not satisfy the Secretary’s burden on the abatement prong. The Secretary must show that his proposed abatement will materially reduce the hazard. To meet that obligation, the Secretary largely relies on the expert testimony of Dr. Welch. Before offering his opinion, Dr. Welch conducted an extensive review of Pembroke documents and relevant peer reviewed literature. (Tr. 919-23, 1143-44.) He also surveyed how other similar facilities abated the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based on his experience and research, he concluded that each abatement measure outlined in the amended citation was a feasible means by which an employer could materially reduce the hazard of workplace violence. (Tr. 923-24.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Arcadian</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC at 2011 (“Feasible means of abatement are established if conscientious experts, familiar with the industry would prescribe those means and methods to eliminate or materially reduce the recognized hazard”). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents also offered expert testimony on the issue of abatement from Ms. Cooke. Her testimony was largely based on her experience rather than peer reviewed studies or time spent reviewing Pembroke Hospital. (Tr. 1458.) Throughout much of her testimony, Ms. Cooke failed to identify the source material for her expressed beliefs. (Tr. 1458-59.) When asked, Ms. Cooke did not identify any specific literature she reviewed before evaluating this matter. She said that she “might’ve (sic)” re-looked at the Workplace Violence Guidelines or the Joint Commission’s Sentinel Event Alert on Preventing Violence in the Health Care Setting (“Sentinel Alert”). (Tr. 1458;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-97, C-98.) However, these publications were not identified as documents she reviewed in her opinion letter. (Tr. 1459.) Similarly, Ms. Cooke indicated that she “attempted” to look up “some of the research” relied on by Dr. Welch, but does not indicate which studies, if any, she reviewed either before issuing her opinion letter or before testifying at the hearing. (Tr. 1458.) Ms. Cooke was not sure how much time she spent on her review but “would venture to guess” it was 25-30 hours.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref88" href="#ftn88">88</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1461.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ms. Cooke was offered for only limited purposes. (Tr. 1463.) She offered no opinion on whether Pembroke could have materially reduced the hazard of workplace violence. (Tr. 1461.) She was accepted as an expert who evaluated “the suggested feasible abatement methods offered by the Secretary in this case.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In contrast, Dr. Welch was asked to assess, among other things: (1) the risk of workplace violence at Pembroke, (2) the recognition of the risk of workplace violence; (3) what measures would create a material reduction in that risk; and (4) were those methods identified feasible for Pembroke to implement. (Tr. 902.) While satisfying the minimum requirements for admissibility, Ms. Cooke’s testimony is given less weight than that of Dr. Welch. His opinions more fully addressed the contentions at hand and were backed by specifically identified peer reviewed literature. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Staffing</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As discussed in the evaluation of the existing methods of abatement in place, staffing at Pembroke was deficient. Dr. Welch, supported by peer reviewed studies, testified that increasing staffing could materially reduce the risk from the hazard and that doing so was feasible. (Tr. 903, 937-38, 985;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-97, C-98, C-101.) Ms. Cooke agreed that examining staffing was relevant to the cited hazard. (Tr. 1498-99.) She acknowledged that one of the ways to reduce the risk associated with workplace violence is to both review and have “good staffing.” (Tr. 1510.) She has advised hospitals that adequate staffing is important to prevent workplace violence. (Tr. 1529.) The Director of Nursing, Ms. Kent, also recognized the role extra staff can play in diffusing aggressive events. She explained that the facility experienced more crises on the evening shift and that adding an additional person was helpful to both prevent and address crises. (Tr. 1437.) The Secretary established a link between shifts with inadequate staffing and increases in the hazard. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-3, C-78.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary showed that it was feasible to increase staffing at Pembroke Hospital. Levels of staffing at Pembroke Hospital were objectively lower than at similar facilities in the region and nationally. (Tr. 104-5, 937-38.) For example, depending on the shift, Pembroke Hospital had approximately 15-30% fewer nurses than a similar psychiatric facility in the same state.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref89" href="#ftn89">89</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 937.) AS, who worked both at Pembroke Hospital and another similar facility with the same sized units, explained that there was less direct care staff at Pembroke. (Tr. 105.) The other facility had more nurses per shift and no less than three MHAs per unit. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In comparison, Pembroke’s units typically operated with fewer nurses and MHAs. (Tr. 105-6.) The competitor facilities in the region surveyed by Dr. Welch maintain higher levels of staffing and Respondents failed to counter his research that implementing the abatement called for by the Secretary was feasible.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref90" href="#ftn90">90</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Trinity Indus.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">15 BNA OSHC 1481, 1485 (No. 88-2691, 1992) (finding in connection with a violation of a specific standard that the implementation of a safety measure at other facilities shows the action was feasible).</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary proposes five methods to address the staffing deficiency. (Sec’y Br. at 4.) The proposed abatement implicitly acknowledges that there was more than one way to increase staffing at the facility. Respondents twist this flexibility to argue that the Secretary failed to establish the specific steps it must take to sufficiently reduce the hazard. In fact, the Secretary showed that Respondents failed to maintain a sufficient level of staffing: (1) to allow for increased observation of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">particular patients</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">; (2) for the acuity of particular units; (3) for anticipated admissions; (4) to respond to crises, particularly on the evening and overnight shift; and (4) to engage patients in therapeutic group activities. The Secretary established that bringing the facility into alignment with the baseline staffing at other similar facilities was feasible and would reduce the hazard by addressing these deficiencies. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staffing for Medical Orders</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary argues that Pembroke interfered with the issuance of medical orders for staffing and failed to ensure there was enough staff to implement such medical orders:</span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Cease efforts to interfere with the issuance of medical orders that specify</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.034cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">required staffing arrangements. Ensure that staffing is sufficient to allow the issuance and implementation of medical orders that specify staffing</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.021cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">arrangements.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As noted above, when a patient is at high risk for assaultive behavior, a doctor can issue a medical order for direct observation by assigning an MHA to<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">stay at all times</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>within arm’s reach of a patient.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref91" href="#ftn91">91</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 378-79, 1190-91.) Pembroke considered such orders to be a “last resort” to handling patients and were used only temporarily. (Tr. 1191, 1300.) Orders for 1:1 observation are reviewed by the management team. (Tr. 1191.) The focus of these reviews is to assess whether the patient continues to need the higher level of observation.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref92" href="#ftn92">92</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch expressed his view that administrators were pressuring staff to remove patients from 1:1 observation. (Tr. 1037-38.) He explained that interference, by management, with the medical determination of whether such 1:1 observation is inappropriate and increases the risk of workplace violence. (Tr. 1038.) His opinion was based on employee statements as well as testimony about management’s involvement in the decisions about orders for 1:1s. (Tr. 919-24.) He was surprised that the medical decision to implement a 1:1 required notification of the CEO and opined that this practice alone could pressure employees to refrain from seeking a 1:1 even though safety concerns warranted such an arrangement. (Tr. 1004, 1006, 1038.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">An MHA explained her view that 1:1 observation was not consistently put in place when called for on the grounds of employee safety. She testified that after a patient attacked her, the patient was only briefly placed on 1:1 observation for part of the shift.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref93" href="#ftn93">93</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 799-801.) Staff also described pressure to have just enough staff to meet the minimum requirements. (Tr. 1044.) On some shifts, there were just three employees for a unit. (Tr. 380.) If one of the MHAs was assigned to observe a single patient, the other two employees had to handle the remaining patients and tasks. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> If a second patient required a 1:1, that could not always be accommodated until the next shift. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The CEO described receiving “heat” about his decisions around the number of staff per patient but asserted that his determinations about staffing were not over-ridden. (Tr. 732-33.) Still, Pembroke’s approach of having the least number of employees working as possible made fulfilling staffing requests difficult, particularly during the overnight shift. (Tr. 801, 1044.) Notably, Pembroke was not able to consistently implement the Plan of Correction it submitted to the DMH which called for 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to be handled by adding staff. (Tr. 396, 703-4;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-38, C-47.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Compared to other facilities, staff to patient ratios were consistently lower at Pembroke Hospital than at other stand-alone psychiatric hospitals. (Tr. 1046-47.) On average, Pembroke Hospital had less nursing staff per occupied bed as compared to national averages.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref94" href="#ftn94">94</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1046-47.) Dr. Welch opined that it would be feasible for Pembroke to maintain a higher level of baseline staff to bring it in line with other similar facilities. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Such staffing would permit 1:1s to be put in place more quickly rather than waiting for the next shift to begin. (Tr. 1044-47.) While Ms. Cooke indicated staffing was adequate, she did not dispute or counter the evidence relied on by Dr. Welch in reaching his conclusion that increasing the level of staff would reduce the hazard. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for the other part of this proposed abatement, the interference with medical orders concerning staffing arrangements, the record reveals that Pembroke was already abiding by this. Rather than interference with the issuance of orders for 1:1s, the issue was Pembroke’s ability to staff the assignments. The Secretary established that having a greater staff to patient ratio would permit the prompt, appropriate use of 1:1 observation to materially reduce the hazard. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staffing for Acuity and New Admissions</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary argues that to materially reduce the hazard, Respondents need to maintain adequate staffing to address changes in patient acuity and new patient admissions:</span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maintain staffing that is adequate to safely address changes in patient acuity and new patient admissions. For example, do not decrease staffing levels mid-shift regardless of the timing of patient discharges.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Sec’y Br. at 4.) Dr. Welch, supported by peer reviewed literature, explained the need for appropriate staffing, particularly to handle admissions, which are a “high risk time for acuity.” (Tr. 1058.) Increased admissions are associated with workplace violence incidents. (Ex. C-101.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents agree with the need to staff for acuity and admissions. Still, as discussed, Pembroke largely only met the minimum number of staffing hours per patient. There’s no debate that this minimum number was not the appropriate average ratio of staff per patient for all circumstances. In other words, the DMH’s view is that it is never appropriate to have less than the ratio of staff per patient called for by the grid. However, no one contends that the level of staffing called for by the grid is always adequate to address the hazard of patient on staff violence. There is no dispute that to keep workers safe, each unit will routinely require higher staff to patient ratios to address acuity. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While the staffing records showed 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, there was little evidence of increased staffing to address overall acuity. Increasing the number of patients on 1:1 observation caused the remaining employees to be responsible for a higher number of patients. (Tr. 1045.) For example, on some shifts, there were just three employees for a unit. (Tr. 380.) If one of the MHAs was assigned to observe a single patient, the other two employees had to handle the remaining patients and tasks. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ordering 1:1 observation helped to minimize risks associated with a single patient in acute distress, but it left fewer employees to monitor the rest of the patients for agitation or other signs of potential violence. (Tr. 871, 1010-11.) Each employee was responsible for more patients, making it more difficult to work on de-escalation.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref95" href="#ftn95">95</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Maintaining adequate staff for admissions was also a feasible abatement method which the Secretary showed would reduce the hazard. Respondents’ expert, Ms. Cooke, acknowledged that new patients “really need a lot of attention and a lot of care.” (Tr. 1467-68.) She described admissions as “very difficult” and “critical junctures.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In her view, they present “an opportunity for danger.” (Tr. 1468.) Patients may be harmful to others during the transition into the facility. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Adequate staffing was necessary to address the potential of violence from the arriving patient. Admissions also triggered the need for adequate staff to work with the already admitted patients to minimize risks and respond quickly if assaultive behavior occurred. (Tr. 947, 963, 966, 1010, 1057-58.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch opined that there were simply not enough employees to prevent workplace violence incidents and minimize the consequences of such occurrences. (Tr. 963, 1031, 1047-48.) Pembroke argues it staffed for acuity and admissions but did not offer documentary evidence showing a pattern of higher staffing levels to accommodate acuity or anticipated admissions. In contrast to the management witnesses, direct care employees testified that Pembroke did<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not consistently</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>staff for admissions or acuity. (Tr. 132, 839, 863, 871-72, 879.) The number of admissions varied greatly. On at least one shift during the inspection period 14 patients were admitted. (Tr. 1008.) KS recalled having seven patients admitted to one unit during a shift. (Tr. 863.) Another MHA explained that admissions took a patient to staff ratio that was “already stretched too thin” to an even lower level. (Tr. 84.