United States of America 

OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION 

1120 20th Street, N.W., Ninth Floor 

Washington, DC 20036-3457 

SECRETARY OF LABOR, 

Complainant, 

OSHRC Docket No. 13-1124 v. 

INTEGRA HEALTH MANAGEMENT, INC., 

Respondent. 

APPEARANCES: 

Lee Grabel, Attorney; Louise McGauley Betts, Senior Attorney; Charles F. James, Counsel for 

Appellate Litigation; Ann Rosenthal, Associate Solicitor of Labor for Occupational Safety and 

Health; M. Patricia Smith, Solicitor of Labor; U.S. Department of Labor, Washington, DC 

For the Complainant 

Kevin C. McCormick; Whiteford, Taylor & Preston, L.L.P., Baltimore, MD 

For the Respondent 

Lynn K. Rhinehart, Harold C. Becker, Yona Rozen, Angelia Wade Stubbs, Office of the 

General Counsel; Margaret Seminario, Rebecca Reindel, Safety and Health Department 

For Amicus Curiae AFL-CIO, Washington, DC 

Pamela Allen, Carol Igoe, Legal Department 

For Amicus Curiae California Nurses Association/National Nurses United, 

Oakland, CA 

Jacqueline M. Holmes, Jones Day, Washington, DC; Steven P. Lehotsky, Warren Postman, 

U.S. Chamber Litigation Center, Washington, DC 

For Amicus Curiae Chamber of Commerce of the United States 

Randy S. Rabinowitz, Occupational Safety and Health Law Project, Washington, DC 

For Amici Curiae National Association of Social Workers, National Council for 

Occupational Safety and Health, and Service Employees International Union 

Sky Westerlund, Executive Director 

For Amicus Curiae Kansas Chapter, National Association of Social Workers, 

Topeka, KS 

Antonia Domingo, Assistant General Counsel, United Steelworkers, Pittsburgh, PA 

For Amicus Curiae United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, 

Allied-Industrial and Service Workers International Union 
 

 

 

 

 

 

 

 

 

 

 

 

 

DECISION 

Before: MACDOUGALL, Chairman; ATTWOOD and SULLIVAN, Commissioners. 

BY THE COMMISSION: 

Section 5(a)(1) of the Occupational Safety and Health Act of 1970, known as the general 

duty clause, states that “[e]ach employer . . . shall furnish to each of his employees 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). At issue here 

is whether Integra Health Management, Inc., violated this provision by failing to adequately 

address a workplace violence hazard—specifically, the risk of Integra’s employees being 

physically assaulted by a client with a history of violent behavior during a face-to-face meeting. 

In the circumstances of this case, we conclude that a violation has been established and affirm the 

citation. 

BACKGROUND 

Integra employs “service coordinators” to help its clients—referred to by the company as 

“members”—obtain and maintain medical care. Health insurers send the members to Integra after 

reviewing claims histories to identify individuals who are not receiving appropriate care for, in 

many cases, chronic medical conditions like mental illness. Typically, the health insurers have 

been unable to maintain contact with these individuals, who tend to avoid visiting their regular 

physicians and taking their prescribed medications, resulting in costly emergency room visits and 

hospital stays. 

Integra assigns a service coordinator to each member. The service coordinator is 

responsible for locating the member, introducing the company and its services, and obtaining 

consent from the member to receive assistance from Integra. If the member consents, the service 

coordinator will typically contact the member several times a month, both by telephone and faceto-face, and assist in ensuring that the member receives medical treatment. For example, the 

service coordinator will help set up doctor appointments for the member and ensure that the 

member goes to the appointments and takes any prescribed medications. Service coordinators are 

not clinically trained. According to Integra’s president and CEO, the company does not “provide 

a clinical service. We provide a service that a community health worker would provide.” In other 

words, Integra is “really just trying to get the [member] connected with things just like a family 

member might, a neighbor, a friend, if that person existed.” 

2 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Integra trains its service coordinators in several ways. One is an internet-based course 

(referred to as the “Neumann training”) with a session on “In-Home and Community Safety.” This 

training includes PowerPoint presentations on “Screening the Dangerous Member” and “Safety in 

the Community.” The “Screening the Dangerous Member” slides advise service coordinators to 

obtain “critical history about previous unsafe behaviors” and “collateral information from family 

members, friends, [and] clergy,” and the record indicates that the service coordinators could obtain 

such information from the members themselves. At the time of the alleged violation, however, 

Integra did not require that this information be obtained, nor did the company conduct member 

background checks.1 The “Safety in the Community” slides identify certain potential, high-risk 

behaviors, such as a “history of violence or self[-]harm” and “[c]riminal behavior,” and instruct 

service coordinators to “[b]e [s]mart – use common sense” and “[l]isten to your gut.” Service 

coordinators are tested at the end of the training, and they then “shadow” more senior staff in the 

field before taking on cases alone. 

In addition to the Neumann training, Integra: (1) holds in-person training sessions, which 

include safety discussions and role-playing scenarios; (2) conducts weekly conference calls with 

service coordinators, including safety discussions; (3) uses a voluntary “buddy system,” advising 

service coordinators who “feel uncomfortable” to call another service coordinator “and go out 

together;” and (4) maintains a written workplace violence prevention policy, stating that 

“[v]iolence . . . against an employee . . . will not be tolerated,” advising employees to report any 

threatening communications to supervisors, and warning that “[v]iolations of this policy . . . may 

result in disciplinary action.” 

Integra was founded in 2007 and is based in Owings Mills, Maryland. The company began 

operating in Florida in 2012 after contracting with Amerigroup to provide services to several of its 

insureds. An online posting for Integra’s Florida-based service coordinator position, dated July 

17, 2012, stated that the “ideal candidate(s) would be able to provide support services to a specific 

group of individuals with serious mental/somatic illness through community-based teams,” and 

1 By the time of the hearing, Integra had implemented new protocols, including performing 

background checks on all members, “red-flagging” those members with criminal backgrounds, 

taking certain members with violent criminal histories off the company’s rolls, establishing a 

liaison with local law enforcement, instituting a written workplace violence prevention program 

with mandatory reporting of incidents, and conducting de-escalation training for service 

coordinators. 

3 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

must have a bachelor’s degree. The posting also stated that “interest in social work, psychology 

or a related field and possessing 2 years [of] experience in the field is a plus.” In August and 

September 2012, Integra hired several new service coordinators for its Florida team, including 

Employee-A, a 25-year-old recent college graduate with no prior experience in social work or 

working with the mentally ill. After providing the requisite training, Integra assigned EmployeeA the case file for Member-L, who suffered from cardiovascular disease and schizophrenia. 

Unknown to Employee-A, Integra, and Amerigroup, Member-L had a prior criminal record—he 

served a total of approximately 15 years in prison for grand theft of a motor vehicle in 1981, battery 

in 1982, aggravated battery with a deadly weapon in 1990, and aggravated assault with a weapon 

in 1995. 

After several attempts to contact Member-L by phone, Employee-A visited him at his home 

three times in October and November 2012. On October 12, Employee-A made her first visit, 

introducing herself and making an appointment with Member-L to conduct an initial assessment 

three days later at his home. Employee-A stated in her Progress Note Report (Report)—a record 

that Integra requires all service coordinators to complete and submit any time they have contacted 

a member—that Member-L “said a few things that made [her] uncomfortable, so [she] asked [him] 

to be respectful or she would not be able to work with him,” and that, because of this, she was “not 

comfortable being inside [Member-L’s home] alone with [him] and will either sit outside to 

complete [the] assessment or ask another [service coordinator] to accompany her.” 

On October 15, Employee-A visited Member-L’s home for their scheduled appointment, 

but he refused to sign the required consent form without his case manager from his healthcare 

provider being present. Employee-A phoned the case manager and told Member-L that she would 

arrange a meeting among the three of them. Employee-A stated in her Report of this visit that 

Member-L “showed [her] a print of The Last Supper, [erroneously] crediting it to Michelangelo,” 

and identified Jesus as “my father,” “someone else in the picture” as himself, and “a few others in 

the picture” as “people in the community, such as the waitress who works down the street.” On 

November 14, Employee-A returned to Member-L’s home and stated in her Report that he initially 

“pretended to be his own twin brother,” but then “admitted to being himself,” “agreed to sign the 

consent without his [case manager] present,” “discussed how he sometimes has a hard time with 

police stopping him because they say he looks suspicious,” and “told [Employee-A] to get a 

4 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cowboy hat and go to a rodeo.” This Report along with the two previous October Reports were 

reviewed by Employee-A’s supervisors. 

After an unsuccessful attempt to meet with Member-L on November 26, 2012, EmployeeA returned to Member-L’s home on December 10 to complete her assessment, which had to be 

done, per Integra’s requirements, by December 14, thirty days from the date that Member-L signed 

the consent form. During this visit, Member-L attacked Employee-A with a knife, stabbing her 

nine times while chasing her across his front yard. Member-L then went inside his home, leaving 

Employee-A wounded on the lawn. A passerby saw Employee-A lying on the ground and drove 

her to the hospital, where she died later that day. 

Following an inspection, the Occupational Safety and Health Administration issued Integra 

a citation alleging a violation of the general duty clause for exposing employees “to the hazard of 

being physically assaulted by members with a history of violent behavior.” After a hearing, 

Administrative Law Judge Dennis L. Phillips affirmed this citation.2 

DISCUSSION 

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 materially reduce the hazard.3 Arcadian Corp., 

2 The judge also affirmed an other-than-serious citation alleging that Integra violated 29 C.F.R. 

§ 1904.39(a) for failing to notify OSHA of its employee’s death. Integra does not seek review of 

this violation, conceding that the company did not notify OSHA of the fatality. 

3 Commissioners Attwood and Sullivan take issue with their colleague’s assertion in her 

concurrence that these long-standing elements of a general duty clause violation—as articulated 

in well-established precedent from the Commission and Courts of Appeals—are somehow 

“flaw[ed]” because, in her view, they fail to “address the ability of an employer to ‘free’ a 

workplace of a recognized hazard.” This is simply not the case. The text of the general duty clause 

does not limit applicability only to hazards that can be completely eliminated; it simply states that 

the employer shall provide a workplace that is “free from recognized hazards that are causing or 

are likely to cause death or serious physical harm to his employees”—the provision is silent as to 

the extent of an employer’s obligation if it is not possible to eliminate the hazard. 29 U.S.C. 

§ 654(a)(1). 

Under long-standing precedent, the Commission and courts have resolved this question by 

recognizing that employers should not be liable for failing to eliminate a hazard if that is not 

feasible—it is sufficient for employers in such circumstances to reduce the hazard to the extent 

feasible. See, e.g., Carlyle Compressor Co. v. OSHRC, 683 F.2d 673, 677 (2d Cir. 1982) 

5 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Secretary’s proposed abatement “need not completely solve the problem as long as it reduces the 

danger”); Jones & Laughlin Steel Corp., 10 BNA OSHC 1778, 1782 (No. 76-2636, 1982) (“An 

employer’s duty under section 5(a)(1) is to free its workplace—to the extent feasible—of 

recognized hazards that are likely to cause death or serious injury.”) (emphasis added). This 

approach has been justified—quite reasonably—by interpreting “free” as an aspirational goal for 

employers—they are charged only with taking “reasonable steps to protect [their] employees.” 

Beaird-Poulan, 7 BNA OSHC 1225, 1228-29 (No. 12600, 1979) (noting general duty clause’s use 

of “free”). See 29 U.S.C. § 651(b) (“The Congress declares it to be its purpose and policy . . . to 

assure so far as possible every working man and woman in the Nation safe and healthful working 

conditions . . . .”) (emphasis added). 

Reading section 5(a)(1) as limiting the jurisdictional reach of the general duty clause to only those 

hazards that can be completely eliminated is unreasonable—indeed, such a reading would permit 

an employer to do nothing in the face of a known hazard that cannot be eliminated from its 

workplace but could be materially reduced by 95 percent. As Judge J. Skelly Wright, in the D.C. 

Circuit’s landmark National Realty decision, pronounced in interpreting the “free from” language 

in the general duty clause, the record must “indicate that demonstrably feasible measures would 

have materially reduced the likelihood” that hazardous conduct would have occurred. Nat’l Realty 

& Constr. Co. v. OSHRC, 489 F.2d 1257, 1267 (D.C. Cir. 1973) (emphasis added). 

Commissioners Attwood and Sullivan therefore reject the Chairman’s interpretation of National 

Realty. In that case the court distinguished preventable hazards from unpreventable hazards: “[a]ll 

preventable forms and instances of hazardous conduct must . . . be entirely excluded from the 

workplace,” as opposed to “unpreventable instances,” which, to avoid making employers strictly 

liable, are not covered. Id. at 1266-67. The court’s statement that the Secretary must demonstrate 

that feasible measures would materially reduce the hazard, rather than stating that such measures 

would eliminate the hazard, shows that the court’s point in distinguishing the preventable from the 

unpreventable was to emphasize that the alleged hazard must be one over which the employer has 

control: 

Though resistant to precise definition, the criterion of preventability draws content 

from the informed judgment of safety experts. Hazardous conduct is not 

preventable if it is so idiosyncratic and implausible in motive or means that 

conscientious experts, familiar with the industry, would not take it into account in 

prescribing a safety program. Nor is misconduct preventable if its elimination 

would require methods of hiring, training, monitoring, or sanctioning workers 

which are either so untested or so expensive that safety experts would substantially 

concur in thinking the methods infeasible. All preventable forms and instances of 

hazardous conduct must, however, be entirely excluded from the workplace. To 

establish a violation of the general duty clause, hazardous conduct need not actually 

have occurred, for a safety program’s feasibly curable inadequacies may sometimes 

be demonstrated before employees have acted dangerously. At the same time, 

however, actual occurrence of hazardous conduct is not, by itself, sufficient 

evidence of a violation, even when the conduct has led to injury. The record must 

additionally indicate that demonstrably feasible measures would have materially 

reduced the likelihood that such misconduct would have occurred. 

6 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20 BNA OSHC 2001, 2007 (No. 93-0628, 2004). On review, Integra contends that the Secretary 

has failed to prove a violation because he has not established that either Integra or its industry 

recognized the cited hazard and that his proposed abatement measures would have materially 

reduced that hazard. As a threshold matter, Integra also argues that the hazard alleged here is 

beyond the scope of the Act itself—as the company puts it, “the hazards encompassed by the 

general duty clause [do not] include the risk of criminal assaults upon employees by third parties.” 

Essentially, the company contends that certain hazards, even if recognized by an employer, cannot 

be the basis of a general duty clause violation.4 We begin with this jurisdictional issue. 

Id. (emphasis added). Numerous Commission and Court of Appeals decisions have interpreted 

National Realty in precisely this way. See, e.g., SeaWorld of Fla. v. Perez, 748 F.3d 1202, 1207 

(D.C. Cir. 2014) (“Notwithstanding the ‘unqualified and absolute’ textual imperative that the 

workplace be ‘free’ of the recognized hazard, . . . the court [in National Realty] further observed 

that ‘Congress quite clearly did not intend the general duty clause to impose strict liability: The 

duty was to be an achievable one,’ . . . . So understood, the court held that ‘[a]ll preventable forms 

and instances of hazardous conduct must . . . be entirely excluded from the workplace.’ ”). 

In short, the court’s statement that an employer must “free from” its workplace all preventable 

instances of hazards cannot mean that the court was excluding from the general duty clause’s 

coverage hazards that can be materially reduced. Indeed, no Commission or Court of Appeals 

decision has adopted the Chairman’s novel theory, which would largely eliminate the applicability 

of the general duty clause. 

As he notes in his concurring opinion, Commissioner Sullivan ascribes to a “reasonable 

foreseeability” test because any practice or condition which is unforeseeable cannot be 

prevented. An employer cannot render a workplace, therefore, “free” of a recognized hazard if the 

hazard is unforeseeable. 

4 Commissioner Attwood notes that the Chairman, in her concurring opinion, asserts that the 

general duty clause should be viewed as a “ ‘placeholder,’ to be used only until section 6(b) 

rulemaking could be initiated to address hazards.” The Fourth Circuit provided an apt response to 

such a theory forty years ago in Bristol Steel & Iron Works, Inc. v. OSHRC, 601 F.2d 717 (4th Cir. 

1979). The court in Bristol Steel stated that the Act contemplates the promulgation of specific 

safety standards and the use of general safety standards and the general duty clause, “which are 

designed to fill those interstices necessarily remaining after the promulgation of specific safety 

standards.” Id. at 721. The court added that “[i]t would be utterly unreasonable to expect the 

Secretary to promulgate specific safety standards which would protect employees from every 

conceivable hazardous condition.” Id. n.11. And, although the Chairman dismisses the difficulties 

associated with modern section 6(b) rulemaking, a review of recent OSHA rulemaking efforts is 

instructive. Between 1981 and 2010, it took an average of 7 years to promulgate an OSHA 

standard. U.S. Gov’t Accountability Off., GAO-12-330, Workplace Safety and Health: Multiple 

Challenges Lengthen OSHA’s Standard Setting 7-8 (2012). And the difficulties associated with 

rulemaking have only increased over the ensuing years. Thus, for example, from the pre-rule phase 

7 
 

 

 

 

 

 

 

 

 

 

 

I. Jurisdiction 

Before the judge, Integra argued that “the violent conduct of a third party is an inherently 

unpredictable act of a different nature than the hazards typically regulated under the general duty 

clause.” The judge viewed this argument as a challenge to OSHA’s jurisdiction—“that the violent 

conduct at issue is fundamentally unpredictable and therefore cannot be regulated by the OSH 

Act”—and rejected it, stating that “the . . . violent incident . . . was reasonably foreseeable,” and 

“the hazard in this case [was] obvious.” According to Integra, the judge’s conclusion is erroneous 

because nothing “supports the Secretary’s contention that the general duty clause imposes upon an 

employer a duty to anticipate and prevent criminal attacks on employees by third parties.” The 

Secretary responds that the general duty clause does not exclude such a hazard from its coverage— 

he contends that, apart from having to be recognized and causing serious harm, “there is no further 

limitation on the scope of hazards that employers must address under section 5(a)(1).” For the 

reasons that follow, the allegation of workplace violence as presented in this case is a cognizable 

“hazard” under the Act. 

“[T]he starting point for interpreting a statute is the language of the statute itself.” 

Consumer Prod. Safety Comm’n v. GTE Sylvania, Inc., 447 U.S. 102, 108 (1980). We “must 

assume that Congress intended the ordinary meaning of the words it used, and absent a clearly 

expressed legislative intent to the contrary, that language is generally dispositive.” Gonzalez v. 

McNary, 980 F.2d 1418, 1420 (11th Cir. 1993); see also Blount Int’l, Ltd., 15 BNA OSHC 1897, 

1902 (No. 89-1394, 1992) (if provision’s wording is unambiguous, plain language governs); FDA 

v. Brown & Williamson Tobacco Corp., 529 U.S. 120, 132 (2000) (“The meaning—or ambiguity— 

of certain words or phrases may only become evident when placed in context.”); Am. Fed’n of 

Gov’t Emps., Local 2782 v. Fed. Labor Relations Auth., 803 F.2d 737, 740 (D.C. Cir. 1986) 

(“[S]tatutes . . . are to be read as a whole with each part or section . . . construed in connection with 

every other part or section.”) (citation omitted). As noted, the general duty clause provides that 

“[e]ach employer . . . shall furnish to each of his employees employment and a place of 

employment which are free from recognized hazards that are causing or are likely to cause death 

to final rule publication, two recently promulgated standards took eighteen years and twenty-one 

years, respectively, to complete. See Occupational Exposure to Respirable Crystalline Silica, 81 

Fed. Reg. 16,286, 16,295 (Mar. 25, 2016) (final rule); Confined Spaces in Construction, 80 Fed. 

Reg. 25,366 (May 4, 2015) (final rule). 

8 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or serious physical harm to his employees.” 29 U.S.C. § 654(a)(1). Thus, the jurisdictional issue 

presented here is whether the workplace violence alleged by the Secretary is a “hazard.” 

The term “hazard” is not defined in the Act, but its commonly understood meaning is 

“[s]omething causing danger,” “peril, risk, or difficulty.” RANDOM HOUSE DICTIONARY OF THE 

ENGLISH LANGUAGE 652 (1971); see United States v. Sherburne, 249 F.3d 1121, 1126 (9th Cir. 

2001) (“turn[ing] to the dictionary for guidance” in absence of statutory definition); Crawford v. 

Metro. Gov’t of Nashville & Davidson Cty., 555 U.S. 271, 276 (2009) (undefined term “carries its 

ordinary meaning”). The context in which the term is used makes clear that in the Act, “hazard” 

means a danger/peril/risk arising out of the employee’s work—in a broad sense. Specifically, the 

general duty clause references both “employment” and “place of employment,” so the hazards 

addressed by this provision include not only those arising out of the physical setting of the work, 

but those arising out of the “employment.” See RANDOM HOUSE DICTIONARY OF THE ENGLISH 

LANGUAGE at 468 (defining “employment” as “an occupation by which a person earns a living” or 

“work”); Allen v. U.S.A.A. Cas. Ins. Co., 790 F.3d 1274, 1284 (11th Cir. 2015) (rejecting “narrow 

interpretation” of undefined statutory term in light of term’s “ordinary meaning”). The broad 

nature of this concept is echoed in the Act’s findings and purpose section, which states that the 

statute is meant not only “to assure . . . safe and healthful working conditions” but also to address 

“personal injuries . . . arising out of work situations.” 29 U.S.C. § 651(a)-(b) (emphasis added). 

Here, there is a direct nexus between the work being performed by Integra’s employees 

and the alleged risk of workplace violence. Integra requires its service coordinators to meet faceto-face with members, many of whom have been diagnosed with mental illness and have criminal 

backgrounds as well as a history of violence and volatility.

5 Integra team supervisor Laurie 

Rochelle described certain members as just “getting out of jail,” “drug seeking,” “people with 

severe mental health issues,” and having “a history of violence.” In addition, the primary “place 

of employment” where the service coordinator’s work is performed is the member’s home, where 

5 Integra contends that it is “a disturbing line of reasoning” to conclude that service coordinators 

are at a heightened risk of violence because many of the individuals they serve are mentally ill, 

and that no scientific evidence was presented at the hearing showing that individuals with mental 

illness pose such a heightened risk. Our decision today makes no such conclusion about mental 

illness in general. Moreover, Integra’s concerns are belied by its own training materials, which 

specifically identify “[p]aranoia,” “[p]sychosis,” “[a]nti-social personality,” and “manic behavior” 

as “[r]isk [f]actors” and “[h]igh-[r]isk [b]ehaviors” tending toward violence from its members. 

9 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the service coordinator often makes unannounced visits. Service coordinators also use their own 

cars to drive members to medical appointments and occasionally must locate members in homeless 

shelters.6 Integra’s own training on “In-Home and Community Safety” assumes that providing 

these services to its members in these locations presents potential safety issues for service 

coordinators. Indeed, the training instructs service coordinators to “[k]now as much ahead of time 

what [you are] getting involved in,” “[v]isit during normal business hours if at all possible,” and 

“[d]on’t take chances, take precautions.” In short, the hazard identified by the Secretary is rooted 

in the very reason for Integra’s services—this means the hazard arises from the employment itself. 

Under these circumstances, the workplace violence risk at issue here is a “hazard” that fits plainly 

within the text of the general duty clause.

7 

6 In its amicus brief, the Chamber of Commerce suggests that these face-to-face meetings do not 

occur at a “place of employment,” as contemplated by the Act. 29 U.S.C. § 654(a). We disagree. 

As noted above, “employment” means “an occupation by which a person earns a living” or “work,” 

RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE at 468, so the plain meaning of “place 

of employment” is simply the location where that work occurs. Just as the “place of employment” 

of a construction worker is not limited to one permanent location but occurs wherever the work 

takes place, meeting with members at their homes and/or in their community is the foundation of 

Integra’s business model and a required aspect of the service coordinator’s employment. Integra’s 

lack of control over these locations may bear on what abatement measures are feasible, but it is 

undisputed that those locations are where the work at issue is performed. Cf. Capform, Inc., 13 

BNA OSHC 2219, 2222 (No. 84-556, 1989) (explaining the multi-employer worksite defense as 

predicated on an employer’s lack of “control [over] the violative condition such that it could [not] 

have abated the condition in the manner required by the standard,” but “not alter[ing] the general 

rule that each employer is responsible for the safety of its own employees”), aff’d, 901 F.2d 1112 

(5th Cir. 1990). 

7 Integra notes that the D.C. Circuit found in Oil, Chem. & Atomic Workers Int’l Union v. Am. 

Cyanamid Co., 741 F.2d 444 (D.C. Cir. 1984), that “[t]he words of the [Act]—in particular, the 

terms ‘working conditions’ and ‘hazards’—are not so plain that they foreclose all interpretation.” 

Id. at 448. American Cyanamid, however, did not find the term “hazard” ambiguous on its face. 

Instead, the court simply found an ambiguity as applied to the unusual facts of the case before it, 

and then concluded that a “policy which required women employees to be sterilized in order to be 

eligible to work in the areas of [the employer’s] plant where they would be exposed to certain toxic 

substances” was not a hazard cognizable under the Act. Id. at 446-47 (emphasis added). Here, by 

contrast, being physically assaulted by members is a risk in the ordinarily understood sense; it is 

not a direct and certain result of an employer’s policy, but rather arises directly out of the very 

duties a service coordinator is required to perform. As a result, in these factual circumstances, the 

term “hazard” is not ambiguous. See PGA Tour, Inc. v. Martin, 532 U.S. 661, 689 (2001) (“[T]he 

fact that a statute can be applied in situations not expressly anticipated by Congress does not 

demonstrate ambiguity. It demonstrates breadth.”). 

10 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notwithstanding the general duty clause’s plain language, Integra makes essentially three 

arguments as to why the provision cannot be invoked here. First, citing to the Commission’s 

decision in Pelron Corp., 12 BNA OSHC 1833 (No. 82-388, 1986), the company claims that “the 

decision of a human, imbued with free will, to engage in a violent attack on another person is 

inherently resistant to prediction,” so using the general duty clause to regulate such a hazard “is 

directly contrary to the principle that the clause . . . encompass[es] only those risks which an 

employer can reasonably be expected to prevent.”8 This concern, however, is addressed by the 

Act itself through the proof required to establish a general duty clause violation—the existence of 

a hazard, hazard recognition, feasibility of abatement, and material reduction of the hazard. It is 

also addressed, as discussed above, by the Act’s use of “hazard” in the context of “employment” 

and “place of employment”—in other words, the provision encompasses only hazards that arise 

out of (that is, have a sufficient nexus with) the work at issue. There is no basis for Integra’s 

implication that, beyond these express criteria, there are other, implicit jurisdictional limitations 

that exclude certain types of workplace hazards, particularly in light of the broad language of the 

8 Similarly, the Chamber of Commerce, in its amicus brief, cites Pelron for the proposition that 

“the normal activities of a business do not represent the types of ‘hazards’ that the general duty 

clause was intended to regulate”—specifically, the Chamber contends that the general duty clause 

has no application here because “[h]uman interaction . . . is an essential component of” Integra’s 

business. (Emphasis added.) Pelron, however, neither holds nor suggests that certain types of 

workplace hazards are beyond the Act’s coverage. Rather, the Commission in Pelron held that, in 

defining the hazard in a general duty clause case, the Secretary must specify “conditions or 

practices over which [an employer] can exercise control, which is the basis for [the employer’s] 

duty under section 5(a)(1).” 12 BNA OSHC at 1835; see SeaWorld of Fla. v. Perez, 748 F.3d 

1202, 1212 (D.C. Cir. 2014) (“Nothing . . . in Pelron immunizes a workplace’s dangerous ‘normal 

activities’ from oversight; the Commission simply applied well-established law that only 

‘preventable’ hazards can be considered as recognized.”); Beverly Enters., Inc., 19 BNA OSHC 

1161, 1187 n.58 (No. 91-3344, 2000) (consolidated) (“Pelron does not stand for the proposition 

that customary work activities cannot be a recognized hazard . . . [but rather] addresses . . . the 

preliminary question of how the hazard is to be defined . . . .”). Here, the alleged hazard goes 

beyond the omnipresent, background risk of violence; the Secretary specifically alleges the 

presence of an enhanced risk of violence arising from the nature of Integra’s work with a particular, 

high-risk group, and has specified conditions and practices (such as the circumstances under which 

service coordinators meet with members) over which Integra has control. Therefore, Pelron does 

not support the contention that workplace violence hazards are per se excluded from the general 

duty clause’s coverage, nor does it compel a ruling that the particular workplace violence hazard 

alleged in the instant case is excluded. 

11 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

general duty clause.9 See Allen, 790 F.3d at 1284 (applying “broad” ordinary meaning of pertinent 

term); GTE Sylvania, 447 U.S. at 108 (declining to limit meaning of ordinarily broad phrase in 

Consumer Product Safety Act); Gonzalez, 980 F.2d at 1421 (“Absent a clearly expressed 

legislative intent to the contrary, the plain and unambiguous language of the statute must prevail.”); 

see also Brown & Williamson Tobacco, 529 U.S. at 132 (statutory words and phrases are to be 

read in context). 

Second, Integra contends that invoking the general duty clause here raises public policy 

concerns. Specifically, the company contends that it would be inappropriate to deny its services 

to “uniquely vulnerable persons” with a history of violence, “notwithstanding the fact that such 

individuals are not presently under any restriction by the police or civil authorities.” Additionally, 

Integra claims that “given the racial disparities in criminal prosecutions in this country, any policy 

that an employer may enact to screen out individuals from receiving services based on their 

criminal histories would raise troubling concerns of discrimination.” These arguments, however, 

presuppose that the sole means of abating the alleged hazard is for Integra to refuse to serve certain 

individuals, a measure the Secretary has not proposed—in fact, he makes clear that his proposed 

abatement measures “are primarily designed to make such . . . interactions safer.” Moreover, even 

if such screening were the only means of abatement sought by the Secretary and doing so would 

violate anti-discrimination laws, the citation would necessarily fail under the feasibility of 

abatement element of the Secretary’s burden of proof, so there is no need to account for this “public 

policy” concern by narrowing the jurisdictional reach of the general duty clause. 

Finally, Integra asserts that “there is no rational way to define th[e] obligation [to screen 

its members] in such a way that it would not also apply to a range of employers whose workers 

perform work in the homes of their customers.” This claim lacks merit given the facts of this case. 

The danger or risk of workplace violence arises from the nature of both the “employment” and 

“place of employment” of Integra’s service coordinators. This renders the service coordinator 

position distinct from that of a generic service employee (such as a cable television or appliance 

technician); the latter interacts with the general population, while service coordinators assist a 

9 Indeed, counsel for the Secretary asserted at oral argument that it would be “extreme” to conclude 

that this hazard is outside the limit of the broadly-worded general duty clause given that, according 

to the Bureau of Labor Statistics, “[w]orkplace homicides remained the number one cause of 

workplace death for women in 2009.” OSHA Directive No. CPL 02-01-052, at 4 (Sept. 8, 2011). 

12 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

specific group of people with particular mental health conditions and criminal and/or violent 

backgrounds that create an enhanced potential for aggression and hostility.

10 Accordingly, 

Integra’s jurisdictional argument is rejected. 

II. Hazard Recognition 

Hazard recognition “may be shown by proof that ‘a hazard . . . is recognized as such by the 

employer’ or by ‘general understanding in the [employer’s] industry.’ ” Otis Elevator Co., 21 

BNA OSHC 2204, 2207 (No. 03-1344, 2007) (quoting Kokosing Constr. Co., 17 BNA OSHC 

1869, 1873 (No. 92-2596, 1996)); see Kelly Springfield Tire Co. v. Donovan, 729 F.2d 317, 321 

(5th Cir. 1984) (“Establishing that a hazard was recognized requires proof that the employer had 

actual knowledge that the condition was hazardous or proof that the condition is generally known 

to be hazardous in the industry.”). The judge concluded that recognition was established here, 

based in part on “Integra’s own training, handbook, and existing policies.” The record supports 

concluding that the hazard of a service coordinator being physically assaulted during a face-toface meeting by a member with a history of violent behavior was clearly recognized by Integra. 

Work rules addressing a hazard have been found to establish recognition of that hazard. 

See Otis Elevator, 21 BNA OSHC at 2207 (recognition established by work rules and safety 

protocols); Gen. Elec. Co., 10 BNA OSHC 2034, 2035 (No. 79-0504, 1982) (recognition 

established by safety “precautions [employer] has taken”); Wheeling-Pittsburgh Steel Corp., 10 

BNA OSHC 1242, 1246 (No. 76-4807, 1981) (consolidated) (“That [the employer] took some 

[safety] measures . . . to protect against this hazard, demonstrates that the hazard was recognized 

within the meaning of Section 5(a)(1).”); Ted Wilkerson, Inc., 9 BNA OSHC 2012, 2016 (No. 

13390, 1981) (“That Respondent . . . required the use of personal protective 

equipment . . . indicates that [Respondent] recognized the existence of a hazard . . . .”). While the 

10 Integra maintains that a decision finding the cited workplace violence hazard covered under the 

general duty clause will necessarily mean that all employers that provide in-home services— 

including services in the homes of the general population, such as cable TV installation—must 

screen their customers. Our decision today carries no such implication because, as explained, the 

requisite nexus between the risk of violence and the work involved must be present, as it is here. 

Nonetheless, Integra’s speculation in this regard highlights the benefits of addressing the hazard 

of workplace violence through notice-and-comment rulemaking. In a rulemaking proceeding, all 

interested persons would have the opportunity to be heard, and the Secretary would give clear 

notice of what is required of the regulated community. Indeed, the California Division of 

Occupational Safety and Health has promulgated a Workplace Violence Prevention in Health Care 

standard that went into effect in April 2017. Cal. Code Regs. tit. 8, § 3342. 