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Records reveal consistently low staffing levels, and even some occasions where the level of staff did not meet the DMH minimum requirements. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-29, C-47, C-78.) The testimony from direct care providers about the failure to staff appropriately for admissions and acuity is credited over the management witnesses on this issue. Management employees could have offered documentary evidence to support their claims, if it was available, but chose not to do so. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Capeway</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">20 BNA OSHC at 1342-43. Dr. Welch explained that Pembroke could feasibly maintain sufficient staffing to accommodate changes in patient acuity and new patient admissions. He noted that another similar facility maintains a much higher patient to staff ratio for newly admitted patients. (Tr. 1117-18.) The higher ratio allows more staff to safely respond to assaultive behavior as opposed to Pembroke’s approach of having a single employee in an isolated room handle searches and other tasks with the new patients. (Tr. 947, 1031, 1118.) The Secretary showed it is feasible for Pembroke to maintain staffing that is adequate to safely address changes in patient acuity and new patient admissions. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for the second part of this abatement method, ending the practice of sending employees home mid-shift, employees explained that when the ratio of patients to staff exceeded the minimum requirement set out in the grid, an employee would be sent home before the end of his or her shift. (Tr. 109, 329, 838-39.) </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">AS and KS both described instances where staff was sent home, and then a new admission would leave the unit short staffed for the remainder of the shift. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Tr. 109, 838-39.) According to AS, the other psychiatric facility he was familiar with did not adjust staffing downward partway through shifts.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref96" href="#ftn96">96</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 109.) Pembroke acknowledges that this occurred and recognizes that the facility “may or may not” be able to add staff after the start of a shift if admissions increase the census to the point that additional staff is needed either by terms of the grid or because of acuity. (Tr. 382.) Dr. Welch viewed the practice of mid-shift reductions as unsafe, particularly given the low baseline level of staffing at Pembroke. (Tr. 1060-61.) The practice made it more likely that Pembroke would be left unable to respond appropriately to prevent or mitigate violent situations if admissions or the overall level of acuity changed. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke had no separate staff focused on admissions, so being understaffed when a new patient arrived, made it particularly difficult for staff to handle potentially violent patients who may be in acute distress.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref97" href="#ftn97">97</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1059-61.) The Secretary established that ending the practice of sending employees home mid-shift was one way to increase the number of workers available to address changes in unit acuity and handle new admissions.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref98" href="#ftn98">98</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Provide security staff and/or crisis intervention specialists</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary proposes security staff “and/or” crisis intervention specialists on all three shifts. (Sec’y Br. at 4.) Dr. Welch, supported by peer reviewed literature, opined that the presence of security personnel reduces the rate of assaults. (Tr. 980; Ex. C-96.) Similarly, having inadequate security is a risk factor for workplace violence. (Tr. 985, 995; Ex. C-97, C-99.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke did not have “security” personnel. (Tr. 96.) Instead, all individuals with direct patient care responsibilities were trained in a de-escalation technique, called Handle with Care. (Tr. 1189;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. R-10, R-32.) Only on the evening shift did Pembroke employ a “crisis intervention specialist.” (Tr. 1233.) The crisis intervention specialist is not assigned to any<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">particular unit</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and does not have direct patient care tasks. (Tr. 964, 1437.) The employee rounds through the units to identify problems and address them before they escalate. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The individual is also responsible for making sure doors are appropriately locked. (Tr. 964.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In proposing security or crisis intervention specialists for all shifts, the Secretary does not insist that Pembroke specifically designate employees as “security”—the proposal permits use of crisis intervention specialists instead. (Sec’y Br. at 4.) The abatement method calls for there to be employees without specific direct care tasks focused on safety who could immediately respond to actual or threatened incidents of violence. The Secretary argues that having such people available is feasible and would materially reduce the hazard. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch conceded that the crisis intervention specialist on the evening shift was effective. (Tr. 1009, 1051.) However, it was only one employee on one shift. The one employee was responsible for six units, including making sure multiple doors were locked and secured. (Tr. 1009.) Dr. Welch opined that there should have been enough people available on all three shifts to ensure safety and to prevent and minimize the hazard. (Tr. 1010, 1051-52.) He explained how abating the hazard required regular rounds focused on security. (Tr. 995.) </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">And,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>he emphasized the importance of having staff dedicated to responding to immediate crises. (Tr. 1052, 1087.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">At Pembroke Hospital, MHAs and nurses had numerous patient care tasks, such as dispensing medications, running groups, housekeeping, and coordinating care. (Tr. 1087.) Many tasks could not be instantly stopped to permit the person to respond to a call for assistance. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> In addition, MHAs were responsible for routinely taking patients off units for fresh air<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">breaks</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and meals in the cafeteria. (Tr. 55-56, 863.) When conducting such tasks, MHAs could not leave patients alone to respond to requests for assistance. (Tr. 863, 949.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch also explained that some staff did not feel physically capable of managing very large, violent patients --- particularly on their own. (Tr. 1087.) In his view, Pembroke needed employees physically capable of assisting with restraining large patients and who were focused on safety as opposed to other tasks. (Tr. 1087, 1093-94.) The single person in the role of crisis intervention specialist on one shift was not adequate for the degree of patient aggression and the number of workplace violence incidents. (Tr. 1051.) Dr. Welch opined that other behavioral health facilities were able to have staff dedicated primarily to safety and opined that Pembroke could feasibly do the same. (Tr. 1053.)</span></p>
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			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">While Ms. Cooke had concerns with maintaining a security staff, she acknowledged the value of having additional staff available to respond to crises and manage situations. (Tr. 1492, 1495-96.) She noted that managing patient behavior is particularly difficult on the evening shift. (Tr. 1496.) However, in her view, having only one person on the evening shift as a crisis intervention specialist was not problematic. As for the lack of someone in such a role on the night and day shift, Ms. Cooke cited the float position at night and the availability of other staff during the day. (Tr. 1478.) However, the float could be assigned patient care tasks, including a 1:1 assignment that would prevent him/her from being available to respond to a crisis. (Tr. 374-75, 379, 1437, 1478.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Importantly, Ms. Cooke did not dispute Dr. Welch’s opinion that having staff focused on security was feasible. She did not specifically review the studies relied on by Dr. Welch in reaching his conclusions. (Tr. 1518.) Also, she admitted awareness of other facilities that had building security. (Tr. 1493-94.) In particular, she acknowledged being familiar with facilities that have security respond to a code, such as to “be manpower” and “help restrain” patients or de-escalate situations.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref99" href="#ftn99">99</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1492-93.) Ms. Cooke did not address the two concerns with Pembroke’s approach cited by Dr. Welch: (1) the lack of anyone assigned only to safety on the day and night shifts; and (2) the lack of physical capabilities of some of the individuals tasked with controlling violent patients. Additionally, her testimony failed to rebut the Secretary’s evidence of feasibility and effectiveness. Altogether, Ms. Cooke’s testimony did not rebut the Secretary’s evidence that having security staff “and/or” crisis intervention specialists on all three shifts was feasible and would materially reduce the hazard.</span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Staffing for Therapeutic Activity Groups and Recreation Periods</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary proposes that Pembroke maintain sufficient staffing for “therapeutic activity groups and recreation periods.” (Sec’y Br. at 4.) Dr. Welch, supported by peer reviewed literature, explained that canceling therapeutic activities can increase the level of acuity for the unit. (Tr. 969-70; Ex. C-101.) Boredom and insufficient activities are also precipitants for violence. (Tr. 967-68, Ex. C-101.) Structured organized activities, along with the reliability and predictability of their occurrence promotes positive engagement and reduces acuity. (Tr. 820-21, 949-50, 1062.) Conversely, unmet needs can trigger violence. (Tr. 946-47, 949-50, 960, 1030; Ex. C-101 at 9.) If an MHA can engage some patients in an activity, this frees staff to better intervene with sicker patients. (Tr. 970.) Dr. Welch, informed by the employee statements, noted that the lack of activities<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>particularly detrimental for the adolescent units. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Teenagers “tend to be very stimulus prone” and failing to engage them consistently can lead to adverse consequences such as agitation. (Tr. 965, 970-71.) Engaging patients in therapeutic group activities and recreation reduces patient agitation and incidents of workplace violence, making it an effective method to materially reduce the hazard.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref100" href="#ftn100">100</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 967-68, Ex. C-101.)</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As discussed, therapeutic groups were routinely canceled due to inadequate staffing. (Tr. 819-20.) Dr. Welch explained that increased staffing would allow therapeutic group activities to occur consistently as scheduled. (Tr. 1062-63.) He noted that another similar facility has a dedicated staff for conducting therapeutic group activities. (Tr. 1063.) Because the employees running the groups have no direct care responsibilities, the need to handle admissions or emergencies did not result in therapeutic activities being canceled. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ms. Cooke recognized that group activities were regularly canceled but alleged that the number of cancellations was not “an overabundance.” (Tr. 1503.) She did not refute Dr. Welch’s view that therapeutic groups materially reduce the hazard. Nor did she address whether Pembroke could maintain a higher staff to patient ratio to ensure groups more consistently occurred as scheduled. The Secretary established that it was feasible to maintain a higher level of staffing which would reduce the frequency with which groups were canceled. The Secretary also established that maintaining therapeutic group activities would materially reduce the hazard. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Change how admissions occur</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The next proposed abatement method is to have an admissions area separate from the on-going care units for admissions and requiring that new patients remain in the separate area until all clinical assessments are complete. Specifically, the Secretary proposes that Pembroke: </span></p>
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			<p style="margin-left:96px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">1.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Establish a team of nurses and mental health associates (MHAs) that focuses primarily</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.042cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the performance of the tasks associated with the admission and assessment of new patients. This team should not be staffed by employees who are assigned to care for already-admitted</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; letter-spacing:-.002cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">patients.</span></p>
			<p style="margin-left:96px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">2.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dedicate a physical area, apart<span>
					</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from all other units of the hospital,</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
					</span>to the admission and assessment of new patients. </span></p>