13 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commission has been “reluctant to rely solely on an employer’s safety precautions to find hazard 

recognition absent other ‘independent evidence,’ ” Mid South Waffles, Inc., No. 13-1022, slip op. 

at 8 (OSHRC Feb. 15, 2019) (citing Pepperidge Farm, Inc., 17 BNA OSHC 1993, 2007 (No. 89-

0265, 1997)), the record here establishes both that Integra had work rules addressing the hazard of 

workplace violence and that the company, through its supervisory personnel, otherwise recognized 

this hazard. 

As to work rules, the company’s training materials cover two topics addressing dangerous 

behavior from members—“Screening the Dangerous Member” and “Safety in the Community,” 

the latter of which included instruction on “[o]btaining critical history about previous unsafe 

behaviors,” “[o]bserving for . . . threats,” and identifying “[h]igh-[r]isk [b]ehaviors.” Dr. Melissa 

Arnott, Integra’s Vice President of Community Programs and co-developer of this training, “felt 

it was necessary to instruct [s]ervice [c]oordinators on how to identify and assess dangerous 

members, because [the service coordinators] would work directly with persons who were mentally 

ill,” and she conceded that she “recognize[d] . . . certain members might be dangerous” and might 

have had criminal histories.11 See Coleco Indus., Inc., 14 BNA OSHC 1961, 1966 (No. 84-546, 

1991) (hazard recognition established through actual knowledge of supervisor). Additionally, the 

OSHA compliance officer who conducted the inspection here testified that two other Integra 

supervisory employees told him that they were aware that members had criminal and violent 

11 Integra contends that the judge erred in considering evidence outside the record in evaluating 

Dr. Arnott’s credibility, and that his error warrants a remand for a new hearing. While 

summarizing Dr. Arnott’s testimony, the judge questioned the quality of the school from which 

she obtained her doctoral degree, relying on information that appears to be the product of his own 

research. For instance, the judge pointed out that the school filed a bankruptcy petition in 1991 

and had been described in some court filings as “a non-traditional university.” This led the judge 

to give Dr. Arnott’s degree less weight “than that [which would be] accorded a similar degree 

awarded following completion of a full-time, resident study program taken over the course of 

several years at a traditional university with a suitable accredited program.” The judge’s analysis 

and his reliance on information outside the record here is inappropriate. Nevertheless, it 

constitutes harmless error because Dr. Arnott’s testimony focused primarily on the various forms 

of training Integra provides its service coordinators, and the company does not challenge the 

judge’s finding that this training, along with the company’s other abatement measures, was 

inadequate. Indeed, as noted below, Integra’s only abatement argument concerns the efficacy of 

the Secretary’s proposed abatement measures. In short, while Integra describes Dr. Arnott as its 

“chief witness . . . concerning the nature of the Service Coordinator position and [the sufficiency 

of] Integra’s training programs,” her opinion regarding these issues is of little significance to the 

issues in dispute here. 

14 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

histories. See Caterpillar, Inc. v. OSHRC, 122 F.3d 437, 440 (7th Cir. 1997) (imputing 

supervisor’s recognition of hazard to employer). Finally, the record shows that threatening 

incidents were previously reported to Integra supervisors by several service coordinators, both in 

person and in the Reports they submitted. See Pepperidge Farm, 17 BNA OSHC at 2007, 2030-

31 (using employer’s knowledge of prior accidents and injuries as basis for recognition). Taken 

together, this evidence shows that before the alleged violation, Integra was aware that training its 

service coordinators to deal with violence from members was necessary, and therefore recognition 

of the hazard has been established. Id. at 2007 (voluntary safety efforts may be considered in 

conjunction with other, “independent evidence” to establish recognition element). 

On review, Integra relies on Megawest Financial, Inc., No. 93-2879, 1995 WL 383233 

(OSHRC May 8, 1995) (ALJ)—an unreviewed judge’s decision that is not binding Commission 

precedent—as support for its contention that recognition has not been proven. See Leone Constr. 

Co., 3 BNA OSHC 1979, 1981 (No. 4090, 1976) (“[A] Judge’s opinion . . . lacking full 

Commission review does not constitute precedent binding upon us.”). In that case, former 

Administrative Law Judge Nancy Spies found that what would suffice for recognition in “the 

typical [general duty clause] case” is insufficient with regard to a workplace violence hazard. 

Megawest, 1995 WL 383233, at *8. According to Judge Spies, “[i]t is not enough that an employee 

may fear that he or she is subject to violent attacks, even if that fear is communicated to the 

employer, . . . [n]or is it sufficient that there has been a previous injury from a violent incident.” 

Id. at *9. There is simply no need for “a high[er] standard of proof . . . to show that the employer 

itself recognized the hazard of workplace violence” than for employer recognition of other hazards 

alleged under the general duty clause. Id. Putting aside that Judge Spies cited no precedent in 

support of imposing this higher burden, her three-part rationale for reaching this conclusion is 

unconvincing. 

First, Judge Spies noted that the typical workplace hazard involves “inanimate 

objects . . . over which [an employer] can exercise . . . control,” not “people, capable of volitional 

acts.” Id. Control over employees, however, has long been required in the context of compliance 

with the Act—for example, employers must ensure that employees use ladders correctly, 29 C.F.R. 

§ 1926.1053(b); maintain proper clearance distances from electrical lines, 29 C.F.R. 

§ 1926.955(e)(15); use eye protection when welding, 29 C.F.R. § 1910.252(b)(2)(C); take certain 

actions when working in a confined space, 29 C.F.R. § 1910.146(h); and verify isolation and 

15 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

deenergization of equipment that is subject to lockout/tagout requirements, 29 C.F.R. 

1910.147(d)(6). See also Morrison-Knudsen Co., 16 BNA OSHC 1105, 1120-21 (No. 88-0572, 

1993) (noting Commission precedent holding that “the general duty clause is applicable to require 

a particular form of personal protective equipment . . . where . . . there is no [applicable] 

standard”); PSP Monotech Indus., 22 BNA OSHC 1303, 1307 (No. 06-1201, 2008) (affirming 

§ 5(a)(1) violation based on employer’s failure to keep employees clear of suspended loads). Even 

compliance with OSHA requirements that are not specifically directed at the actions of employees 

typically depends on employees properly executing assigned tasks that are necessary for 

compliance. See, e.g., 29 C.F.R. §§ 1926.652(b)(1)(i) (“Excavations shall be sloped at an angle 

not steeper than one and one-half horizontal to one vertical . . . .”), 1926.502(b)(1)-(b)(15) (criteria 

for “[g]uardrail systems” used as fall protection), 1926.451(f)(3) (“Scaffolds . . . shall be inspected 

for visible defects by a competent person . . . .”). Indeed, the expectation that employees will 

complete such tasks is the underlying basis for the unpreventable employee misconduct defense. 

See L.E. Myers Co., 16 BNA OSHC 1037, 1042 (No. 90-945, 1993) (concept underlying UEM 

defense is that employee “failures . . . to comply with the applicable standards [have] occurred 

despite a vigorous program of safety education and enforcement”). 

In Commissioner Attwood’s view, the judge’s second rationale—that an “employer has 

even less control over . . . third parties not in its employ”—ignores a number of OSHA standards 

that address the “third-party” hazards posed by vehicular traffic. Megawest, 1995 WL 383233, at 

*9. See 29 C.F.R. §§ 1926.200(g) (requiring traffic signs), 1926.201(a) (criteria for flaggers), 

1926.202 (requiring traffic barricades), 1926.651(d) (excavation requirement regarding 

“[e]xposure to vehicular traffic”), 1910.269(e)(7) (regarding electrical work in enclosed spaces, 

and requiring “an attendant with first-aid training . . . to provide assistance if a hazard exists 

because of traffic patterns in the area of the opening used for entry”). Cf. Summit Contractors, 

Inc., 23 BNA OSHC 1196, 1206 (No. 05-0839, 2010) (affirming § 1926.404(b)(1)(ii) violation 

against controlling employer for defective electrical box supplied by third party), aff’d, 442 F. 

App’x 570 (D.C. Cir. 2011). Several of these requirements predate the Act and remain largely 

unchanged today. See Safety and Health Regulations for Construction, 36 Fed. Reg. 7,340, 7,356-

57 (Apr. 17, 1971) (promulgating predecessor traffic safety standards under Construction Safety 

Act, 29 C.F.R. §§ 1518.200, 1518.201, 1518.202). Thus, Commissioner Attwood finds no basis 

16 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for viewing this “third-party” consideration as justification for a higher standard of proof for 

employer recognition.

12 

Finally, the judge noted that “violence exists in society [at large],” which has 

“empower[ed] the police,” and not employers, “to control [violent] conduct.” Megawest, 1995 

WL 383233, at *9. The ubiquity of violence in society, however, is not an indicator of the difficulty 

of recognizing a workplace hazard. For example, medical emergencies and fire hazards are quite 

common, and emergency medical personnel and fire departments have traditionally been relied 

upon to address such hazards, but these are not grounds to conclude that they are less easily 

recognized as workplace hazards. Cf. 29 C.F.R. §§ 1910.151 (medical and first aid standard), 

1910.155 through 165 (fire protection), 1926.24 (fire protection and prevention in construction).13 

As discussed, a more relevant factor in assessing whether a workplace violence hazard is 

recognized by an employer is the extent to which there is a nexus between the nature of that hazard 

and the work being performed, which is clearly the case here. 

Two circuit court cases have addressed the Megawest decision, but neither dictates 

reaching a different conclusion on the issue of hazard recognition. In SeaWorld of Fla. v. Perez, 

748 F.3d 1202 (D.C. Cir. 2014), the court affirmed a general duty clause violation based on the 

hazard of “drowning or injury when working with killer whales during performances” and rejected 

the employer’s contention that, pursuant to Pelron, the hazard posed by the whales was not covered 

by the Act because it was so “idiosyncratic and implausible that it cannot be considered 

preventable.” Id. at 1205, 1210. Without elaboration, the court noted that the facts in SeaWorld 

were distinguishable from those in Megawest: “SeaWorld controls its employees’ access to and 

contact with its killer whales, unlike the employer in Megawest . . . , who could not prevent the 

potentially criminal, violent actions of third parties residing in the apartment buildings it 

managed.” Id. at 1210. In making this distinction, the court relied on what it assumed was 

Megawest’s inability to abate (“could not prevent”) the workplace violence hazard, not its inability 

to recognize it; indeed, Judge Spies never addressed in her Megawest decision whether any 

proposed abatement measure would have been feasible or effective, given that she vacated the 

12 Commissioner Sullivan would find that there is no need for a higher standard of proof for 

employer recognition in cases like Megawest so long as the Secretary is able to prove that the 

hazard in question is reasonably foreseeable by the employer. He is not relying, therefore, on 

OSHA standards addressing third-party behavior in arriving at this determination. 

13 These particular OSHA standards have been in place since the 1970s. 

17 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

citation for lack of hazard recognition. See Megawest, 1995 WL 383233, at *11 (“[W]hether the 

Secretary’s suggested means of abatement would eliminate or materially reduce the hazard need 

not be addressed.”). Accordingly, the SeaWorld court’s reference to Megawest is not an 

endorsement of that decision’s unsupported analysis regarding hazard recognition. 

The other circuit case addressing the Megawest decision, Ramsey Winch, Inc. v. Henry, 

555 F.3d 1199 (10th Cir. 2009), is cited by the Chamber of Commerce in its amicus brief. In that 

case, several businesses seeking to enjoin enforcement of an Oklahoma law requiring employers 

to allow employees to store firearms in locked vehicles on company property argued that the state 

law was preempted by the Act’s general duty clause. Id. at 1202. The court disagreed, concluding 

that the presence of the stored firearms is “too speculative” a danger to be a “recognized hazard” 

under the general duty clause—accordingly, an employer’s general duty clause obligation would 

not conflict with its ability to comply with the state law. 555 F.3d at 1207; see also id. at 1206 

(describing hazard in Megawest as “random physical violence”) (emphasis added). The Chamber, 

in arguing that the workplace violence hazard cited here is not “recognized,” attempts to analogize 

it to this “speculative” firearm hazard. The court in Ramsey Winch, however, expressly 

distinguished the firearm hazard from a circumstance “in which a psychiatric hospital . . . fail[ed] 

to protect its workers from patients’ violent behavior,” stating that “[a] primary function of a 

psychiatric hospital’s work is to manage unstable and often violent behavior . . . arising out of 

work situations.” 555 F.3d at 1207 n.8 (emphasis added) (citation omitted). In other words, the 

court acknowledged that such violence at a psychiatric hospital could be a recognized hazard, 

given the nexus between it and the employment at issue. That is precisely the case here. 

Accordingly, Integra’s reliance on Megawest is misplaced. The Secretary, therefore, has proven 

employer recognition. 

III. Feasibility of Abatement 

The final issue is whether the Secretary has established “that the [proposed abatement] 

measures are capable of being put into effect and that they would be effective in materially 

reducing the incidence of the hazard.”14 Beverly Enters., Inc., 19 BNA OSHC 1161, 1190 (No. 

14 The Secretary must also show, “as a threshold matter, that the methods undertaken by the 

employer to address the alleged hazard were inadequate.” U.S. Postal Serv., 21 BNA OSHC 1767, 

1773-74 (No. 04-0316, 2006). The judge concluded that the Secretary carried this burden and 

Integra does not challenge the judge’s ruling. 

18 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

91-3344, 2000) (consolidated). The Secretary asserts in the citation that “[a]mong other methods, 

feasible means to abate this hazard include” the following: 

• Creat[ing] a stand-alone written Workplace Violence Prevention Program for 

all the service programs[,] . . . includ[ing] . . . a policy that workplace violence 

will not be tolerated and every incident will be investigated[,] . . . [t]raining 

and education of all staff[,] . . . [i]ncident reporting and 

investigation[,] . . . [and] [a] system for reporting safety concerns internally. 

• Determin[ing] the behavioral history of new/transferred 

member[s]; . . . identify[ing] members with assaultive behavior 

problems . . . and . . . communicat[ing] such pertinent information to all 

potentially exposed employees; . . . and hav[ing] a system for holding members 

accountable for violent behavior through consequences or interventions. 

• Put[ting] procedures in place that would communicate any incident of 

workplace violence to all staff who could potentially be exposed to the 

member(s) involved in the violent incident in a timely manner . . . . 

• Training all employees on effective methods for responding during a workplace 

violence incident[,] . . . [including] recognizing aggressive behavior exhibited 

by members or others, and . . . techniques for timely de-escalating the behavior. 

• Implement[ing] and maintain[ing] a buddy system as appropriate based on a 

complete hazard assessment which includes procedures for all staff to request 

and obtain double coverage when necessary, including but not limited to 

situations where an employee communicates that he or she feels unsafe being 

alone with a particular member. 

• Provid[ing] all staff with a reliable way to summon assistance when 

needed, . . . including when an employee is with a member . . . . 

• Establish[ing] a liaison with law enforcement representatives. 

The judge noted that Integra did not claim that the Secretary’s proposed abatement methods were 

infeasible—indeed, he found that the company had since implemented some of these methods, 

such as regularly performing background checks on members before assigning them to service 

coordinators; initiating “red flags” on those members with criminal histories, so that employees 

are notified; and instituting a written workplace violence prevention program with mandatory 

reporting requirements. 

The only abatement argument Integra made to the judge, and the only one the company 

now makes on review, is that the Secretary failed to establish that the proposed abatement measures 

would materially reduce the incidence of the workplace violence hazard. The judge rejected this 

contention largely based on the testimony of Janet Nelson, the Secretary’s expert in clinical social 

work, personal safety awareness, and personal safety skills and safety programs for health and 

19 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

human service workers. On review, Integra contends that Nelson was “noncommittal” on the issue 

of abatement efficacy and that her testimony was therefore insufficient to establish that the 

methods would materially reduce the incidence of the hazard. Specifically, Integra focuses on 

three aspects of Nelson’s testimony in which, the company contends, she was equivocal on this 

element of the Secretary’s burden. 

Integra first points to an exchange between Nelson and the Secretary’s counsel concerning 

safety training: 

Q. In your opinion, even though Service Coordinators are not clinicians, would 

more – more adequate, more . . . appropriate safety training have made them 

less exposed to the workplace violence, risk of workplace violence? 

A. I don’t know if they would be less exposed. They may be better able to 

assess . . . red flags . . . . 

Nelson was not equivocating here. She was simply distinguishing between the extent of exposure 

(that is, the number of potentially violent members with whom the service coordinator may 

work)—a factor that would be unaffected by training—and training service coordinators as to how 

to respond when encountering such members. In any event, Nelson later explained how and why 

training in de-escalation and self-defense techniques would be effective—it would allow service 

coordinators “to move [their] bod[ies] in a certain way so that [they] can escape without actually 

ever even touching the person,” and would be “useful to [them] in the type of work that they were 

doing.” 

Integra next claims that Nelson conceded in the following exchange that violent incidents 

could still occur even if a buddy system were made into a mandatory, formalized program: 

Q. Are you saying that . . . Integra should have required its Service Coordinators 

to always be partnered? 

A. No, no. [] I think given the population they’re dealing with and because they 

have a paucity of information, that double teaming on an initial . . . helps. 

Does that mean violence won’t happen? It still could. It still could. 

Again, this testimony is not equivocal, particularly in light of Nelson’s testimony immediately 

following that “the likelihood [of violence] is less because you have two people,” and that using a 

buddy system for “at least the first few visits where you’re familiarizing yourself with the client 

and establishing the relationship” would help “the worker feel safe,” and “through that, the client 

feels safe.” 

20 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The final exchange upon which Integra relies shows, according to the company, that Nelson 

“could offer only a guess” regarding the effectiveness of member background checks: 

Q. In your opinion, does a risk – violence risk assessment . . . does that decrease 

the incidence of workplace violence? 

A. I don’t know statistics on that, but yes, the more information you have on 

what you’re walking into, the better off you are. 

Q. (Nodding affirmatively.) 

A. So I guess I would say yes. 

In the context of the rest of her testimony, however, Nelson’s use of the word “guess” does not 

weaken her expert opinion on this issue. As a whole, her expert testimony is sufficient to establish 

the feasibility and efficacy of the Secretary’s proposed abatement measures. Beverly Enters., Inc., 

19 BNA OSHC at 1190.15 Therefore, the Secretary has established the feasibility of abatement 

element of his case. 

15 Integra contends that the general duty clause is unconstitutionally vague as applied here because 

the Secretary has failed to show that a reasonably prudent employer would have known that it was 

required to implement the proposed methods of abatement. Specifically, the company cites 

Donovan v. Royal Logging, 645 F.2d 822 (9th Cir. 1981), which states that “problems of fair notice 

[posed by general duty clause citations] . . . dissipate when we read the clause as applying when a 

reasonably prudent employer in the industry would have known that the proposed method of 

abatement was required.” Id. at 831. Royal Logging, however, is not relevant precedent in this 

case, which could be appealed to the Fourth Circuit (Integra is headquartered in Maryland), the 

Eleventh Circuit (the events giving rise to the citation were in Florida), or the D.C. Circuit. See 

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 . . . .”); Kerns Bros. Tree Serv., 18 

BNA OSHC 2064, 2067 (No. 96-1719, 2000) (Commission generally applies law of circuit where 

it is probable case will be appealed). 

In any event, Commission precedent states that “[t]he question is whether a precaution is 

recognized by safety experts as feasible, and not whether the precaution’s use has become 

customary.” Beverly Enters., 19 BNA OSHC at 1191. Also, Integra’s constitutional vagueness 

challenge fails because the proposed abatement measures here were available to, and readily 

knowable by, the industry—indeed, as the CO testified, they were derived from OSHA’s 

workplace violence directive, which was issued in September 2011, more than a year prior to the 

inspection. OSHA Directive No. CPL 02-01-052 (Sept. 8, 2011); see Pegasus Tower, 21 BNA 

OSHC 1190, 1191 (No. 01-0547, 2005) (affirming judge’s finding that feasibility-of-abatement 

element was satisfied by means “set forth in OSHA Instruction Compliance Directive 2-1.29” 

regarding fall hazards). 

21 
 

 

 

 

 

 

 

 

 

 

 

For all of these reasons, we conclude that a violation of the general duty clause has been 

proven and therefore affirm the citation.16 

SO ORDERED. 

/s/_________________________ 

Cynthia L. Attwood 

Commissioner 

Dated: March 4, 2019 

/s/_________________________ 

James J. Sullivan, Jr. 

Commissioner 

16 Integra contends that the violation should not be characterized as serious because the company 

did not know, and could not reasonably be expected to know, that it was in violation of the Act. 

To avoid a serious characterization, the record must show that “the employer did not, and could 

not with the exercise of reasonable diligence, know of the presence of the violation.” 29 U.S.C. 

§ 666(k) (emphasis added). Here, the Secretary has established Integra’s actual knowledge of the 

violative condition, based on testimony showing supervisor awareness that service coordinators 

were interacting with potentially dangerous members. See Trumid Constr. Co., 14 BNA OSHC 

1784, 1788-89 (No. 86-1139, 1990) (equating knowledge element of Secretary’s prima facie case 

with knowledge necessary to establish serious violation under 29 U.S.C. § 666(k)). As such, and 

in light of the fact that Integra challenges no other aspect of characterization, nor does the company 

contest the amount of the penalty, we affirm this violation as serious and assess the Secretary’s 

$7,000 proposed penalty. 

22 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 I 

SULLIVAN, Commissioner, concurring: 

I am in agreement with Commissioner Attwood for the reasons stated in our opinion.

write separately to expand on several aspects of that opinion. I believe that Congress did not 

contemplate that the Secretary would apply the general duty clause to workplace violence hazards. 

Nevertheless, I agree that the general duty clause does cover the hazard alleged in this specific 

case, but I arrive at this conclusion because, in addition to the conclusions I reach with 

Commissioner Attwood regarding hazard recognition and feasible abatement, I find that the 

Secretary established that the hazard cited here was reasonably foreseeable to a “reasonable 

employer” presented with the specific facts and circumstances in this case. 

The general duty clause was “designed to fill those interstices necessarily remaining after 

the promulgation,” through notice-and-comment rulemaking, “of specific safety standards.” 

Bristol Steel & Iron Works, Inc. v. OSHRC, 601 F.2d 717, 721 (4th Cir. 1979). Although specific 

obligations under the general duty clause are not subject to notice-and-comment, they are as 

subject to the constitutional requirement of fair notice as any other law. See, e.g., Otis Elevator 

Co., 21 BNA OSHC 2204, 2206 (No. 03-1344, 2007) (“[T]he Secretary must define the cited 

hazard [in a general duty clause case] in a manner that gives the employer fair notice of its 

obligations . . . .”). Because of section 5(a)(1)’s broad language, meeting the fair notice 

requirement in a general duty clause case is, however, inherently problematic—employers cannot 

be left only to guess at their legal obligations. When it comes to hazards that are also of a broad 

nature, such as workplace violence, this notice problem is further compounded, so employers need 

some way of evaluating whether they could be held in violation of the general duty clause in the 

event of a violent incident at the workplace. Unsurprisingly, in such situations OSHA often 

proffers guidance to the regulated community, as it has done here, to establish the requisite notice. 

See, e.g., Reflections Tower Serv., Inc., No. 00-1201, 2001 WL 777056, at *4 (OSHRC July 2, 

2001) (ALJ) (“In [attempting to] prov[e] the alleged violation, the Secretary is relying on OSHA 

Instruction CPL 2-1.29 . . . .”). This practice is troubling because such guidance, which is an 

obvious attempt to provide the specificity lacking in the general duty clause itself, effectively 

becomes a mandatory compliance requirement that was neither contemplated by Congress nor 

23 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

subjected to notice-and-comment rulemaking.1 Accordingly, especially when dealing with a broad 

hazard such as workplace violence, a check on the application of the general duty clause is 

necessary. 

In a case involving workplace violence, proof of reasonable foreseeability is the only way, 

in my view, that the Secretary can prove that a hazard “exists” or is “cognizable” under the general 

duty clause. “Congress quite clearly did not intend the general duty clause to impose strict 

liability: The duty was to be an achievable one.” Nat’l Realty & Constr. Co. v. OSHRC, 489 F.2d 

1257, 1265-66 (D.C. Cir. 1973). As such, the intent was “to limit the general duty imposed by 

section 5(a)(1) to preventable hazards.” Pelron Corp., 12 BNA OSHC 1833, 1835 (No. 82-0388, 

1986). Preventability, in my view, must include some element of foreseeability—indeed, any 

hazard that is unforeseeable cannot meaningfully be prevented, nor can it be truly “recognized.” 

29 U.S.C. § 654(a)(1). In other words, an employer cannot be held responsible for a hazard over 

which it has no control, and the occurrence of which it cannot predict. See Pratt & Whitney 

Aircraft v. Sec’y of Labor, 649 F.2d 96, 101 n.2 (2d Cir. 1981) (violation must, at a minimum, be 

reasonably foreseeable to be deemed a serious violation). Put another way, “[i]f an employer, in 

the exercise of reasonable diligence cannot foresee that a hazardous incident will occur, the 

employer cannot be found in violation of the Act.” U.S. Steel Corp., 10 BNA OSHC 1752, 1760 

(No. 77-1796, 1982) (Cottine, Comm’r, concurring) (citing Gen. Elec. Corp., 9 BNA OSHC 1722, 

1733 (No. 13732, 1981)). 

1 The Department of Justice has recently emphasized that “[g]uidance documents cannot create 

binding requirements that do not already exist by statute or regulation.” Justice Manual, Title 1-

20.000 (Dec. 2018) (adopting Memorandum from Assoc. Att’y Gen. to Heads of Civil Litigating 

Components and U.S. Attorneys, “Limiting Use of Agency Guidance Documents in Affirmative 

Civil Enforcement Cases” (Jan. 25, 2018)). The Justice Manual instructs Justice Department 

attorneys to “not treat a party’s noncompliance with a guidance document as itself a violation of 

applicable statutes or regulations,” but instead to “establish a violation by reference to [the] statutes 

and regulations” themselves. Id. Although this Manual is inapplicable to agencies outside the 

Justice Department, OSHA guidance documents do typically contain disclaimers asserting that the 

guidance does not create any legal obligations. See, e.g., “Guidelines for Preventing Workplace 

Violence for Health Care and Social Service Workers,” OSHA Publication 3148-01R (2004) 

(“This informational booklet . . . does not alter or determine compliance responsibilities in OSHA 

standards or the Occupational Safety and Health Act of 1970.”). These disclaimers, however, are 

rendered meaningless when the agency uses its guidance in enforcement actions to compensate for 

the lack of specificity in the general duty clause. 

24 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is especially relevant in the workplace violence context—one cannot just rely on broad 

assumptions concerning the potentially violent behavior of a whole population. Moreover, such 

violence is in many cases inherently unpredictable, as it is the result of an individual’s affirmative, 

volitional, and deliberate choice. We should not, therefore, adopt a broad reading of the Act that 

would make an employer liable for every violent act committed against the employer’s employees. 

OSHA itself has acknowledged as much, instructing its personnel to gather specific documentation 

when “conducting a programmed inspection where a reasonably foreseeable workplace violence 

hazard has been identified.” OSHA Directive, Enforcement Procedures and Scheduling for 

Occupational Exposure to Workplace Violence, CPL 02-01-058, at 4 (Jan. 10. 2017). Indeed, 

OSHA instructs its personnel that, in analyzing whether a workplace violence hazard exists in a 

given case, the question is, “Were the employer’s own employees exposed to a foreseeable, 

hazardous workplace condition or practice?” Id. at 8 (emphasis added). Accordingly, in my view, 

a workplace violence “hazard” exists, and may be citable under the general duty clause, only when 

the hazard was reasonably foreseeable based on facts that would lead a “reasonable employer” to 

conclude that a violent incident could occur in its workplace. 

I join with Commissioner Attwood in recognizing that foreseeability (though described 

differently in that opinion) is an important consideration with regard to both the existence of the 

hazard and the “hazard recognition” elements in a case alleging a workplace violence hazard under 

the general duty clause. Specifically, our opinion applies the “nexus” concept in finding both the 

“existence” of a hazard in this case and, in part, in finding “hazard recognition.” For example, in 

discussing the required proof of the “existence” of a hazard that is “cognizable” under the general 

duty clause in this case, the opinion states that “there is a direct nexus between the work being 

performed and the alleged risk of workplace violence.”2 The opinion also states that “the requisite 

nexus between the risk of violence and the work involved must be present.” At the same time, 

when discussing the second step of “hazard recognition” the opinion states that the more relevant 

factor in assessing whether a workplace violence hazard is recognized by an employer is the extent 

to which there is a nexus between the nature of that hazard and the work being performed, which 

is clearly the case here. 

2 Our opinion states: “In short, the hazard identified by the Secretary is rooted in the very reasons 

for Integra’s services—this means the hazard arises from the employment itself.” 

25 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I believe this is no coincidence, as the examination of “cognizable hazard” and “hazard 

recognition” necessarily implicates the question of whether it was reasonably foreseeable to a 

“reasonable employer” presented with the same set of facts. For example, the “nexus” discussed 

in our opinion may be readily apparent in the case of a psychiatric hospital, but what are the factors 

to consider when examining the nexus question when it is not so obvious? If such a nexus is not 

so apparent, how will an employer know whether the “nexus” applies where its employees work? 

For instance, if a “security company” employee in the lobby of a downtown office building 

is murdered by a mentally disturbed law firm client, is there a sufficient nexus between the 

homicide and the specific work duties of that employee—i.e., checking identifications of those 

wishing to enter the building? Is the fact that the employer calls its employees “security guards” 

sufficient to prove the “nexus”? What other factors does an employer need to examine in advance 

to determine whether it may be subject to a citation under section 5(a)(1) in these hypothetical 

circumstances? Does it matter that the employer’s “security” personnel are neither expected nor 

trained to confront a “dangerous” visitor, but only are expected to call law enforcement? What if 

no other security employee of this company has ever been confronted by any act of violence in 

this workplace, or at any of its other sites of employment? What if these security guards do receive 

some limited training by their employer in “handling” angry or upset visitors? Consequently, the 

“nexus” question must necessarily include an examination of reasonable foreseeability, which 

involves facts such as a prior history of any exposure to violence. Without the express 

incorporation of such a reasonable foreseeability inquiry, the “nexus” test alone will not provide 

an employer with fair notice that a workplace violence hazard exists or is “cognizable” at a specific 

workplace. 

In Bomac Drilling, 9 BNA OSHC 1681 (No. 76-0450, 1981) (consolidated), overruled by 

U.S. Steel Corp., 10 BNA OSHC 1752 (No. 77-1796, 1982), the Commission held that “to 

establish a section 5(a)(1) violation, the Secretary must show that . . . the occurrence of an incident 

[of the hazard] was reasonably foreseeable.” Id. at 1691 (emphasis added). The Commission 

overruled Bomac because it concluded that the “reasonable foreseeability” element is the “same 

as [whether] the employer had failed to free its workplace from a recognized hazard,” and because 

it found that the reasonable foreseeability concept “simply added an unnecessary complication to 

the analysis of section 5(a)(1) cases.” See U.S. Steel, 10 BNA OSHC at 1756-57; see also Bomac, 

9 BNA OSHC at 1700-01 (Cleary, Comm’r, concurring) (“[R]easonable foreseeability . . . 

26 
 

 

 

 

 

 

 

 

 

 

 

 

 

unnecessarily complicates the analysis of section 5(a)(1) violations while serving no useful 

purpose in that analysis.”). In my view, the Commission got it wrong in U.S. Steel. I agree with 

Commissioner Cottine’s concurrence in U.S. Steel in which he cites National Realty and 

emphasizes that “requiring . . . an incident to be reasonably foreseeable is necessary to assure that 

the employer is not held to a standard of strict liability under section 5(a)(1).” U.S. Steel, 10 BNA 

OSHC at 1760. Indeed, the Commission in Bomac, in a decision written by Commissioner Cottine, 

held that the Secretary had to prove four elements: (1) the Respondent failed to render the 

workplace free from a hazard that is recognized; (2) the occurrence of an incident was reasonably 

foreseeable; (3) the likely consequence in the event of an accident was death or serious physical 

harm to its employees; and, (4) there were feasible means available to abate the hazard. Bomac, 9 

BNA OSHC at 1691. 

Since it is clear that reasonable foreseeability is a necessary element in both (1) cognizable 

hazard and (2) hazard recognition, I view the test set forth by Commissioner Cottine in the majority 

opinion in Bomac as the more accurate reading of what the Act requires the Secretary to prove in 

a general duty clause case. In short, I do not believe a workplace violence “hazard” can exist, nor 

can it be truly “recognized,” if the violence at issue cannot be reasonably foreseen. Therefore, I 

would require the Secretary to show that an incident of violence (for example, an assault, battery, 

or homicide) was reasonably foreseeable. As the Commission ruled in Bomac, this does not mean 

that the occurrence of an incident of violence need be likely, only that it is foreseeable. While I 

concur in the result here, and therefore find a recognized workplace violence hazard, it is only 

because the record establishes the reasonable foreseeability of Integra’s service coordinators being 

physically assaulted by members with a history of violent behavior.

3 

In sum, I believe that requiring the Secretary to demonstrate that it was “reasonably 

foreseeable” to a “reasonable employer” that the employer’s employees would be subject to an 

alleged workplace violence hazard is the only way to provide fair notice to an employer that a 

“hazard” of workplace violence “exists” and is “cognizable” for purposes of the general duty 

clause. Facts that would be considered in finding such a “cognizable” hazard in such a case would 

3 This test does not use the word “reasonable” in the context of a standard of care an employer 

owes to its employees, but rather it distinguishes a preventable danger from an unpreventable one. 

An employer cannot be held responsible for not taking feasible precautions to prevent a hazard 

over which it has no control or means to anticipate its occurrence. 

27 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

be the objective facts that were available to a “reasonable employer,” which would inform the 

employer of the risks of violence to which its employees may be exposed, i.e., whether it was 

“reasonably foreseeable” for the employer to anticipate such exposure. 