			<p style="margin-left:96px; text-indent:-.635cm; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:96px; text-indent:-.635cm; margin-right:48px; widows:0; orphans:0; margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; color:#000000; padding-right:20px;">3.</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Do not allow new patients into other units until the tasks associated with admission, including clinical assessments and the provision of medical orders, are complete.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(Sec’y Br. at 4.) The first method calls for an admissions team focused solely on the tasks associated with admitting new patients. The Secretary showed there was an overall need for additional staff at the facility to reduce the cited hazard. (Tr. 1058.) Carefully screening newly admitted patients was critical to addressing the hazard. The initial assessments looked at the patients’ history of violent behavior and sought information on how patients could be de-escalated. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. R-1, R-9.) As part of this assessment, MHAs searched patient belongings to identify materials that could harm staff. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Most of the admissions process took place in a small room with the MHA alone with the patient even before the belongings search was completed. (Tr. 81.) The room had no phone to commence a Code Green and even with a radio it was difficult to call for help from the room. (Tr. 82.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The record reveals that admissions tasks are time consuming and that there is an increased risk for an employee to experience violence during this time. (Tr. 1006-7, 1011-13.) The overall level of staffing was often too low to handle the acuity of existing patients and more than a few admissions. Admissions took time away from existing patients and sometimes introduced an acute patient into the unit population before he/she had adequate medication. (Tr. 1030-31.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In those instances where there was enough staff to adequately handle the admissions tasks and care for existing patients, the Secretary did not adequately explain how precluding employees who handle admissions from other care responsibilities would materially reduce the hazard. In other words, the Secretary showed that Pembroke failed to maintain adequate staffing<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">levels</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>but he did not show how implementing the additional abatement method of precluding admissions staff from having other care responsibilities would materially reduce the hazard if staffing was already adequate to handle admissions. Unlike other facilities, Pembroke Hospital does not accept “walk-ins,”<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">i.e.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients that have not yet been assessed by someone outside of the facility. (Ex. R-9.) The information obtained during these pre-admissions calls is often incomplete. Still, the facility had some information about the patients and sometimes the patients were stabilized before their arrival at Pembroke.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref101" href="#ftn101">101</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 1468-69; Ex. R-9.) Dr. Welch indicated that admissions could take as many as twenty-two hours of nursing time per day. (Tr. 1008.) On average, however, much less time was necessary for admissions at Pembroke. To reach twenty-two hours of nursing time, there would have to be fifteen admissions, and each would have to take ninety minutes. (Tr. 1008.) While some admissions took the full ninety minutes and sometimes there were many admissions, the record indicates that in 2016, on average, Pembroke had approximately seven admissions per day. (Tr. 1436.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Regarding the admission and assessment of new patients in a dedicated physical area, Dr. Welch opined that a separate admissions unit would materially reduce the risk of workplace violence. (Tr. 1028-30.) In his view, the existing spaces on the units used for some of the admissions tasks were unsafe because they were isolated and small. (Tr. 1031.) Further, patients went directly from the small rooms into the common area with existing patients. (Tr. 1033.) The newly admitted patients find themselves in uncertain situations, may be frustrated, and could lack proper medication. (Tr. 1032-34.) Dr. Welch explained that Pembroke’s approach creates a “destabilizing situation.” (Tr. 1034.) AS and KS also asserted that a separate unit would be helpful to abate the hazard. (Tr. 83-84, 861-65.) AS explained that while a separate unit would not change patient behavior it would eliminate “a big risk factor” in terms of the new patient interacting with existing patients. (Tr. 164.) Similarly, Ms.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Wollner</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Director of Admissions, acknowledged that a separate admissions unit would reduce the burden on the units. (Tr. 1386-87.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">In terms of technical feasibility, the facility had space apart from the units that could be used for admissions. (Tr. 93, 1034.) Other similar facilities also had dedicated admissions areas. (Tr. 104-5.) Dr. Welch discussed other similar facilities at which the assessment, evaluation, and medication of new patients occur in dedicated areas apart from where existing patients are located. (Tr. 936, 1027, 1031-32, 1034, 1101.) The Secretary presented evidence that it was technologically feasible to dedicate a physical area apart from the other units to handle assessments before patients are moved into the treatment units.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">However, the Secretary falls short on persuading how moving admissions from the units to this separate area would materially reduce the hazard if Pembroke was adequately staffed to handle such admissions and addressed the difficulties with summoning assistance. Again, the Secretary showed that Pembroke failed to consistently staff in anticipation of admissions and addressing this deficiency would materially reduce the hazard. Rather than being a separate abatement method, the proposal to have a separate admissions area appears to be one approach to handling the inadequate staffing and insufficient means to summon assistance. In other words, if Pembroke had enough employees on the units and employees could quickly summon assistance, then a separate admissions unit might not be necessary to further reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Cerro Metal Prods. Div.<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">12 BNA OSHC 1821, 1822-23 (No. 78-5159, 1986) (noting that the abatement actions must be “necessary and valuable”).</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for Pembroke’s practice of allowing new patients into the units before all assessments and the provision of medical orders are complete, the evidence reveals that this increased acuity and created workplace violence risks. The evidence of record also reveals that increasing staff to appropriately address acuity and 1:1<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">assignments</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>would materially reduce the risk. The Secretary established that waiting to integrate new patients into the units was one way to handle the acuity new admissions bring. However, if the facility had adequate staff and means to summon assistance it is not clear that segregating the patients would further reduce the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Cerro,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>12 BNA OSHC at 1822-23. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary proved that establishing a team of nurses and MHAs focused primarily</span><span style="font-size:12pt; font-family:Times New Roman; letter-spacing:-.042cm; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">on the performance of the tasks associated with the admission and assessment of new patients, was feasible and would materially reduce the hazard. He failed to show that if the other identified abatement was in place, (1) that the employees on this team could not have any other responsibilities; (2) that admissions had to occur in an area apart from all other units of Pembroke Hospital, or (3) that patients had to remain segregated until<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">all of</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the tasks associated with admission were complete.<span>
						</span></span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:144px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; font-style:italic; ">Equipment</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Finally, the Secretary calls for two types of equipment: personal panic alarms and equipment to implement patient crisis prevention plans. (Sec’y Br. at 4.) </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Personal Panic Alarms</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary proposes that Pembroke provide “personal panic alarms for all employees who may work in close proximity to patients, including but not limited to nurses, MHAs, housekeeping staff, and case workers.” </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke’s approach to summoning help in the event of a workplace violence incident was ineffective. JS, a nurse, discussed her experience with personal panic alarms at two other behavioral health hospitals. (Tr. 241.) She found them to be an effective way to seek immediate assistance. (Tr. 241-42.) Dr. Welch explained that personal panic alarms are more effective at summoning assistance than Pembroke’s current approach, and that providing them would reduce the likelihood of staff members becoming victims of workplace violence. (Tr. 937, 974-75.) Unlike radios and the overhead paging system, panic alarms allow for discreet requests during emergencies. (Tr. 1049.) Dr. Welch relied on studies which found that access to panic alarms correlated with significantly lower rates of assault against staff in a healthcare setting. (Tr. 972-74, 995, Ex. C-95 at 3-10, C-96.) Workers without access to such equipment were victims of workplace violence more often. (Ex. C-95 at 10.) Regarding feasibility, other similar facilities provide personal panic alarms and literature discusses their successful use in healthcare settings.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref102" href="#ftn102">102</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 974, 1049; Ex. C-95.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Ms. Cooke argued that there was no evidence to support the efficacy of panic alarms in reducing risk. (Tr. 1481.) It is unclear if she reviewed the studies Dr. Welch cited in reaching his conclusion that panic alarms are effective at materially reducing the hazard. (Tr. 1458.) She only indicated that she “might’ve (sic)” re-looked at the Sentinel Alert. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> The Sentinel Alert describes physical and verbal violence against health care workers. (Ex. C-99 at 1-2.) It cites, among other things, lack of access to emergency communication such as a “call bell” as a contributing factor to violence against healthcare workers.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref103" href="#ftn103">103</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Ex. C-99 at 3, 6.) Ms. Cooke acknowledged there were times when panic alarms may be easier, but said they were not “standard.” (Tr. 1485-86, 1521.) </span></p>
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			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The general duty clause requires employers to “take all feasible steps” to protect against recognized hazards. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Gen. Dynamics</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 599 F.2d at 464. Employers must implement abatement measures safety experts agree are feasible even if they are “not of general usage in the industry.” 599 F.2d at 464. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See also Beverly</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC at 1191 (finding abatement measures may be required even if the practice is not yet customary in the industry). Ms. Cooke did not testify that panic alarms were technologically or economically infeasible and agreed they may be an easier way to obtain assistance with a violent patient. (Tr. 1483.) No witness testified they were too expensive or would not work at Pembroke for technological reasons. Ms. Cooke’s testimony does not refute the evidence establishing that personal panic alarms would materially reduce the hazard and constitute a feasible means of abatement. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary’s burden is to establish that the abatement in place, a limited number of unreliable radios, was ineffective and that this issue could be addressed feasibly. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Integra</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 27 BNA OSHC at 1849;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Armstrong,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">8 BNA OSHC at 1073-74 (upholding a violation of the general duty clause when the employer failed to maintain an abatement measure it implemented). Dr. Welch’s opinion that personal panic alarms are feasible and effective at reducing the likelihood a worker would be injured by the hazard was well supported by the testimony of other witnesses and numerous studies. (Tr. 241, 309-10;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-95, C-96, C-99.)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary established that personal panic alarms are a feasible and effective means to abate the hazard by making it easier for additional people to respond to violent incidents or threats of violence. </span></p>
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			<p style="margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; margin-left:168px; widows:0; orphans:0; margin-top:13.333px; margin-bottom:0px; line-height:2; text-align:justify; ">
				<span style="font-size:12pt; font-family:Times New Roman; padding-right:20px;"></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Equipment for Crisis Intervention Plans</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The final abatement method proposed calls for Pembroke to “maintain equipment that is sufficient for the implementation of each patient’s crisis prevention plan.” (Sec’y Br. at 4.) Pembroke asks patients to complete forms about what helps to calm them down and what helps them to cope with situations. (Tr. 512, 1423, 1432, 1439; Ex. R-18.) Some patients decline to complete it. (Tr. 512, 1432.) However, staff can add information to the plans even if a patient does not provide any. (Tr. 512-13, 1249, 1431-32.) The plans assist staff with knowing how to deescalate a patient who becomes aggressive. (Tr. 512-13, 1432.) Most of the plans call for the use of music to de-escalate patients. (Tr. 73, 830, 1434.) </span></p>
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			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dr. Welch opined that having music playing equipment would significantly reduce the risk of workplace violence and indicated that the equipment necessary for patients to have access to music could be affordably obtained. (Tr. 1064.) He explained that patients most often cite music as a calming technique, and he had seen it work effectively. (Tr. 962.) Dr. Welch asserted that providing access to calming modalities would decrease the hazard. (Tr. 1064-65.) In his experience, the headsets for playing music could be affordably maintained to allow them to be given out by request, rather than having waiting lists as was the case at Pembroke during the inspection period. (Tr. 963.) Employees agreed that providing music worked effectively at Pembroke to soothe and calm aggressive patients. (Tr. 73-74, 666, 831.) A nurse considered it a great help in handling patients who were distressed or agitated. (Tr. 666.) Ms. Cooke did not dispute the evidence regarding the usefulness of crisis prevention plans or providing music when patients indicate it has helped calm them in the past. Rather, her testimony revealed that she was unaware of any studies that proposed a specific number of devices based on the patient count. (Tr. 1505-6.) The Secretary established that being able to implement patient crisis prevention plans by providing music to calm distressed patients would materially reduce the hazard. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for technical feasibility of implementing the abatement, by the time of the hearing, Pembroke had improved the ability of caregivers to routinely provide music consistent with de-escalation plans. </span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Fed. R. Evid. 407 (evidence of subsequent remedial measures may be admitted<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">to show</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>“the feasibility of precautionary measures”); </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">SeaWorld</span><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 748 F.3d at 1215. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Accordingly, there is no dispute that providing music as part of implementing patient crisis prevention plans was technologically and economically feasible.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref104" href="#ftn104">104</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Relationship of UHS DE and Pembroke<span>
						</span></span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary contends that despite being separate corporate entities, UHS DE and Pembroke should be treated as a single employer of the workers exposed to the hazard. Related employers are treated as a single entity when “they share a common worksite, have interrelated and integrated operations, and share a common president, management, supervision, or ownership.”</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref105" href="#ftn105">105</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Loretto-Oswego Residential Health Care Facility</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC 1356, 1359 (No. 02-1174, 2011)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 692 F.3d 65 (2d Cir. 2012);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">C.T. Taylor Co</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 20 BNA OSHC 1083, 1086 (No. 94-3241, 2003) (consolidated);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Trinity Indus., Inc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 9 BNA OSHC 1515, 1518 (No. 77-3909, 1981). The Secretary fails to satisfy these criteria.</span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke and UHS DE have different worksites: UHS DE operates out of Pennsylvania, while Pembroke operates in Massachusetts. (Tr. 724.) As the First Circuit explained in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">A.C. Castle</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the common worksite element requires consideration of the location of where the employees work and are exposed to the hazard. 882 F.3d at 42. The Secretary does not allege that any UHS DE employees were exposed to the cited hazard. Nor does he allege that employees were exposed to the hazard of workplace violence at locations other than Pembroke Hospital. The record is clear that UHS DE and Pembroke have different business addresses and there is no allegation of workplace hazards at both locations. </span></p>