Therefore, to establish a violation of the general duty clause in a workplace violence case, 

I believe the Secretary must show that at the time of the incident: 

 there was a recognized hazard because the Secretary has shown (a) there was 

“a tangible and appreciable risk,” Beverly Enters., Inc., 19 BNA OSHC 1161, 

1172 (No. 91-3144, 2000) (consolidated), of the act of violence coming to 

fruition—that is, employees were faced with something more than the risk of 

violence to which the public at large is subject—and (b) the occurrence of a 

violent incident was reasonably foreseeable in the circumstances presented by 

the case;4 

 the violence was likely to cause death or serious physical harm; and 

 there were feasible means of abating the hazard by preventing employees from 

being exposed to the violence. 

I join with Commissioner Attwood in our analysis of the latter two elements, and I therefore 

agree that those elements have been established. As to the first element, I find that Integra clearly 

recognized the hazard cited here. Its supervisors were well aware that service coordinators were 

being sent, in many cases unannounced, to meet face-to-face with members with a history of 

violent behavior. Additionally, in Employee-A’s case, Integra’s supervisors ignored several 

warning signs in the reports she submitted concerning her visits to Member-L’s home and allowed 

her to continue those visits by herself. I find that in the circumstances presented here, an incident 

involving an act of violence was reasonably foreseeable and that was likely to cause death or 

serious physical harm. Furthermore, I find that Integra had knowledge that the hazard of violence 

posed by its members existed at its service coordinators place of employment, such that they were 

4 In my view, the “jurisdictional” argument presented by Integra concerning “hazard” under the 

general duty clause is a red herring. The question of whether any allegation of a workplace hazard 

in a particular case “exists,” or is “cognizable” under the general duty clause is, in my opinion and 

as discussed above, answered by whether it is foreseeable by a “reasonable” employer that 

employees are presented with a risk of violence at work that is “preventable.” In other words, the 

nexus between the risk of violence and the work involved is part of the foreseeability question. If 

such a hazard is not “preventable” and thus not foreseeable, the violence hazard is not “related” to 

the workplace, but is simply the same risk of violence to the general public in the same area. 

28 
 

 

 

-

exposed to it, and that there were feasible means of abatement to materially reduce or eliminate 

the hazard. Accordingly, I concur in affirming the citation item at issue. 

/s/________________________________ 

Dated: March 4, 2019 James J. Sullivan, Jr. 

Commissioner 

29 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MACDOUGALL, Chairman, concurring: 

Today, for the first time, the Commission is faced with deciding whether an alleged 

workplace violence hazard—specifically, one posed by a schizophrenic client of an employer in 

the social services industry—is a recognized hazard that the employer must “free” from its 

workplace.1 One aspect of this question is not difficult: there is no doubt that Integra’s service 

coordinators were vulnerable employees and the tragedy in this case was foreseeable. Indeed, the 

hazard of workplace violence could be said to not only be known by Integra’s industry but by 

anyone paying attention to the news media today. The other aspect of this question is more 

challenging: it is the broader issue of whether in 1970, when Congress enacted the Occupational 

Safety and Health Act, it intended for workplace violence to be covered as a hazard under section 

5(a)(1). 

In assessing Congress’ intent and addressing the scope of the general duty clause as it 

applies in this case, I am mindful of two essential touchstones—an employer’s constitutional right 

to fair notice and the fact that an employer’s liability under the general duty clause is limited to 

conditions and practices that it can control. When a hazard alleged under section 5(a)(1) is defined 

in a way that is overly broad, it deprives the employer of the requisite notice and often invokes a 

risk that is inherent (and thus unpreventable) in the workplace. Pelron Corp., 12 BNA OSHC 

1833, 1835 (No. 82-0388, 1986) (“To permit the normal activities in . . . an industry to be defined 

as a ‘recognized hazard’ within the meaning of section 5(a)(1) is to eliminate an element of the 

Secretary’s burden of proof and, in fact, almost to prove the Secretary’s case by definition, since 

under such a formula the employer can never free the workplace of inherent risks incident to the 

business.”) (underline emphasis added). See also Mid South Waffles, Inc., No. 13-1022, slip op. 

at 22-23 (OSHRC Feb. 15, 2019) (“Waffle House”) (MacDougall, Chairman, concurring) 

(Secretary’s overly broad hazard definition—risk of burns from failing to properly maintain grease 

drawer to prevent grease fire—fails to provide adequate notice of protective measures employer 

could implement); Mo. Basin Well Serv., Inc., 26 BNA OSHC 2314, 2316 n.5 (No. 13-1817, 2018) 

(MacDougall, Chairman, concurring) (alleged hazard—unsafe distance between pump and 

discharges of oil and gas from tank—was too broadly defined to give employer fair notice). 

1 The Secretary alleges a violation of the general duty clause for exposing employees “to the hazard 

of being physically assaulted by [clients] with a history of violent behavior.” 

30 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

I wrote separately in A.H. Sturgill, and do so again here, to highlight these fundamental 

limitations on enforcement and to express my concern about the Secretary’s invocation of the 

general duty clause in circumstances Congress likely never contemplated. Recent cases like A.H. 

Sturgill—where the Secretary alleged that an excessive heat hazard existed at an Ohio roofing 

worksite in August—demonstrate that the Secretary has failed to give these considerations 

sufficient regard. A.H. Sturgill Roofing, Inc., No. 13-0224, slip op. at 2 (OSHRC Feb. 28, 2019). 

These cases include allegations of a fire hazard the Secretary claims was posed by a restaurant 

grill’s grease drawer that employees were required to clean three times per day and three times as 

often as the grill manufacturer recommends, as well as an explosion hazard the Secretary claims 

was posed by a pump placed less than 100 feet from a water tank used in a fracking operation. See 

Waffle House, slip op. at 22 (MacDougall, Chairman, concurring); Mo. Basin Well Serv., 26 BNA 

OSHC at 2316 n.5 (MacDougall, Chairman, concurring). As I stated in A.H. Sturgill: 

To implicate the general duty clause, a work situation must present a “hazard.” The 

term “hazard” refers to a concrete condition that poses a risk of harm. Longstanding 

Commission and court of appeals precedent requires that to constitute a cognizable 

hazard under the general duty clause, a worksite condition must pose more than the 

mere possibility of harm. See Pelron Corp., 12 BNA OSHC at 1835 (“Defining 

the hazard as the ‘possibility’ that a condition will occur defines not a hazard but a 

potential hazard.”); Pratt & Whitney Aircraft v. Donovan, 715 F.2d 57, 64 (2d Cir. 

1983) (“[T]he Secretary must show more than the mere possibility of injury; he 

must show that the potential hazard presents a significant risk of harm.”) In 

addition, to comport with due process, the Secretary must define the hazard that he 

charges an employer with allowing to exist at its worksite in a manner that 

“apprise[s] [the employer] of its obligations and identif[ies] conditions or practices 

over which the employer can reasonably be expected to exercise control.” Davey 

Tree Expert Co., 11 BNA OSHC 1898, 1899 (No. 77-2350, 1984). 

A.H. Sturgill, slip op. at 23 (MacDougall, Chairman, concurring). 

The Secretary’s proclivity to overreach in his application of the general duty clause not 

only runs afoul of the prohibitions against holding employers liable for ill-defined hazards that 

cannot be controlled, it also stands in stark contrast to the unmistakable Congressional preference 

in the overall structure of the Act for specific standards. See Reich v. Arcadian Corp., 110 F.3d 

1192, 1196 (5th Cir. 1997) (“Courts have held that enforcement through the application of 

standards is preferred because standards provide employers notice of what is required under the 

OSH Act.”) Section 6(a) of the Act directed the Secretary to promulgate “any national consensus 

standard, and any established Federal standard” as an OSHA standard for a two-year period after 

the effective date of the Act; while section 6(b) set forth a rigorous process for the promulgation 

31 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of hazard-specific standards through the Administrative Procedure Act’s notice-and-comment 

rulemaking process. 29 U.S.C. § 655(a)-(b). As such, instead of viewing the general duty clause 

as a catch-all provision that Congress intended to be used indefinitely, it is more reasonable to 

view the clause as a “placeholder,” to be used only until section 6(b) rulemaking could be initiated 

to address hazards. See S. Rep. No. 91-1282 (1970), reprinted in 1970 U.S.C.C.A.N. 5185-86 

(stating the Act’s general duty clause would not be “a general substitute for reliance on 

standards”). In other words, Congress intended the general duty clause to facilitate the Secretary’s 

duty to “insure protection of employees who are working under special circumstances for which 

no standard has yet been adopted.”2 Id. at 5186. See also Donald L. Morgan and Mark N. Duvall, 

OSHA’s General Duty Clause: An Analysis of Its Use and Abuse, 5 BERKELEY J. EMP. & LAB. L. 

283 (1983); Teal v. E.I. DuPont de Nemours and Co., 728 F.2d 799, 804 (6th Cir. 1984) (purpose 

of general duty clause was to cover unanticipated hazards not covered by a specific regulation). 

Another limitation on the reach of the general duty clause that bears noting—one which 

has been almost entirely ignored—is that Congress intended section 5(a)(1) to be restricted to 

recognized hazards that can be made, in the words of the statutory clause itself, “free” from the 

workplace. 29 U.S.C. §654(a)(1). As I discuss in detail below, were we writing on a clean slate, 

I would have found this to be a controlling issue in this case. 

It is against this backdrop, with these concerns in mind, that I consider the question of 

Congress’ intent regarding the Act’s coverage of the hazard alleged here. I have no doubt that as 

2 The Secretary’s expanded use of the general duty clause in recent years under the guise that he 

does not have sufficient resources to engage in difficult rulemaking disrupts the split enforcement 

model Congress enacted whereby the Secretary of Labor was delegated authority for rulemaking 

and the Commission responsibility for adjudication. See Cuyahoga Valley Ry. Co. v. United 

Transp. Union, 474 U.S. 3, 6-7 (1985) (“It is the Secretary . . . who sets the substantive standards 

for the work place, [while] . . . [t]he Commission’s function is to act as a neutral arbiter and 

determine whether the Secretary’s citations should be enforced . . . .”). In cases such as the one 

before us, the Commission essentially engages in adjudicative lawmaking—without notice and 

comment. Thus, while I am sympathetic to the Secretary’s and Commissioner Attwood’s concerns 

that rulemaking has become too difficult, even on important issues such as workplace violence, 

this does not allow the Commission to circumvent Congress’ intent. Nor can it be said that 

workplace violence, which has been a serious concern of OSHA, see Prevention of Workplace 

Violence in Healthcare and Social Assistance, 81 Fed. Reg. 88,147, 88,150 (Dec. 7, 2016) (OSHA 

request for information noting that since September 2011, OSHA has taken “important step[s] 

toward . . . address[ing] workplace violence in healthcare and other high-risk settings”), falls into 

unchartered seas where the Secretary cannot be expected to think to promulgate a standard on 

“every conceivable hazardous condition.” 

32 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

an historical matter, the 91st Congress never contemplated covering the hazard alleged here under 

the Act; violence as a workplace safety issue simply did not have the national attention then that 

it does now. I am constrained, however, by the silence of the Act’s legislative history. While there 

is nothing in the statute or its legislative history to show that workplace violence was contemplated 

as a hazard in 1970 by Senator Harrison Williams, Congressman William Steiger, or the collective 

mind of the 91st Congress, thereby allowing it to be swept into the scope of section 5(a)(1), neither 

does the legislative history evidence an intent to exclude it. 

Given that the plain meaning of the term “hazard” as used in the statute is, as my colleagues 

discuss, broad enough on its face to include the hazard presented by the specific facts of this case, 

Congress’ use of that term in such a circumstance is determinative here. United States v. Mitchell, 

39 F.3d 465, 468-69 (4th Cir. 1994) (“The plain language of the statute will control unless the 

history demonstrates that Congress clearly intended a contrary meaning.”) (citing Reves v. Ernst 

& Young, 507 U.S. 170, 177 (1993)). As to the other elements of the Secretary’s burden of proving 

a general duty clause violation, as discussed below, I join with my colleagues in finding that they 

have been established in this case. 

DISCUSSION 

I. The Threshold Issue: Employer’s Duty to Provide a Workplace “Free” from 

Recognized Hazards 

When interpreting a statute, “the beginning point must be the language of the [provision], 

and when a statute speaks with clarity to an issue[,] judicial inquiry into the statute’s meaning, in 

all but the most extraordinary circumstances, is finished.” Arcadian Corp., 17 BNA OSHC 1345, 

1347 (No. 93-3270, 1995) (quoting Estate of Cowart v. Nicklos Drilling Co., 505 U.S. 469, 475 

(1992)), aff’d, 110 F.3d 1192 (5th Cir. 1997). See Sharon & Walter Constr., Inc., 23 BNA OSHC 

1286, 1293 (No. 00-1402, 2010) (“[T]he first step in our analysis is to determine whether the 

[statutory] language at issue has a plain meaning with regard to the particular dispute before us, or 

whether it is ambiguous.”) (citing Robinson v. Shell Oil Co., 519 U.S. 337, 340 (1997)). The 

“plainness or ambiguity of statutory language is determined by reference to the language itself, the 

specific context in which that language is used, and the broader context of the statute as a 

whole.” Shell Oil, 519 U.S. at 341. The remedial purpose of the Act—“[t]o assure so far as 

possible every working man and woman in the Nation safe and healthful working conditions,” 29 

U.S.C. § 651(b)—“does not give license to disregard the plain meaning of” one of its provisions. 

Arcadian, 17 BNA OSHC at 1348 (citing Kiewit Western Co., 16 BNA OSHC 1689, 1694 (No. 

33 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

91-2578, 1994); Symons v. Chrysler Corp. Loan Guarantee Bd., 670 F.2d 238, 241 (D.C. Cir. 

1981)). “We should prefer the plain meaning since that approach respects the words of Congress.” 

Lamie v. U.S. Trustee, 540 U.S. 526, 536 (2004). 

The general duty clause states that “[e]ach employer . . . shall furnish to each of his 

employees 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). From this language, the courts and the Commission have derived the four traditional 

elements of a general duty clause violation—(1) a workplace condition or activity that presents a 

hazard; (2) recognition of that hazard by the employer or its industry; (3) a likelihood that the 

hazard will cause serious physical harm; and (4) a feasible method of materially reducing the 

hazard. See, e.g., Nat’l Realty & Constr. Co. v. OSHRC, 489 F.2d 1257, 1265 (D.C. Cir. 1973); 

Kokosing Constr. Co., 17 BNA OSHC 1869, 1872 (No. 92-2596, 1996). There is a flaw in this 

existing framework, however, because nowhere does it address the ability of an employer to “free” 

a workplace of a recognized hazard—an express requirement of section 5(a)(1). While my 

colleagues have apparently not been troubled by this restriction on the hazards that may be 

addressed by a general duty clause citation, I remain so. 

“Free” is defined as “clear, exempt, relieved,” “not obstructed or impeded,” “open,” and 

“not subject to a particular ruling, authority, or obligation.” WEBSTER’S THIRD NEW 

INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE UNABRIDGED 904-05 (1971); see United 

States v. Sherburne, 249 F.3d 1121, 1126 (9th Cir. 2001) (“turn[ing] to the dictionary for guidance” 

in absence of statutory definition); Crawford v. Metro. Gov’t of Nashville & Davidson Cty., 555 

U.S. 271, 276 (2009) (undefined term “carries its ordinary meaning”). These definitions suggest 

that a hazard must not only be recognized, but also be of the type over which an employer can 

exercise control such that it can be removed from the workplace entirely. 

Indeed, in looking at the broader context of the Act, a significant distinction between the 

language of sections 5(a)(1) and 5(a)(2) supports this reading. An employer’s duty under section 

5(a)(2) is unconditional: employers “shall comply with occupational safety and health standards 

promulgated under this Act.” 29 U.S.C. § 654(a)(2). This is because the “standards promulgated 

under this Act” are the result of notice-and-comment rulemaking, are typically directed at 

34 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

particular hazards, and ordinarily proscribe specific means of abatement.3 See Pratt & Whitney 

Aircraft v. Sec’y of Labor, 649 F.2d 96, 104 (2d Cir. 1981) (“[B]efore [the Secretary] can 

promulgate any permanent health or safety standard, [he] is required to make a threshold finding 

that a place of employment is unsafe in the sense that significant risks are present and can be 

eliminated or lessened by a change in practice.”) (quoting Indus. Union Dep’t, AFL-CIO v. Am. 

Petroleum Inst., 448 U.S. 607, 642 (1980)). By contrast, an employer’s duty under section 5(a)(1) 

is conditional and by no means absolute: the broad obligation to protect the safety and health of 

employees applies only to those hazards from which an employer can “free” its workplace. See 

Nat’l Realty, 489 F.2d at 1266 (“Congress’ language is consonant with its intent only where the 

‘recognized’ hazard in question can be totally eliminated from a workplace.”). This more limited 

obligation makes sense when one considers that the duty under section 5(a)(1) “was [meant] to be 

an achievable one.” SeaWorld of Fla., LLC v. Perez, 748 F.3d 1202, 1207 (D.C. Cir. 2014) 

(quoting Nat’l Realty, 489 F.2d at 1265-66).4 

Additionally, Commission case law has recognized the significance of the general duty 

clause’s inclusion of the word “free.” In Pelron, the hazard at issue was an explosion caused by a 

build-up of ethylene oxide at the company’s workplace, but because the accumulation of ethylene 

oxide was a possibility that could never be entirely prevented—in other words, the workplace 

could never be “free” of it—the Commission rejected the judge’s finding that it was the type of 

hazard to which Congress intended the general duty clause to apply. In other words, “[t]o respect 

Congress’ intent, hazards must be defined in a way that apprises the employer of its obligations, 

and identifies conditions or practices over which the employer can reasonably be expected to 

3 As a result, Commissioner Attwood’s reliance on OSHA standards addressing third-party 

behavior seems misplaced. All of those standards (e.g., 29 C.F.R. §§ 1926.200(g), 1926.651(d), 

and 1910.269(e)(7)) were promulgated under section 5(a)(2) pursuant to notice-and-comment 

rulemaking. As such, they would have no bearing on whether OSHA may address a third-party 

hazard under the general duty clause. 

4 To be clear, I find the dissent in SeaWorld to be more instructive than the majority’s decision in 

that case regarding the meaning of the general duty clause for purposes of the issue before us. See 

SeaWorld, 748 F.3d at 1218-19 (Kavanaugh, J., dissenting) (“The courts and the Department of 

Labor have recognized that the broad terms of the General Duty Clause must be applied reasonably 

lest the Clause morph into a blunt instrument by which absolute workers’-compensation-like 

liability is imposed on employers for all workplace injuries.”). Nevertheless, the SeaWorld 

majority’s decision itself was based on the reasonable ability of the employer to control the cited 

conditions—it was able to eliminate direct interactions with a killer whale on its property. Id. at 

1212. 

35 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

exercise control.” Pelron Corp., 12 BNA OSHC at 1835. Court precedent has made similar points. 

See Pratt & Whitney, 649 F.2d at 104 (“Section 5(a)(1) . . . obligates employers to rid their 

workplaces not of possible or reasonably foreseeable hazards, but [only] of recognized hazards.); 

Nat’l Realty, 489 F.2d at 1266 (noting that some “hazard[s] . . . cannot . . . be totally eliminated,” 

because a “demented, suicidal, or willfully reckless employee may on occasion circumvent the 

best conceived and most vigorously enforced safety regime”). These same considerations hold 

true for workplace violence, which is a condition that results from the acts of third parties, engaged 

in unpredictable human behavior, and outside of the employer’s control; no matter how sound an 

employer’s safety program might be for the particular circumstances at its workplace, it is possible 

the employer cannot free the workplace of the hazard. 

Moreover, even if “free” could be considered an ambiguous term such that resort to the 

Act’s legislative history would be necessary, that history, although extensive, offers nothing to 

refute the foregoing. As might be expected, much of the discussion over the general duty clause 

involves how to define the limitations on an employer’s obligation. Many legislators voiced 

concern that the enforcement agency would unfairly hold employers to a vague standard or cite 

them for hazards of which they were unaware. See, e.g., 116 Cong. Rec. 38,713 (1970) (comments 

of Rep. Robison), reprinted in Senate Committee on Labor & Public Welfare, Legislative History 

of the Occupational Safety & Health Act of 1970, at 1087-88 (June 1971) (“Legislative History”) 

(employers should furnish safe jobs and places of employment, but vague duty provision of Act 

imposes impossible burden); 116 Cong. Rec. 38,368 (1970) (comments of Rep. Anderson), 

reprinted in Legislative History at 982 (broad, general, and vague duty provision defies practical 

interpretation and responsible enforcement); H.R. Rep. No. 91-1291, at 51 (1970), reprinted in 

Legislative History at 881 (unfair to require employers to comply with vague mandate in highly 

complex industrial circumstances). Legislators eventually deemed the change in language from 

“readily apparent” to “recognized” hazards in the final draft sufficient to address these concerns. 

See S. Rep. No. 91-1282, at 57 (1970) (Javits Amendments), reprinted in Legislative History at 

197 (general duty clause changed from applying to “readily apparent” to “recognized” hazards); 

116 Cong. Rec. 42,206 (1970) (comments of Rep. Steiger), reprinted in Legislative History at 

1217 (conference bill general duty clause provision made realistic by application to only 

“recognized hazards” likely to cause serious injury or death); 116 Cong. Rec. at 38,367 (1970) 

(comments of Rep. Smith), reprinted in Legislative History at 980 (limited duty more reasonably 

36 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enforceable and more fair); 116 Cong. Rec. 37,326 (1970) (comments of Sen. Williams), reprinted 

in Legislative History at 416 (vagueness and broadness of duty clause corrected by restricting 

liability to “recognized hazards”). Because much of the debate in Congress centered on whether 

to include a general duty requirement in the statute at all, see H.R. Rep. No. 91-1291, at 21-22, 50-

51, 54 (1970); S. Rep. No. 91-1282, at 9-10, 58 (1970), many particular questions relating to the 

meaning of the requirement were never considered.5 Thus, the legislative history provides no basis 

to disregard the plain meaning of “free” in section 5(a)(1).6 

In sum, I am compelled by longstanding precedent outlining the elements of a general duty 

clause violation, as well as the lack of briefing on this issue and its impact on our precedent, to 

affirm the citation item at issue here. Nevertheless, unlike my colleagues, I find that a valid 

question remains regarding whether Congress intended the Secretary to address workplace 

violence hazards pursuant to the general duty clause.7 There is no question that the better course 

5 To complicate matters, coverage of the general duty clause was narrowed somewhat as the 

provision passed through several versions during its consideration; the original bills with the 

“broader” general duty requirements provided no penalties for violation. Hence, a number of the 

explanations that do appear in the legislative record with regard to the precise scope of the clause, 

in addition to reflecting the usual degree of inconsistency among themselves, refer to earlier 

versions of the provision, which were quite different in concept from the final version. 

6 Furthermore, an interpretation that is inconsistent with the plain meaning of a statute is not 

entitled to deference. Chevron U.S.A. Inc. v. Natural Res. Def. Council, Inc., 467 U.S. 837, 843 

(1984). See also INS v. Cardoza-Fonseca, 480 U.S. 421, 432 n.12 (1987) (if the plain meaning of 

the statutory language is clear, the legislative history is reviewed only to determine whether there 

is “clearly expressed legislative intention” contrary to that language “which would require us to 

question the strong presumption that Congress expresses its intent through the language it 

chooses”). 

7 In a footnote, my colleagues take issue with this observation. In doing so, they disregard the 

plain meaning of the statutory term “free” by suggesting that it should not be read literally but 

instead as “aspirational” in nature and interpret it to require that the Secretary show only that 

feasible measures would have materially reduced the likelihood that hazardous conduct would 

have occurred. This allows them to jump all the way to the end of the general duty clause analysis 

rather than grapple with its first step—that the hazard must be defined a way that comports with 

the Act’s plain language. While my colleagues claim that no court of appeals has adopted my 

theory and in support of their arguments they cite and quote Judge J. Skelly Wright’s opinion for 

the D.C. Circuit in National Realty, a fuller reading of that case undercuts their view here and 

indeed supports my interpretation of the general duty clause: 

A workplace cannot be just “reasonably free” of a hazard, or merely as free as the 

average workplace in the industry. On the other hand, Congress quite clearly did 

37 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

would be for the Secretary to promulgate, pursuant to notice-and-comment rulemaking, a specific 

standard addressing such hazards under section 5(a)(2). 

II. Beyond the Threshold Issue: The Elements of the Alleged General Duty Clause 

Violation 

As noted, despite the concerns I raise here, I join my colleagues in their conclusion that the 

Secretary has established a violation of the general duty clause. I do so with the understanding 

that the citation is affirmed in accordance with Commission precedent regarding the elements of a 

not intend the general duty clause to impose strict liability: The duty was to be an 

achievable one. Congress’ language is consonant with its intent only where the 

“recognized” hazard in question can be totally eliminated from a workplace. A 

hazard consisting of conduct by employees, such as equipment riding, cannot, 

however, be totally eliminated. A demented, suicidal, or willfully reckless 

employee may on occasion circumvent the best conceived and most vigorously 

enforced safety regime. This seeming dilemma is, however, soluble within the 

literal structure of the general duty clause. Congress intended to require elimination 

only of preventable hazards. It follows, we think, that Congress did not intend 

unpreventable hazards to be considered “recognized” under the clause. Though a 

generic form of hazardous conduct, such as equipment riding, may be “recognized,” 

unpreventable instances of it are not, and thus the possibility of their occurrence at 

a workplace is not inconsistent with the workplace being “free” of recognized 

hazards. 

489 F.2d at 1265 (emphasis added) (footnotes omitted). Thus, the D.C. Circuit declined to impose 

a general duty clause test requiring an employer to “reasonably free” a workplace of a hazard. 

I also note that violations of the general duty clause have been found in a variety of cases where 

the hazards were ones that the employer could control. See, e.g., Noble Drilling Servs., Inc., No. 

00-0462, 2002 WL 538935, at *5-7 (OSHRC Apr. 3, 2002) (ALJ) (fall hazard from crane-hoisted 

personnel baskets could be controlled by installation of inside grab rails); Wiley Organics, Inc., 17 

BNA OSHC 1586, 1593 & n.7 (No. 91-3275, 1996) (hazard of “valves and vents of the 

reactor . . . not [being] configured so as to discharge to a safe location away from employee work 

areas” could be eliminated by “diverting the vent to a catch tank, header pipe, or similar safe 

location”); Waste Mgmt. of Palm Beach, 17 BNA OSHC 1308, 1309, 1311 (No. 93-0138, 1995) 

(hazard of collapse of trash loader boom, exacerbated by employer’s unauthorized reinforcement 

of boom, could be eliminated by replacing boom entirely); Anoplate Corp., 12 BNA OSHC 1678, 

1686-87 (No. 80-4109, 1986) (hazard of common storage of cyanide and acid containers could be 

eliminated by separate storage); Safeway, Inc., 382 F.3d 1189, 1195 (10th Cir. 2004) (employer 

“could have eliminated the hazard of using a forty-pound tank with the grill by simply using a 

twenty-pound tank”); St. Joe Minerals Corp., 647 F.2d 840, 844 (8th Cir. 1981) (employer did not 

“render its workplace ‘free’ of hazard” when it bypassed broken interlock system on freight 

elevator by having employee operate elevator manually; employer could have eliminated hazard 

by “fully repair[ing] or replac[ing] malfunctioning equipment”). Thus, my colleagues’ fear for the 

virtual elimination of this statutory provision is unfounded. 

38 
 

 

 

 

 

 

 

 

 

 

 

 

general duty clause violation. I am also mindful that the parties in this case were not asked to brief 

the issue of whether this, admittedly long-standing, precedent should be revisited. In joining my 

colleagues, I note that our ruling today is a narrow one limited to the facts before us in that there 

was much Integra could have done to implement a sound safety program in the particular 

circumstances that exist at its workplace. 

A. Nexus Between the Work Being Performed and the Alleged Risk at a “Place 

of Employment” 

I join my colleagues in their conclusion that the interactions between the service 

coordinators and clients occur at a “place of employment.” 29 U.S.C. § 654(a)(1) (“Each 

employer . . . shall furnish to each of his employees 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.”) (emphasis added). Although the terms “employment” and “place of 

employment” are not defined in the Act, I agree that for purposes of the general duty clause, these 

terms have been construed liberally, and the broad definition of “workplace” can include 

customers’ homes, hospitals, restaurants, and public spaces extending beyond the walls of an 

employer’s physical office or plant. See Usery v. Marquette Cement Mfg., 568 F.2d 902, 904-05 

(2d Cir. 1977) (employer violated Act although employee injured in alley between employer’s 

buildings); Clarkson Constr. Co. v. OSHRC, 531 F.2d 451, 458 (10th Cir. 1976) (employer liable 

for unsafe conditions on public highway); Anning-Johnson Co. v. OSHRC, 516 F.2d 1081, 1085 

(7th Cir. 1975) (Act places primary responsibility on employers because they have control); see 

also S. Rep. No. 91-1282, at 9 (1970), reprinted in Legislative History at 149-50 (employers have 

primary control of work environment and should insure that it is safe and healthful); H.R. Rep. 

No. 91-1291, at 21 (1970), reprinted in Legislative History at 851 (employers bound by common 

duty to bring no adverse effects to employees because they have primary control over work 

environment). In Clarkson, the court noted that the broad construction of “employment” and 

“place of employment” is consistent with the broad remedial purposes of the Act. 531 F.2d at 458 

(drawing narrow boundaries on worksite would defeat purpose of Act). 

I also agree with my colleagues that a sufficient nexus between the risk of violence and the 

work involved is required and that a direct nexus exists here—Integra requires its service 

coordinators to meet face-to-face with members, many of whom have been diagnosed with mental 

illness and have criminal backgrounds as well as a history of violence and volatility. I find this 

nexus distinguishable from generic service providers because Integra’s service coordinators’ place 

39 
 

 

 

 

 

 

 

 

 

 

 

 

of work has an enhanced potential for aggression and hostility. Consequently, I do not view our 

decision today as creating an employer’s open-ended obligation under the Act to address potential 

workplace violence. In future cases, in my view of our holding today, it will remain the Secretary’s 

burden to establish a sufficient, direct nexus between the work being performed and the alleged 

risk of workplace violence. 

B. Hazard Recognition 

In addition, I would find the hazard of being physically assaulted by members with a history 

of violent behavior to be a “recognized hazard” in the circumstances present here—both on the 

basis that Integra had actual knowledge of this hazard, for the reasons discussed by my colleagues, 

and because the hazardous condition is generally recognized in the social services industry.8 See 

Duriron Co., 11 BNA OSHC 1405, 1407 n.2 (No. 77-2847, 1983) (using standard proposed by 

National Institute for Occupational Safety and Health as evidence of industry recognition of 

hazard); Beverly Enters., Inc., 19 BNA OSHC 1161, 1188 (No. 91-3144, 2000) (consolidated) 

(rejecting employer’s “criticisms of the NIOSH Lifting Equation as evidence of industry 

recognition,” even where equation was advisory, because of general acceptance in scientific 

community of methodology upon which it was based). See also OSHA Directive, Enforcement 

Procedures for Investigating or Inspecting Workplace Violence Incidents, CPL 02-01-052 (Sept. 

8, 2011); OSHA’s Guidelines for Preventing Workplace Violence for Health Care and Social 

Service Workers, OSHA 3148-01R (2004). Indeed, there are numerous publications and studies 

within the social services and healthcare industry addressing workplace violence such as the 

National Association of Social Workers’ Guidelines for Social Worker Safety in the Workplace 

and several NIOSH publications.9 

8 I reach this conclusion without the need to reference either Megawest Financial, Inc., No. 93-

2879, 1995 WL 383233 (OSHRC May 8, 1995) (ALJ), a nonprecedential, unreviewed 

administrative law judge decision, or the D.C. Circuit’s decision in SeaWorld, which as previously 

noted addressed the employer’s ability to recognize the hazard of a killer whale, a hazard the court 

determined was one over which the employer could “reasonably be expected to exercise control.” 

SeaWorld, 748 F.3d at 1212. 

9 Further, the record shows that Integra relied upon these guidelines in designing training for its 

service coordinators. 

40 
 

 

 

 

 

 

 

 -

C. Feasibility of Abatement 

I find no need to repeat my colleagues’ discussion on the feasibility of the Secretary’s 

proposed abatement measures. I agree with their determination that the Secretary has met his 

burden to establish the feasibility of abatement element in this case. 

CONCLUSION 

In line with the adage that “bad facts make bad law,” Tharpe v. Sellers, 138 S.Ct. 545, 547 

(2018) (Thomas, J., dissenting), we establish precedent today that the workplace violence hazard 

alleged here is a hazard covered by the general duty clause. See also Sucic v. McDonald, 640 F. 

App’x. 901 (Fed. Cir. 2016) (Wallach, J., dissenting) (“[H]ard cases[ ] make bad law. So do bad 

facts.”)).) (citations omitted). I recognize that it is easier to fit a decision within the safe haven 

of stare decisis than to boldly overrule precedent, even where the precedent may have failed to 

account for a key term in a statute. My hope is that this precedent will be revisited in a future 

decision and, even better, that OSHA will continue in its effort to promulgate a standard that 

addresses workplace violence. My concurring opinion today should not be construed as a failure 

to acknowledge that workplace violence is a serious employee safety concern, particularly in 

healthcare and social service settings where employees are at the greatest risk of violent events. 

However, while the desire to address workplace violence is admirable, the result cannot be reached 

at the expense of the law that binds us. 

/s/___________________________ 

Dated: March 4, 2019 Heather L. MacDougall 

Commissioner 

41 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please note that personal identifiers have been removed. 

United States of America 

OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION 

1120 20th Street, N.W., Ninth Floor 

Washington, D.C. 20036-3457 

SECRETARY OF LABOR, 

Complainant, 

OSHRC Docket No. 13-1124 v. 

INTEGRA HEALTH MANAGMENT, INC., 

Respondent. 