			</div>
			<div>
				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">With regard to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>operations, Gary<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Gilberti</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, the Senior Vice President in the Behavioral Health Division for UHS DE, testified that UHS DE and Pembroke were related, but distinct businesses. (Tr. 724.) Pembroke provides direct patient care, while UHS DE is a management and consulting business. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">
					</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Pembroke primarily develops and sets its own budgets.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref106" href="#ftn106">106</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> (Tr. 643-44, 1326.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Loretto-Oswego</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC at 1359 (finding healthcare facility and management company were not a single employer). There is no evidence that Pembroke lacked sufficient capital or other resources to address worker health and safety.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As for personnel, Pembroke Hospital’s CEO (Dr. Hickey) was employed by UHS DE. (Tr. 695;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Stips</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. 10-11.) Other UHS DE employees routinely visited the Pembroke Hospital but did not provide daily oversight of Pembroke Hospital. (Tr. 533-34.) UHS DE had its own management structure with a separate CEO, chief financial officer, and management group. (Tr. 741.) Dr. Hickey had no managerial duties for UHS DE. (Tr. 741.) </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Cf. C.T. Taylor</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 20 BNA OSHC at 1085</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">(finding two entities to be a single employer when both companies were owned and controlled by the same person and operated from the same office). The Secretary failed to establish that UHS DE and Pembroke operate as a single entity. Accordingly, the finding of a violation and assessment of a penalty are against UHS of Westwood Pembroke only. The Secretary’s allegation against UHS DE is DISMISSED.</span></p>
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				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Repeat Characterization</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondents argue that if UHS DE and Pembroke are not a single employer, then the citation cannot be characterized as repeat. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Resp’t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>Br. at 42.) This misconstrues the record evidence of Respondents’ own corporate structure. The Secretary does not rely on a citation issued to UHS DE to support the repeat characterization. Instead, he relies on one issued to Pembroke itself. (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Exs</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. C-14 thru C-17.) </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A violation is repeated if the same employer was previously cited for a substantially similar violation. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Potlach Corp.,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">7 BNA OSHC 1061, 1063 (No. 16183, 1979);<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Lake Erie Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 21 BNA OSHC 1285, 1289 (No. 02-0520, 2005) (similarity of hazards is a “</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">principle</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>factor” in assessing the appropriateness of a repeat characterization).<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A violation of the general duty clause may be “found to be repeated on the basis of either a prior section 5(a)(1) or section 5(a)(2) violation.” 7 BNA OSHC at 1064. When relying on previous general duty citation, the Secretary must show substantial similarity based on the circumstances surrounding the hazard. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">GEM Indus., Inc</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">., 17 BNA OSHC 1861, 1865-66 (No. 93-1122, 1996) (declining to rely on a previous 5(a)(1) citation to support characterizing a subsequent violation of a specific standard as repeat)<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 149 F.3d 1183 (6th Cir. 1998). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary argues that the hazard cited in 2016 at Pembroke’s Lowell Treatment Center and the one cited in 2017 at Pembroke Hospital are substantially similar. (Sec’y Br. at 74.) </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">But,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the Secretary failed to offer enough information about the circumstances surrounding the cited hazard at Lowell Treatment Center. The limited information in the record reveals only that the cited workplaces had significant differences related to the hazard. For example, while the Secretary proposed some similar abatement measures, others were notably different. (Ex. G-14.) The undersigned finds that while the hazards appear to share some commonality the record does not establish that the two violations are sufficiently<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">similar to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>support a repeat characterization. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">GEM</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 17 BNA OSHC at 1866 (declining to conclude that two violations were substantially similar even though both involved fall hazards). </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The Secretary has met his burden to establish, by a preponderance of the evidence, that UHS of Westwood Pembroke violated 29 U.S.C. § 654(a)(1) of the Act and such violation was “serious” rather than “repeat”.</span></p>
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				<p style="margin-top:32px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">Penalty</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“Section 17(j) of the Act, 29 U.S.C. § 666(j), requires that when assessing penalties, the Commission must give due consideration to four criteria: the size of the employer's business, the gravity of the violation, the employer’s good faith, and any prior history of violations.”  </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Hern Iron Works, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC 1619, 1624 (No. 88-1962, 1994).  When determining gravity, the Commission considers the number of exposed employees, the duration of their exposure, whether precautions could have been taken against injury, and the likelihood of injury.  </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Capform</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 19 BNA OSHC 1374, 1378 (No. 99-0322, 2001), </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">aff’d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 34<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">F.App’x</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>85 (5th Cir. 2000 (unpublished).  Gravity is typically the most important factor for determining the penalty.  </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Id.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">  </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">When initially issued, the Citation included a proposed penalty of $12,675. In the Amended Complaint, the Secretary increased the proposed penalty to $25,350. This amount could only be imposed if the violation was characterized as repeat rather than serious. Under the Act, as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, Public Law 114-74, sec. 701, the maximum penalty for a violation cited in 2017 and characterized as “serious” was $12,675.00. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Having considered the four factors, the undersigned finds that a penalty of $12,675 is appropriate. The hazard caused serious injury and<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">was capable of causing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>death. Many employees were exposed to the hazard, with several suffering serious injuries. (Ex. C-60.) There is no evidence that Pembroke is a small employer. While it took some steps to mitigate the hazard, it failed to implement feasible abatement measures even after they were identified. In terms of history, it was previously cited for a violation related to workplace violence. (Ex. G-14.) Although the prior citation is not enough to support a repeat characterization, it is relevant to the evaluation of Pembroke’s history. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">As to good faith, as noted above, employees felt pressure to be less than forthcoming with investigators. (Ex. C-1; Tr. 883-84, 886-89.) Also, it is worth noting that MHAs were provided with a “cheat sheet” on how to communicate with regulators and then told to destroy it after reviewing it. (Tr. 125-26.) However, there is no evidence of actual obstruction. The MHA AS explained that they were to be direct and honest with surveyors, including OSHA. (Tr. 181-82.) Further, Respondents had a safety program<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>as noted, had taken steps to minimize the hazard. On this record, neither an increase nor a decrease for good faith is warranted.</span><span style="font-size:12pt; font-family:Times New Roman; position:relative;font-size:0.58em; bottom: 1ex;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><a name="ftnref107" href="#ftn107">107</a></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:center; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">FINDINGS OF FACT AND CONCLUSIONS OF LAW</span></p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:2; text-align:justify; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>The foregoing constitutes the findings of fact and conclusions of law in accordance with Rule 52(a) of the Federal Rules of Civil Procedure.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:center; "><span style="font-size:12pt; font-family:Times New Roman; font-weight:bold; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-weight:bold; ">ORDER</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Based upon the foregoing findings of fact and conclusions of law, it is ORDERED that:</span></p>
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				<p style="margin-top:.067px; margin-bottom:16px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Citation 1, Item 1 for a violation of section 5(a)(1) of the Act is AFFIRMED as SERIOUS, and a penalty of $12,675 is ASSESSED against UHS of Westwood Pembroke. </span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">SO</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>ORDERED.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>__</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; text-decoration:underline ;font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; text-decoration:underline ;">/s/</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">_________</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Keith E. Bell</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span style="mso-tab-count:1">  </span>Administrative Law Judge, OSHRC</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Dated: February 19, 2020</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:1; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> Washington, D.C.</span></p>
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				<p style="margin-top:.067px; margin-bottom:0px; line-height:2; text-align:justify; text-indent:1.27cm; widows:0; orphans:0; "> </p>
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			<hr/>"
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					<a name="ftn-1" href="#ftnref-1"></a> </p>
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				<p style="margin-top:0px; margin-bottom:0px; line-height:1; ">
					<a name="ftn0" href="#ftnref0"></a> </p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn1" href="#ftnref1"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">1 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>The general duty clause provides that “[e]ach employer . . . shall furnish to each of his<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">employees</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.” 29 U.S.C. § 654(a)(1).</span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn2" href="#ftnref2"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">2 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Throughout our decision, e</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">ach company<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">is<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">referenced by name<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">when</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>relevant<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">to the discussion and</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>referenced as Respondent when being addressed as a single employer.</span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn3" href="#ftnref3"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">3 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>The number of MHAs<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">increase</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>or decrease</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>in correlation with</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>the number of patients on each unit. </span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">For instance, the record reflects that<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">the number of patients<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">on each unit</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>could</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">var</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">y</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>from five to twenty-seven,<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">with</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>the<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">corresponding<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">number of MHAs rang</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>from one to<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">about<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">five.</span></p>
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				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn4" href="#ftnref4"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">4 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Separate<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">review</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>briefs were filed by UHS-WP and UHS-DE. The briefs filed by UHS-WP address the abatement issue and repeat characterization issue. The briefs filed by UHS-DE are limited to the single</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">employer</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>issue.</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">
					</span></p>
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				<p style="margin-top:8px; margin-bottom:8px; line-height:1; text-align:justify; ">