Appearances: Lydia J. Chastain, Esquire; Rolesia B. Dancy, Esquire 

U.S. Department of Labor, Office of the Solicitor, Atlanta, Georgia 

For the Secretary 

Kevin C. McCormick, Esquire 

Whiteford, Taylor & Preston, L.L.P., Baltimore, Maryland 

For the Respondent 

Before: Dennis L. Phillips 

Administrative Law Judge 

DECISION AND ORDER 

This proceeding is before the Occupational Safety and Health Review Commission 

(Commission) pursuant to sections 2-33 of the Occupational Safety and Health Act of 1970, 29 

U.S.C. §§ 651-678 (OSH Act). Following a fatality-related safety and health inspection, the 

Occupational Safety and Health Administration (OSHA) issued two citations to Integra Health 

Management, Inc. (Integra or Respondent), alleging a violation of section 5(a)(1) (the general 

1 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

duty clause)1 of the OSH Act and a violation of OSHA’s reporting standard. Integra filed a 

timely notice of contest, bringing this matter before the Commission. A hearing was held in 

Tampa, Florida from May 6 to May 9, 2014. Both parties filed post-hearing briefs and posthearing reply briefs. For the reasons set forth below, the Court affirms both citations. 

JURISDICTION 

Integra admits that, as of the date of the alleged violations, it was an employer engaged in 

business affecting commerce within the meaning of section 3(5) of the OSH Act. (Answer at ¶¶ 

II, III). Based upon the record, the Court finds that at all relevant times Integra was engaged in a 

business affecting commerce and was an employer within the meaning of sections 3(3) and 3(5) 

of the OSH Act. The Court concludes that the Commission has jurisdiction over the parties and 

subject matter in this case. (Answer at ¶ I, where Integra admits jurisdiction). 

STIPULATED FACTS 

The parties stipulate to the following facts: 

Integra, based in Owings Mills, Maryland, performs mental and physical health 

assessments and coordinates case management via contracts with various insurance 

companies. These assessments are performed by employees known as “community 

service coordinators.” Integra performs these services in four states: Tennessee, 

Pennsylvania, Maryland, and Florida. There are no company offices in Florida; 

service coordinators work from their homes or in the field. The Integra service 

coordinator program focuses on helping clients receive appropriate medical care. 

Service coordinators are assigned a caseload of clients and are responsible for calling 

them and for face to face meetings during which the clients are assessed and 

encouraged or persuaded to register for services. Insurance companies apparently 

1 Specifically, Citation 1, Item 1, alleged (in part): 

OSH ACT of 1970 Section (5)(a)(1): The employer did not furnish employment and a place of employment which 

were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees, 

in that employees were exposed to the hazard of being physically assaulted by members with a history of violent 

behavior: 

a) On or about December 10, 2012, an employee providing health care management services was fatally stabbed by 

a member with a violent criminal history. Employees acting as service coordinators regularly interacted on their 

own directly with members with a history of violent behavior. 

2 
 

 

 

 

 

 

 

 

 

 

refer these clients to companies such as Integra due to chronic difficulties in 

contacting them. Many of the clients suffer from mental 

illness. 

On December 13, 2012, an inspection was initiated when the OSHA Tampa Area 

Office received an anonymous phone call reporting a workplace violence fatality. 

Three days earlier, on December 10, 2012, [redacted], an Integra service coordinator, 

was fatally stabbed by a mentally ill client. The victim was meeting the assailant at 

his house for a required face to face visit to conduct an initial assessment. 

(Jt. Pre-Hr’g Statement, at p. 8). 

BACKGROUND 

Incident 

Integra provides mental and physical health assessments and coordinates healthcare/case 

management services. It is hired by insurance companies to help their insureds avoid hospital 

admissions and emergency room visits. Integra has about 62 employees. On December 10, 

2012, one of its employees, [redacted], went to work. She was a newly- hired Integra Service 

Coordinator (SC) working out of the Tampa, Florida branch. She was 25 years old, and had 

about three months on the job. She had no prior experience in the community health or social 

worker industries. [redacted] had a virtual office consisting of her home in Lakeland, Florida, a 

computer, a phone, and her car. In the morning on December 10, [redacted] took and received 

phone calls. She then drove out into “the field,” to Apartment 1, 37020 Coleman Avenue, Dade 

City, Florida, to make an unscheduled visit to [redacted], age 53. (Tr. 88, 198, 248, 1064-65; 

Exs. C-5, at p. 8, C-6, at p. 3, C-8, C-27, at p. 2, R-P, at p. 1, R-T, at p. 3, R-GG, R-LL; Jt. PreHr’g Statement, at p. 8). 

3 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mr. [redacted], a diagnosed schizophrenic, was on [redacted]’ list of clients, called 

“members,” for which she was responsible.2 [redacted] had a history of violent behavior. He 

had been convicted of violent crimes and incarcerated for many years.3 This history of violent 

behavior was not reported by anyone to [redacted] when [redacted] was assigned to her. 

[redacted] attempted to contact [redacted] by telephone on September 9, September 16, and 

September 23, 2012. These three attempts were unsuccessful because [redacted] could not locate 

a valid telephone number for [redacted]. (Tr. 136-41, 270-75, 356-57). 

The first time [redacted] visited [redacted], on October 12, 2012, she went to his house 

unannounced, introduced herself and Integra, and arranged a return visit for October 15, 2012 to 

conduct an initial assessment. [redacted] reported in her progress note report for that day that 

during their conversation, [redacted] “said a few things that made SC [[redacted]] uncomfortable, 

2 [redacted] was assigned as a member to [redacted] within about a month of her being hired. The Integra progress 

note report approved by her supervisor on September 8, 2012 identifies [redacted] as [redacted]’s SC and states: 

AMG [Amerigroup, the medical insurance carrier] reports the following past issues for this member [[redacted]]: 

Cohort: Cardiovascular 

MH [Mental Health]: Schizophrenia 

SA [substance abuse]: Blank 

(Tr. 140-41; Ex. C-7, at p. 1). 3 [redacted]’s prison record shows that he was convicted of: 1) Grand Theft Motor Vehicle and sentenced to 

prison for two years on August 12, 1981, of which he served two months and 16 days, 2) Battery and sentenced to 

prison for five years on September 21, 1982, of which he served three years, two months, and 15 days, 3) 

Aggravated battery with a deadly weapon and sentenced to prison for five years on April 30, 1991, of which he 

served nearly four years, 4) Aggravated battery with a deadly weapon and sentenced to prison for 10 years on 

April 27, 1998 for an offense that occurred on August 13, 1990, and 5) Aggravated assault with a weapon and no 

intent to kill and sentenced to prison for 10 years on April 27, 1998 for an offense that occurred on September 9, 

1995. He served more than seven and one-half years in prison for these two latter convictions. He was also 

adjudged guilty in a Florida state court on March 15, 2006 for battery for an offense he committed on September 

19, 1997. On March 15, 2006,[redacted] was sentenced to time served for this conviction. (Tr. 136-38, 223; Exs. C25, R-MM). 

4 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SC asked member to be respectful or she would not be able to work with him.” She also 

documented in her progress note report that “[b]ecause of this situation, SC is not comfortable 

being inside alone with member and will either sit outside to complete assessment or ask another 

SC to accompany her.”4 (Tr. 136-43, 273-75, 356-59; Exs. C-7, C-25, R-KK at pp. 73, 77, RMM). 

A few days later, on October 15, 2012, [redacted] arrived at [redacted]’s house for their 

appointment at about 2:45 p.m. When she presented him with the Integra “Consent to Receive 

Services” form to sign that would give Integra his consent to provide him with services, 

[redacted] refused and told [redacted] that he would not sign anything without his case manager 

present.5 He then pointed to a picture of The Last Supper, crediting it to Michelangelo,6 and 

stated that Jesus was his father and that he and other people in his community, including a 

4 On October 18, 2012, Laurie Rochelle, [redacted]’ supervisor, approved [redacted]’ October 12, 2012 progress 

note report. She testified that she could not say for sure when she approved this progress note report because 

Integra’s “database was also very shady.” She said that she put in assessments that were later found gone. 

Compliance Safety & Health Officer (CO) Jason Prymmer testified that Integra’s management took no further 

action. It did not perform a background check or criminal background check on [redacted] and it relied upon 

[redacted]’ discretion to arrange for any “buddy” to accompany her on her next visit. CO Prymmer testified that 

there was no Integra work rule for the buddy system, it was discretionary and not a mandate, and SCs “fended for 

themselves.” When interviewed, Dr. Melissa Arnott, then Integra’s Vice President of Behavioral Health, told CO 

Prymmer that [redacted] did not need any additional management input after first visiting with [redacted]. CO 

Prymmer testified as follows: 

Q And what did she [Dr. Arnott] tell you? 

A Melissa Arnott stated that additional input was not needed because they felt [redacted] did such a great job that 

she wouldn’t need management direction, that she would get somebody. They felt that she would get somebody and 

they don’t need to input, give any – enforce anything. They don’t need to direct anything. They basically put it all 

on [redacted]. 

(Tr. 143-44, 147-48, 275-76, 296-98, 340; Ex. R-QQ, at p. 15). 5 [redacted] noted that [redacted]’s case manager was Mellissa Jones, from BayCare. At [redacted]’s request, 

[redacted] contacted Ms. Jones by telephone during her visit with [redacted]. [redacted] also told [redacted] that he 

had an upcoming court date relating to trespassing charges against him. The trespass charge was filed against 

[redacted] on September 12, 2012. Ms. Rochelle testified that a lot of members insured by Amerigroup had case 

managers. (Tr. 314; Exs. C-7, at p. 6, R-T, at p. 3). 

6 CO Prymmer testified that he concluded that [redacted] entered [redacted]’s apartment on October 15, 2012 

because she described the picture in her progress note report. The Court takes judicial notice that The Last Supper 

was painted by Leonardo da Vinci. (Tr. 149-50). 

5 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

waitress, were also in the picture. [redacted] noted in her progress note report that she planned to 

meet again with [redacted] the following week to schedule an appointment with him, Ms. Jones, 

and herself. On October 15, 2012, Ms. Rochelle approved [redacted]’ October 15, 2012 progress 

note report.7 (Tr. 149-50, 280, 297, 360-62; Exs. C-7, at p. 6, R-EE, at p. 2, R-KK at p. 78). 

On November 2, 2012, Dr. Arnott sent [redacted] an email identifying [redacted] as a 

member missing a consent form. Later that day, [redacted] sent Dr. Arnott an email response 

saying: “[redacted] refused to sign a consent unless his case manager was present. I am working 

7 CO Prymmer also testified about an email exchange that occurred in March, 2013 between him and Integra’s Chief 

Operating Officer (COO), Diane (Dee) Brown. On March 13, 2013, CO Prymmer asked Ms. Brown if Integra’s 

management had reviewed [redacted]’ October 12 and October 15, 2012 progress note reports, and if it made certain 

that someone else accompanied [redacted] on her next visit with [redacted]. Ms. Brown told CO Prymmer that she, 

Dr. Arnott and others had reviewed [redacted]’ progress note reports. She also told him that “we do not make 

certain people are doing their jobs.” She also told CO Prymmer that there was no management intervention at all 

with regard to [redacted]’ October 12 and October 15, 2012 progress note reports. The Court notes the following 

email exchange that occurred on March 14, 2013: 

From: CO Prymmer [extraneous material omitted] 

Sent: Thursday, March 14, 2013, 12:57 PM 

To: Dee Brown 

Subject: RE: Other State Workplace Violence Recognition 

Hi Dee, 

The notes were well documented/reported and reviewed (10/12/12, 10/15/12); was there management intervention at 

all in these two circumstances for the service coordinator? 

[Extraneous material omitted] 

From: Dee Brown [extraneous material omitted] 

Sent: Thursday, March 14, 2013, 1:15 PM 

To: Prymmer, Jason P. – OSHA 

Subject: RE: Other State Workplace Violence Recognition 

[N]o. Management needs to intervene only if a plan described in the notes is not adequate or a statement is made 

that [sh]ould be accompanied by a plan and no plan is noted. 

[Extraneous material omitted] 

(Tr. 144-47; Ex. C-19, at pp. 2-3). 

6 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on that situation, but he has not been entirely cooperative in setting an appointment and does not 

have a phone.” Shortly thereafter, Dr. Arnott responded: “Can you contact the CM [Case 

Manager] and introduce yourself and our services and possibly schedule to go see the member 

with the CM. Sounds like the member trusts the CM.” Minutes later that same day, [redacted] 

responded by email and informed Dr. Arnott that she had “been in contact with his CM and she 

was willing to meet, but the member would not agree on a date. There is a note on it. I will 

probably just schedule a time with her and show up unannounced at his house.” (Ex. R-EE). 

On November 14, 2012, [redacted] returned unannounced to [redacted]’s house at about 

2:05 p.m., without his case manager, Ms. Jones, present. During this meeting, [redacted] initially 

told [redacted] that he was not [redacted], and that he was actually his twin brother. He then 

admitted to being himself. [redacted] agreed to sign the consent form without his case manager 

present.8 [redacted] brought a chair outside so [redacted] could sit and the two spoke for about 

twenty minutes. He also told [redacted] to “get a cowboy hat and go to a rodeo.” They set up a 

meeting for November 26, 2012 for [redacted] to return to conduct the initial assessment.9 No 

one from Integra’s management approved [redacted]’ November 14, 2012 progress note report.10 

(Tr. 150-52, 189, 363-65; Exs. C-7 at p. 7, C-8, at p. 9, R-KK, at p. 79). 

8 Ms. Rochelle testified that Integra needed to have its consent form signed by the member in order to get paid by 

Amerigroup. She also said that “we were pressured to get those papers signed and get those members signed up no 

matter what.” (Tr. 154, 279-82; Ex. C-8, at p. 9). 

9 [redacted] needed to complete [redacted]’s initial assessment, consisting of eight pages, within thirty days of his 

conveying consent to receive services; i.e. by December 14, 2012. CO Prymmer testified that Integra’s assessment 

required SCs to gather information from the member concerning a member’s: 1) medications, 2) addictions history, 

3) legal/criminal history, 4) medical history, 5) domain Issues including bathing, bladder and bowel continence, and 

toileting, and 6) personal routine/condition. SCs were also required to conduct a Memory Orientation and make 

behavioral observations. (Tr. 155, 366). 

10 Ms. Rochelle left Integra on November 6, 2012. The role of acting team lead was filled by Ms. Whitney Ferguson 

and Dr. Arnott. CO Prymmer testified that SCs told him that after Ms. Rochelle left progress note reports were not 

getting approved by management and they were not getting feedback from management about questions and 

concerns they had about members. (Tr. 152, 187, 217, 281). 

7 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On November 26, [redacted] arrived at [redacted]’s house to conduct the initial 

assessment, but [redacted] was not at home. She left a note on his door. No one from Integra’s 

management approved [redacted]’ November 26, 2012 progress note report. (Tr. 152, 189; Exs. 

C-7 at pp. 7-8, R-KK, at pp. 79-80). 

On her final December 10, 2012 visit, [redacted] had still to assess [redacted] and his 

needs.11 The assessment was never completed by [redacted].12 Instead, during her unscheduled 

visit to his home, [redacted] attacked [redacted] at 12:45 p.m., and stabbed her about 9 times, 

reportedly with a butcher knife. She attempted to run away, but [redacted] chased her while 

stabbing her repeatedly. He then went inside his house, leaving her mortally wounded on his 

front lawn. A passerby saw [redacted] lying on the ground, and drove her to Pasco Regional 

Hospital, where she died of her wounds at 1:30 p.m. [redacted] was arrested, incarcerated and 

charged with murder in the first degree, a capital felony, but on about May 3, 2013 was found 

mentally/physically unable to stand trial before the Florida state criminal court. (Tr. 152-55, 

365-66; Exs. C-5 at p. 1, C-6, at p. 3, C-8, R-P, R-T). 

OSHA Investigation 

On Monday, December 10, 2012 at about 7:05 p.m., OSHA received an anonymous 

telephone call reporting a fatality in Dade City, Florida. The OSHA Duty Officer followed up 

the tip and prepared an OSHA Fatality/Catastrophe Report (OSHA Fatality Report) on about 

December 12, 2012 that described the circumstances surrounding [redacted]’ death.

13 CO 

11 CO Prymmer testified that Integra did not require anyone to accompany [redacted] on this visit. (Tr. 240). 12 [redacted]’s assessment only included his name, address, date of birth, age, social security number, and some 

information regarding his living arrangements. It was otherwise blank. (Tr. 154; Ex. C-8). 

13 The OSHA Fatality Report identified the incident as “work place violence” and stated [redacted] “was assigned to 

deliver insurance papers and ensure patient was taking medications. When she arrived as the patient’s home he 

attacked her and subsequently caused her death by multiple stab wounds.” (Ex. C-3). 

8 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prymmer investigated the claim by interviewing Integra officials and employees,14 and 

requesting records.15 CO Prymmer followed OSHA’s workplace violence directive as guidance 

and consulted with the OSHA regional office in Atlanta, Georgia as to what questions he should 

ask Integra employees to get pertinent information. CO Prymmer interviewed several Integra 

representatives, management and non-management, including many SCs, face-to-face, over the 

telephone, and via e-mail. He learned about Integra’s business model, the role of the SCs, and 

Integra’s approach to safety in the workplace. He also investigated [redacted]’ role specifically, 

and the circumstances surrounding her death. (Tr. 81-155; Exs. C-3, C-4, C-33; Jt. Pre-Hr’g 

Statement, at p. 8). 

As a result of the OSHA investigation, the Secretary issued Integra two citations alleging 

violations of the OSH Act. The Secretary alleged that Integra committed a serious violation of 

the general duty clause because Integra employees “were exposed to the hazard of being 

physically assaulted by members with a history of violent behavior.”16 The Secretary asserted 

that, as illustrated by the stabbing on December 10, 2012, Integra did not furnish employment 

and a place of employment which were free from recognized hazards that were causing or likely 

to cause death or serious physical harm to employees because Integra “service coordinators 

regularly interacted on their own directly with members with a history of violent behavior.” For 

14 In the Jt. Pre-Hr’g Statement, Respondent objected to Ex. C-6, OSHA’s Violation Worksheet, as hearsay. At the 

hearing, Respondent limited its objection to only parts of Ex. C-6. Initially, Respondent objected to pp. 3-6, and 11 

through 21, Ex. C-6, that contained transcriptions of interviews conducted by CO Prymmer. It then confirmed that it 

had no objections to Ex. C-6, pp. 1-3 and 5 – 10, and these pages were admitted at trial. (Tr. 17-18). The Court 

notes that Respondent offered and the Court admitted as Ex. R-QQ, OSHA’s Violation Worksheet, including pp. 3-

6, at the start of the trial, without objection. (Tr. 39). The Secretary later withdrew his p. 4 (already in evidence at 

Ex. R-QQ, at p. 4) and pp. 11-21, Ex. C-6, at the trial. (Tr. 748). 

15 CO Prymmer has been a CO and industrial hygienist at OSHA since 2009. Before that, he was employed as an 

industrial hygienist at EE&G Environmental Services where he worked nearly full-time on health and safety matters 

for about 3 years. He has a Bachelor of Science degree in environmental health. (Tr. 77-79). 

16 Section 5(a)(1) of the OSH Act, the “general duty clause,” requires that each employer “furnish to each of his 

employees 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). 

9 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this serious citation item, the Secretary proposed a $7,000 penalty. (Tr. 346; Exs. C-1, C-6, at 

pp. 7-8). 

The Secretary also cited Integra for an other-than-serious violation of 29 C.F.R. 

§ 1904.39(a) because Integra failed to timely report [redacted]’ death to OSHA.17 (Ex. C-1, at p. 

9). The Secretary proposed a $3,500 penalty for this citation item. (Ex. C-1, at p. 9). Integra 

claimed in its Answer that it did not violate the general duty clause because its “existing 

procedures meet or exceed the general industry standards concerning the events that lead to the 

events referenced in the citations.”18 (Answer, at ¶ IX). 

Integra 

Hiring requirements for Integra SCs included a bachelor’s degree, and at least one year of 

experience in the field of Behavioral Health was desired.19 Integra also looked for “individuals 

17 Section 1904.39(a) requires employers to report any work-related death of an employee within eight hours of the 

death to OSHA. 29 C.F.R. § 1904.39(a). 18 With regard to the workplace violence citation item, Integra also raised the unpreventable employee 

misconduct (UEM) affirmative defense in its Answer, arguing that the attack was the result of “unauthorized actions 

by a certain employee and the criminal misconduct of another individual.” (Answer, at ¶ IX). As a basis for its UEM 

defense, Integra claimed: 

[redacted] was properly trained in how to avoid dangerous/unsafe working conditions, by either 

meeting with clients outside of the residence, having a second Service Coordinator present for a 

client visit, leaving if circumstances warranted it or not attending the meeting, if the Service 

Coordinator felt unsafe. [redacted] was aware of these specific safety procedures, had followed 

them in the past, but on the day of the incident, for whatever reasons did not follow them, and 

attempted to meet with the client, by herself, without a partner. Her death was caused by the 

criminal act of a third party, who has been found mentally incompetent to stand trial. 

(Jt. Pre-Hr’g Statement, at p. 10).

19 Integra’s “Job Snapshot” for the SC position posted on the internet on July 17, 2012 stated that the Job Type was 

Health Care, with a 4 year degree needed, along with at least two years of experience. The job posting further stated 

(in part) that [t]he ideal candidate would be able to provide support services to a specific group of individuals with 

serious mental/somatic illness through community-based teams. ... 

REQUIREMENTS 

10 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

who have particular characteristics and traits that ... are indicative of their ability to relate to 

people, to engage in conversation, to ... help them be accepted as a coach in essence.” (Tr. 98, 

104-05, 590, 758; Exs. C-9, C-10). 

At the time of her death, [redacted] had just recently graduated from the University of 

South Florida with a degree in psychology. She was enrolled in a program to get a teaching 

certificate to be a teacher. She had no previous experience working with the mentally ill and had 

no previous experience or certifications in social work. She had never had a job where she 

visited people at their homes. Despite this lack of experience, [redacted] was hired, according to 

her team lead at the time, because of “that heart that she wanted to help others.” CO Prymmer 

testified that during the course of his investigation he learned that [redacted] was very motivated, 

Individuals must possess a Bachelor’s Degree. An interest in social work, psychology or a related field and 

possessing 2 years experience in the field is a plus. The applicants should demonstrate the following skills 

[including, in part]: 

· Knowledge of community resources 

· Able to conduct hospitalization risk assessments ... 

· Ability to form strong positive relationships with the member, family and hospital/facility staff ... 

· Ability to formulate a written service plan 

Integra’s internal Job Description for SC, dated January, 2012, stated: 

Job Function: The Community-Based Service Coordinator will provide community-based service coordination 

services to a specific group of individuals with serious mental illness/somatic illness, while under the 

supervision of the Team Lead. Responsibilities include maintaining a caseload, as directed by the Team 

Leader, provide on-going evaluation of the client’s needs, facilitation and coordination of service 

plans. The community-based Service Coordinator will meet with clients in their home setting or treatment 

facility. 

Education Required: Bachelors Degree in Social Work, Psychology, or a related field. Those with a combination 

of experience and education will be considered. 

Experience: 1 year experience in the field of Behavioral Health is desired. 

Job Duties [including, in part]: · Knowledge of community resources. 

· Conduct hospitalization risk assessments 

· Telephonic and in-person triage ... 

· Ability to form strong positive relationships with the patient, family and hospital/facility staff.... 

· Ability to formulate a written treatment plan. 

(Tr. 99, 104-05; Exs. C-9, C-10). 

11 
 

 

 

 

 

 

 

 

 

 

wanted to do a good job, and wrote good progress note reports. (Tr. 105, 136, 199, 248-49; Ex. 

R-KK, at pp. 82, 84). 

[redacted]’ job as an Integra SC was to coordinate community resources for Integra 

“members.” These members were people that had been identified by the member’s insurance 

company as those who incurred high costs associated with emergency room care and in-patient 

hospitalization. These members had a history of non-compliance with their medical orders – i.e., 

they were failing to fill their prescriptions, or they were failing to schedule or show up to their 

doctor’s appointments. Insurance companies, and in this case, Amerigroup, contracted with 

Integra to address these “gaps in care.” For example, a gap in care would be when a diagnosed 

diabetic did not get retinal eye examinations. “That would be something a health plan would 

know about because they have seen claims come in with a diagnosis of diabetes and they’re not 

seeing claims come in for these lab tests.” Integra and Amerigroup entered into a contract, with 

the possibility of annual renewal, to address these “gaps in care” and achieve a cost-savings goal 

for the insurance company. (Tr. 87, 270, 755-56, 772, 786, 1017-18). 

Integra’s approach to fulfilling its end of the contract was to personally find these noncompliant members, determine what obstacles prevented them from following doctor’s orders, 

and connect them with community resources that would empower them to get back on track, 

medically. Obstacles that the member might be facing may be traced back to a lack of basic 

needs being met. Many of these members were not getting food, clothing or shelter, preventing 

them from even thinking about medical care. Integra SCs, described as “feet on the street,” 

would personally contact these members and help them with their basic needs, “as a family 

member might,” so that they could eventually address their medical needs. Along with a salary, 

SCs got a $350 monthly gas allowance for using their own personal cars to meet, visit, and 

12 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

handle members. SCs were expected to personally drive, in their privately owned vehicle, 

members to doctor’s appointments. (Tr. 315, 418, 438, 453, 757, 779, 896, 926-27). 

Integra asserted that Amerigroup “typically” sent Integra background information about 

potential members before Integra assigned a member to a SC that included the following: 1) 

member’s name, address and telephone number, 2) name of primary care physician, 3) primary, 

secondary and tertiary diagnosis, 4) prescriptions and their costs, 5) substance abuse and mental 

health conditions, 6) name of health plan case manager, 7) number/cost of inpatient behavioral 

health admissions, 8) number/costs of Emergency Room admissions, and 9) total medical costs 

per member per month. Integra supposedly transmitted this information to the SC team lead in 

Tampa, who assigned each SC approximately 35-38 members for which they were responsible.20 

The team lead assigned members to SCs based on geographic location, for “geographic and 

scheduling efficiencies;” and not by member risk. When assigned a new member, the record 

shows that SCs sometimes might have only a member’s residence address and a telephone 

number if one was available. (Tr. 87-88, 127-28, 254-55, 315, 915-16; Ex. C-28, at pp. 12-14, 

Resp’t Answers to Sec’y First Set of Interrogatories). 

For each member, Integra required the SC make two telephone contacts and two face-toface contacts, per month. SCs were also required to personally visit with any member admitted 

to a hospital within seven days. The SC first had to obtain a consent form signed by the member, 

because Integra would be working with the member regarding his or her health. Integra then 

required SCs to complete a written health “Needs Assessment” of the member during a followon face-to-face meeting within 30 days of obtaining the consent form. The Needs Assessment 

included topics such as the member’s health, daily activities including bathroom habits, legal and 

20 Based on the testimony discussed herein, the Court finds that SCs at Integra’s Tampa office did not routinely 

receive all of this background information on each member. 

13 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

criminal history, substance abuse, and medications. To complete the Needs Assessment, the SC 

asked the member questions and transcribed the member’s answers “in real-time during the faceto-face.” Using the Needs Assessment as a baseline, the SC developed a service plan to meet the 

health, social, and community care management needs of the member with the goal to preempt 

members from unnecessary hospitalizations. All interactions with members were documented in 

progress report notes that were recorded and uploaded into Integra’s electronic database, called 

ServiceConnect, for the team lead to review and ultimately approve.21 Integra’s services were 

measured based on whether it was saving Amerigroup money by reducing unnecessary 

hospitalizations. (Tr. 87-96, 250, 255, 351-52, 1017-18; Exs. C-8, C-34). 

WITNESS TESTIMONY 

Jason Prymmer, OSHA CO. CO Prymmer testified that Integra conducted a program in 

Florida where SCs coordinated heath care related services for mentally and/or physically 

disabled members. Most members were severely mentally ill, with maladies including bipolar 

disorder and schizophrenia. Most members also had criminal backgrounds.22 Many were 

21 SC team leads were supposed to review and approve progress report notes on a daily basis. This was not always 

done. For clarification purposes, Respondent withdrew Ex. R-AA, Florida Supervision Summary, Nov. 1 2012 – 

Dec 12, 2013, and it is not in evidence. The Court notes that Complainant made hearsay and relevance objections to 

its admissibility in the Jt. Pre-Hr’g Statement, at p. 4. (Tr. 96, 1071). 22 CO Prymmer testified that Dr. Arnott and Ms. Brown told him that most of Integra’s members have criminal 

backgrounds. (Tr. 89, 177). Specifically, on December 14, 2012, Dr. Arnott told CO Prymmer in a signed 

statement that: 

The service coordinators case list is mostly mental patients. We knew [redacted] was not comfortable 

with the assailant [[redacted]]. We didn’t have high risk groups [identified]. We are going to do that 

now. I read the note [about [redacted]’s reluctance to meet with the client in his home]. ‘That is how we 

know [redacted] was not comfortable. We do not have a written policy or procedure for the buddy 

system. We are evaluating our safety practices. We know a large percent, it is common knowledge have 

criminal history. We are dealing with the toughest people that no one wants to deal with. We don’t have 

a workplace violence prevention program. We haven’t formalized a buddy system until now [after the 

fatality]. ...’ (Ex. R-QQ, at pp. 14-15). 

Ms. Rochelle also knew that the majority of Integra’s members had mental illness and criminal backgrounds. (Tr. 

133). 

14 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

substance abusers. CO Prymmer testified that Dr. Arnott told him during a face-to-face 

interview that when [redacted] was killed Integra did not: 1) have a workplace violence 

prevention program, 2) perform criminal background checks on members, and 3) identify “high 

risk groups” before assigning SCs their individual caseload.

23 Integra did not require SCs to 

perform their own background checks on members. He testified that Integra was paid “based on 

the two phone calls and two face-to-face visits and the ... seven-day period hospital 

readmission.” Integra’s SCs helped members schedule medical and social services 

appointments, drive members or arrange for travel to their appointments, and assisted them in 

completing paperwork. SCs were required to “track down” and visit with the many members 

who did not have telephones. Members generally lived in publicly provided housing located in 

“high crime neighborhoods.” SCs often met with members alone in areas off the beaten path, in 

areas where the general public could not see them; e.g. trailer parks, government housing 

projects, and high crime areas.24 Integra had no office in Florida. SCs worked out of their 

homes and privately owned vehicles, and drove out to members’ residences. (Tr. 87-93, 109-10, 

127-28, 134-35, 177, 786; Exs. C-8, R-QQ, at pp. 14-15). 

CO Prymmer testified that Dr. Arnott developed the Neumann University training 

(Neumann training), an about 40 hour online training course for SCs.25 CO Prymmer testified 

23 OSHA’s Safety Narrative, Accident Investigation Summary & Findings, stated Integra “did not have a cohesive 

and comprehensive written workplace violence prevention program to address hazards that included engineering and 

administrative controls, personal protective equipment and training programs.” (Ex. C-5, at p. 1). On March 8, 

2013, Jessica Cooney, Coordinator of Programs and Implementation of Training, told CO Prymmer that “[t]here 

were no check-in procedures for service coordinators. A challenging or difficult client was not defined. All notes 

are to be reviewed. There was no workplace violence program previous to the incident. There wasn’t any 

categorizing of clients of difficulty level and a way of assigning a client bases [sic] on the experience of a service 

coordinator.” (Ex. R-QQ, at p. 15). 24 CO Prymmer testified that an OSHA directive identified high crime areas and areas not visible to the public as 

risk factors for workplace violence. (Tr. 134-35). 

25 The Summer 2012 Syllabus for the Neumann training, also referred to as the Community Intervention Specialist 

Certificate Program or Integra Health Management Program, stated that the course was designed to enable SCs to 

effectively understand “the field of Behavioral Health – future needs” and the “importance of integrating integrated 

Behavioral Health and Physical health.” (Tr. 106; C-15). 

15 
 

 

 

 

 

 

 

 

 

that Session 8, In-Home & Community Safety, dealt with workplace violence or safety, 

including: 1) Screening Dangerous Members, 2) Identifying Risky Situations, 3) Safety in the 

Community, 4) Recognizing High Risk Behaviors, and 5) Minimizing Risk on the Job. CO 

Prymmer testified that two slide presentations in Session 8, concerning Screening Dangerous 

Members and Safety in the Community, consisted of general bullet points with no assigned 

additional readings or classroom training. He testified that the bullet points, including the 

“Partner with someone” bullet point, were not mandates and following them was up to the selfdiscretion of each SC.26 The terms “Dangerous Member,” “dangerous situation,” or “potential 

danger” used in the Screening the Dangerous Member presentation were not defined. He further 

said that the Screening the Dangerous Member slide presentation showed that “[t]he employer 

recognized somewhat of a hazard recognition of a dangerous member. The – the employer has – 

has a recognition.” (Tr. 105-13, 347; Exs. C-6, at p. 7, C-15 through C-17). 

CO Prymmer testified that the Safety in the Community slide presentation included bullet 

points that stated that high risk behaviors included: 1) A history of violence or self-harm, 2) 

Paranoia/Suspiciousness, 3) Psychosis/Confusion, 4) Substance Abuse, 5) Hopelessness, 6) 

Verbal Threats, 7) Lack of Future Plans, and 8) Criminal Behavior. Another slide identified 

more risk factors including: 1) Antisocial Personality, 2) Head Injury, 3) Family History of 

Violence, 4) Noncompliance, 5) History of Impulsive Behavior, 6) Loud/Manic Behavior, and 7) 

Possessor of Weapons. CO Prymmer testified that SCs first learned of the existence of any of 

these high risk behaviors when conducting their face-to-face health assessment of the member in 

the field. He further stated that the Safety in the Community slide presentation showed that 

Integra recognized members with these risk factors as a hazard. He testified that Integra 

26 CO Prymmer testified that Ms. Rochelle and other SCs told him that Integra pressured SCs not to seek to partner 

with other SCs when visiting members. (Tr. 111-13; Ex. C-17). 

16 
 

 

 

 

 

 

 

 

 

 

 

 

 

recognized that its members could be violent and exhibit criminal behavior. CO Prymmer 

testified that when he interviewed SCs “[t]hey had nothing good to say about it [Neumann 

training] in terms of how to do their job and how to be safe on their job.” (Tr. 114-17; Ex. C17). 

CO Prymmer stated that there was a general statement regarding “Workplace Violence” 

in Integra’s employee handbook that said “Violence by an employee or anyone else against an 

employee, supervisor or member of management will not be tolerated.” He testified that the 

general statement did not identify the specific types of workplace violence that SCs were most 

likely to be exposed to. He stated that Integra “didn’t have a written comprehensive workplace 

violence preventive program.” CO Prymmer also testified that many of the SCs received on-thejob training in the form of shadowing other SCs. Shadowing was not required and he reported 

an instance where an Integra SC, Ellen Rentz, just went out and did face-to-face visits without 

first shadowing anyone or completing the Neumann training. He testified that [redacted] 

shadowed SC Andy Macaluso a couple times. (Tr. 117-26,134-35, 341-42; Exs. C-5, at pp. 1-2, 

C-18, at p. 96). 

CO Prymmer testified that he recommended Integra receive Citation one, Item one, a 

violation of the general duty clause, because Integra “failed to materially reduce or eliminate the 

hazard of workplace violence.” He stated that he relied upon OSHA Instruction Directive 

Number: CPL02-01-052, effective date: September 8, 2011, Subject: Enforcement Procedures 

for Investigating or Inspecting Workplace Violence Incidents (OSHA Directive 052).27 He said 

that he also followed other publications and guidelines OSHA has for social service work and 

27 OSHA Directive 052 identifies “Types of Workplace Violence” and includes classifications of workplace 

violence that describe the relationship between the perpetrator and the target of workplace violence, including Type 

2 – Customer/Client/Patients: Violence directed at employees by customers, clients, patients, students, inmates or 

any others to whom the employer provides a service. (Ex. C-33, at p. 10). 

17 
 

 

 

 

 

 

 

 

 

health care. He testified that OSHA does not have a standard for workplace violence. He stated 

that Integra was required to create a workplace violence prevention program because health care 

and social services have a higher incidence of workplace violence than other industries. He 

classified Integra as being in the social services and health care industries. He testified about the 

known risk factors for OSHA compliance officers to consider as criteria for initiating workplace 

violence related inspections. These include: 1) working with unstable or volatile persons in 

certain healthcare, and social service settings, 2) working alone, 3) having a mobile workplace 

and 4) working in high-crime areas. He testified that he considered these risk factors when 

determining whether to cite Integra. He testified that the hazard present in this case was 

workplace violence with SC and management face-to-face exposure to violent members who 

have violent histories with a criminal background. He testified that [redacted] was exposed to 

workplace violence when she was required to be around [redacted], a member with a violent 

criminal background unknown to the employee, where no criminal background check was first 

performed by the employer.28 (Tr. 155-61, 239; Exs. C-5, at p. 8, C-33). 

CO Prymmer further testified that the social service and health care industries recognize 

the hazard of violence from exposure to persons with a violent behavior. He identified OSHA 

Publication 3148-01R 2004, Guidelines for Preventing Workplace Violence for Health Care & 

Social Service Workers (OSHA Guidelines), as a guide to help employers establish effective 

workplace violence prevention programs. CO Prymmer relied upon the OSHA Guidelines when 

determining that the social service industry recognized a heightened risk of workplace 

violence.29 He testified that Integra recognized the hazard of workplace violence from exposure 

28 Following [redacted]’ death, CO Prymmer testified that Integra started to perform criminal background checks 

and stopped providing services to eight members because it deemed them to be too dangerous. (Tr. 160). 

29 The OSHA Guidelines state: 

18 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to persons with violent behaviors based upon what he saw in the Neumann training and 

employee handbook. He testified that Integra’s response to the threat of workplace violence 

prior to [redacted]’ death was insufficient because Integra did not: 1) have a written 

comprehensive workplace violence program, 2) perform criminal background checks on 

members and stop providing services to members found to be dangerous, and 3) have procedures 

requiring SCs to use a buddy system.30 He also testified that he relied upon OSHA Directive 

052, Appendix B – Potential Abatement Methods, when he developed his list of recommended 

feasible abatements in the citation.31 (Tr. 161-66, 238-39, 362; Exs. C-5, at pp. 1-2, C-6, at pp. 

8-9, C-32, C-33). 

CO Prymmer testified that he also recommended that Integra be cited for failing to report 

[redacted]’ death to OSHA within eight hours. He stated that Ms. Brown told him that Integra 

did not do it. She told CO Prymmer that she did not think Integra was responsible for calling 

The Bureau of Labor Statistics (BLS) reports that there were 69 homicides in the health services from 

1996 to 2000.... BLS data shows that in 2000, 48 percent of all non-fatal injuries from occupational 

assaults and violent acts occurred in health care and social services. ... Injury rates also reveal that 

health care and social service workers are at high risk of violent assault at work. BLS rates measure the 

number of events per 10,000 full-time workers – in this case, assaults resulting in injury. In 2000, health 

service workers overall had an incidence rate of 9.3 for injuries resulting from assaults and violent acts. 

The rate for social workers was 15, .... This compares to an overall private sector injury rate of 2. 

(Ex. C-32, at p. 5).

30 OSHA’s Safety Narrative, Accident Investigation Summary & Findings, stated: Integra “didn’t have a set 

standard for double teaming; the buddy system wasn’t formalized. There were no high risk groups.” On December 

13, 2012, Ms. Brown told CO Prymmer that “We practice if you feel at risk you double team, don’t have a set 

standard for it. I think Stefanie was following policies. We were not looking at criminal history. Most of these 

people have a background, not a general practice to do background checks on patients....” On March 8, 2013, Dr. 

Arnott told CO Prymmer that “[i]n Pennsylvania we tried to go in pairs all of the time, but it took too long.” (Exs. 

C-5, at p. 2, R-QQ, at pp. 14-15).

31 CO Prymmer testified that since [redacted]’ death, Integra has developed a written workplace violence prevention 

program, updated safety assessments, performed background checks, stopped providing services to potentially 

violent members, created a color code system to identify members who are more dangerous than others, and 

provided more workplace violence training to their employees. OSHA’s Safety Narrative, Accident Investigation 

Summary & Findings, states: “Since the workplace violence incident, Integra Health Management has put in place 

the following, such as, but not limited to: critical incident debriefing, workplace analysis, background checks, 

member lists, member alerts, mandatory two service coordinator visits, safety checklists, M3MobileHelp 

transponder devices, staff tracking, and enhanced internal/external training.” These are all additional measures 

OSHA or CO Prymmer identified as feasible abatements. He said that all of these measures were feasible for 

Integra to have implemented before [redacted]’ death. (Tr. 166-67; Ex. C-5, at p. 2). 

19 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OSHA to report the fatality.32 He stated that Integra never kept OSHA injury and illness logs or 

documented any incidence of workplace violence. CO Prymmer testified that it was his 

understanding that an anonymous family member first reported [redacted]’ death to OSHA. (Tr. 

88, 163, 167-68, 176-77; Exs. C-1, at p. 9, C-3, C-4, C-28, at p. 4; Jt. Pre-Hr’g Statement, at p. 

8). 

Michael Yuhas is the President and CEO of Integra. He founded Integra in 2007. He 

does not manage Integra’s “day-to-day operations.” Mr. Yuhas has a Master’s degree in 

community clinical psychology, and has done additional graduate work towards a Doctorate in 

public and mental health, and epidemiology. He has a background in psychology, mental health, 

behavioral health and public health training. He has been in the health care business for more 

than 25 years, having worked at Blue Cross BlueShield in Maryland, the National Institute of 

Mental Health, the University of Maryland School of Medicine, and a company in Tampa called 

Health Integrated. In these positions, he has worked in research, administration, and executive 

level management. (Tr. 753-54, 785). 

Integra began operating in Florida in May, 2012. Mr. Yuhas testified that Integra worked 

“with people who fall through the cracks.” Integra’s members in Florida are covered by 

Medicaid. According to Mr. Yuhas, Integra was paid based on the numbers of members it 

worked with each month. These members most commonly have multiple chronic illnesses that 

do not get treated properly. They do not access preventive care. They do not take their 

medications or visit their primary care doctor. They regularly visit emergency rooms and are 

often hospitalized. Their health care providers are often unable to contact them. Mr. Yuhas 

testified that the health care insurers realize “that the only way you’re going to engage some of 

32 Integra’s Response to Interrogatory No. 4 states (in part) that Integra “was unaware of its obligation to report this 

matter to OSHA within eight hours. The OSHA log was completed on 12/13/2012.” (Ex. C-28, at p. 9). 

20 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

these members is to really do it on a personal level and – talk face to face and get them 

engaged.” The health care insurer identifies members for Integra and informs Integra of the 

members’ fundamental problems. At that time, Integra has no information concerning a 

member’s criminal background.33 Integra locates the member and helps the member connect to 

health care services and reminds them to take their prescribed medications. Mr. Yuhas testified 

that “it’s much more common that these individuals are likely to have depression and anxiety 

disorders and other mental health problems accompanying them.” He said that the range of 

mental health diagnosis for members is from the mild end, a minor depression, to the more 

severe end of mental illnesses, which is a cognitive disorder like a schizophrenia bipolar. He 

said members “have behavioral health which can include mental health and/or substance abuse 

conditions.” He said that there are members with criminal backgrounds that range from credit 

card fraud to violent crimes. SCs help facilitate the care plan that members and their health care 

providers have set up. About 35 members are assigned to each SC. He said that Integra’s 

guidelines call for SCs to make telephone calls to, and visit with, members several times a 

month. (Tr. 755-57, 760-65, 770-74, 778-79, 781, 786). 

Mr. Yuhas testified that in Florida during the fall of 2012 Integra’s SC training included 

training conducted online, face-to-face in the field, and by telephone each week. He said that 

Integra asked its employees to “avoid any situation that shows any indication of danger, potential 

danger.” He said that Integra recommended its SCs bring along another SC to member visits 

where there was any indication of being unsafe going alone. (Tr. 767). 

33 Mr. Yuhas testified that many of Integra’s SCs took it upon themselves to conduct a public information check on 

members in the fall of 2012; “but it was not something that was a hundred percent done by everybody.” (Tr. 774). 

The Court finds that there is insufficient evidence in the record to support this assertion. 

21 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

He testified that Integra’s work is within the community health work industry.34 The 

industry, according to Mr. Yuhas, was not social work because Integra’s industry was not 

clinical. Mr. Yuhas described Integra’s industry as “community health work,” and explained that 

“80 percent of the factors that impact people’s health are not related to health care at all. They 

... are related to basic 101 issues, uh, barriers to care that are ... educational, ... psychosocial, 

behavioral, environmental, and not clinical.” While doctors, nurses, and social workers, i.e., 

clinicians, focus on the other 20 percent of the factors that impact people’s health, Integra’s 

industry, according to Mr. Yuhas, focuses on the non-clinical solutions that would connect 

members to their clinicians. He said that it was not standard practice for the community health 

industry to conduct criminal background checks before sending employees out to visit members. 

Mr. Yuhas testified that there are no national or Florida regulations for the community health 

industry. (Tr. 762, 768, 774-77, 883, 1018). 

Dr. Melissa Arnott is the vice-president of community programs at Integra.35 (Tr. 340). 

She has a Doctorate in counseling education from the University of Sarasota awarded in 2004,36 

34 Mr. Yuhas testified that Integra changed its SC designation to Community Coordinator in about January, 2014. 

He said that there are about 50,000 community health workers in the nation, including 2,500 in Florida. (Tr. 758, 

762, 769, 783). 

35 Dr. Arnott has served in a variety of positions serving the mental health community since 1990 to the present. 

From 1997 through 2008, she also privately practiced as a therapist providing individual, group and family 

counseling. She has also been an instructor at Rowan and Neumann Universities. (Tr. 863-65; Ex. R-TT). 

36Dr. Arnott testified that the University of Sarasota was bought by Argosy University. On November 8, 1991, the 

University of Sarasota, Inc. filed a voluntary bankruptcy petition No. 8:91-bk-14551-TEB under Chapter 11 in the 

United States Bankruptcy Court, M.D. FL. A plan was confirmed on April 8, 2002. Dr. Arnott’s resume shows that 

she worked in Pennsylvania from the time she was awarded her Master’s degree in 1995 through 2004, the year she 

was awarded her Doctorate degree in Florida, suggesting most of the work for her Doctorate degree was done off 

campus. In at least one instance, the University of Sarasota has been seen as a “non-traditional” university and had 

its doctorate programs called into question. See No. 78-2294, Dr. John Gullo v. Fla. Bd. of Exam’r. of Psychology, 

1979 WL 63236 (Fla. Div. Admin. Hrgs, June 28, 1979) (noting that University of Sarasota does not have an 

accredited degree program that would qualify the plaintiff to sit for the board examination for certification). The 

Court is crediting Dr. Arnott’s Doctorate degree in counseling education with weight less than that accorded a 

22 
 

 

 

 

 

 

 

 

 

 

 

 

 

a master’s of science degree in counseling education in higher education and counseling from 

West Chester University awarded in 1995, and an undergraduate degree in liberal studies with a 

concentration in psychology from Neumann University awarded in 1993. She is a licensed 

professional counselor in Pennsylvania and New Jersey; a licensed clinical addictions counselor 

in New Jersey; a certified Addictions Counselor Diplomat in Pennsylvania, and an international 

certified Advanced Alcohol and Other Drug Abuse Counselor. (Tr. 858, 861-62; Ex. R-TT). 

Dr. Arnott joined Integra in August, 2010 as the team lead for Philadelphia, Pennsylvania 

where she oversaw eight SCs in a new program. She helped train the SCs at her Philadelphia 

office and was with them every day. She testified that she also “spent time with them 

[Philadelphia SCs] in the field, much time training.” During the 18 months of that program, the 

SCs in Philadelphia did the same thing as the SCs in Florida later did starting in May, 2012. 

After Integra’s contract expired in Philadelphia about February, 2012, Dr. Arnott helped develop 

Integra’s new program in Memphis and train its new team there comprising a team lead, lead SC, 

and 6 SCs. In about May, 2012, she also created a similar SC program for Integra at Pittsburgh 

and Harrisburg, Pennsylvania. She testified that even though the job was “not clinical”, she had 

a clinician overseeing each of the teams. (Tr. 866-75, 897). 

She developed the Neumann training for the new SCs along with Dr. Krajewski.37 The 

Neumann training was available by late August, 2012. Integra hired the majority of its SCs in 

Florida in August/September, 2012. Dr. Arnott directly supervised Ms. Rochelle, Integra’s team 

similar degree awarded following completion of a full-time, resident study program taken over the course of several 

years at a traditional university with a suitable accredited program. (Tr. 858; Ex. R-TT). 

37 Dr. Arnott testified that Neumann University wanted the training to “go through them, so we were going to start 

through adult education. And then they were going to make it a minor in the university because, you know, as we 

know with the Affordable Care Act, this is where the industry is heading with this community care or community 

health worker.” She said Neumann University “called it a Community Intervention Specialist” Certificate Program. 

(Tr. 884; Ex. R-J). 

23 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lead in Florida, from about April 30 through November 6, 2012. SCs in Florida and one or two 

from Tennessee and Pennsylvania took the Neumann training in 2012.38 Integra scheduled up to 

49 hours for Florida SCs to take the Neumann Training from August 27 through September 7, 

2012. The Neumann training consisted of 15 sessions, where the SC had to: 1) post at least two 

paragraphs of reaction reflection responses for each session (represented 50 percent of the 

grade), 2) prepare a one-page paper (representing 25 percent of the grade), and 3) complete a 

final examination (representing 25 percent of the grade). Integra paid $1,500 to Neumann 

University each time a SC took the training. (Tr. 105-06, 340-50, 876-81, 888-90, 894-95, 

998,1015-16; Exs. C-15, C-16, at pp. 1-4, C-17, at pp. 4-5, R-J, R-Y). 

Dr. Arnott said she felt it necessary to instruct SCs on how to identify and assess 

dangerous members because they worked directly with persons who were mentally ill. She said 

that the SCs used the Brief Psychiatric Rating Scale (BPRS) looking for psychotic symptoms 

changing over time. She further said that the Team Lead would also look at the BPRS and 

evaluate whether a member was making progress, a criteria for discharge. Dr. Arnott testified 

that “the team lead is the one that discharges [members]” and “when it came time to discharging, 

then that would be the team lead’s decision.” She considered standards for both social workers 

and community health workers when developing the Neumann training. She testified that she 

used the National Association of Social Workers’ (NASW) social worker standard for safety and 

material from “SAMHSA.”39 She noted that best practices for the community health worker 

38 [redacted] completed the Integra Health Management Program in October, 2012. She made Neumann training 

reaction reflections on September 27, 2012 to both Crisis Services and Safety Discussions. On that date she 

authored a reflection that stated re: Safety Tips, (in part): “I also think having some background information on a 

client can help determine whether he or she could be dangerous. But in the end, one can never really be sure, so it is 

always best to put safety first.” The court finds [redacted] was working on completing the Neumann training in late 

September, 2012. (Tr. 948-54, 992-93; Exs. R-VVV, R-QQQQ, at p.8, R-RRRR, at p. 11).

39 Although not defined in the record, the Court notes that SAMHSA is the federal government agency Substance 

Abuse and Mental Health Service Administration within the U.S. Department of Health and Human Services. Ms. 

24 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

“didn’t have any safety in there.” She also said that she looked at agencies where she had 

worked and said that there was “very little safety training out there. And I never had safety 

training in places I worked.” (Tr. 344-50, 876-81, 1002-03, 1102). 

She initially said that the initial assessment form “was a health and behavioral health and 

basic needs type assessment” that did not require SCs to have any clinical skills to complete.40 

Later on, she testified that when completing the assessment form, SCs recorded behavioral 

observations, including whether a member was confused or depressed. She agreed that the 

assessment form called for SCs to summarize their assessment of the member and state whether 

member’s answers to their questions were consistent with their clinical observations. She also 

said that the assessment form called for SCs to write a psychosocial note and watch GAF and 

BPRS scores for each member over time.41 (Tr. 873-74, 897, 1006-07; Ex. C-34). 

She testified that both Neumann training and training given monthly by Dr. Krajewski 

included on overview of psychotropic medications. She said by knowing the medications, SCs 

know more about their members and possible medicinal side effects. She testified that the 

Janet Nelson, the Secretary’s expert, testified that NASW’s social worker guidelines are generally applicable to all 

human service workers. (Tr. 1102). 

40 At one point in her testimony, Dr. Arnott said Integra “didn’t want assessments done like a clipboard going 

through and checking off boxes. It was a discussion. It’s engaging the person.” Later she said that the assessment 

“is really like a checklist. I don’t know why we call it an assessment.” In rebuttal, Ms. Nelson testified that SCs 

perform as clinicians, in part. She said the initial assessment form called for SCs to conduct a brief mental status 

examination of the member, make clinical observations of the member, write biopsychosocial notes, and use 

clinical tools such as Global Assessment of Functioning (GAF) and BPRS scores. She said that SCs without a 

Bachelor’s degree in social work or any field experience lacked the experience or knowledge necessary to apply 

these tools. She further testified that the use of inexperienced and unqualified workers to apply these clinical tools 

affected the worker’s exposure or ability to respond to workplace violence. Ms. Nelson testified that the ability to 

do a clinical assessment informs the person doing the assessment of the risk of violence. She said that is well 

understood in the field. She said the problem with Integra’s program is its use of workers without much experience 

to perform an assessment that includes a violence risk assessment. She said Integra’s client population of members 

with severe and persistent mental illness provides a challenge to inexperienced workers to assess a member’s 

propensity for violence. (Tr. 106, 897, 905, 1099-1104; Ex. C-34). 41 Dr. Arnott described GAF as a clinical score in the DSM. DSM commonly refers to the Diagnostic and Statistical 

Manual of Mental Disorders which is the standard classification of mental disorders used by mental health 

professionals in the United States. She said Integra gave the SCs a member’s GAF score. (Tr. 1008-09). 

25 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neumann training included a session entitled “Layperson’s Guide to Mental Health” where SCs 

are given information about mood, thought, and personality disorders so that they know what to 

expect when seeing members with any of these disorders. She testified that Session 13 dealt 

with substance abuse and that Integra wanted its SCs to be able to identify when a member was 

impaired. She testified that “20 to 25 percent of [Integra’s] members have severe mental 

illness.”42 (Tr. 905-09; Exs. C-J, at p. 4, R-J, at pp. 4-5). 

The Neumann training also included a PowerPoint slide in Session 8 that suggested SCs 

“[o]btain critical history about previous unsafe behaviors” of members.43 Dr. Arnott admitted 

that Integra did not require SCs try to obtain such information before visiting with a member. 

She testified that Amerigroup did not provide criminal background information about a member 

to Integra.44 She also said that when visiting a member for the first time SCs should assume 

“anybody had the potential of violence.” Dr. Arnott testified that SCs would learn of a member’s 

history of violence, or a family’s history of violence, when doing the initial assessment or from 

any research they might do online.45 She also admitted that, at the time of [redacted]’ death, 

Integra did not require taking another SC along on a face-to-face visit when a SC suspected that 

42 She also testified that many of Integra’s mentally ill members in Florida also had medical issues. (Tr. 342). 

43 Dr. Arnott initially testified that the Neumann training did not include any discussion about Integra’s buddy 

system. (Tr. 898). Later on, when discussing page 4 of the Screening the Dangerous Member module of the 

Neumann’s training Session 8 she discussed a SC’s consideration of taking another SC when visiting a dangerous 

member. She stated Integra would probably discharge a member thought to be dangerous. She further said that if 

the member was thought to be something less than dangerous, Integra would want SCs to take another SC along on a 

visit, or meet with the member in a public place. (Tr. 943-44; Ex. C-16, at p. 4). 44 Dr. Arnott testified that many of the Florida SCs checked the criminal database themselves. Dr. Arnott testified 

that she talked about SCs checking “mugshot” during training, but also stated “[i]t’s not accurate” and “you can’t 

rely on mugshot.” She also said that Integra tried to contract with Pinkerton to perform criminal background checks, 

but Pinkerton told Integra that it would not do it because it was a violation. The Court finds SCs did not regularly 

check a reputable criminal database in the fall of 2012. (Tr. 109-10, 916-17). 

45 Dr. Arnott also said that SCs could ascertain a member’s past criminal behavior by getting a member’s consent to 

contact a member’s family, friends, or clergy. She also testified that Integra discharged members when learning 

during the assessment that the member had a gun. (Tr. 936-40). 

26 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

there was a potential danger. It was suggested that the SC ask another colleague to join the SC 

as a “buddy” if the SC felt unsafe. It was up to the SC to arrange for a “buddy” to accompany 

them on a face-to-face visit to a member. Dr. Arnott said if they were unable to do so, they were 

to go to their supervisor, who would assign someone or go along themselves. Integra did not 

have a written procedure for requesting a “buddy.” Dr. Arnott testified Integra had an unwritten 

procedure where SCs told their “safety partner” and “program manager” where they were at all 

times.46 She also testified that Integra saw no reason to conduct “takedown training” for SCs. 

She said that Integra’s guidance to SCs confronting criminal behavior is to “just leave.” ( Tr. 

344-54, 915-16, 923-24, 931-35, 938-41, 1012; Exs. C-15, C-16, at pp. 1-4, C-17, at pp. 4-5, RJ). 

Dr. Arnott testified that she and Ms. Cooney conducted face-to-face training in 

September and November, 2012 in Florida. She also said that Integra provided three additional 

safety trainings pursuant to Integra’s yearly training schedule that were conducted by telephone 

or webinar.47 She testified that SCs were expected to identify the high-risk behaviors listed in 

the Neumann training’s Safety in the Community segment identified above while doing their 

46 Dr. Arnott’s testimony on this procedure does not make reference to a time frame when any such policy was in 

effect. The Court notes that on August 28, 2012 Dr. Arnott posted material with the “Topic: Safety Tips”, “Subject: 

Safety Tips” that included at Step 1 a reference to designating a team colleague as a monitor or informing the 

Director. The posting also said: 

[t]he monitor needs to know your visitation schedule for field visits. Provide the monitor all visitation 

addresses and directions to each destination. You can call the monitor to check in when you arrive at the 

home. The Monitor should set a timer for the time allotted for the visit. Check in with the monitor again 

when you get in your car and leave the visit. The monitor should contact you if you do not call within 

the agreed-upon timeframe. 

(Ex. R-RRRR, at p. 7). 

The Court finds insufficient evidence to support a finding that any such monitoring procedure was actually in effect 

or followed by SCs in Florida prior to December 10, 2012.

47 Integra’s training schedule called for training in a variety of topics including Psychotic Disorders, Personality 

types, and High Risk Behaviors. (Ex. R-A). There are no records of attendance for any of these telephone or 

webinar yearly training sessions in evidence and the Court is unable to determine if any Florida SCs actually 

participated in any of these sessions in 2012. 

27 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

face-to-face initial assessment of the member. Integra relied upon members self-reporting their 

own criminal behavior, feelings of hopelessness and history of violence.48 She said that 

Integra’s initial assessment would be used anywhere in the health care industry. It was similar 

to those used at doctor’s offices. (Tr. 344-50, 959-60, 974-79; Exs. C-15, C-16, at pp. 1-4, C-17, 

at pp. 4-5, R-A, R-G, R-Y). 

Dr. Arnott testified that she reviewed [redacted]’ October 12, 2012 progress note report 

shortly after it was created. She thought that [redacted] knew what she was supposed to do; be 

outside or not go alone if she felt anything.49 Dr. Arnott testified that she did not know whether 

[redacted] had a history of violent behavior. She said she knew he had an injectable, 

antipsychotic medication. She did not have confirmation from [redacted]’s psychiatrist whether 

he was being properly monitored and medicated for his schizophrenia before [redacted]’ death. 

Dr. Arnott testified that Amerigroup did not report any history of violence by [redacted] to 

[redacted]. Dr. Arnott did not know whether [redacted] took another SC with her when she 

visited [redacted] on October 15, 2012. She testified that she did not consider [redacted]’s 

October 15, 2012 discussion about his The Last Supper picture to be delusional or alarming. She 

said that for a member to be considered dangerous there needed to be more than one symptom. 

Dr. Arnott did not follow up with Mmes. Rochelle or [redacted] to determine how [redacted] 

intended to subsequently meet with and provide services to [redacted]. (Tr. 140-41, 270-72, 356-

63; Ex. C-7, at pp. 1,5). 

48 Dr. Arnott also testified that SCs may obtain some information of high-risk behaviors from the member’s family 

or Amerigroup. (Tr. 350-51). 

49 Dr. Arnott testified that during her training Integra told SCs: 

not to go in the home when they’re alone, ..., and there’s no one else in the home. But then also we also 

tell them to look at who’s in the home, because people in the home could be dangerous as well as the 

member. So everything could be a dangerous situation. 

(Tr. 929-30). 

28 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After Ms. Rochelle left Integra, Dr. Arnott began to act as the team lead in Florida. She 

testified that she promptly reviewed [redacted]’ November 14, 2012 progress note report of her 

visit to [redacted] which indicated he reportedly initially pretended to be his twin brother, and 

later signed the Integra’s consent form as himself. Dr. Arnott did not follow-up with [redacted] 

to ascertain whether she had not met with [redacted] inside his home alone. She testified that 

after three face-to-face visits with [redacted] at his home, [redacted] remained unaware of his 

history of violent behavior. (Tr. 356, 363-66; Ex. C-7, at p. 7). 

Dr. Arnott testified that Integra’s services were evaluated based on whether it was saving 

Amerigroup money by reducing unnecessary hospitalizations. She described Integra’s industry 

as a “niche in the market that other people are not doing in this community health worker type 

role, ....” (Tr. 883, 1017-18). 

Dr. Thomas Krajewski, referred to throughout the hearing as “Dr. K,” is the Medical 

Director at Integra, and has served in that position since 2007.50 As the Medical Director, Dr. 

Krajewski “provide[s] consultation, education services and help[s] with program development.” 

He helped Dr. Arnott develop the Neumann training by providing input based on his experience 

in the field. Dr. Krajewski testified that, in developing the Neumann training, he surveyed other 

programs in which community health workers go out and do home visits. He found some 

programs had virtually no training and other programs had a maximum of two weeks of training. 

He said Integra wanted SCs to: 1) be well informed when they go out in the community, 2) be 

50 Dr. Krajewski had previously served in the administration of Springfield Hospital, “the largest state mental health 

facility in Maryland.” In 1984, he was appointed Maryland’s Assistant Secretary for Health, and Chief Physician. 

In 1986, Dr. Krajewski was appointed Assistant Secretary for Developmental Disabilities, Mental Health and 

Addictions. In the late 1980’s, he was appointed Director of the Medical Surgical Psychiatric Unit and Director of 

Geropsychiatry for Spring Grove Hospital. In the 1990’s, Dr. Krajewski served as the Senior Medical Advisor to 

Magellan Health Services. He continued seeing patients with his private practice. Dr. Krajewski graduated from 

Loyola University in Maryland, and then went to the University of Maryland Medical School, where he was the 

chief resident. (Tr. 1023-25). 

29 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

prepared to develop what they can see are a member’s needs, and 3) connect members to those 

missing services. He testified that Integra developed the Neumann training, weekly rounds, onsite face-to-face training, and a hot-line for SCs to contact management to satisfy its training 

needs. He stated that Integra’s training was “superior” to what he saw in the community health 

worker community because Integra provided weekly rounds, on-site training, and on-call 

availability. (Tr. 1023-26). 

Dr. Krajewski testified that the SCs were “not supposed to make any clinical judgments 

... or provide any clinical therapy or treatment.” He said the SC’s role is to connect members to 

clinical services they are missing. He stated SCs are not required to be licensed in Florida. He 

stated what Integra’s SCs “do is very unique.” He testified that Integra’s safety policy of 

“universal precautions”, where an employee “[a]ssumes everybody you deal with could have the 

potential for harm” was in its employee handbook. He discounted the need for self-defense 

training and said “if there’s a danger, you get out.” (Tr. 1029-31, 1034). 

Diane Brown is the Chief Operating Officer at Integra. Ms. Brown testified that the 

primary performance problem with Ms. Rochelle concerned her reliance on her own clinical 

training and her need to complete the Neumann training. (Tr. 1037, 1061-62). 

She also testified about [redacted]’ telephone records on December 10, 2012. She 

testified that the records show that at 10:00 a.m., Scott Schneider called [redacted] and was on 

the line for two minutes.51 At 10:05 a.m., she spoke with Mr. Schneider by telephone for 12 

minutes. At 11:05 a.m. and from 11:19 a.m. to 11:22 a.m., she was in telephone contact with 

another member that was assigned to her, not [redacted]. (Tr. 1064-65; Ex. R-GG). 

51 The telephone record for this call includes a reference to “CALL WAIT”. (Ex. R-GG, at p. 1). It is unclear to the 

Court who initiated the telephone calls between [redacted] and Mr. Schneider because the telephone records at Ex. 

R-GG, at p. 1, show [redacted] initiating the calls and the records at Ex. R-GG, at p. 2, show Mr. Schneider initiating 

the calls. (Ex. R-GG, at pp. 1-2). 

30 
 

 

 

 

 

 

 

 

 

 

 

 

 

Ms. Brown further testified that Dr. Arnott resided in New Jersey and did not have an 

office at Integra’s Maryland corporate facility. (Tr. 1066). 

At the time of [redacted]’ death, Ms. Brown was unaware of OSHA’s policy concerning 

injury logs. She admitted that Integra did not report [redacted]’ death to OSHA. (Tr. 1068; Ex. 

C-5, at p. 1). 

Jessica Amy Cooney – Coordinator of Program Implementation and Training 

Ms. Cooney was hired by Integra in 2010 as a SC in Philadelphia, Pennsylvania.52 Ms. 

Cooney has been Integra’s coordinator of program implementation and training since about the 

fall of 2012.53 Her business address is in Owings Mills, Maryland. Ms. Cooney’s duties include 

shadowing, database training with data entry, and participating in classroom training. In about 

September/October, 2012, she participated in two of the three face-to-face training sessions 

conducted by Integra at a Florida hotel.54 She testified that the training consisted of a 

PowerPoint presentation that covered from the point when a SC first received a caseload to being 

in the community. She also testified it included some role playing and a discussion about safety. 

She said each training session lasted two days. In addition to the face-to-face training, Ms. 

Cooney provided “shadowing” or “mentoring” type training. This field training consisted of 

showing SCs what it is like to do their job. She went with SCs to visit members. She watched 

them perform a visit with members, providing tips along the way. Ms. Cooney mentored 

52 Before that she worked in sales for Verizon Wireless. She also did volunteer work for a domestic abuse project 

in her neighborhood. She also volunteered at Impact Systems, where she took members from their home to doctors’ 

appointments and grocery stores. After a year-and-a-half as a SC, she took a six-eight month break from Integra and 

worked as a consultant for Ameritox. She has earned some college credits in general studies at the community 

college level. She does not have a bachelor’s or associates degree. (Tr. 796, 806). 

53 Ms. Cooney still also performs the duties of a SC from time to time. (Tr. 799). 

54 Ms. Cooney testified that she did not recall the dates she conducted any training in Florida. (Tr. 803). 

31 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Messrs. Schneider and Macaluso, as well as Annie Hinman and Marisa Donahue. (Tr. 788-93, 

797, 800). 

Ms. Cooney testified that Integra implements the buddy system whenever someone is 

uncomfortable. She said if nobody was around to buddy up, “then you just don’t go. You save it 

for a time when somebody can come with you.” Ms. Cooney testified that no SC communicated 

to her any concerns related to the buddy system or safety training that Integra provided. She 

never trained [redacted]. (Tr. 793-95, 801). 

Laurie Rochelle – Service Coordinator Team Lead 

Laurie Rochelle worked at Integra from April 30, 2012 through November 6, 2012.55 

She was the Tampa office team lead. She supervised Ms. Ferguson, the lead SC, and all of the 

other SCs, including Mmes. [redacted], Rentz, Hinman, Donahue, “Yvonne,” “Claire,” and 

“Danielle”, and Messrs. Macaluso and Schneider. Ms. Rochelle reported to Dr. Arnott at 

Integra. Ms. Rochelle interviewed all of the prospective SCs in the Tampa office, except for Ms. 