					<a name="ftn5" href="#ftnref5"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">5 </span></a><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">After<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the close of<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">briefing on review, t</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">he Secretary filed a letter</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“direct[</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">] the Commission’s attention to relevant [</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">single</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">] findings in a recent decision by Administrative Law Judge Dennis L. Phillips in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Secretary of Labor v. UHS of Delaware, Inc., and Premier Behavioral Health Solutions of Florida d/b/a Suncoast Behavioral Health Center</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, OSHRC Docket No. 18-0731.”  In<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">decision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, which was issued on<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">April 9, 2021,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and is<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">currently<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">pending on review before the<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Commission,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">the judge found that UHS-DE and the cited mental health facility operated as a single<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">for</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>purposes of liability under the Act as it pertained to the general duty clause<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">violation alleging<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">workplace violence at issue.  We do not rely on this<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">unreviewed<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">decision</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">addressing</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the inquiry before us here<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">and</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>in any event,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the judge’s findings are limited to the record<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in that case</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Leone Constr. Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 3 BNA OSHC 1979, 1981 (No. 4090, 1976) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">“</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">[A] Judge</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">’</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s opinion</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "> . . . </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">lacking full Commission review does not constitute precedent binding upon us.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">”</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">).</span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn6" href="#ftnref6"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">6 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>The First Circuit is a relevant circuit here, as UHS-WP and Pembroke<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">are located in</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Massachusetts. </span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">See<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">29 U.S.C. § 660(a) (“Any person adversely affected or aggrieved by an order of the Commission . . . may obtain . . . review . . . in any United States court of appeals for the circuit in which the violation is alleged to have occurred or where the employer has its principal office, or in the Court of Appeals for the District of Columbia Circuit . . . .”); s</span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">ee<span>
						</span></span><span style="font-size:12pt; font-style:italic; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">Kerns Bros. Tree Serv</span><span style="font-size:12pt; background-color:#FFFFFF; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">., 18 BNA OSHC 2064, 2067 (No. 96-1719, 2000) (Commission generally applies law of the circuit where it is probable a case will be appealed).</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">
					</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">he Third Circuit is also relevant because UHS-DE is based in Pennsylvania.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn7" href="#ftnref7"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">7 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Dr.</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Hickey served as Pembroke’s CEO until<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">January<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">3</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">1,</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>2017, approximately three months before OSHA issued the citation.<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn8" href="#ftnref8"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">8 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">UHS-DE</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">also relies on the judge’s findings that</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Pembroke’s CEO and CFO</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">—both UHS-DE employees—</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">have no managerial duties for<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">UHS-DE</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">and there are no shared management employees between UHS-DE and Pembroke because UHS-DE’s corporate structure does not include<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">either hospital official</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">But this</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>merely shows that Pembroke’s management did not control UHS-DE, not the converse. </span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn9" href="#ftnref9"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">9 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>The<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">proposed<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">abatement measures are:</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">a. Establish a team of nurses and mental health associates (MHAs) that focuses primarily on the performance of the tasks associated with the admission and assessment of new patients. This team should not be staffed by employees who are assigned to care for already-admitted patients.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">b. Dedicate a physical area, apart<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">from all other units of the hospital,</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>to the admission and assessment of new patients. Do not allow new patients into other units until the tasks associated with admission, including clinical assessments and the provision of medical orders, are complete.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">c. Cease efforts to interfere with the issuance of medical orders that specify required staffing arrangements. Ensure that staffing is sufficient to allow the issuance and implementation of medical orders that specify staffing arrangements.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d. Provide personal panic alarms for all employees who may work<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">in close proximity to</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>patients, including but not limited to nurses, MHAs, housekeeping staff, and case workers. Provide training on this equipment and ensure that the equipment is maintained in<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">working order at all times</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">e. Provide security staff and/or crisis intervention specialists on all three shifts to assist in preventing and responding to violent events.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">f. Maintain staffing that is adequate to safely address changes in patient acuity and new patient admissions. For example, do not decrease staffing levels mid-shift regardless of the timing of patient discharges.</span></p>
			</div>
			<div>
				<p style="margin-top:0px; margin-bottom:8px; line-height:1; text-align:justify; margin-left:48px; margin-right:48px; "><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">g. Maintain adequate staffing to support therapeutic activity groups and recreation periods, thereby engaging patients in activities that reduce patient agitation and incidents of workplace violence. Maintain equipment that is sufficient for the implementation of each patient’s individual crisis prevention plan.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn10" href="#ftnref10"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">10 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">We note that t</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">he judge</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">cite</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>to</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">Sturgill</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>in his analysis<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">of</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Respondent’s due process claims, which<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">he rejected. Those claims<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">are not at issue on review.<span>
						</span></span></p>
			</div>
			<div>
				<p style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn11" href="#ftnref11"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">11 </span></a><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">The judge also found that the Secretary established that Pembroke was inadequately staffed in several respects,<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">including<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">regarding</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>its</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>admissions<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">procedure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>and found that the Secretary had established feasible and effective abatement measures to remedy those deficiencies. </span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Because we conclude that the Secretary has proven two of his proposed abatement measures, we need not reach the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>other proposed abatement measures. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">Sturgill</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 2019 WL 1099857, at *9;<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">s</span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">ee S. Scrap Materials Co.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 23 BNA OSHC at<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">1599</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>n.1 (“Although the parties briefed Citation 2, Item 40, as requested, we decline to review the judge’s disposition of this item.”) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">citations</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>omitted).</span></p>
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			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn12" href="#ftnref12"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">12 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Respondent does not dispute the feasibility of providing personal panic alarms to employees.</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn13" href="#ftnref13"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">13 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Dr. Welch, a board-certified physician in psychiatry and neurology, holds degrees from Harvard College and Columbia University, and has served as a professor of psychiatry at Harvard Medical School; he also has had overall clinical responsibility and served as chief of psychiatry at mental health hospitals, and is a member of numerous professional organizations for psychiatry. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn14" href="#ftnref14"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">14 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>We note that on review,<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">does not rely on its expert witness, Monica<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Cooke</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, with respect to the efficacy of personal panic alarms</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, or otherwise dispute the judge’s decision to<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">afford less weight to Cooke’s expert testimony</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">. According to the judge,<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">“[w]</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">hile</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>satisfying the minimum requirements for admissibility,”<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Cooke</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>failed to identify the source material for her<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">opinions</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>and her testimony was largely based on her experience rather than peer-reviewed studies or time spent reviewing<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Pembroke</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">’s records. Indeed, on this<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">particular issue</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, the judge found<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">that<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">it is unclear if Cooke had reviewed any studies or peer-reviewed literature in reaching her conclusion. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn15" href="#ftnref15"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">15 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">G</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">iven how this case was argued and tried by the parties, the Secretary need only show that<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">at least<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">one of the citation’s proposed abatement measures was feasible and effective to establish this element of his case. This does not, however, preclude our consideration of more than one abatement measure, and we find that it is appropriate to do so here. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn16" href="#ftnref16"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">16 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">On review,<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">claims that “the decision regarding the appropriate therapeutic means for managing patient agitation is a clinical one properly made by a patient’s treating doctors and clinical staff and should not be second guessed or regulated by the Secretary with a one-size-fits-all approach.” While a clinical judgment may be present in determining how best to de</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">-</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">escalate a situation</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>involving an agitated patient</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">,</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">the fact remains that</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">the vast majority of</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>Pembroke patients identified music as<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">their</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>preferred calming strategy, yet the hospital lacked sufficient music equipment to meet that demand. </span></p>
			</div>
			<div>
				<p style="margin-top:8px; margin-bottom:8px; line-height:1; text-align:justify; ">
					<a name="ftn17" href="#ftnref17"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">17 </span></a><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">A</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">fter the inspection, Pembroke switched to providing wireless headphones and supplied as many as<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">ten pairs per unit. </span><span style="font-size:12pt; font-family:Times New Roman; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; font-style:italic; ">See Pitt-Des Moines, Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 16 BNA OSHC 1429 (No. 90-1349, 1993) (</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">employer’s</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">post-inspection<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">implementation of abatement<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">measure</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>admissible to establish feasibility).</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn18" href="#ftnref18"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">18 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">specifically<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">relies on the Commission’s decision in<span>