Ferguson. She testified that she understood that the SC’s job was to coordinate services for 

members.56 She described their job as trying to get members to connect with their doctors and 

avoid getting re-admitted into hospitals. She testified that every week SCs “were supposed to 

either make a face-to-face contact or a call, but they had to make at least two face-to-face 

55 Before working at Integra, Ms. Rochelle worked as a clinical supervisor for a few months at Gulf Coast Jewish 

Community Services and before that at Ceridian where she provided assistance to military personnel who needed 

counseling. She has a Bachelor’s degree in psychology and a Master’s degree in counseling. She has a Florida license 

in Mental Health Counseling. She also had a private practice providing weekly couple’s counseling to five long-term 

patients of hers. She is employed as a Care Manager at Wellcare. (Tr. 243-44, 288, 316, 320-21). 

56 Ms. Rochelle testified that it made no sense to describe the SC’s job as nonclinical because they were required to 

make assessments of a member’s medical, mental health, counseling, and treatment of substance abuse needs. (Tr. 

265). 

32 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contacts per month.” Ms. Rochelle testified that Integra did not get paid by Amerigroup for its 

provision of services to a member if two face-to-face contacts were not made each month. She 

also said that Dr. Arnott told her that SCs who did not make two face-to-face contacts each 

month with members would not be paid. Ms. Rochelle testified that she was getting pressure 

from Integra management to insure that SCs made two face-to-face contacts each month. (Tr. 

245-50, 255, 259-60, 281, 287-88, 312-13). 

According to Ms. Rochelle, the SC applicants were first screened at Integra by someone 

other than her, and then the applicants were passed on to her with Ms. Arnott’s instructions on 

which questions to ask them. She then passed on the information she received from the 

interviews to Dr. Arnott, who had the final say in the hiring process. Ms. Rochelle testified that 

Dr. Arnott encouraged her to hire those “just getting out of school” with a Bachelor’s degree. 

She explained that this was so because “the salary was very low” and the company wanted to 

“train them the Integra way, you know, train them a certain way.” According to Ms. Rochelle, 

Integra did not value experience as much as she did in its hiring process. She felt that SCs 

needed to have some experience in a mental health facility. She did not know when conducting 

interviews that the SCs were going to be working with members “that were getting out of jail.” 

Ms. Rochelle preferred to hire SCs who had at least six months of experience entering a person’s 

home.57 She felt that SCs “needed to have some street smarts.” Ms. Rochelle interviewed 

[redacted]. [redacted] did not have this experience. Ms. Rochelle testified that she initially did 

not want to hire [redacted] because “she was very young” and seemed “somewhat fragile in a 

way.” But Ms. Rochelle hired her anyway because [redacted] had “that heart that she wanted to 

help others,” and Ms. Rochelle hired “as [she] was instructed.” (Tr. 247-49, 312). 

57 Ms. Rochelle testified that she completed three years of in-home counseling during her own internship. (Tr. 249). 

33 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As the office team leader, Ms. Rochelle assigned the SC workload according to 

geography, reviewed and approved SC progress note reports, held weekly office meetings via 

teleconference, and carried her own full caseload of 32-40 members.58 Ms. Rochelle testified 

that SCs had to first locate members who were staying in hospitals, mental health facilities, 

homes, group homes, and homeless shelters. Integra required SCs to go to a member’s home 

unannounced and knock on the door where a member did not have a phone. One member lived 

in a tent. Other members met them at restaurants because they did not want SCs coming to their 

homes. Ms. Rochelle described the type of members that SCs visited as being “drug seeking,” 

those just “getting out of jail,” “people with severe mental health issues,” including some who 

were schizophrenic or had personality disorders,59 and members with a history of violence. She 

testified that SCs were not given any information regarding a member’s criminal background or 

history of violence. She explained that SCs had to find a member “or you don’t get paid because 

Amerigroup would only give us 325 [members]. It was a pilot program. So, you know, the more 

members that we found – and they were known to be the hard to find members.” (Tr. 251-54, 

258-59, 267, 272, 287-88). 

Ms. Rochelle testified that she conducted weekly telephone conferences with the SCs on 

Wednesdays from 11:00 a.m. to noon. She said that they discussed members and other topics 

she did not recall. She also testified that Drs. Krajewski and Arnott conducted weekly “rounds” 

by telephone with the SCs in Florida. She testified that [redacted] raised [redacted]’s situation 

regarding “some very strange” statements he made concerning The Last Supper on October 15, 

58 Ms. Rochelle testified that the SC case load once reached 50 members. She stated that each SC was supposed to 

be assigned “no more than 35” members. (Tr. 253-54). 

59 Ms. Rochelle testified that SCs were required to visit members who were admitted to a hospital or mental health 

facility within 24 hours of learning of their admission. She stated that often these visits occurred after the member 

was discharged. (Tr. 253-54). 

34 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2012 at a weekly rounds conference call in which Dr. Krajewski participated. She did not recall 

anyone offering any advice to [redacted] as to how to proceed with [redacted].60 She saw the 

situation as a “small red flag” involving a mentally ill person who did not say “I’m going to kill 

you.” She said “[w]e all knew that the person [[redacted]] – these people are mentally ill.” She 

said that the situation “would have been a little bit different” had the progress note report said 

[redacted] was “paranoid schizophrenic” and not just “schizophrenic.” (Tr. 292-94). 

She testified that she also fielded concerns from her SCs. She affirmed that SCs 

expressed concerns about safety. She testified that she had “a lot of safety concerns.”61 Ms. 

Rochelle testified that Mr. Schneider weighed jumping a fence and being chased by dogs against 

the “pressure[] to find [a] member.” She testified that Mr. Macaluso called her regarding safety. 

She testified that a member Ms. Hinman was driving to doctors’ appointments was later found to 

have burned down his mobile home, gone to prison, and had “thoughts of killing her.” She 

testified that she could not tell Dr. Arnott these stories because if she did, “pretty much you’re 

fired.” SCs did not have personal protective equipment, such as panic buttons or alarms. There 

were no procedures in place at Integra to allow her to know which members SCs were visiting or 

where they were at any time during the week. She testified that Integra did not provide safety 

training to its employees. (Tr. 133, 256-61, 266-69). 

Ms. Rochelle testified that she was “not comfortable” with [redacted]’ stated intention, 

set forth in her September 9, 2012 progress note report, to make an unplanned visit to [redacted] 

at his home address, but Ms. Rochelle stated “but that was the only way that you could get to the 

member, uh, is to go to their house.” Ms. Rochelle testified that there was nothing for Integra to 

60 Ms. Rochelle testified that, right after this, she was told by Dr. Arnott “not to talk to any of the Service 

Coordinators.” (Tr. 275).

61 Ms. Rochelle testified that the SCs did not receive notice of a member’s diagnoses. She was concerned that SCs 

were unknowingly entering homes of members who were paranoid schizophrenic. (Tr. 256-57). 

35 
 

 

 

 

 

 

 

 

 

 

 

 

do for safety with regard to the progress note report [redacted] prepared for her October 12, 2012 

face-to-face visit to [redacted] where she said [redacted] said things that made her 

uncomfortable. She said “everybody was uncomfortable with a lot of these members, the new 

members that were coming in. The new 325 [members] that we got, I mean there was a lot of 

shady people. Uh, I was feeling very uncomfortable the more and more that I met.” Ms. 

Rochelle testified that [redacted] was not supposed to visit [redacted] alone on October 15, 2012. 

She said that [redacted] should have asked Ms. Ferguson [to accompany her] since she was the 

closest geographically to her; even though she knew Ms. Ferguson might not do so. Ms. 

Rochelle testified that it was not her job to insure that SCs had other SCs accompany them on 

face-to-face visits to members. She said that Integra did not ensure that a “buddy” accompanied 

[redacted] on any of her face-to-face visits with [redacted].62 She said “[t]he most important 

thing with Integra was to go meet that member and have them sign the paperwork.” (Tr. 273-74, 

277-78, 284, 294; Ex. C-7, at p. 2). 

Ms. Rochelle also testified that, following her October 15, 2012 face-to-face meeting 

with [redacted], [redacted] said in their “rounds meeting” that [redacted] said “some very strange 

things” to her about a depiction of The Last Supper he had on his wall. Integra did not conduct 

any sort of safety assessment(s) of the situation [redacted] reported in her October 12 and 15, 

2012 progress note reports concerning [redacted] after Ms. Rochelle approved them. She also 

said that Integra did not have a policy that called for incident reports to be prepared. She also 

testified that the buddy system was not effective because SCs were spread thin over four counties 

62 Ms. Rochelle testified that “a big part” of the Lead SC’s [Ms. Ferguson] job was to ensure that [redacted] had a 

buddy with her when she visited face-to-face with [redacted]. She also said that [redacted] was never disciplined for 

not taking someone with her. Ms. Rochelle was never told to discipline any SC for not taking a buddy along. She 

stated that a lot of the SCs told her in October/November, 2012: “We don’t know what to do.” Ms. Rochelle told 

them she was leaving Integra, and they were “just as lost as I was.” (Tr. 284-86). 

36 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and were not available, and time for it “just was not allowed.”63 The buddy system was not 

mandatory. Ms. Rochelle testified that she did not recall asking any SC to go with [redacted] on 

her next face-to-face visit to [redacted] after she approved [redacted]’ October 15, 2012 progress 

note report. (Tr. 265-66, 275-81, 298-99; Ex. C-7, at p. 6). 

Ms. Rochelle testified that Dr. Arnott developed the Neumann training about a month or 

two after Integra hired the SCs. Ms. Rochelle took the Neumann training on November 4 and 

November 5, 2012, five and a half months after she started at Integra, because the human 

resources office demanded her to.64 Integra gave her two days to complete the 40 hour training 

course. She mentioned that there was not time before then to take the Neumann training and that 

there were technical issues with the computer system. 65 She testified that she and many of the 

SCs found the Neumann training to be “a joke.” She found the Neumann training to be “very 

basic” with five percent of it being “a little bit informational.” She testified that she was 

perturbed that Dr. Arnott told her that the SCs needed only to complete the Neumann training, 

and nothing else. (Tr. 119, 261-64, 319-20, 329-30). 

63 CO Prymmer testified that Ms. Rochelle told him that prior to [redacted]’ death there was not time for SCs to 

consider taking along another SC because there was pressure on SCs to complete their calls and conduct their faceto-face interview with members. CO Prymmer further testified that after [redacted]’ death, the new SC team lead, 

Ms. Tonya Flores, told SCs “if you don’t get out and do your two face-to-face visits, there are going to be fewer of 

you.” (Tr. 111-13, 203-04). 

64 CO Prymmer testified that Ms. Rochelle told him that the Neumann training was insufficient and did not prepare 

SCs to perform their job. He also testified that she told this to Dr. Arnott. In her letter to COO Brown of December 

3, 2012, Ms. Rochelle stated: “After finally given the time to complete the Neumann training which was 

embarrassingly a cut and paste of the SAMSA (sic) website and not what SCs really need to do their job ‘(the 

Integra way)’ - ....” She also stated that there was a “lack of proper or any appropriate training.” (Tr. 117-19; Ex. 

C-14). On November 6, 2012, Ms. Rochelle authored a reaction to the Safety Tips topic, Subject: Safety and 

dangerous neighborhoods that stated (in part): 

Safety is vitally important with being a community intervention specialist. I know that when we did not 

have many employees when starting out program I took a couple of risks in a couple crack 

neighborhoods. I would not recommend any one else to do the same. I wanted to find that member but I 

did notice it was crack infested and everyone to get a buddy to go into some of these neighborhoods – if 

something bad happens well then you can' t [sic] help anyone!! (Ex. R-RRRR, at p. 2). 

65 CO Prymmer testified that Ms. Rochelle told him that she tried to increase the safety and health training for SCs. 

She was unsuccessful because Dr. Arnott did not want that to happen since it took too much time, and she did not 

have time for it. (Tr. 133). 

37 
 

 

 

 

 

 

 

 

 

 

 

 

 

On November 7, 2012, Ms. Rochelle submitted her resignation letter and gave Integra 30 

days’ notice of her proposed December 6, 2012 termination of employment. She testified that 

she resigned because there was: 1) not enough training, 2) a lack of teamwork, 3) a lack of 

direction from Dr. Arnott and 4) a lot of conflict between her and Ms. Ferguson. She also said 

Amerigroup did not work with Integra and she did not want to put her mental health counselor 

license in jeopardy. By letter, dated November 26, 2012, Ms. Brown told Ms. Rochelle that she 

ended her employment duties with Integra on November 7, 2012. She told her that her final pay 

would occur on November 30, 2012, which paid her through the pay period ending November 

24, 2012. She also told Ms. Rochelle that Integra was recouping company property and $300 for 

debit card charges that it questioned from her final pay. Integra seeks to discredit this witness 

due to the alleged workplace performance problems and unauthorized charges on Integra’s card. 

Ms. Rochelle has denied making the alleged unauthorized charges on the company debit card. 

(Tr. 259, 281, 330, 332-37; Exs. C-13, C-14, R-RRR, R-TTT, R-UUU; Resp’t Reply Br., at 3 

n1).

66 

The Court finds that Ms. Rochelle’s testimony is consistent with the overwhelming bulk 

of the evidence surrounding Integra’s practices and procedures toward members, the SCs, and 

their work environment. The Court also observed the demeanor of this witness and found her to 

be credible, straightforward and trustworthy. The Court credits Ms. Rochelle’s testimony 

discussed herein. 

Ellen Elaine Rentz – Service Coordinator 

66 The record shows that on October 21, 2012, Integra issued a Written Warning & Corrective Action Plan, Re: 

Leadership and Management Performance Deficiencies, to Ms. Rochelle that included a plan for improvement that 

included (among other things) her completing training by November 15, 2012 and assuring she and all of her team 

members attended weekly telephone rounds on Wednesdays at noon. (Ex. R-RRR). 

38 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ellen Rentz worked at Integra from September, 2012 until February, 2013. Her job 

duties included two face-to-face meetings with a member per month, typically at the member’s 

home, where she would obtain consent from the member to assist them in what they needed. Her 

duties also included making two telephone calls to a member each month. The types of 

assistance included “getting food stamps, transportation, food, [and] housing.” She carried about 

a 25-35 member caseload. Her work day and work environment depended on how successful 

she was in chasing down the face-to-face interaction: sometimes she worked more than eight 

hours per day, driving into unfavorable areas, sometimes at night, and across neighboring 

counties, in order to procure the “face-to-face.” For each member, Integra provided Ms. Rentz a 

telephone number and an address, and usually no other information. (Tr. 369, 373-74, 406-07). 

Ms. Rentz took the Neumann training using a computer, which lasted “probably six 

hours,” but she did not complete the training before she went into the field.67 She never 

shadowed anyone while working at Integra.

68 She testified that she did not receive any 

classroom training at Integra regarding safety in the workplace. After Ms. Rochelle left, she 

participated in the weekly telephone meetings on Wednesdays with Drs. Arnott and Krajewski. 

She testified that these telephone meetings were mandatory, although attendance was not taken. 

She testified that people would ask questions or tell Dr. Krajewski about situations they did not 

know how to handle. An example she gave was a member that “may have been hospitalized or 

they were in, you know, a hospital where they were having mental breakdowns and stuff.” She 

said that Dr. Krajewski would “probably say, well, when this person is discharged, you need to 

make sure that you’re there to help that person.” She testified that she was not sure a SC could 

67 Neumann University certified that she completed the Integra Health Management Program in December, 2012. 

(R-BBB).

68 CO Prymmer testified that new SCs were expected to be in the field visiting members “pretty rapidly.” He also 

testified that Ms. Rentz told him there was a lot of pressure to “saddle up and go [into the field].” (Tr. 97, 124, 134). 

39 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

discuss safety issues during these calls because the discussions were about helping the members, 

“[n]ot so much about anything else.” (Tr. 122-24, 135, 369-72, 379-80, 394). 

According to Ms. Rentz, Integra instituted a “sign-in” and “sign-out” procedure after 

[redacted]’ death. Before her death, Integra had no sign-in/sign-out procedure for SCs. Integra 

also did not give SCs a member’s history of violence or criminal background when a member 

was initially assigned. After [redacted]’ death, Integra started “red-flagging” members in “the 

system” by providing any criminal background information associated with the members. Ms. 

Rentz testified that one of her members, who she had visited alone inside her home prior to 

[redacted]’ death, was “red-flagged” after [redacted]’ death by Integra because of mental health 

and criminal backgrounds, involving a gun. She testified that after learning this information, she 

was “in shock” and “would not go back out there to see this lady.” She said “[b]ut going into her 

home, I would never do that again.” Ms. Rentz testified that she was not concerned about safety 

before [redacted]’ death because she “assumed we were safe. We were working for a company. 

I felt I was safe to go out there. They had already possibly done all the legwork necessary to 

make sure they were not sending me into harm’s way somehow.” She said Integra never 

discussed with her any risk associated with her job. (Tr. 375-77, 380-81, 389, 395-96, 410). 

After [redacted]’ death, Integra pulled the SCs out of the field for four or five weeks. 

Instead of visiting members, SCs made telephone calls. Then, Ms. Flores, her new supervisor, 

“started telling us we needed to get over it and get back out there and help these people.” Ms. 

Rentz testified that Integra did not have a policy regarding partnering or buddying with another 

employee. She said before [redacted]’ death, “[w]e didn’t have one. We were not told to partner 

up and go with anyone.” After [redacted]’ death, Ms. Flores told the SCs that: 

the only reason you would need two people to go to an individual’s home is that another 

Service Coordinator has never seen that person before, so then two people should go. But if a 

40 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Coordinator has already been there, you can go alone. And that was the point 

where I realized that I’m not staying here. I am going to leave this job. It’s not worth my life. 

(Tr. 382-84; Ex. C-11). 

Integra terminated Ms. Rentz’s employment on February 7, 2013.69 She testified that 

she was not upset over being terminated because she was not going to stay at Integra anyway. 

Ms. Rentz then testified that she wrote a letter “to Ms. Flores or some management person” 

explaining her concerns about safety at Integra, but she does not know when she sent it or even if 

she sent it at all. 70 She testified that she left Integra “with a sad heart because I was worried that 

someone else may get hurt.” She said that the SCs needed more things in place for safety. She 

testified that she did not know that she was working with people “who had criminal 

backgrounds, who may have killed someone before or may have assault and battery.” (Tr. 385-

89, 407-09; Exs. C-11, R-AAA). 

Yaharya Denise Stevens – Service Coordinator 

Yaharya Stevens was a SC for Integra from December 3, 2012 through mid-February, 

2013.71 She visited members in their homes twice a month, called them twice a month, and 

transported them to medical appointments and public housing offices in her own car. She took 

69 Respondent seeks to discredit this witness due to the circumstances that led to her firing that occurred starting in 

January, 2013. (Exs. R-VV through R-AAA; Resp’t Reply Br., at p. 3 n1). The Court finds that this witness’s 

testimony is consistent with the other evidence in the record regarding Integra’s practices and procedures. The 

Court also observed this witness’s demeanor and found her to be a credible, straightforward, and trustworthy 

witness. The Court credits Ms. Rentz’s testimony. 

70 Among other things, the letter states: 

I am saddened by the way that your management staff is handling the safety concerns of the employees. 

... Some of the other service coordinators simply left without having another employment in place this 

action was due to being in fear for their lives. I have been in management for over 21 years and have 

never worked for a company that does not have or follow any safety rules when it comes to making the 

dollar/meeting numbers for the company. ... (Friday – 1/15/13) ... It is obvious that no one cares about 

the employees’ safety here at Integra it seems to be all about the dollar. 

(Ex. C-11).

71 Before then, she worked in administration at the Polk County Health Department for about a year. She was also 

in the military for four years, where she worked in Human Resource. She has a degree in health care administration. 

She had no background in social work. (Tr. 416-17). 

41 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the online interactive Neumann training when she first started on December 3rd. She shadowed 

Ms. Ferguson for two to three days. She participated in the rounds held on Wednesdays at 12 

o’clock with Drs. Arnott and Krajewski by telephone. At the time, she thought that Ms. 

Ferguson was her supervisor. She verbally shared her concerns with Ms. Ferguson about driving 

certain members who were not taking their medication. She felt uncomfortable and unsafe 

transporting the members because she was “concerned if I’m driving and they get upset and they 

want to attack me.” She thought this because she learned that most of the members she was 

responsible for had severe mental illnesses that either chose not to take medication or did not 

have access to their medication. Ms. Stevens described two incidents in which she and Ms. 

Ferguson were in cars with mentally ill patients who were not taking their medications. “They 

were not on medication and they just were not themselves. The members were, uh, fidgety and 

uncomfortable.” In one instance, a member told her that he was uncomfortable driving with her 

because of her ethnicity. She testified that Dr. Krajewski made it clear that we had to drive them 

around in her own car to appointments. She testified that SCs were required to drive members to 

psychiatric appointments. She was never told by management to get members bus passes; other 

SCs suggested how to get bus passes or transportation through the county. (Tr. 416-21, 424-30). 

She still had safety concerns regarding transportation when she left Integra in February, 

2013. She left due to an incident that occurred after [redacted]’ death when she was told she had 

to physically find a member. She went to the member’s primary care doctor’s office to speak to 

the doctor. She waited in the waiting room for an hour-and-a-half, and got up to leave her 

contact information with the receptionist for the doctor to contact her. As she was waiting to 

speak to the receptionist, a “patient” of hers came up to her and pushed her out of the way as she 

was speaking to the receptionist. She did not report that incident at that time to Integra. She 

42 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

decided to resign because two other coworkers had similar incidents happen to them and even 

though they reported it, they were told that it was part of their job and that they had to “deal with 

it.” (Tr. 132-33, 422, 429). 

Kimberly Michelle Daniel – Service Coordinator 

Kimberly Daniel worked for Integra from August, 2012 through February, 2013. 

Before that, she worked as a crisis counselor, where she did field work. She was a former coworker of Ms. Rochelle at Ceridian with Military Once Source. When she started, Ms. Rochelle 

was her supervisor, then Dr. Arnott, and finally Ms. Flores. She did not shadow anyone at 

Integra. She learned her job through trial and error. She took the Neumann training and 

received the certificate within a month of starting the job. The Neumann training was delayed 

that month due to computer glitches. She testified that it was “very simplified” and not 

“anything that really helped” her do her job. When assigned members, she knew her member’s 

medical diagnosis and sometimes their mental health diagnosis. She said that she did not receive 

any safety training at Integra before [redacted]’ death. She found out later that members had 

violent histories, including robbery, armed robbery, and sexual assault backgrounds, that were 

not initially disclosed to the SCs. Her first duty was “doing whatever they could to locate them 

[members]. Go in wherever, no matter what the conditions looked like, no matter what the 

situation was to try and locate them.” Ms. Daniel testified this included sometimes going to 

“abandoned looking buildings” and apartment buildings that should be condemned that had 

“roaches and ants crawling about, things falling down from the ceilings.” Sometimes she 

would go inside members’ homes or go to homeless shelters. She said that Dr. Arnott told the 

SCs to locate members “at any cost necessary.” (Tr. 433-37, 441-43). 

43 
 

 

 

 

 

 

 

 

 

 

 

Once she located the member, she determined whether “they were compliant,” i.e., 

whether “they were taking their medications” or whether “they are in services.” If not, she 

would offer to help them become compliant by driving them to the doctor’s office and back 

home, and otherwise connecting them with resources. She would be in her car driving with 

members for up to 45 minutes to the doctor’s office, and then another 45 minutes driving back 

home. She was required to meet with the members twice a month. Before December, 2012, any 

request she had for a buddy was denied because the other SCs were working on their own 

caseload, “everybody was too busy” and nobody was available. She said that using the buddy 

system “wasn’t an option” available to SCs. She recalled some type of training with Dr. Arnott 

and Ms. Cooney in Florida in October that she attended, but felt it was “incomplete,” so she did 

not “sign off on everything.” She sent an email to “all service coordinators and management” 

requesting additional training “that they had been promising us” in December, 2012 after 

[redacted]’ death. Ms. Daniel was laid off in February, 2013 due to a reduction in force, and she 

“was not too upset about that.” (Tr. 439-46). 

Scott Matthew Schneider72 – Service Coordinator 

Scott Schneider was an Integra SC from the end of August, 2012 until about February 19, 

2013. His duties included developing a “care plan” and providing members the resources that 

“would hopefully mitigate them from either being admitted into a crisis stabilization unit or a 

hospital, as well as provide them with any third party resources that may not have been covered 

under their current health insurance benefits.” Examples of services he provided included 

locating “durable medical equipment” for a morbidly obese woman, and convincing health 

professionals that a replacement insulin pump was required due to the member breaking the 

72 The original court transcript, since corrected by Court identified errata, spelled his last name as “Snyder”. (Ex. 

R-P, at p. 9). 

44 
 

 

 

 

 

 

 

 

 

 

 

 

 

pump by accident and not abusing the medication. Mr. Schneider testified that he spent 15-20% 

of his time driving members to appointments at mental health facilities and personal errands in 

his own car.73 He testified that he never transported anybody that had any type of erratic 

behavior. He carried a 25-30 member caseload at first, and the caseload grew to 50-60 members. 

SCs had to act as “detectives and hunt them [members] down by any means” because Integra 

provided SCs with so little information about assigned members. (Tr. 450-54, 459-60, 465). 

Mr. Schneider took the Neumann training when he started at Integra in August, 2012. 

He received his certificate in October, 2012. He stated that he did not receive any safety training 

at Integra prior to [redacted]’ death. He did not shadow any SC when he started working at 

Integra. In October, 2012, as part of a one day group training, he accompanied Ms. Cooney into 

a very dangerous area of town. He testified that Integra did not have a workplace violence 

policy. He also participated in the weekly rounds on Wednesdays with Drs. Arnott and 

Krajewski. He testified that when he or another SC discussed safety concerns during the weekly 

rounds, Dr. Krajewski had the “ultimate say” on how to handle the situation, and typically 

“nobody was really getting any resolve. So we all tried to keep quiet as best as we could because 

it was just a colossal waste of our time.” He also participated in the weekly meetings with Ms. 

Rochelle, but testified that no safety concerns were brought up until after [redacted]’ death. 

They instead typically discussed “better ways that we could serve the clients,” explaining that 

“we were all kind of new. There was a pilot project. We all had to kind of feed off each other to 

kind of find out what resources were available in the community to better service the clients that 

we were serving.” He testified that whenever he asked questions of management, he “never 

73 Mr. Schneider testified that: “We had to do errands too. We were like, you know, little do boys and do girls.” 

These errands included driving members to the bank, pharmacy, Department of Motor Vehicles (DMV), food store 

and medical appointments. (Tr. 465; Ex. C-29, at p. 6). 

45 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

really got answers.” He testified that he had to find “solutions out for myself because there was 

no support from management.” He did not recall getting answers from management to his 

concerns about safety that included feeling unsafe going to a member’s house. (Tr. 454-56, 460, 

481-88; Ex. R-PPP). 

He did not raise any safety concerns with Integra before [redacted]’ death because, “I 

think I was really naive, and I believed that the company had my best interest at heart, they 

properly screened these people, and I never really thought about it, you know.” Ms. Rochelle 

had no problem with SCs going out in pairs. He testified that he buddied up several times with 

Mmes. Rentz and [redacted].74 In January, 2013, Ms. Flores “relayed to us that it [the buddy 

system] was a misappropriation of time and that we needed to do that individually. It got to the 

point that if I had somebody that I felt [] uncomfortable around, I would go out with the SC and I 

just would not document it.” He testified that “[m]anagement disapproved of us going out in – in 

a team.” (Tr. 457, 485-87). 

He recalled an incident, prior to [redacted]’ death, where a schizophrenic member made a 

verbal threat against him. According to Mr. Schneider, the member made it “abundantly clear,” 

in a public place, that “he would have knocked me in the middle of next week.” This incident 

occurred during the initial assessment. He said a lot of the questions were very personal, 

including those about medical or psychiatric conditions, medications, or institutionalizations. 

Mr. Schneider confirmed that on September 13, 2012 a member also disclosed during the initial 

assessment that he had “a history of anger management issues which has led to many physical 

altercations.” Despite this disclosure, Mr. Schneider continued to meet with this member several 

74 Mr. Schneider testified that he helped train [redacted] and teamed up with her about five or six times. He said that 

“[t]here was no support or training, so I had to tell her [[redacted]] what needed to be done.” He also testified that 

he and [redacted] and Rentz had lunch at Panera Bread to therapeutically vent because of “the stress that we were 

under, the large amount of pressure to produce an unrealistic goal in an unrealistic time frame.” (Tr. 487, 494). 

46 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

times afterward because “you had to continue meeting with them until they got rolled off or, uh – 

you know, even if they said they didn’t want to participate, you still had to badger them, uh, until 

they – until management decided yeah, we’re going to roll them off.”75 In order to get a member 

“rolled off,” Mr. Schneider testified that a safety concern or “tendencies that are violent in 

nature” were not enough. “It had to go before management and the doctor. The doctor was the 

one that made the decision to my understanding.” He said that Integra did not “roll off” too 

many members because doing so caused Integra to lose money. (Tr. 458-59, 466-67, 492; Ex. C29, at p. 6). 

Mr. Schneider testified about other experiences that he had while working at Integra. He 

recalled a member that was frequently “Baker Acted” by his family, “almost every other 

month.”76 (Tr. 462-63; Ex. C-29, at p. 6). 

He recalled that he visited a member [on November 20, 2012] whose house was plastered 

with “no trespassing” and “beware of dog” signs. He noted that in his progress note report 

because “this person obviously doesn’t want unsolicited people coming up to their doors, and 

they need to be aware of that.” Mr. Schneider testified that he was scared that a dog, that he 

viewed as unfriendly, could break away from its rope and bite him. He reported his concern 

about the dog during one of the “rounds” and was “probably” told to find some other way to 

contact the member. He said that the member’s broken down trailer home was “in the middle of 

75 “Rolling them off” meant Integra stopped providing services to the member. (Tr. 833-34). 76 Mr. Schneider explained that he used the term “Baker Acted” to mean that a judge has determined that “you’re 

a threat to yourself or somebody else and you need to be institutionalized.” He stated that the institutionalization 

“generally lasts anywhere from 48-72 hours.” With regard to this member, Mr. Schneider testified that, as of 

September 13, 2012, he was institutionalized for an “extended period[] of time” into “Peace River Center,” which 

he described was “a sanitarium in a nice way.” Neither party mentioned the “Baker Act” in their briefs. Based on a 

cursory search, it is presumed that the witness is referring to the Florida Mental Health Act, codified at Fla. Stat. § 

394.451 et seq. (Tr. 463-64; Ex. C-29, at p. 6). 

47 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

nowhere” and “[t]here was no way to get in contact with them.” (Tr. 468, 495-96; Ex. C-29, at 

p. 15). 

He noted that “15 to 20 percent of [his] caseload” included members who had bipolar 

disorders and multiple personalities.” One of those members, he recalled, made him “extremely 

uncomfortable” because “she just was very promiscuous and very forthcoming towards me.” He 

described one instance where “like a light switch flicks, looks like a light went off and then all of 

a sudden it was like Dr. Jekyll, Mr. Hyde. She was this completely different person. She had 

this knife in her hand like a kitchen knife, and she was just kind of like twirling it around. And I 

was like I need to get the heck out of here.” He met with her two or three more times after that, 

but always outside of her home. (Tr. 469-71; Ex. C-29, at p. 18). 

He also recalled a member that “scared the bejesus out of me, and I refused to go to that 

house.” He told his supervisor at the time that he was not going to that member’s house. He had 

originally met with that member at a psychiatric unit in a hospital. He likened his interaction 

with her to sitting in a “courtroom with Charles Manson on trial.” He had recorded on December 

10, 2012 that her mother told him that: 1) “[t]he whole family has been terrified of her and has 

sought shelter elsewhere....”, and 2) the member had physically assaulted her boyfriend and had 

“a serious addiction to meth and becomes violent and thinks she’s God.” Despite sharing his 

safety concerns with his supervisor, he was still required to go to the member’s house. He 

refused to do so, except on one occasion, when accompanied by Ms. Rentz, they visited her 

house together, but she did not answer the door. (Tr. 471-72, 492-93; Ex. C-29, at p. 24). 

Mr. Schneider testified that he left Integra because he was assigned a member that 

required a face-to-face encounter who had a very lengthy criminal record. He informed 

management that he “did not feel comfortable going and meeting with this person.” After being 

48 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

told to “just meet in a public place,” he left Integra because his “life was more important than 

that.” (Tr. 457-58). 

Andrew Macaluso – Service Coordinator 

Mr. Macaluso was an Integra SC from August, 2012 to December, 2013. His duties 

include assisting members in finding community resources, and helping to “make sure they were 

taking their medications as prescribed.” He would “locate transportation for them if they needed 

it,” and he would “confer [] with clinical staff if [he] had questions about [] some of their 

conditions.” It was one of his duties to transport members to their doctor’s appointments or to 

alternative places to live when their current placement was not stable. (Tr. 500, 508-09). 

On October 15, 2012, Mr. Macaluso had a discussion with his supervisor, Ms. Rochelle, 

about Mr. D, one of the members assigned to him. He wrote in his October 15, 2012 progress 

note report that he spoke with Ms. Rochelle that day regarding Mr. D’s “positive homicidal 

ideations with plans, probable means (access to a firearm), and intent.” He also noted “the 

member’s suicidal ideations regarding the member shooting himself in the mouth with the same 

gun.” He further noted that he did “not want to transport the member due to the extreme possible 

safety risks to himself and others. These ideations and access to a weapon could prove 

dangerous to the SC or other individuals in the vicinity of the transport.” He also noted that he 

told Ms. Rochelle that Mr. D has been placed in the state mental hospital for four years for 

suicidal and homicidal ideations. He further recorded that he informed Ms. Rochelle that Mr. D 

“had multiple felony charges including assault with attempt to maim.” (Tr. 504-05, 510; Ex. C30, at p. 21). 

The next day, he sent her an e-mail to discuss the “possible duty to warn the target of Mr. 

D’s homicidal ideations.” He also requested “take down training and hands-on crisis de49 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

escalation training.”77 He testified that he sent the email because “I had some concerns about 

some of the members that I was working with. That I felt it would be beneficial to have that type 

of training. Other places I’ve worked we’ve had similar types of training [ ] to deal with people 

who have [ ] different types of mental health issues where there might be a problem with them 

being aggressive.” He wrote on October 16, 2012: “I’m concerned that as I have had to 

transport and visit more than one member who has a history of violence towards others resulting 

in severe bodily injury.” (Tr. 504-10; Exs. C-30, at p. 21, C-31 at pp. 1, 9). 

He followed up with another e-mail to Ms. Rochelle on October 19, 2012: 

I am uncomfortable being alone with Mr. D as he has expressed homicidal 

ideations and access to a firearm. [] Mr. D has a history of multiple felony 

assaults including a felony assault with attempt to maim. He currently has 

domestic violence charges pending against his girlfriend. I am also 

uncomfortable with placing a member who has shown himself to be aggressive 

with staff on the inpatient unit in my car. All Mr. D. would need to do is jerk the 

steering wheel to kill or gravely injure both of us. ... What is the safety plan given 

the homicide plan that he has told me and his history of assault behavior?”78 

He testified that Mr. D’s homicidal ideations were directed at a former roommate: “he had 

wanted to shoot this fellow that he [] had stayed with before [] in the head with a firearm.” (Tr. 

508, 511; Exs. C-30, at p. 30, C-31 at pp. 2-3). 

On November 1, 2012, Mr. Macaluso noted in his progress note reports that Mr. D had 

assaulted the driver of a car earlier in the week and expressed suicidal ideations to law 

77 Mr. Macaluso explained that “take down training” was “a type of training where you could [] in a nonviolent 

fashion make someone who is, say, hostile [] unable to engage in those activities without injuring them.” He further 

explained that “usually it’s a combination of de-escalation, which would be verbal, and [] physical, which would be, 

you know, the last resort.” “Physical,” he explained, would include some way of physically having contact with a 

patient to take him down to the ground. It’s intended to prevent members “from harming themselves or harming 

someone else.” Mr. Macaluso testified that he received “take down training” at Eckerd Reentry, Department of 

Juvenile Justice, where he worked as a reentry counselor. He also said that he received “team training” that had 

been developed by the Florida Mental Health Institute while working briefly at Northside Mental Health. He 

described “team training” as a nonviolent way to guide a person having a violent episode either to the floor or a 

chair; or to free yourself where someone has grabbed your hair or shirt. (Tr. 520-24).

78 Mr. Macaluso testified that he “was saying that I felt like I would be unsafe in that situation.” (Tr. 597). 

50 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enforcement that resulted in his admission to the Mental Health Care’s Crisis Center. He also 

noted that Mr. D was “ROLLED OFF (REMOVED) FROM THE INTEGRA PROGRAM 

TODAY AFTER THE EVENTS DISCUSSED IN THIS NOTE.” (Ex. C-30, at p. 30). 

On November 15, he sent an e-mail to Dr. Arnott and Ms. Ferguson regarding the 

previous emails he had sent to Ms. Rochelle, who had left Integra by that time. In this email to 

Dr. Arnott and Ms. Ferguson, Mr. Macaluso recounted an incident that occurred on November 2, 

2012. He wrote that “Mr. D is the member who threatened to ‘kick my ass’ when Whitney and I 

attempted to transport him a few weeks ago. This threat made me afraid for my safety as I 

thought I was going to be assaulted and would have to defend myself.” (Tr. 129-30, 511-15; 

Exs. C-30 at pp. 28-33, C-31, at p. 2). 

Neumann University certified that Mr. Macaluso completed the Integra Health 

Management Program in October, 2012.79 Mr. Macaluso resigned from Integra in December, 

2013, when he was offered a position at a community agency closer to his house.80 Mr. 

Macaluso is currently a case manager where he visits pregnant mothers in the field. His current 

employer conducts background checks and he believes also has a workplace safety program. 

(Tr. 500, 519; Ex. R-KKK) 

Annie Marie Hinman – Service/Community Coordinator 

At the time of the trial, Annie Hinman was an Integra Community Coordinator. She 

started working at Integra in September, 2012, and testified that she works out of her home in 

79 He also testified that Integra provided some de-escalation training to him on May 1, 2013. (Tr. 525). 

80 Respondent seeks to discredit this witness through documented workplace performance issues that arose in 2013. 

(Tr. 1053; Exs. R-FFF, GGG, HHH, III, JJJ; Resp’t Reply Br., at p. 3 n1). No witness testified to these exhibits. 

Mr. Macaluso was not given an opportunity to address them at the trial. The Court finds that his testimony is 

consistent with the other evidence in the record regarding Integra’s practices and procedures. The Court also 

observed the demeanor of this witness and found him to be credible, straightforward, and trustworthy. The Court 

credits Mr. Macaluso’s testimony. 

51 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Port Richey, Florida. She is also currently working on a master’s degree in mental health 

counseling. Her duties as a Community Coordinator include calling members and checking in 

with them to see if that have gone to their provider appointments, transporting members to 

provider appointments, attending telephone staff meetings, and putting in notes at the end of the 

day. (Tr. 807-09, 826). 

Ms. Hinman testified that after getting her case load from her supervisor, she now checks 

“to see if there are any red flag members where I would need to bring someone with me to visit 

them.” She testified that she now checks public records at the Pasco County or Pinellas County 

Sheriff’s departments. She enters member’s names to see any information that comes up. If she 

finds any criminal background, she reports it to her supervisor “so that they could review it and 

determine if we would keep that member or if they would be discharged.” She testified that, for 

example, if a member’s history showed a “dog bite case from 12 years ago,” she “would put a 

red flag in. Make sure you go there with a partner.” She did not recall when she started 

checking public records. Ms. Hinman testified that in September, 2012, Integra did not require 

her to do the criminal background checks. (Tr. 809-12, 825). 

Ms. Hinman completed the Neumann training online, which she characterized as 

“average,” before she began to work in the field visiting members. She then shadowed Ms. 

Rochelle for two days.81 She attended two or three training sessions with Dr. Arnott and Ms. 

Cooney that lasted “an hour or two maybe.” There was no role playing involved in the training. 

She testified that Ms. Rochelle also gave training. She participated in the weekly telephone 

rounds on Wednesdays, which she testified lasted 45 minutes to an hour. She did not recall any 

81 CO Prymmer testified that Ms. Hinman told him that she completed the Neumann training in eight hours and 

thought it was a joke. Here also testified that none of the SCs told him that they thought that the Neumann safety 

training was sufficient. (Tr. 119-20). 

52 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

safety issues discussed during the Wednesday rounds. She also attended mandatory telephone 

conference meetings with Ms. Rochelle and the Florida SCs once or twice a month, during 

which, “similar to the rounds call,” they would discuss issues on how to better serve their clients. 

She testified that she utilized Integra’s buddy system in the fall of 2012. She buddied up with 

Ms. Ferguson and Mr. Macaluso. She never had “any occasion when [she] felt the need to have 

a buddy and [she] couldn’t get one.” (Tr. 814-24). 

Ms. Hinman testified that Ms. Rochelle was her first supervisor, followed by Dr. Arnott. 

There was a period of time in 2012 that she felt that her supervision was “inadequate,” and that 

there was a lag of time of two days in getting her progress note reports approved by a supervisor 

in the database. (Tr. 829-30). 

Ms. Hinman recalled a member who had been jailed for burning down his mobile 

home.82 In 2012, the member told his health care provider at a medical office, in front of her, 

that he had homicidal thoughts toward her. “And the [medical] provider asked him if he had 

suicidal or homicidal thoughts, and he said yes. And the therapist asked him to explain. And he 

said, the thoughts are telling me to harm her, which was me. He pointed to me.” She had seen 

him many times, having worked with him “for a long period of time,” and had never known of 

these homicidal thoughts toward her and “never felt like I needed to ask him if he was suicidal or 

homicidal or if he had thoughts of harming me.” She said she “wasn’t told to ask those 

questions, ....” She said that Integra required her to continue to provide services to the member. 

After that incident, Ms. Hinman buddied up with Mr. Macaluso and Ms. Cooney, on one 

occasion, to meet with him. This member was eventually “discharged” or “rolled off” her 

caseload after she had worked with him “for a long period of time.” (Tr. 830-34). 

82 Ms. Hinman testified she learned that the member had burned down his home by conducting her own search of 

police public records. She did not state when she conducted her public records search of this member. (Tr. 831). 

53 
 

 

 

 

 

 

 

 

 

Whitney Ferguson – Service/Community Coordinator 

At the time of the trial, Whitney Ferguson was an Integra Community Coordinator. She 

began working at Integra in the Philadelphia office as an intern and became a SC in the 

Philadelphia office in October, 2010. In August, 2011, she transferred to the Memphis office. In 

May, 2012, she transferred to the Tampa office where she was the lead SC. Her supervisor in 

May, 2012 was Ms. Rochelle. At that time, Integra had 50 members assigned and she and Ms. 

Rochelle split them evenly. She worked in the Tampa office during the fall of 2012, with the 

exception of a six week maternity leave from September through mid-October. She reported to 

Dr. Arnott after Ms. Rochelle left. (Tr. 836-38, 843, 854-56). 

When Ms. Ferguson started at Integra, she received training by Dr. Arnott and field 

training by other SCs. Her training, which included safety training, continued in Memphis and 

Tampa. In Tampa, there were three training sessions that occurred in September, October, and 

about November/December of 2012. According to Ms. Ferguson, “safety was one of the things 

that was incorporated in all of the trainings.” This was because she believed “it’s such an 

important part of what we do.” The September training was “a few days” and was at a Marriott 

Hotel. She did not attend all of the training because she was getting ready to go on maternity 

leave.83 Ms. Cooney conducted the training, which Ms. Ferguson said included safety-related 

“role-playing.” Mr. Yuhas gave the introduction and attended, in part. The October and 

November/December training sessions were also “two or three days,” at a hotel, and included 

safety issues. She did not know if there was any role playing in the October training. Dr. Arnott 

and Ms. Cooney conducted the October training. Only Dr. Arnott conducted the 

November/December training. (Tr. 838-43, 958). 

83 Because of her partial attendance at the September, 2012 training, the Court affords little or no weight to her 

testimony regarding the substance and scope of the training. 

54 
 

 

 

 

 

 

 

 

 

According to Ms. Ferguson, the Integra Tampa office hired seven SCs from September 

through December, 2012. The number of Integra members grew from the original 50 to 200. 

About 30 members were assigned the each SC. During this time, Ms. Ferguson testified that she 

oriented Mmes. Hinman and Stevens, as well as Mr. Macaluso. Shadowing entailed bringing the 

new SC along for the day so that they could see what she did and she could explain why she did 

things a certain way. (Tr. 843-46). 

She testified that during the fall of 2012 she would buddy up with someone if she was 

going to an area or visiting a member that made her uncomfortable. If she could not get a buddy, 

she said she would reschedule the appointment, or sometimes buddy up with Ms. Rochelle. She 

recalled Ms. Rochelle accompanying her on one visit to a member’s home in 2012. She did not 

recall ever requesting anyone accompany her on a visit to a member’s home in 2012.84 (Tr. 847-

48, 857). 

She testified that all the new SCs took the Neumann training, although she herself did not 

because she started at Integra before the Neumann training was created and she had already 

received face-to-face training. Ms. Ferguson also testified that she participated in the 

Wednesday rounds with Drs. Krajewski and Arnott, as well as Ms. Rochelle. She testified that 

safety issues were discussed during the Wednesday rounds, although she could not recall any 

specific safety related discussion. (Tr. 848-51). 

Ms. Ferguson recalled one instance in which she buddied up with Mr. Macaluso to visit 

one of his members. Ms. Ferguson could smell marijuana when the member opened the door to 

his apartment. According to Ms. Ferguson, she called Dr. Arnott from outside the member’s 

84 The Court finds Ms. Ferguson’s testimony regarding her use of the buddy system in 2012 to be contradictory and 

affords it little or no weight. 

55 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

door, told her about the marijuana, and Dr. Arnott told her that they should leave.85 As they 

went to leave, the member “got in Andy’s face and – you know, I don’t remember verbatim what 

he said, but he made some statements that made us, you know, continue on leaving like Melissa 

had instructed us to do, and we left.” That member was later “discharged from the program.” 

(Tr. 852-53, 925-26). 

Expert Testimony 

Janet Ann Nelson was qualified at trial as an expert witness by knowledge, skill, 

experience, training and/or education in three areas: (1) clinical social work, (2) personal safety 

awareness, and (3) personal safety skills and safety programs for health and human service 

workers.86 See Fed. R. Evid. 702; Daubert v. Merrell Dow Pharm., Inc., 509 U.S. 579, 589 

85 Dr. Arnott testified that she was not sure if Integra made an incident report for this event. (Tr. 1010-11). 86 Ms. Nelson has been working in the social work field since 1977, when she graduated with a Bachelor of Arts 

degree from the University of Florida. Ms. Nelson began her career at the Florida Department of Health and 

Rehabilitative Services, where she did some in-home visits to clients. She then worked as an informational referral 

specialist at the Alachua County Crisis Center “phone banks” for almost a year. After that, Ms. Nelson pursued and 

mastered martial arts. She has a fourth degree black belt and has taught martial arts since 1978. She earned her 

Master’s degree in Social Work (MSW) in 1994 at Florida State University. Ms. Nelson explained that she saw a need for 

self-defense training because the social service field “is a women’s based profession for the most part,” and the work itself 

can be threatening due to home visits, certain clients, and certain neighborhoods. After earning her MSW degree, Ms. 

Nelson worked at the Pace Center for Girls, a Departmental of Juvenile justice program in the state of Florida. Ms. Nelson 

also provided Pace Center staff training that included conflict resolution, adolescent mental health issues and 

behaviors, adolescent suicide, de-escalation, crisis intervention, behavior management, working with adolescents, 

and self-defense. Ms. Nelson became a licensed clinical social worker (LCSW) in Florida in February, 2005. To become 

licensed, Ms. Nelson had to have 1,500 “face-to-face contact hours,” which she explained was field experience. She 

testified that “‘clinical’ means that you’re focused on basically three pieces, which is assessment, diagnosis and 

treatment. And so it’s a special track.” She chose the clinical track during her master’s studies. As a LCSW, Ms. Nelson 

had a private practice. Her clients included mainly juveniles, but also adults, from her clinical supervisor’s private 

practice. In her private practice, she treated mentally ill persons. She performed mental health assessments on all 

her clients. Along with her private practice, Ms. Nelson remained at the Pace Center as a LCSW and also started 

working part-time at Tallahassee Community College (TCC), providing mental health services for the college and the TCC 

police department. She worked 10-12 hours each week at TCC for seven years. She testified that she worked with TCC 

in response to the Virginia Tech massacre because “the whole orientation towards safety on campus changed, and 

mental health was of course seen as a piece of that.” She confirmed that the purpose of the project was to “to help 

identify, uh, students with mental illness who may become violent.” She completed her Tension and Trauma Releasing 

56 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1993) (finding that judge serves as a “gatekeeper” to “ensure that any and all scientific 

testimony or evidence admitted is not only relevant, but reliable”); Kumho Tire Co. v. 

Carmichael, 526 U.S. 137, 149 (1999) (extending the court's gatekeeper function to all expert 

testimony).87 She testified that she had been retained and paid $15,000 by the Department of 

Labor for her expert opinion in this case at $200 per hour. She had never been an expert witness 

before this case. She has testified in court for clients who she treated. (Tr. 562-64, 584; Ex. C27, at p. 2). 

Integra argues Ms. Nelson’s testimony should be afforded little weight due to her lack of 

experience as an expert witness, her lack of publications, and the fact that she “has not 

Exercises (TRE) Level 1 Certification in August, 2012 and TRE Level II Certification in February, 2013. She is certified in 

TRE at the individual and group levels, which is “a program that [is] physically based [as opposed to pharmaceutically 

based] to treat PTSD.” She has been a member of the NASW since 1994. In 2002, she received her certification from 

NASW’s Academy of Certified Social Workers. Certification required two years of full-time work post Master’s 

degree, peer review and recommendations, and successful passing of a national test. Ms. Nelson has taught selfdefense for social workers classes for NASW chapters in Illinois, Iowa, West Virginia, Kansas, Missouri, 

Pennsylvania, Minnesota, and Florida; and other organizations elsewhere. She developed a course called National 

Safety based upon her analysis of murders of social or human service workers that occurred around the nation. She 

testified that she looked into the murder of Teri Zenner, a social worker, that occurred in Overland Park, Kansas in August, 

2004. In 2004, she published a book entitled “Everyday Self Defense for Social Workers,” which is also dually titled, 

“Everyday Self Defense for Human Service Workers.” In 2010, she made a presentation to the Council on Social 

Work Education entitled “Effective Strategies for Teaching Personal Safety Skills to Social Work Students.” Her selfdefense courses are designed to meet the qualifications for social work licensing, including in Kansas where each 

social work licensee has to complete six hours of training in personal self-protection. (Tr. 529-61, 567, 570-72, 575; 

Ex. C-26). 

87 Fed. R. Evid. 702 provides that: 

If scientific, technical, or other specialized knowledge will assist the trier of fact to 

understand the evidence or to determine a fact in issue, a witness qualified as an expert 

by knowledge, skill, experience, training, or education, may testify thereto in the form of 

an opinion or otherwise, if (1) the testimony is based on sufficient facts or data, (2) the 

testimony is the product of reliable principles and methods, and (3) the witness has 

applied the principles and methods reliably to the facts of the case. 

57 
 

 

 

 

 

 

 

 

 

 

 

 

 

undertaken any doctoral studies or served as a faculty member at any institution of higher 

learning.” Integra does not deny and does not criticize Ms. Nelson’s field experience or her 

experience providing safety training to those who work in the field. The Court finds that Ms. 

Nelson’s experience in the field, and years of providing safety and safety awareness training to 

those in similar workplaces, is persuasive when weighing the issues presented in this case. 

ACME Energy Servs. dba Big Dog Drilling, 23 BNA OSHC 2121, 2125 (No. 08-0088, 2012) 

(comparing experts and finding one “in a better position” based on “professional training and 

extensive experience”), aff’d, 542 F. App’x 356 (5th Cir. 2013) (unpublished). She proved to be 

a credible, informative witness whose opinions assisted the Court. (Resp’t Br. at 13 n.4; Tr. 82-

83). 

Ms. Nelson testified that Integra’s service workers were exposed to the hazard of 

workplace violence and that prior to December 10, 2012, Integra did not adequately protect its 

SCs from workplace violence. She testified that Integra’s worker safety program was inadequate 

because: 1) its management did not support the need for adequate safety training of SCs,88 2) the 

isolated nature of the SCs’ job increased their risk to workplace violence, 3) SCs were placed at 

increased risk to workplace violence by being expected to apply clinical knowledge of social 

work they did not have and use clinical assessment tools that they were not qualified to 

administer or interpret, 4) the personal safety training materials provided to SCs were vague, 

88 Ms. Nelson testified that Integra exhibited a sense of dismissal and disregard when workers raised safety issues or 

the need for safety training. She recalled a statement attributed to Dr. Arnott that workers were responsible for their 

own lives and Integra did not need to provide any self-defense training. On March 8, 2013, Dr. Arnott told CO 

Prymmer that “[t]he employees wanted self defense training. We don’t do that in this industry. I would take a self 

defense class myself. The employees should take a self defense class by themselves. They should do that. They 

don’t take self responsibility for their lives.” In rebuttal, Ms. Nelson testified that she disagreed with Dr. Arnott’s 

testimony that self-defense, personal protection or personal safety awareness training was not appropriate for 

Integra SCs. (Tr. 674-75, 1094-95; C-27, at pp. 4-5, Ex. R-QQ, at p. 15). 

58 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lacking practical content and incomplete,89 and 5) its safety practices and protocols were 

incomplete and inadequate.90 (Tr. 585-87, 602-16, 678-79; Ex. C-27). 

Ms. Nelson testified that Integra required its SCs to have a bachelor’s degree. They were 

not required to be licensed in social work. She testified SCs were doing social work based 

activities and required to apply the BPRS as a clinical tool when completing their initial 

assessments of members.91 Ms. Nelson testified that the initial assessment called for SCs to 

apply clinical analysis and/or skills that they did not have, to accurately and safely complete the 

Personal Routine/Condition section of the assessment.92 She likened it to a brief mental status 

examination that a clinician would normally complete, or the conduct of a biopsychosocial 

assessment normally completed by someone with a Bachelor’s degree in social work. She said 

SCs were tasked to make a psychosocial impression of members using BPRS and GAF scores. 

She described the initial assessment as “a very extensive assessment” that included histories of 

violence and substance abuse. She said that these were two of the top five predictors of violence. 

The assessment also included questions concerning the member’s current living arrangement and 

conditions to ascertain whether the member is a loner, another predictor of violence. She 

89 Ms. Nelson testified that the portion of Integra’s Employee Handbook that addressed workplace violence was a 

“very general statement” that “was not specific to social workers or Service coordinators in the field per se.” It did 

not adequately prepare SCs to prevent and deal with workplace violence. She further testified that section 8 of the 

Neumann training was “vague and lacked depth and there was no how to’s. There was no experiential process.” 

She said that she “didn’t see any de-escalation techniques” in Integra’s training. She also said that a SC’s 

shadowing of a more senior SC was on-the-job training “of the most minimal kind”, was “not enough” and did not 

always occur. (Tr. 608-09, 613, 745; Ex. C-27, at p. 9). 

90 Ms. Nelson testified that SCs were at risk to violence because Integra did not conduct criminal background checks 

on its members before SCs visited member’s homes. She considered it a poor practice for Integra not to conduct a 

criminal background check considering it was serving members who were seriously mentally ill that may also have 

criminal backgrounds. She said that it was particularly dangerous to do an unscheduled visit to a member’s home 

because of the element of surprise. She further testified that she knew of health and human services agencies that 

did perform criminal background checks before sending workers out. (Tr. 616-19, 675, 718-22; Ex C-27, at p. 11). 

91 Ms. Nelson testified that the BPRS is a clinical tool used by psychiatrists, generally in an inpatient setting, to 

assess patients with psychosis. (Tr. 590). 

92 Ms. Nelson testified that Integra’s SCs were performing work in Florida that should have been done by clinicians 

or licensed social workers with bachelor’s or master’s degrees in social work. (Tr. 690-93; Ex. C-27, at p. 7). 

59 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

testified that not having this information before meeting with members at their homes placed SCs 

at a very high risk to violence situations. She stated that the assessment asks the SCs for their 

clinical impressions and a psychosocial summary of the member. (Tr. 590-93, 621-34, 689-90, 

695; Exs. C-8, C-27, at pp. 7-9). 

Ms. Nelson further opined that Integra’s SCs were not able to safely assess or determine 

some of the high risk behaviors identified in the Neumann training; such as paranoia, 

suspiciousness, antisocial personalities, impulsiveness, and hopelessness reflecting a higher risk 

for suicide. She said that SCs who are not good at assessing members because of a lack of 

clinical skills “are less able to recognize the propensity of someone to engage in violence or 

become violent.” She testified that [redacted] was expected to apply clinical tools that she was 

not qualified to apply and was exposed to a heightened risk of workplace violence due to her 

inexperience. She stated that SCs performed the jobs of clinical social workers, in part. She said 

that these considerations “[m]ost definitively” contributed to the risk of workplace violence. She 

also opined that the lack of safety training at Integra contributed to the risk of workplace 

violence that occurred on December 10, 2012. Additionally, Ms. Nelson suggested that Integra’s 

SCs were isolated, both in their working environment and by the online Neumann training, and 

that this isolation could have had “a negative psychological impact on a worker, particularly as it 

pertains to a worker’s belie[f] that he must be self-reliant[.]” (Tr. 593-99, 601-02, 614, 1103-04; 

Exs. C-17, at pp. 4-5, C-27, at pp. 5-9). 

Ms. Nelson testified that Integra’s “buddy system” was insufficient before [redacted]’ 

death. It was discretionary, not commonly practiced, not standardized, and more of a backup 

when a SC was going on vacation. (Tr. 624-26, 742). 

60 
 

 

 

 

 

 

 

 

 

 

 

 

 

Ms. Nelson testified that [redacted] “was most likely having a delusional episode” when 

he explained the print of The Last Supper to [redacted] on October 15, 2012. She referred to the 

September 8, 2012 progress note report which reported that [redacted] had a past mental health 

issue involving “schizophrenia.” She said that delusion is the number one symptom in 

schizophrenia. She said that it would also be useful to know if [redacted] was a catatonic or 

paranoid schizophrenic because a member with the latter might “react much more violently” to a 

home visit. Ms. Nelson stated that schizophrenics and people with any kind of paranoid, 

delusional or antisocial personality disorders are considered to be at higher risk for violent 

behavior. (Tr. 600-01, 619; Ex. C-7, at p. 1). 

Ms. Nelson testified that Integra was part of the social services/healthcare industry. She 

also testified that the social service worker industry recognized the risk of workplace violence 

when working under conditions similar to Integra’s SCs. Ms. Nelson believes that workers in 

this industry may not report an incident for fear of reprimand, being seen as not doing their job, 

saving face with peers, self-blame, or ‘it comes with the job.’ Ms. Nelson also stated that 

another common mentality within the human service field also puts workers at risk: the “belief 

that if you are a good person out there helping people, i.e., ‘doing good,’ that nothing bad will 

happen to you.” Characterizing this mentality as “false and naïve,” Ms. Nelson claims that “this 

core belief that a good heart and a helping hand will be a safety shield [is what] truly puts 

workers at risk. It has the effect of enabling the worker to operate ‘in denial’ that this type of 

work could really become dangerous.” (Tr. 555-57, 575, 605, 679, 1103-04; Exs. C-27, C-32, C33). 

61 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ms. Nelson testified to a laundry list of activities that were feasible and could have been 

taken by Integra to provide a safe workplace for its SCs before December 10, 2012.93 For 

example, she testified that it would have been reasonable for Integra to always buddy up, or 

double team, SCs when visiting members with a higher risk for violent behavior when obtaining 

their consents and completing initial assessments, even where two or three visits are needed. She 

also stated “challenging” members with a propensity to violence should have been assigned to 

more experienced SCs. Ms. Nelson testified that Integra did not use any sort of tracking system 

for its SCs.94 She said that it was fairly common practice for social workers to have some sort of 

tracking device. Integra also did not use a risk assessment tool to assess any risk of violence. 

She stated that Integra could feasibly implement, at low cost, an assessment process to identify 

and decrease any risk of violence. Ms. Nelson also testified that Integra could devise a method 

to alert SCs to members with assaultive behavior problems. She also stated that Integra lacked a 

workers’ incident reporting program, which she described as a “really vital” activity.95 Ms. 

Nelson also testified that she found Mr. Macaluso’s October 16, 2012 request for takedown and 

hands-on crisis de-escalation training to be reasonable.96 (Tr. 636-41, 650-51, 661-63; Exs. C-1, 

at p. 6, C-5, at p. 1, C-27). 

93 Ms. Nelson testified that her listing included a few activities that did not apply to Integra; e.g. “minimize 

crowding and noise.” (Tr. 733-35; Ex. C-27, at p. 13). 

94 Dr. Arnott testified that SCs could not use their laptops to find other SCs. (Tr. 899). 

95 OSHA’s Safety Narrative, Accident Investigation Summary & Findings, stated that Integra “did not document, 

track or have a system for identifying workplace violence occurrences while employees reported several incidents 

within a year that included being chased by clients, verbal confrontations/lashing out, transporting erratic clients in 

SC-owned vehicles, pursuing clients in poor neighborhoods and being pushed in line by an agitated person at a 

clinic.” (Ex. C-5, at p. 1). 

96 In rebuttal, Ms. Nelson testified that recent NASW guidelines include the use of verbal de-escalation and nonharming techniques, exit strategies, and a safety plan in their safety training section. She also testified that SCs 

having these tools would be more prepared to face workplace violence. She also said that the NASW guidelines are 

a reference tool that can be used for community health workers. (Tr. 1095-96, 1101-02). 

62 
 

 

 

 

 

 

 

 

 

 

Ms. Nelson also testified that Citation 1, Item 1, included a list of methods that were 

feasible means of abating the hazard of workplace violence alleged therein. (Tr. 636-79; Exs. C1, at pp. 7-9, C-27, at p. 12, C-31, at p. 1). 

DISCUSSION 

I. Serious Citation I, Item 1 – Alleged General Duty Clause Violation 

a. Merits 

The Secretary alleges that Integra violated the general duty clause of the OSH Act 

because its “employees were exposed to the hazard of being physically assaulted by members 

with a history of violent behavior.” (Sec’y Br., at p. 3). To prove a violation of the general duty 

clause, the Secretary has the burden to establish that “a condition or activity in the workplace 

presented a hazard, that the employer or its industry recognized this hazard, that the hazard was 

likely to cause death or serious physical harm, and that a feasible and effective means existed to 

eliminate or materially reduce the hazard.” ACME Energy Servs., 23 BNA OSHC at 2123; see 

also Robert Sands Co., LLP, v. Sec’y. of Labor, 568 F. App’x. 758, 759 (11th Cir. 2014) 

(unpublished); SeaWorld of Florida, LLC v. Perez, 748 F.3d 1202, 1207 (D.C. Cir. 2014). The 

Court affirms this Citation Item. 

1. Nature and Existence of the Hazard 

“A safety hazard at the worksite is a condition that creates or contributes to an increased 

risk that an event causing death or serious bodily harm to employees will occur.” Baroid Div. of 

NL Indus., Inc. v. OSAHRC and Marshall, 10 BNA OSHC 1001, 1003 (No. 79-1775, 1981). “A 

‘hazard’ is defined in terms of conditions or practices deemed unsafe over which an employer 

can reasonably be expected to exercise control.” Valley Interior Sys., Inc., No. 06-1395, 2007 

WL 2127305, at * 4 (O.S.H.R.C.A.L.J. June 11, 2007) (citing Morrison-Knudson Co./Yonkers 

63 
 

 

 

 

 

 

 

 

 

 

Contracting Co., A Joint Venture, 16 BNA OSHC 1105, 1121 (No. 88-572, 1993), aff’d 288 F. 

Appx. 238 (6th Cir. 2008) (unpublished). The hazard “is not defined in terms of the absence of 

appropriate abatement measures.” Wheeling-Pittsburgh Steel Corp., 10 BNA OSHC 1242, 1245 

(No. 76-4807, 1981) (consolidated), aff’d, 688 F.2d 828 (3rd Cir. 1982) (unpublished). A hazard 

has also been defined “to mean ‘a condition or practice in the workplace’ which introduces an 

element of danger into the work environment.” Foseco, Inc., No. 81-944, 1982 WL 22452, at 

*13 (O.S.H.R.C.A.L.J. July 28, 1982) (citing Empire-Detroit Steel Div., Detroit Steel Crop. v. 

OSHRC, 579 F.2d 387 (6th Cir. 1978)). A hazard must be defined in a way that apprises the 

employer of its obligations, and identifies conditions or practices over which the employer can 

reasonably be expected to exercise control.” Arcadian Corp., 20 BNA OSHC 2001, 2007 (No. 

93-0628, 2004). The Commission may define the hazard itself when the Secretary’s definition is 

too broad or generic. Davey Tree Expert Co., 11 BNA OSHC 1898, 1899 (No. 77-2350, 1984). 

Here, the Secretary defined the hazard as “being physically assaulted by members with a 

history of violent behavior.” As an example, the Secretary stated that “an employee [[redacted]] 

providing healthcare management services was fatally stabbed by a member with a violent 

criminal history. Employees acting as SCs regularly interacted on their own directly with 

members with a history of violent behavior.” (Ex. C-1, at pp. 7-9; Sec’y Br., at p. 23). 

Integra argues that the Secretary essentially defines the hazard as “the potential criminal 

acts of the citizens being served by Integra.” (Resp’t Br., at p. 9). Integra further claims that the 

Secretary includes in his definition of the hazard not only Integra members but also, 

“presumably, by extension, other residents of these same communities with whom Integra staff 

may have occasion to interact or even pass on the street in the course of performing their jobs.” 

(Resp’t Reply Br., at p. 4). Integra’s presumption is ill-founded. Citation 1, Item 1, deals with 

64 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

physical assaults by, and direct interactions with, Integra members that have a history of violent 

behavior; not public passersby. 

The arguments here illustrate a disagreement over the definition of the hazard. It is 

essential that the hazard be defined to the extent that Integra is apprised of: (1) its obligations, 

and (2) the conditions or practices it can reasonably be expected to exercise control. Arcadian, 

20 BNA OSHC at 2007; see also Pelron Corp., 12 BNA OSHC 1833, 1835 (No. 82-388, 1986) 

(noting hazard must be defined in terms of preventable practices or conditions). 

Under the general duty clause, Integra is obligated to provide a “place of employment” 

free of hazards, to the extent required under the OSH Act. 29 U.S.C. § 654(a)(1). The 

workplace in this case may be viewed as essentially virtual, but that fact does not relieve Integra 

of its obligation. Anywhere an Integra SC performs work-related tasks is a workplace. Anthony 

Crane Rental v. Reich, 70 F.3d 1298, 1303 (D.C. Cir. 1995); Reich v. Simpson, Gumpertz & 

Heger Inc., 3 F.3d 1, 5 (1st Cir. 1993); Clarkson Constr. Co. v. OSHRC, 531 F.2d 451, 458 (10th 

Cir. 1976); REA Express v. Brennan and OSAHRC, 495 F.2d 822, 825 (2d Cir. 1974); Access 

Equip. Sys. Inc., 18 BNA OSHC 1718, 1720-22 (No. 95-1449, 1999). The record shows that 

Integra SCs work at member’s homes, in their own personal vehicles, or in public places such as 

hospitals, restaurants, and doctor’s offices. All of these places are considered an Integra 

workplace. 