						</span></span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">Angelica Textile Serv</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">., 27 BNA OSHC 1246, 1254-</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">5</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">9 (No. 08-1774, 2018),<span>
						</span></span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">vacated as moot</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, 803 F. Appx. 542 (2d Cir. 2020, unpublished),<span>
						</span></span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">dismissed case on remand</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, 2020 WL 4475583 (OSHRC July 27, 2020), a case<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">identified</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>in the Commission’s briefing notice, to argue that the prior citation “did not place [</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Respondent</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">] on notice of what additional measures were required to prevent subsequent violations,” and the present citation should not be characterized as repeat because it does not indicate a failure to learn from the prior citation. </span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">T</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">he Second Circuit</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, however, has since</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>vacated the Commission’s<span>
						</span></span><span style="font-size:12pt; font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; font-style:italic; ">Angelica<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">decision</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">, rendering<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">any arguments that rely on the rationale of<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">that case</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>unsupported</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">. </span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">803 F. Appx. 542</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Accordingly,</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>we do not consider th</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">ose arguments</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>here</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">.</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">
					</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:8px; margin-bottom:8px; text-align:justify; ">
					<a name="ftn19" href="#ftnref19"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">19 </span></a><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">Although the similarity of abatement measures is not relevant to the inquiry here, we note that<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">at least one<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">of the</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">measures proposed in the prior citation<span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">is essentially the same as</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">one</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">proposed in the present citation—maintain</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; ">ing</span><span style="font-size:12pt; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-size:12pt; "><span><span></span>
						</span>sufficient equipment to summon assistance. </span></p>
			</div>
			<div>
				<p style="margin-top:8px; margin-bottom:8px; line-height:1; text-align:justify; ">
					<a name="ftn20" href="#ftnref20"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">20 </span></a><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">Respondent<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">has<span>
						</span></span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">not dispute</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">d</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>the $25,350 proposed penalty</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>throughout the</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">se</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; "><span><span></span>
						</span>proceedings</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">. </span><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_Emphasis style_Emphasis " style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-style:italic; font-family:Times New Roman; font-size:12pt; ">See KS Energy Servs., Inc.</span><span style="font-size:12pt; font-family:Times New Roman; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:12pt; ">, 22 BNA OSHC 1261, 1268 n.11 (No. 06-1416, 2008) (assessing proposed penalty where undisputed).</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn21" href="#ftnref21"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">21 </span></a><span><span></span>
					</span>The Joint Exhibit of the parties’ Stipulations indicates that: “Respondent timely filed its Notice of Contest on May 17, 2018.” (Ex. J-1, Sec’y Br. at 1; Tr. 194.) The undersigned accepts the acknowledgment that the Notice of Contest was timely, but rejects the date listed in the Stipulation. The record reflects that the Secretary issued the Citation on April 7, 2017, and Pembroke filed a Notice of Contest on April 12, 2017. Pembroke then filed an Answer to the Secretary’s Complaint on May 17, 2017. (Resp’t<span><span></span>
					</span>Br. at 5.) The record does not reflect a document filed on May 17, 2018. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn22" href="#ftnref22"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">22 </span></a><span><span></span>
					</span>Stipulation 4 is: “The Occupational Safety and Health Review Commission has jurisdiction in this proceeding pursuant to<span>
					</span>§<span><span></span>
					</span>10(c) of the [Act].” Stipulation 5 is: “The Citation and Notification of Penalty underlying this proceeding was issued on April 7, 2017.” </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn23" href="#ftnref23"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">23 </span></a><span><span></span>
					</span>Stipulation 1 states: “Respondents are employers engaged in a business affecting commerce within the meaning of Section 3(5) of the Occupational Safety and Health Act of 1970, 29 U.S.C.<span>
					</span>§<span><span></span>
					</span>6252(5).”</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn24" href="#ftnref24"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">24 </span></a><span><span></span>
					</span>As explained by Stipulation 10, “Raymond Robinson, Gary<span>
					</span>Gilberti, Diane<span>
					</span>Airosus, and Gina Gilmore were employed by UHS of Delaware, Inc. during the time of the inspection.” Thomas Hickey was the chief executive officer (“CEO”) from the start of the inspection until January 21, 2017. (Tr. 692-93; Stip. 11 (“Thomas Hickey was employed by UHS Delaware, Inc. during a portion of the time of the inspection.”) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn25" href="#ftnref25"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">25 </span></a><span><span></span>
					</span>Stipulation 2 states: “Pembroke Hospital is an inpatient psychiatric hospital.” Stipulation 3 states: “Pembroke Hospital has six patient care units with a total of 120 beds.” </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn26" href="#ftnref26"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">26 </span></a><span><span></span>
					</span>Mealtimes themselves were a “very high time for assault” at Pembroke. (Tr. 960;<span>
					</span>Exs. C-55 at 2, C-58 at 2.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn27" href="#ftnref27"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">27 </span></a><span><span></span>
					</span>Respondents neglect to note the critical phrase “at this time” when discussing this document. (Resp’t<span><span></span>
					</span>Br. at 21.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn28" href="#ftnref28"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">28 </span></a><span><span></span>
					</span>There is no evidence that the conditions, particularly those related to the cited hazard, were the same during the two inspections. For example, the number of staff injuries increased in the year after this letter was sent. (Exs. C-60; C-68, C-69; R-38 at 3.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn29" href="#ftnref29"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">29 </span></a><span><span></span>
					</span>After the 2015 inspection, but before the one which led to the present matter, OSHA conducted another inspection of Pembroke Hospital. That investigation commenced after OSHA received two employee complaints alleging several hazards related to workplace violence. (Ex. R-38 at 1-2.) Pembroke Hospital participated in the investigation, including by answering questions and providing responses to various document requests. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span>at 3-5. Ultimately, OSHA closed this inspection on August 4, 2016, without issuing any citations. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span>at 5. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn30" href="#ftnref30"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">30 </span></a><span><span></span>
					</span>This citation related to the Lowell Treatment Center. After this Pembroke’s acceptance of this citation, another inspection of Pembroke Hospital concluded without the issuance of any citations. (Ex. R-38 at 5.) However, OSHA never indicated there were no hazards at Pembroke Hospital or that Pembroke did not have a duty to provide its<span>
					</span>employees<span>
					</span>with<span>
					</span>a<span>
					</span>workplace “free from recognized hazards that are causing or are likely to cause death or serious physical harm.” 29 U.S.C. § 654(a)(1). </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn31" href="#ftnref31"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">31 </span></a><span><span></span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">A.H. S</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">t</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">urgill Roofing, Inc</span>., 27 BNA OSHC 1809 (No. 13-0224, 2019) is also instructive. There, the citation was somewhat ambiguous about the scope of the proposed abatement. 27 BNA OSHC 1818-19. However, before the record closed, the Secretary subsequently clarified it. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>The Commission did not require the Secretary to show that the employer understood the proposed methods of abatement before the citation was issued. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>The Commission was satisfied that during the hearing the Secretary made clear that the measures in the citation were alternative means of abatement. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn32" href="#ftnref32"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">32 </span></a><span><span></span>
					</span>This case can be appealed to the First and D.C. Circuits. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">See</span><span><span></span>
					</span>29 U.S.C. § 660(a) (“Any person adversely affected or aggrieved by an order of the Commission ... may obtain ... review ... in any United States court of appeals for the circuit in which the violation is alleged to have occurred or where the employer has its principal office, or in the Court of Appeals for the District of Columbia Circuit ....”);<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Kerns Bros. Tree Serv</span>., 18 BNA OSHC 2064, 2067 (No. 96-1719, 2000) (Commission generally applies law of circuit where it is probable case will be appealed). </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn33" href="#ftnref33"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">33 </span></a><span><span></span>
					</span>Respondents also quote the discussion in<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">M</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">issouri</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; "><span><span></span>
						</span>Basin Well Serv</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">ice</span>, 26 BNA OSHC 2314 (No. 13-1817, 2018) about how the hazard must be defined and attempt to apply the statements more broadly. (Resp’t<span><span></span>
					</span>Br. at 20, 28.) In this matter, there is no dispute as to how the hazard is defined or Pembroke’s recognition of it. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn34" href="#ftnref34"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">34 </span></a><span><span></span>
					</span>Separate from these Constitutional considerations is the requirement for the Secretary to establish feasible means of abatement. The requirement is not set forth in the text of the general duty clause itself. 29 U.S.C. § 654(a)(1). <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">See e.g., SeaWorld of Fla. v. Perez,<span>
						</span></span>748 F.3d 1202, 1207 (D.C. Cir. 2014);<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">A.C. Castle Constr. Co., Inc. v. Acosta</span>, 882 F.3d 34, 44 (1st Cir. 2018) (limiting the scope of the fair notice requirement); Mark A. Rothstein,<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Occupational Safety and Health Law<span>
						</span></span>§§ 6:1, 6:9 (2019 ed.). It arose<span>
					</span>as a means to<span><span></span>
					</span>interpret the Act so as to avoid the application of strict liability. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">See<span>
						</span></span>29 U.S.C.<span>
					</span>§ 651(b) (requiring employers “to assure<span>
					</span>so far as possible<span><span></span>
					</span>... safe and healthful working conditions”). Respondents<span><span></span>
					</span>other contentions that the Secretary failed to meet the abatement prong of the test for establishing a violation of the genera duty clause as developed by the Commission and relevant Circuits are discussed below. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn35" href="#ftnref35"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">35 </span></a><span><span></span>
					</span>The parties stipulated that this is an applicable principle of law. (Am. Pre-Hr’g<span><span></span>
					</span>Stmt. at 16;<span>
					</span>Resp’t<span><span></span>
					</span>Br. at 6.)</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn36" href="#ftnref36"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">36 </span></a><span><span></span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">National Realty</span><span><span></span>
					</span>predates<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Waldon<span>
						</span></span>and the development of the Commission’s four-part test for sustaining violations of the general duty clause. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">See Integra</span>, 27 BNA OSHC 1841 at n.3. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn37" href="#ftnref37"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">37 </span></a><span><span></span>
					</span>In addition to the stipulation, Respondents’ counsel also acknowledged at the hearing that both Pembroke Hospital and the industry<span>
					</span>as a whole recognized<span><span></span>
					</span>the hazard. (Tr. 924.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn38" href="#ftnref38"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">38 </span></a><span><span></span>
					</span>This MHA (KS) was employed by Pembroke for over two years. (Tr. 792.) She left her position approximately two weeks before the hearing to work in another type of psychiatric care facility. (Tr. 792-93.) Her demeanor lent her testimony credibility. Her testimony about safety concerns related to the hazard of workplace violence at Pembroke was supported by the documentary evidence. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn39" href="#ftnref39"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">39 </span></a><span><span></span>
					</span>Respondents’ expert, Monica Cooke, was offered only as an expert who evaluated the suggested feasible abatement methods offered by the Secretary. (Tr. 1463.) She was not offered (or accepted) as an expert who assessed whether the hazard was causing serious physical harm. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn40" href="#ftnref40"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">40 </span></a><span><span></span>
					</span>Respondents risk management training does not appear to label any<span>
					</span>particular behavior<span><span></span>
					</span>as “workplace violence,” but discusses “issues inherent” in the patient population and indicates that patients are to be monitored for increases in “assaultive/homicidal potential ....” (Ex. C-30 at 8-9.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn41" href="#ftnref41"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">41 </span></a><span><span></span>
					</span>Five employee injury reports all dated in November 2016 refer to injuries from patient aggression. (Exs. C-3, C-60 at 2-3.) In each of these circumstances, the employee required medical attention. (Tr. 563; Ex. C-60 at 3.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn42" href="#ftnref42"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">42 </span></a><span><span></span>
					</span>AS, a former MHA at Pembroke, explained that employees were trained to verbally de-escalate patients by using conversation to engage a patient and then attempt to calm them down. (Tr. 89.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn43" href="#ftnref43"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">43 </span></a><span><span></span>
					</span>For example, about one week before her assault, KS reported to her supervisor that the same patient tried to hit her. (Tr. 798.) The patient was not placed on 1:1 observation after that incident. (Tr. 799.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn44" href="#ftnref44"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">44 </span></a><span><span></span>
					</span>AS was employed by Pembroke during the inspection and left after the Citation was issued. (Tr. 47.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn45" href="#ftnref45"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">45 </span></a><span><span></span>
					</span>In addition, a former nurse at the facility, TL, indicated that in her three years at the facility serious staff injuries from assaults regularly occurred. (Tr. 651-52.) She left before the latest investigation commenced. However, her testimony is relevant to whether the recognized hazard<span>
					</span>was capable of causing<span><span></span>
					</span>serious physical harm. Although TL was terminated, her testimony had multiple indices of credibility. She explained that she had wanted to leave the position but remained on for financial and family reasons. She was forthright in her testimony, directly answering questions without a suggestion of malice or ill will toward her former employer. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn46" href="#ftnref46"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">46 </span></a><span><span></span>
					</span>In October and November 2016, there were seven incidents of aggression for which medical attention was sought and an additional six incidents of aggression, such as hits or kicks, for which the affected employees declined to seek medical attention. (Tr. 563; Ex. C-60.) Overall, UHS DE tracked 151 incidents of aggressive behavior for the fourth quarter of 2016. (Ex. C-61.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn47" href="#ftnref47"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">47 </span></a><span><span></span>
					</span>The form specifies that only nurses should complete this section of the form; not the MHAs who typically perform the Observation Rounds. (Ex. R-17.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn48" href="#ftnref48"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">48 </span></a><span><span></span>
					</span>Although Pembroke cites this document as its policy on debriefings, it indicates that Pembroke “<span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">shall develop procedures</span><span><span></span>
					</span>to ensure debriefing activities occur.” (Ex. R-12 at 2 (emphasis added).) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn49" href="#ftnref49"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">49 </span></a><span><span></span>
					</span>After the December 2016 regulatory visit, Pembroke indicated to the DMH that it corrected, or planned to correct, these deficiencies. (Exs. C-26, R-13.)<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">
					</span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn50" href="#ftnref50"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">50 </span></a><span><span></span>
					</span>Because it is based on days away, restricted duties and transfers, the rate of injury is often referred to as the DART rate. (Sec’y Br. at 7.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn51" href="#ftnref51"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">51 </span></a><span><span></span>
					</span>Dr. Welch relied on several studies, including, Paul Morrison & Michael<span>
					</span>Lehane,<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Staffing Levels and Seclusion Use</span>, 22<span>
					</span>J. of Advanced Nursing<span><span></span>
					</span>1193-1202 (1995) (hereafter,<span>
					</span>Lehane<span><span></span>
					</span>Study). The<span>
					</span>Lehane<span><span></span>
					</span>Study found “a highly significant difference between the levels of staffing” and the number of violent incidents requiring patient seclusion. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span>at 1193. Similarly, Vanya<span>
					</span>Hamrin,<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">et al</span>.,<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">A<span>
						</span></span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Review of Ecological Factor</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">s</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; "><span><span></span>
						</span>Affecting Inpatient Psychiatric Unit Violence</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">:</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; "><span><span></span>
						</span>Implications for Relational and Unit Cultural Improvements</span>, Issues in Mental Health Nursing, 30:214-226 (2009), also found that violence is prevented by having adequate staff to patient ratios. (Ex. C-101 at 9.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn52" href="#ftnref52"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">52 </span></a><span><span></span>
					</span>Because admissions and discharges alter the number of patients, the census is based on the average number of patients on the unit as counted at least once during a shift. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn53" href="#ftnref53"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">53 </span></a><span><span></span>
					</span>The adolescent unit also only has one nurse on the night shift, but its census is capped at eighteen patients. On the night shift, Pembroke added one “float” position on for the entire hospital. (Tr. 375, 730.) The DMH concluded that this was insufficient. (Ex. C-47 at 6-7.) During its four-day survey in the spring of 2016 (before the OSHA inspection commenced, the DMH noted one unit operating with 22 patients but only two employees (one nurse and one MHA). <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>While there was a float, that employee was also needed in another unit. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.</span>
				</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn54" href="#ftnref54"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">54 </span></a><span><span></span>
					</span>Ms. Gilmore’s letters regarding her loss control visits to Pembroke Hospital also note increased episodes of aggression on weekends. (Ex. C-59.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn55" href="#ftnref55"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">55 </span></a><span><span></span>
					</span>The Secretary does not specifically allege that staffing was inadequate from a medical perspective. However, he does argue that the “unmet needs” of patients increases the likelihood of a workplace violence incident. (Sec’y Br. 37-38.) As discussed above, patients were dependent upon staff for meals, bathroom access,<span>
					</span>medication<span><span></span>
					</span>and other needs. If there was inadequate staff to respond to such needs, certain patients can become aggressive and angry. (Tr. 946-47; Ex. C-101 at 7-9.) “A recurring theme in the research was that unmet needs trigger aggression or violence.” (Ex. C-101 at 9.) Pembroke’s training materials on de-escalation also acknowledged this can occur. (Ex. R-32.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn56" href="#ftnref56"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">56 </span></a><span><span></span>
					</span>Pembroke’s policy permitted “special precautions” for “Assaultive/Destructive Behavior” as well “other reasons deemed appropriate by the physician or nursing staff.” (R-11 at 2.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn57" href="#ftnref57"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">57 </span></a><span><span></span>
					</span>Per Pembroke’s “Special Precautions Guidelines” there was a preference for the assigned staff member to be of the same gender, but it was not required other than during certain time, such as for personal hygiene and toileting. (Ex. R-11.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn58" href="#ftnref58"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">58 </span></a><span><span></span>
					</span>While DMH findings relate to patient care, not employee safety, they still had the impact of notifying Respondents that its staffing levels were low. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn59" href="#ftnref59"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">59 </span></a><span><span></span>
					</span>The Secretary does not allege that Pembroke’s approach to 1:1 staffing would still be deficient if it had followed what was called for by the December 2016 Plan of Correction consistently during the inspection period.</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn60" href="#ftnref60"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">60 </span></a><span><span></span>
					</span>The undersigned notes that the DMH review of Pembroke over three days in December 2016 found that documentation about what level of precaution patients were on was not consistent. (Ex. R-13.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn61" href="#ftnref61"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">61 </span></a><span><span></span>
					</span>The Secretary also cites Pembroke’s coaching of employees only to answer the questions investigators asked and to not offer information. (Tr. 113, 119, 125; Ex. C-1.) After management provided information about how it expected employees to act during investigations in writing, employees were specifically directed to destroy the instructions. (Tr. 125.) Respondents argue that the instructions were perfectly appropriate. The written instructions do not direct employees to lie or provide misinformation. (Ex. C-1.) AS acknowledged that he did not fear reprisal after speaking with OSHA. (Tr. 184.) Although the Secretary’s curiosity about why Pembroke would direct employees to destroy instructions about regulatory investigations is understandable, he did not establish that the coaching practices warrant adverse inferences. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn62" href="#ftnref62"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">62 </span></a><span><span></span>
					</span>In 2016, UHS DE conducted a staff survey of “safety culture.” Several of the comments cite a need to staff appropriately for acuity. (Ex. C-22.) Although admissible, less weight is given to these survey results than the testimony of the current and former employees at the hearing. There is no information about the credibility of the persons providing the information in the survey and it is not clear what<span>
					</span>time period<span><span></span>
					</span>the survey responses relate to. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn63" href="#ftnref63"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">63 </span></a><span><span></span>
					</span>The undersigned notes that in contrast to the scope of Dr. Welch’s review of staffing at Pembroke, Ms. Cooke only reviewed two days of staffing records in depth. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn64" href="#ftnref64"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">64 </span></a><span><span></span>
					</span>Pembroke’s policy Code Greens also contemplates the involvement of multiple employees. (Ex. R-9 at 3.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn65" href="#ftnref65"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">65 </span></a><span><span></span>
					</span>A UHS DE conducted regular “loss control” visits of Pembroke Hospital and prepared summary letters after the visits. (Ex. C-55.) The December 12,<span>
					</span>2016<span><span></span>
					</span>letter notes an increase of “aggression episodes on weekends due to large number of admissions ....” <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span>at 2. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn66" href="#ftnref66"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">66 </span></a><span><span></span>
					</span>AS indicated that the room was eight feet by eight feet in one of the units. (Tr. 82.) Some of the other units might have had slightly bigger rooms. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn67" href="#ftnref67"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">67 </span></a><span><span></span>
					</span>The window is described as about the size of “loaf of French bread.” (Tr. 88.) There were no security cameras on the units, but a few offices have cameras. (Tr. 512.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn68" href="#ftnref68"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">68 </span></a><span><span></span>
					</span>Searches were also required after patients returned to the units from appointments off-site. (Ex. R-8.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn69" href="#ftnref69"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">69 </span></a><span><span></span>
					</span>Per Pembroke’s policy, patients could decline the searches. (Ex. R-8.) According to the policy, the patient was to “remain in open areas unit assessed” if they declined. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>The policy does not call for them to be secluded from staff. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id.<span>
						</span></span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn70" href="#ftnref70"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">70 </span></a><span><span></span>
					</span>It can take up to twenty-four hours before a physician completes his or her complete assessment of the patient. (Tr. 1291; Ex. R-7.) Typically, at Pembroke, a doctor sees a patient within two hours to assess their competency and conduct a brief assessment. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>Patients are also seen by a social worker within three days (72 hours). (Tr. 1423; Ex. R-7.)</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn71" href="#ftnref71"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">71 </span></a><span><span></span>
					</span>Ms. Gilmore, the UHS DE Loss Control Manager, also noted that the lack of clinical case management for patients admitted over the weekends can increase these patients becoming upset. (Ex. C-58 at 2.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn72" href="#ftnref72"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">72 </span></a><span><span></span>
					</span>Pembroke’s “Seclusion and/or Restraint Use” policy indicates that staff was also to be trained annually in “Handle with Care” and “Trauma Informed Care.” (Ex. R-12 at 1.) Ms. Kent cited trauma informed care as being part of the initial training, but it’s unclear if that was also part of the annual re-training. (Tr. 1420-21.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn73" href="#ftnref73"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">73 </span></a><span><span></span>
					</span>Exhibit R-32 does not include the term “workplace violence” but does refer to violence and “dangerous behaviors.” (Ex. R-32.) It states that one of the goals of the training is to “Reduce staff and patient injuries.” <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn74" href="#ftnref74"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">74 </span></a><span><span></span>
					</span>Respondents did not introduce Exhibit C-31 (a PowerPoint presentation discussing workplace violence) or raise it with any witness. The Secretary’s counsel showed Ms. Burns Exhibit C-31 on cross examination. (Tr. 1219-20.) Ms. Burns did not use the materials herself and was unsure if the other employees who conducted training used them. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn75" href="#ftnref75"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">75 </span></a><span><span></span>
					</span>Dr. Welch also noted that verbal de-escalation can be ineffective. (Tr. 1010-1011.) For example, if the patient is already violent or if their untreated psychosis precludes rational conversation, verbal de-escalation is ineffective. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>Ms. Gilmore, the Loss Control Manager for UHS DE, noted in both her October 25, 2016, and December 12,<span>
					</span>2016<span><span></span>
					</span>letters that while non-clinical staff can recognize escalating situations and had training on verbal de-escalation, at the time of her visit certain employees “DO NOT know how to defend themselves if attacked.” (Ex. C-55 at 2 (capitalization in original); Ex. C-59 at 2 (same capitalization).) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn76" href="#ftnref76"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">76 </span></a><span><span></span>
					</span>The Handle with Care program also called for structure and having employees be able to provide calming modalities. (Ex. R-32.) As discussed below in addition to a lack of adequate staffing, Pembroke also fell short in implementing these aspects of the program. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn77" href="#ftnref77"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">77 </span></a><span><span></span>
					</span>Ms. Gilmore assessed whether groups were occurring and how they were functioning as part of her routine reviews of Pembroke Hospital. (Tr. 549;<span>
					</span>Exs. C-55, C-57, C-59.) Her reports discuss how groups can help patients and how not having groups as scheduled can trigger aggression. (Ex. C-59 at 2; C-57 at 2.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn78" href="#ftnref78"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">78 </span></a><span><span></span>
					</span>One witness said that she was not aware of any policies related to when groups would be canceled. (Tr. 228.) The risk manager indicated that Pembroke had an “activities therapy policy,” as well as policies related “running groups” and the “staff to patient ratio” for groups. (Tr. 535.) Pembroke did not introduce any of these policies into the record. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn79" href="#ftnref79"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">79 </span></a><span><span></span>
					</span>Per Pembroke’s Code Green policy, psychiatric emergencies also “should be announced using walkie talkies and the overhead paging system.” (Ex. R-9.) Employees described using either a walkie or the phone system. (Tr. 57, 59-60.) Some incidents would require multiple calls for assistance. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn80" href="#ftnref80"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">80 </span></a><span><span></span>
					</span>It is unclear if patients also used these phones. (Ex. R-28.) An audit by the DMH from May 2016 specifically called for more phones in at least two units. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn81" href="#ftnref81"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">81 </span></a><span><span></span>
					</span>More recently, Pembroke increased the number of radios to six per unit and implemented steps to make sure each unit had<span>
					</span>a sufficient number of<span><span></span>
					</span>working radios. (Tr. 456.) The Secretary does not argue that this revised approach was still deficient. However, the suitability of Pembroke’s abatement program is assessed as of the time in the Citation. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn82" href="#ftnref82"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">82 </span></a><span><span></span>
					</span>About six months before the hearing, Pembroke had implemented a new approach that improved patient access to music for de-escalation. (Tr. 1255-56.) The Secretary’s arguments are limited to the conditions observed at the time of the inspection.</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn83" href="#ftnref83"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">83 </span></a><span><span></span>
					</span>Dr. Welch cited a study that pointedly notes the lack of research supporting the effectiveness of training alone in reducing workplace violence. (Ex. C-96 at 15.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn84" href="#ftnref84"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">84 </span></a><span><span></span>
					</span>Dr. Welch acknowledged the role of patient behavior but argued that individual patient factors should not be over-emphasized at the expense of other factors, particularly environmental or administrative factors well within the facility’s control. (Tr. 973, 1010-11.) Peer reviewed literature supports his opinion. (Exs. C-95 at 2-3, C-96 at 16.)</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn85" href="#ftnref85"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">85 </span></a><span><span></span>
					</span>The abatement methods proposed for the workplace violence hazard in<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Integra<span>
						</span></span>included: creating a written workplace violence prevention program, creating a system for<span>
					</span>reporting<span><span></span>
					</span>and tracking safety concerns, providing employees with a reliable way to summon assistance when needed, and increasing the number of staff for certain types of assignments. 27 BNA OSHC 1849-50.</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn86" href="#ftnref86"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">86 </span></a><span><span></span>
					</span>The Secretary divides his proposed abatement into seven paragraphs, labeled (a) through (g). (Sec’y Br. at 4.) Some of the paragraphs require more than one action. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn87" href="#ftnref87"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">87 </span></a><span><span></span>
					</span>In the year prior to this letter, Pembroke had thirteen injuries related to aggressive behavior. (Ex. R-37.) After its issuance, the number of injuries at Pembroke increased. (Tr. 292, 926;<span>
					</span>Exs. C-60, C-68, C-69.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn88" href="#ftnref88"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">88 </span></a><span><span></span>
					</span>“About six hours” of her time was spent at Pembroke Hospital itself. (Tr. 1474.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn89" href="#ftnref89"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">89 </span></a><span><span></span>
					</span>Pembroke also had more patients per doctor than other facilities surveyed by Dr. Welch. (Tr. 938.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn90" href="#ftnref90"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">90 </span></a><span><span></span>
					</span>Respondents do not contend that the facility failed to make a profit. Respondents did not introduce any information regarding the facility’s finances such as budget documents. There is no evidence the facility could not afford any of the Secretary’s proposed abatement measures. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">See<span>
						</span></span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Capeway</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; "><span><span></span>
						</span>Roofing Sys., Inc.,<span>
						</span></span>20 BNA OSHC 1331, 1342-43 (No. 00-1968, 2003)<span>
					</span><span style="color:#000000; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">(party would have produced evidence if it had been favorable)</span>. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn91" href="#ftnref91"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">91 </span></a><span><span></span>
					</span>Sometimes 1:1 observation would be limited to only those times that the patient was awake. (Tr. 379.) Patient behavior is unpredictable, and patients wake at unexpected times. In such instances, there would be an immediate need for an employee to observe the patient directly. (Tr. 379-80.) Ms.<span>
					</span>Devane<span><span></span>
					</span>indicted that in such situations the supervisor would have the float take over that patient. (Tr. 380.) However, only one person worked as a float on the overnight shift. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn92" href="#ftnref92"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">92 </span></a><span><span></span>
					</span>A smaller group also assesses the need for such observation at other times, so that orders for 1:1s are reviewed approximately every eight hours. (Tr. 1191.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn93" href="#ftnref93"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">93 </span></a><span><span></span>
					</span>Ms.<span>
					</span>Devane<span><span></span>
					</span>explained that 1:1 observation could be intrusive for patients. (Tr. 1191.) The Secretary does not dispute this. His contention is limited to situations when 1:1 observation is clinically warranted for assaultive behavior that creates a risk of violence directed at employees. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn94" href="#ftnref94"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">94 </span></a><span><span></span>
					</span>Pembroke Hospital operated shifts with 15 to 20 percent fewer nurses than other similar psychiatric facilities in the same state. (Tr. 1047.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn95" href="#ftnref95"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">95 </span></a><span><span></span>
					</span>Dr. Welch explained that verbal de-escalation requires several people. (Tr. 966, 1010.) It requires enough staff who can both quickly identify who is escalating and then change tasks so there can be a quick intervention. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span>Even then, patients may not have sufficient connection with reality for verbal intervention to work. (Tr. 1010-11.) So, a program needs additional forms of abatement to be effective. (Tr. 1011.) Similarly, Mr. Quinn, the crisis intervention specialist, indicated that he can spend considerable amounts of time trying to talk to a patient to find reasonable alternatives to their violent behavior. (Tr. 1250.) However, there are six patient units and typically only one crisis intervention specialist on one shift for all the units. (Tr. 1250-53.) KS, an MHA, explained that often there were multiple agitated patients and frequently there were not enough people to de-escalate two or three agitated patients. (Tr. 871-72.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn96" href="#ftnref96"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">96 </span></a><span><span></span>
					</span>The other facility was a state-run hospital. (Tr. 103.) It has fewer units, but the unit size is the same as at Pembroke Hospital. (Tr. 103-4.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn97" href="#ftnref97"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">97 </span></a><span><span></span>
					</span>Dr. Welch also explained that when staff was tied up with admissions tasks, other patients have “unmet needs.” (Tr. 1030-31.) The frustration associated with unmet needs is a well-documented pre-cursor to violent acts by patients. (Tr. 946-47, 962, 1033; Ex. C-101.) KS explained that this occurred at Pembroke Hospital. (Tr. 871-72.) There were times when the number of agitated patients exceeded the number of caregivers resulting in staff being unable to timely address patient agitation. <span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Id. </span></p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn98" href="#ftnref98"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">98 </span></a><span><span></span>
					</span>Ending the practice of having employees leave mid-shift was not the only way to maintain sufficient staffing to manage increases in acuity and/or admissions. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn99" href="#ftnref99"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">99 </span></a><span><span></span>
					</span>Pembroke’s Code Green policy directed employees to contact 911 for “psychiatric emergencies or as deemed appropriate.” (Ex. R-9 at 3-4.) Ms. Cooke argued that uniformed personnel could increase a patient’s agitation but did not discuss Pembroke’s policy of contacting outside emergency responders for psychiatric emergencies. (Tr. 1495.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn100" href="#ftnref100"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">100 </span></a><span><span></span>
					</span>The proposed abatement calls for both group activities and recreation periods. (Sec’y Br. at 4.) MHAs took patients off the units for fresh air<span>
					</span>breaks. (Tr. 55-56.) The Secretary failed to show that the few times during the inspection period when these breaks did not occur materially contributed to the hazard. Pembroke appeared to have sufficiently implemented the need for fresh air<span>
					</span>breaks. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn101" href="#ftnref101"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">101 </span></a><span><span></span>
					</span>When Ms. Cooke was discussing admissions, she was not always clear about whether she was describing the situation at Pembroke or her experience at other facilities. (Tr. 1469.) For example, she indicated that at “most” in-patient facilities she was aware of, or worked act, they would not accept “highly psychiatrically unstable” patients. (Tr. 1468.) She did not clarify whether that was true of Pembroke. (Tr. 1468-69.) Further, when describing the threats associated with newly admitted patients, she said that “we mitigate the risk.” (Tr. 1468.) When asked by counsel whether she meant “Pembroke” when she used the term “we,” Ms. Cooke explained that she meant Pembroke or was using the term “we” in the sense of the “behavioral health world.” (Tr. 1469.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn102" href="#ftnref102"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">102 </span></a><span><span></span>
					</span>One peer reviewed study Dr. Welch relied on,<span>
					</span>Simha<span><span></span>
					</span>F. Landau,<span>
					</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">Personnel Exposure to Violence in Hospital Emergency Wards</span><span style="font-style:italic; font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; font-style:italic; ">: A Routine Activity Approach</span>, 34 Aggressive Behavior 88, 91 (2008), described access to an “emergency button” as a “widely used” and “important physical protective device.” (Ex. C-95.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn103" href="#ftnref103"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">103 </span></a><span><span></span>
					</span>The Sentinel Alert was issued after the inspection occurred and was not considered as evidence of Respondents’ knowledge of the hazard. (Ex. C-99.) However, it was reviewed by Dr. Welch and possibly by Ms. Cooke to assess the feasibility of the proposed abatement. </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn104" href="#ftnref104"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">104 </span></a><span><span></span>
					</span>To the extent that the proposed abatement could be interpreted as requiring other types of equipment, the Secretary failed to sufficiently identify such equipment or establish how it would materially abate the hazard.</p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn105" href="#ftnref105"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">105 </span></a><span><span></span>
					</span>The parties agree that this is the appropriate test to assess whether two legal entities functioned as a single employer. (Am. Pre-Hr’g<span><span></span>
					</span>Stmt. at 16;<span>
					</span>Resp’t<span><span></span>
					</span>Br. at 6.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn106" href="#ftnref106"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">106 </span></a><span><span></span>
					</span>Respondents assert that Pembroke set its own budget. (Resp’t<span><span></span>
					</span>Br. at 42.) However, Ms. Gilmore, a UHS DE employee testified that she handled the workers’ compensation budget for Pembroke Hospital. (Tr. 550; Stip. 10.) </p>
			</div>
			<div>
				<p class="style_Normal style_Normal style_FootnoteText style_FootnoteText " style="margin-top:0px; margin-bottom:6.667px; ">
					<a name="ftn107" href="#ftnref107"><span class="style_DefaultParagraphFont style_DefaultParagraphFont style_FootnoteReference style_FootnoteReference " style="font-family:Calibri; font-size:11pt; font-family:Times New Roman; font-size:10pt; ">107 </span></a><span><span></span>
					</span>Respondents limit their argument on the penalty amount to asserting that if the violation is affirmed it should not be characterized as repeat. (Resp’t<span><span></span>
					</span>Br. at 43.) </p>
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