Inside of this workplace, Integra SCs regularly must interact with members who have 

been identified as non-compliant with their doctor’s orders, the essence of Integra’s contractual 

commitment with its funding sources; i.e., insurance companies. The record shows that many 

members had severe mental health issues and/or histories of violent behavior. One member, 

[redacted], had a mental illness diagnosis of schizophrenia and had a publicly documented 

65 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

history of violent behavior. He physically assaulted and killed an Integra employee at an Integra 

workplace, his home. The record also shows that Integra SCs had experienced and reported to 

management many other episodes of violent behavior by members directed toward them. 

The parties discuss at length Megawest Financial Inc., No. 93-2879, 1995 WL 383233 

(O.S.H.R.C.A.L.J. June 19, 1995).97 Megawest is a Commission case dealing with workplace 

violence by another human.98 In Megawest, OSHA cited an owner of an apartment building for 

exposing its staff employees to the violent acts of its tenants. Id., at *1. The judge found that the 

potential hazard arose from a critical element of the apartment staff’s job, i.e. personal 

interaction with the apartment residents. The judge found that the Secretary established the 

existence of the hazard of violence leading to serious physical harm under section 5(a)(1) of the 

OSH Act where: 1) the responsibilities of the office staff led to adversarial relationships with 

tenants, 2) the staff was not trained to defuse anger, 3) the residents often directed intimidating 

threats or conduct towards the staff that was not sanctioned, and 4) no positive measures were in 

effect to discourage attacks.99 The judge concluded that the conditions as they existed at the 

apartments constituted a hazard to the office employees. Id., at **7-8. 

Two circuit courts provide guidance because they have discussed Megawest. In Ramsey 

Winch Inc. v. Henry, 555 F.3d 1199 (10th Cir. 2009), the 10th Circuit reversed a district court’s 

determination that the general duty clause of the OSH Act preempted Oklahoma laws holding 

employers criminally liable for prohibiting their employees from storing firearms in their 

97 Megawest is an unreviewed administrative law judge decision. It is not binding precedent within the Commission. 

See Leone Constr. Co., 3 BNA OSHC 1979, 1981 (No. 4090, 1976) (finding that unreviewed administrative law 

judge decision does not constitute binding precedent for the Commission).

98 This is in contrast to SeaWorld of Florida, LLC, 24 BNA OSHC 1303 (No. 10-1705, 2012), aff’d, 748 F.3d 1202, 

1210 (D.C Cir. 2014), a case where physical violence was inflicted on a Seaworld employee by a killer whale.

99 The judge in Megawest ultimately vacated the alleged violation concluding that the hazard was not recognized by 

Megawest or by its industry within the meaning of section 5(a)(1) of the OSH Act. Megawest, 1995 WL 383233, at 

*11. 

66 
 

 

 

 

 

 

 

 

 

 

 

 

 

personal vehicles on company property. Id. at 1202. “[I]n finding preemption, the district court 

held that gun-related workplace violence was a ‘recognized hazard’ under the general duty 

clause.” Id. at 1205. Disagreeing with the district court, the 10th Circuit characterized the 

violent activity at issue in Megawest as “random,” connecting it to a “general fear” held by a 

Megawest employee. Ramsey Winch, 555 F.3d at 1206. Further distinguishing Megawest’s 

“random” violent activity, the 10th Circuit noted that the general duty clause might be implicated 

from other types of workplace violence situations, such as “injuries ‘arising out of work 

situations’” in a psychiatric hospital. Ramsey Winch, 555 F.3d at 1207 n.8. The 10th Circuit 

cited to OSHA’s Standard Interpretation Letter, Dec. 10, 1992, regarding workplace violence 

which states that “[w]hether or not an employer can be cited for a violation of section 5(a)(1) is 

entirely dependent upon the specific facts, which will be unique in each situation.”100 Id. at 1207 

n.8. Similarly, in SeaWorld, 748 F.3d at 1210, the D.C. Circuit distinguished the hazard in 

Megawest from the hazard of interacting with killer whales. The D.C. Circuit characterized the 

Megawest violence as unpreventable because the employer had no control over third parties 

residing in the apartment building it managed, whereas SeaWorld did have control over “its 

employees’ access to and contact with its killer whales.” SeaWorld, 748 F.3d at 1210. 

Here, the violent behavior is not random. The risk of an Integra SC being physically 

assaulted by a member is recognized by Integra as an inherent part of the SC’s role in performing 

his or her job responsibilities in the field. According to Ms. Nelson, it was particularly 

dangerous for a health and human service worker to do an unscheduled visit to a home. She also 

testified that the limited information that SCs had before meeting the member for the first time 

100 OSHA’s Standard Interpretations Letter, December 10, 1992, is available at http://www.osha.gov/SLTC. 

67 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

put them at a very high risk of a violent situation. She testified that the population that Integra 

served warranted criminal background checks before entering their homes: 

Given the population that [Integra] serve[s], it would be highly recommended that 

they do criminal background checks.... And if you know that you are serving 

seriously mentally ill people that may have criminal backgrounds, it would be 

advisable to check on that background before you enter their home. 

Ms. Nelson also testified that interviewing paranoid schizophrenics is challenging and 

dangerous. (Tr. 619, 624, 722). 

The Court finds that Integra’s practices of requiring SCs to physically meet face-to-face 

with members likely to have a history of violent behavior increased the likelihood of SCs being 

physically assaulted by a member with such a history and constituted a hazard.

101 Integra SCs 

were required to repeatedly interact with members, often in their private homes, with histories of 

violent behavior that were unknown to the SCs. These interactions called for SCs to make faceto-face inquiries and assessments regarding intimate details of members’ lives. Integra’s SCs 

were not adequately trained or experienced to defuse a member’s anger with, or negative 

reaction to, the face-to-face assessment process. Such personal inquiries may be conducive to 

hostile reactions by a severely mentally ill member with a history of violent behavior directed 

toward the SC. Members often directed intimidating threats or conduct towards SCs and before 

December 10, 2012 there is little, or no, evidence that members responsible for such behavior 

101 See Waldon Healthcare Ctr., 16 BNA OSHC 1052, 1060 (No. 89-3097, 1993) (“Rather, the existence of a hazard 

is established if the hazardous incident can occur under other than a freakish or utterly implausible concurrence of 

circumstances.”); Tuscan/Lehigh Dairies, Inc., 22 OSHC 1871, 1885 (No. 08-0637, 2009) (“Freakish and 

unforeseeable deaths do not necessarily trigger statutory liability under the general duty clause of the [OSH] Act.”). 

Here, the Court finds that [redacted]’ death was not the result of an utterly implausible concurrence of 

circumstances. 

68 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

were sanctioned by Integra.102 There were also inadequate positive measures in effect to 

discourage physical assaults of SCs by members. 

Despite Integra’s assertions, Integra members are not classified in such broad categories 

as “citizens” or “third parties.” (Resp’t Br., at p. 9). The members have been pre-screened by 

Amerigroup and placed into a “non-compliant,” distinct category from which Integra is paid to 

make “compliant.” Their very behavior is the essence of Integra’s business, and so the Court 

finds that their behavior in this case is work-related. Additionally, Integra has control over its 

SCs, and how they go about their job interacting with the members. While Integra cannot 

reasonably be expected to control the violent actions of these members, Integra does have control 

of its employees and the precautions that they must take to decrease the likelihood of violence in 

their workplace by members with a history of violent behavior. 

The Court finds based on the evidence in the record that Integra’s practices and 

procedures in place on and before December 10, 2012 increased the likelihood of an Integra SC 

being physically assaulted by members with a history of violent behavior during a face-to-face 

meeting. These practices and procedures included: 1) unannounced visits to a member’s home, 

2) assigning members to a SC’s caseload based on “geographical and scheduling efficiencies” 

rather than on client risk; e.g., assigning a person with a known mental illness, and noncompliant with his medical orders, and who has a history of violent behavior [i.e. [redacted]] to 

102 While one of Mr. Macaluso’s members was “rolled off” on November 1, 2012, Mr. Macaluso noted in his 

progress note report that Mr. D’s violent behavior “resulted in his admission to the Mental Health Care’s Crisis 

Center.” Mr. Macaluso’s experience is consistent with Mr. Schneider’s testimony in that in order to get a member 

“rolled off,” a safety concern or “tendencies that are violent in nature” were not enough. “It had to go before 

management and the doctor. The doctor was the one that made the decision to my understanding.” (Tr. 467; Ex. 

C-30, at p. 30). 

69 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

an inexperienced new hire [[redacted]], 3) requiring face-to-face visits before safety training was 

completed, 4) implementing a non-mandatory buddy system for inexperienced new hires, 5) 

relying on SCs to perform their own background checks, if at all, and 6) assigning heavy 

caseloads such that the buddy system was viewed by Integra employees as unavailable and a 

hindrance.103 

The Court construes the hazard presented to an Integra SC as being physically assaulted 

during a face-to-face meeting by a member with a history of violent behavior.104 See Davey Tree 

Expert Co., 11 BNA OSHC at 1899 (redefining the hazard from “electrocution caused by a limb 

touching a high-voltage line” to “electrocution from a tree limb contacting a power line because 

of the actions of employees in removing the limb.”); Pelron Corp., 12 BNA OSHC 1833, 1835 

(No. 82-388, 1986) (Judge erred by not defining the hazard in terms of preventable practices or 

conditions).105 The existence of the hazard has been established. 

103 The Secretary did not specify in the complaint these specific Integra practices that increased the risk of violence 

here. Administrative pleadings, however, are to be very liberally construed. Baroid Div. of NL Indus., Inc. v. 

OSAHRC and Marshall, 10 BNA OSHC at 1007. The issue of whether Integra’s practices, procedures or conditions in 

place as of December 10, 2012 increased the likelihood of an Integra SC being physically assaulted by members 

with a history of violent behavior was fully litigated at trial. Nat’l Realty & Constr. Co., Inc. v. Occupational Safety 

and Health Review Comm’n, 489 F.2d 1257, 1264 (D.C. Cir. 1973) (“So long as fair notice is afforded, an issue 

litigated at an administrative hearing may be decided by the hearing agency even though the formal pleadings did 

not squarely raise the issue.”). Both CO Prymmer and Ms. Nelson testified to this issue at length on direct 

examination. 

104 Administrative pleadings are to be very liberally construed. Baroid Div. of NL Indus., Inc. v. OSAHRC and 

Marshall, 10 BNA OSHC at 1007. 

105 The Secretary included in the complaint the following practices and procedures that Integra could implement to 

abate this hazard: 1) having a stand-alone written Workplace Violence Prevention Program that included the 

elements set forth in Citation 1, Item 1 at ¶1, 2), a) determining the behavioral history of new/transferred members 

to identify members with assaultive behavior problems and to communicate such pertinent information to all SCs 

before they visit with new members in their homes, b) training all employees to understand a system flagging 

potentially violent members, and c) having a system for holding members accountable for violent behavior, 3) 

having procedures in place to timely communicate incidents of workplace violence to all employees, 4) ensuring 

training: a) is sufficient to make all employees aware of its workplace violence policy, and b) includes effective 

methods for responding during a workplace violence incident, recognizing aggressive behavior exhibited by 

members or others and techniques for timely de-escalating such behavior, identifying risk factors that cause or 

70 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Recognition of the Hazard 

“A hazard is ‘recognized’ within the meaning of the general duty clause if the hazard is 

known either by the employer or its industry.” Waldon Health Care Ctr., 16 BNA OSHC at 

1061; Brennan v. OSHRC, 494 F.2d 460, 464 (8th Cir. 1974) (noting actual knowledge of a 

hazard by an employer makes the hazard recognized for purposes of the general duty clause). 

“Whether a work condition poses a recognized hazard is a question of fact.” SeaWorld, 748 F.3d 

at 1208. Actual knowledge of a hazard by an employer may be gained by means of prior 

episodes, employee complaints, and warnings communicated to the employer by an employee. 

St. Joe Minerals Corp. v. OSHRC, 647 F.2d 840, 845 (8th Cir. 1981) (employer had both actual 

and constructive knowledge of the hazard when previously warned by at least one employee). 

The record establishes that Integra recognized the hazard of being physically assaulted by 

members with a history of violent behavior during a face-to-face interaction. Integra used 

precautions, inadequate as they were, against violence and also was aware of specific incidents 

of violence before [redacted]’ death.106 Waldon Health Care Ctr., 16 BNA OSHC at 1061 

(“precautions taken by an employer can be used to establish recognition in conjunction with 

contribute to assaultive behaviors, mandatory procedures to report all incidents of workplace violence, and 

conducting the training before employees are exposed to members. The Secretary also included: 5) implementing 

and maintaining an effective buddy system based upon a complete hazard assessment, which includes procedures for 

all staff to request and obtain double coverage when necessary, including situations where an employee 

communicates he or she feels unsafe being alone with a particular member, 6) providing all staff a reliable way to 

rapidly summon assistance when needed, and 7) establishing a liaison with law enforcement representatives. (Ex. 

C-1, at pp. 6-8). As discussed in the feasibility of abatement section herein, Integra had the ability to control and 

implement at least some of the above practices, procedures or conditions in an effective manner. It chose not to do 

so before December 10, 2012. 

106 In addition to recognition of the hazard, the Secretary must prove that Integra knew or, with the exercise of 

reasonable diligence, could have known of the hazardous condition. See Burford’s Tree, Inc., 22 BNA OSHC 

1948, 1950 (No. 07-1899, 2010). Here, the evidence shows that Integra’s management, including Ms. Rochelle and 

Drs. Krajewski and Arnott, recognized that the SC’s mandatory face-to-face interaction with members with a history 

of violent behavior was a hazard of the Integra workplace. A supervisor’s actual knowledge of a hazard is imputed 

to the employer, even if the supervisor subsequently departs the employ of the employer. See Caterpillar, Inc. v. 

OSHRC, 122 F.3d 437, 440 (7th Cir. 1997). Dr. Arnott knew that Integra’s SCs were “dealing with the toughest 

people that no one wants to deal with.” She and Dr. Krajewski recognized that Integra’s SCs were performing an 

“unique” role and filling a “niche in the market that other people are not doing” in the community health worker 

industry. (Tr. 883, 1017-18, 1029-34; Ex. R-QQ, at pp. 14-15). 

71 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

other evidence.”). Integra’s own training, handbook, and existing policies establish that it 

recognized that its SCs were exposed to the hazard of workplace violence by members with a 

history of violent behavior. (Tr. 110, 114-17; Ex. C-17). 

As Dr. Krajewski testified, Integra teaches its SCs to use “universal precautions” and to 

“[a]ssume everybody you deal with could have the potential for harm.” The Neumann Training 

has topics devoted to the “Dangerous Member” that an Integra SC must screen by identifying 

“high-risk behaviors” including (as relevant to this case): a history of violence, 

paranoia/suspiciousness, psychosis/confusion, substance abuse, verbal threats, criminal behavior, 

antisocial personality, noncompliance, and possessor of weapons. (Tr. 1030, Exs. C-16, C-17, at 

pp. 4-5). 

The record establishes that [redacted] exhibited some of the high risk behaviors described 

above before he killed [redacted]. The evidence also establishes that Integra recognized that 

[redacted] presented a specific threat to [redacted]. Integra performed no background check on 

[redacted] to determine if he possessed violent tendencies, and took no action when the victim’s 

progress note reports described her discomfort and his alarming, delusional behavior. [redacted] 

noted that [redacted] made her so “uncomfortable” that she did not want to be alone in his house 

with him. Although Integra managers admit to reading this note, Integra took no steps to assess 

the risk posed by [redacted] and made no follow-up to ensure that [redacted] took measures to 

protect her safety. Integra also did not discipline [redacted] for failing to bring a partner on her 

subsequent visits to [redacted] and/or for failing to remain outside his home. Integra made no 

inquiries into whether [redacted]’ interactions with [redacted] had improved or changed since her 

initial visit. Thereafter, [redacted] performed three additional face-to-face visits with [redacted]. 

During these visits, [redacted]’ notes indicate that [redacted] exhibited behaviors that indicated 

72 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

delusional or paranoid behavior. Delusions and paranoia are identified in Integra’s training as 

“high risk” behaviors. [redacted]’ progress note reports show Integra recognized that she was 

exposed to the hazard of workplace violence when visiting [redacted] alone at his home. (Tr. 

139-43, 148, 278, 285-86, 356-65, Exs. C-7, C-19). 

The evidence also establishes that, prior to the fatal attack on [redacted], Integra 

managers were aware of several instances of violence or aggression by members against other 

SCs. The evidence shows that several SCs were exposed to members exhibiting these “high risk 

behaviors.” Furthermore, the record establishes that the SCs brought up their concerns in 

progress note reports, which were reviewed and approved by Integra management. The record 

also shows that SCs brought up their concerns regarding these high-risk behaviors during weekly 

telephone calls with Drs. Krajewski and Arnott, as well as with Ms. Rochelle. In particular, SCs 

Macaluso, Schneider, and Hinman had all reported to their supervisors particular instances in 

which members acted aggressively, threateningly, or so strangely as to raise safety concerns. 

This prior history of workplace violence put Integra on notice that its SCs were exposed to the 

hazard of workplace violence during the face-to-face interaction with members with a history of 

violent behavior. (Tr. 52-59, 268, 458, 470-72, 507, 831; Exs. C-29, at pp. 6, 18, 24, C-31, at p. 

3). 

Integra claims that it did not know, nor could it have known, that it was in violation of the 

OSH Act because “no precedent exists under which the general duty clause has ever been 

construed as supporting enforcement of a citation stemming from a criminal attack on an 

employee.”107 (Resp’t Reply Br., at p. 11). Integra also claims that the general duty clause as 

107 Respondent placed these arguments in the characterization section of its briefs. They are addressed here in the 

knowledge component of this citation item. As noted infra, there is no knowledge component regarding the 

characterization of an affirmed citation item. 

73 
 

 

 

 

 

 

 

 

 

 

 

 

applied in this case was unconstitutional because “a reasonable prudent employer” would not 

have known of the abatement as proposed, asserting that its approach to safety was “robust” and 

“above and beyond” the standard in the industry. (Resp’t Br., at pp. 15-17, Resp’t Reply Br., at 

p. 10). The Court is unpersuaded. 

“The goal of the [OSH] Act is to prevent the first accident, not to serve as a source of 

consolation for the first victim or his survivors.” Arcadian, 20 BNA OSHC at 2008 (citation 

omitted). 

Facial challenges to the general duty clause have been rejected. Courts have 

accommodated possible fair notice problems in this context “by interpreting 

‘recognized hazard’ only to include preventable hazards” or applying the clause 

only “when a reasonably prudent employer in the industry would have known that 

the proposed method of abatement was required. 

SeaWorld, 748 F.3d at 1216 (citations omitted); accord Ensign-Bickford Co. v. OSHRC, 717 

F.2d 1419, 1421 (D.C. Cir. 1983); Donovan v. Royal Logging Co., 645 F.2d 822, 831 (9th Cir. 

1981). “Hazardous conduct is not preventable if it is so idiosyncratic and implausible in 

motive or means that conscientious experts, familiar with the industry, would not take it into 

account in prescribing a safety program.” Nat’l Realty, 489 F.2d at 1266. 

The evidence shows that Integra did not lack fair notice because the hazard associated 

with the likelihood of an Integra SC being physically assaulted in the Integra workplace by 

members with a history of violent behavior was preventable, and not “idiosyncratic and 

implausible.” Given the multiple incidents of aggressive behavior by members directed toward 

SCs, Integra knew, or could have at least anticipated, that readily available abatement measures 

were required to decrease the risk of workplace violence directed toward SCs before December 

10, 2012. 

74 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The record shows that management at all levels of Integra knew about the “high-risk” 

behaviors exhibited by members in the fall of 2012. Despite this fact, and despite what Integra 

has termed a “robust” and “above and beyond” safety program, Integra did not implement its 

own abatement measures even after being told of safety concerns by the SCs. SeaWorld, 748 

F.3d at 1216 (finding recognition because “[g]iven evidence of continued incidents of aggressive 

behavior by killer whales toward trainers notwithstanding SeaWorld’s [practices], SeaWorld 

could have anticipated that abatement measures it had applied after other incidents would be 

required.”). Progress note reports detailing the events of each visit were reviewed and approved 

by Integra managers. E-mails with concerns were sent to management. Drs. Krajewski and 

Arnott held weekly rounds in which everyone was involved, including team leads and all SCs. 

In these weekly rounds, SCs brought up situations about which they sought advice. Both 

testified their advice was to leave a situation in which the SC felt uncomfortable.108 

The problem with this advice is that “feeling uncomfortable” was a prerequisite to safety 

in the Integra workplace. And the record shows that the level at which an Integra SC became 

“uncomfortable” was subjective and dependent on experience, situation, and even naiveté. By 

requiring its employees to “feel uncomfortable” as a prerequisite to feeling safe, Integra shifted 

its responsibility for employee safety and health onto its employees. This Integra may not do, 

especially when there are practices, procedures or conditions that are within its control that 

would decrease the likelihood of violence by members with a history of violent behavior. 

Armstrong Cork Co., 8 BNA OSHC 1070, 1074 (No. 76-2777, 1980), aff’d 636 F.2d 1207 (3d 

108 See contra Question No. 11 of the CIS Final examination that asked, “When confronted with a dangerous 

member the first thing you should do is to?” The correct answer was “b. Assure your own safety” and not “d. Leave 

your belongings and run.” The correct response to Question 17 that asked “If a mentally ill person appears to be 

dangerous:” was “b. You should obtain a consult with a clinician.” The correct response to Question 24 that asked 

“If you are having difficulty providing services to a challenging member you should:” was “b. Be creative, try 

something different even if you fail[.]” (Ex. R-SSSS, at pp. 12, 18, 25). None of the correct responses to these 

questions was to leave the situation. 

75 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cir. 1980) (unpublished) (“The duty to comply with section 5(a)(1) rests with the employer. An 

employer cannot shift this responsibility to its employees by relying on them to, in effect, 

determine whether the conditions under which they are working are unsafe.”). 

With regard to [redacted] in particular, Integra did not implement its own abatement 

measures despite [redacted]’ progress note reports that showed that she was uncomfortable with 

[redacted] and then that she was also showing up to [redacted]’s house unannounced. Integra did 

not assign a mandatory buddy for [redacted] for these visits with [redacted]. Integra did not 

require [redacted] to finish her safety training before attempting to contact [redacted] for the first 

time even though his diagnosis of schizophrenia, which according to Mmes. Nelson and 

Rochelle was cause to consider safety, was on the report provided by Amerigroup. After Ms. 

Rochelle left, Integra did not even review some of [redacted]’s progress note reports.109 

The hazard in this case was recognized by Integra.

110 

109 Respondent argues that the violent conduct at issue is fundamentally unpredictable and therefore cannot be 

regulated by the OSH Act. (Resp’t Reply Br., at p. 5). The Court disagrees. Here, the occurrence of a violent 

incident during [redacted]’ interaction with [redacted] on December 10, 2012 at his home was reasonably 

foreseeable. Sending alone a young, inexperienced, ill-informed and poorly-trained female SC, back into the home 

of a severely mentally ill middle-aged, male member who had displayed alarming behavior toward the SC in prior, 

recent visits, and who had a lengthy criminal history of violent behavior, on an unscheduled visit on a mission to ask 

the member many intimate questions laid the foundation for, and foreshadowed [redacted]’ exposure to, a 

preventable episode of workplace violence. Not only was the hazard in this case obvious, but, as discussed below in 

the feasibility section, Integra’s approach to safety in its workplace was plainly inadequate. See Kelly Springfield 

Tire Co. v. Donovan, 729 F.2d 317, 321 (5th Cir. 1984) (“[W]here a hazard is ‘obvious and glaring,’ the Commission 

may determine that the hazard was recognized without reference to industry practice or safety expert testimony.”); 

see also ComTran Grp., Inc. v. U.S. Dep’t of Labor, 722 F.3d 1304, 1316 (11th Cir. 2013) (holding that 

foreseeability of a supervisor’s misconduct may be found using evidence of the employer’s lax safety standards); 

W.G. Yates & Sons Constr. Co., Inc. v. OSHRC, 459 F.3d 604,60809 (5th Cir. 2006) (finding foreseeability of a 

supervisor’s misconduct not shown when the employer’s safety policy, training, and discipline are sufficient to make 

the supervisor’s conduct in violation of the policy unforeseeable.”). 

110 Respondent argues the Secretary failed to establish industry recognition of the hazard of violence in the 

workplace. (Resp’t Reply Br., at pp. 3, 7, 10). Since the Court finds that Integra recognized the hazard described 

herein, it is unnecessary for it to find that the hazard was alternatively recognized by the community health worker 

or social services and health care industries. See Tuscan/Lehigh Dairies, Inc., 22 BNA OSHC at 1881 (finding no 

need for Court to evaluate every element of the Secretary’s case where doing so is unnecessary). Proof that the 

employer had actual knowledge of a hazard, even absent a showing that the hazard is recognized in a relevant 

industry, is sufficient to establish a “recognized hazard” under section 5(a)(1). See Usery v. Marquette Cement 

76 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Likelihood of Harm 

“[T]he criteria for determining whether a hazard is “causing or likely to cause death or 

serious physical harm” is not the likelihood of an accident or injury, but whether, if an accident 

occurs, the results are likely to cause death or serious harm.” Waldon, 16 BNA OSHC at 1060. 

Here, the record shows that the result of [redacted]’s attack was [redacted]’ death. The Secretary 

has established that the hazard of physical assault by an Integra member with a history of violent 

behavior during a face-to-face interaction is likely to cause death or serious harm. 

4. Feasibility of Abatement 

“To show that a proposed safety measure will materially reduce a hazard, the Secretary 

must submit evidence proving, as a threshold matter, that the methods undertaken by the 

Mfg. Co., 568 F.2d 902, 910 (2d Cir. 1977). Ms. Nelson’s opinion, however, that the SC’s face-to-face interaction 

with an Integra member with a history of violent behavior was recognized, could also establish recognition of the 

hazard. (Tr. at 679); ACME Energy Servs., 23 BNA OSHC at 2124 (“Industry recognition may be shown through the 

knowledge or understanding of safety experts familiar with the workplace conditions or the hazard in question.”). 

Respondent seeks to distinguish the community health worker industry from the Secretary’s expert witness’s 

background. Respondent incorrectly claims that Ms. Nelson’s expert qualification was limited to clinical social 

work. The record establishes that Ms. Nelson was qualified in the areas of clinical social work, personal safety 

awareness, and personal safety skills and safety programs for health and human service workers. (Tr. 584). Ms. 

Nelson has a background in field work, which supported her qualification as an expert in this case in health and 

human service worker safety. The record establishes that Ms. Nelson is a safety expert familiar with the general 

workplace conditions experienced by Integra SCs. With regard to industry recognition, Ms. Nelson’s qualifications 

show that she is an expert in personal safety, which, in this Court’s view, is a basic principle “not confined to any 

one industry” and that she was familiar with interacting with people in the field. Waste Mgmt. of Palm Beach, Div. 

of Waste Mgmt., Inc. of Fla., 17 BNA OSHC 1308, 1310-11 (No. 93-128, 1995) (finding industry recognition based 

on a safety expert’s knowledge of a “basic” and “general principle” combined with knowledge of the company’s 

specific practice) citing Kelly Springfield Tire Co., 10 BNA OSHC 1970, 1973 (No. 78-4555, 1982), aff’d, 729 F.2d 317 

(5th Cir. 1984). The Court, however, relies on Integra’s own recognition of the hazard for affirming this violation. 

The Court also finds that Integra’s claim that SCs are “community health workers”, as defined by the Bureau of 

Labor Statistics (BLS), and not social workers is not dispositive. The Court agrees with the Secretary that both 

social workers and community health workers are considered types of “community and social service occupations” 

by the BLS. (Sec’y Reply Br., at pp. 1-2). 

77 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employer to address the alleged hazard were inadequate.” U.S. Postal Serv., 21 BNA OSHC 

1767, 1773-74 (No. 04-0316, 2006). As a threshold matter, the Court finds that Integra’s 

approach to safety for workplace violence during face-to-face interactions with members on 

December 10, 2012 was inadequate. The Secretary argues that Integra shifted the ultimate 

responsibility of safety onto its employees by instructing them to leave if they felt in danger or to 

bring a buddy if they felt they needed one.111 The Secretary also claims that these “universal 

precautions” fail because they were dependent on a SC’s “accurate assessment and identification 

of potential danger,” which could not be accurate due to a SC’s lack of skills and overly 

demanding caseload. (Sec’y Br., at p. 37). The Court agrees with all of these points and finds 

Integra’s approach to safety inadequate as discussed below. 

a. Integra’s Inadequate Approach to Safety 

This is a tale of two differing views of safety. To Integra’s senior management located in 

Maryland and New Jersey, it was the best of times. To Integra SCs operating in the field in 

Florida during the fall of 2012, it was the worst of times. Integra expected its SCs to “avoid any 

situation that shows an indication of danger, potential danger. If you sense that you are in such a 

situation, remove yourself immediately, notify your supervisor.” As President Yuhas testified, 

“it all starts and ends with if you’re in a situation that appears in any way to be posing danger, 

just don’t do it. It kind of boils down to that.” According to Dr. Krajewski, Integra’s safety 

training was “more than adequate” and “above and beyond” compared to “what was out there in 

111 Integra’s reliance on its SCs to recognize potential danger and thereby prevent violent behavior by the members 

runs counter to the requirements of the OSH Act. See SeaWorld, 24 BNA OSHC at 1324 (stating that employer’s 

reliance on employees to recognize precursors and prevent unpredictable behavior is inconsistent with the 

requirements of the OSH Act). 

78 
 

 

 

 

 

 

 

the field.” He testified that the goal of the training was to ensure that the SC was “well 

informed when they go out in the community, be prepared to [] develop what they can see is the 

needs for the patient, you know, what’s the patient missing, and connect them to those services.” 

(Tr. 767-68, 1026-27, 1034). 

Integra’s safety policies and training consisted of: 1) a portion of the Neumann Training, 

2) face-to-face field-based training, 3) weekly rounds, 4) a buddy system, 5) immediate advice 

via a telephone hotline manned 24 hours per day, and 6) self-empowered “universal precautions” 

– where employees were allowed to leave a situation if they felt unsafe. Ms. Nelson testified that 

Integra’s approach to safety was inadequate. The Court agrees with Ms. Nelson. (Tr. 585, 767, 

1027; Ex. C-27). 

1. The Neumann Training: The Neumann Training was an online slideshow course 

focused on orienting new SCs with their job duties.112 In the summer of 2012, the training 

consisted of 15 sessions. One session addressed safety, Session 8: “In-Home & Community 

Safety.” According to Dr. Arnott, completing all 15 sessions took about 30-35 hours, on 

average. Dr. Arnott affirmed that a SC spent a little more than about 2 hours on Session 8. At 

the end of each session, including the safety session, a SC had the opportunity and was required 

as part of the class participation grade to contribute to an online discussion. (Tr. 889-90, 910-12, 

937-38, 951-54, 994-96; Exs. C-15 through C-17, R-E, R-J, R-V, R-QQQQ, R-RRRR). 

Ms. Nelson’s opinion of the safety portion of the Neumann training was that it was 

inadequate because it “lacked depth, good explanation of items, and a chance for application 

through case studies. Also, personal safety materials provided to SCs were vague, lacking 

practical content and incomplete.” Ms. Nelson believed that the Neumann training did not instill 

112 The record establishes that [redacted] attempted to contact [redacted] before she finished the safety portion of the 

Neumann training. 

79 
 

 

 

 

 

 

 

 

 

 

 

the requisite “ability to assess the person, their situation and the setting” in a novice Integra SC. 

The Neumann training also “failed [to] engage the trainee in an experiential process to improve 

their self-awareness of the ‘flight or fight’ response, increase their ability to maintain calmness 

under pressure, recognize and use non-verbal communication, utilize tone of voice, safe 

language skills, and practice possible case scenarios,” all of which are “fundamental in safety 

training.” Ms. Nelson noted that “[m]uch of the at-risk behaviors and crisis management 

information presented was directed towards client care and not towards the worker.” (Ex. C-27, 

at pp. 9-10). 

Ms. Nelson believed that the assessment form SCs were tasked to fill out required a 

certain skill set to be filled out safely. “Less skill in dealing with potentially dangerous clients 

and situations makes violence inherent in this work.” Workers need “proper training in 

interviewing, assertiveness, de-escalation, verbal/non-verbal communication, mental illness, 

assessment and crisis intervention” to reduce safety risks. Although some safety points were 

covered, Integra failed to “tell workers how to practice them.” Moreover, Ms. Nelson believed 

that the Neumann training increased the danger risk to its novice employees by “providing a list 

[of high risk behaviors] without [providing] the knowledge to truly know[] how to identify high 

risk behaviors[.]” The Court agrees with Ms. Nelson and finds that the Neumann training 

provided inadequate safety training to the Florida SCs for the reasons that she conveyed. (Ex. C27, at pp. 5-10). 

2. Face-to-face training: Dr. Arnott and/or Ms. Cooney conducted face-to-face training 

of the Florida SCs in September, October and November, 2012. From September 4 through 

September 7, 2012, Ms. Cooney shadowed some of the new SCs as they worked with members 

80 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in the community over the course of 17.5 hours.113 During the shadowing, the SC observed Ms. 

Cooney perform various scenarios like finding a member or visiting a member in the hospital or 

at home. On September 4, 2012, Dr. Arnott, Mr. Yuhas and Ms. Cooney conducted a “Team 

Meeting” with the SCs at Amerigroup for three hours. As part of this team meeting, Dr. Arnott 

taught a 45 minute “overview” session concerning the “Day of a Service Coordinator”, that 

included discussion of values, expectations, safety, and tips. Dr. Arnott testified that she passed 

out handouts entitled “Social Worker Safety Tips” from Syracuse University and “Home Safety 

Tips”. She said that these two handouts were also part of the Neumann training.114 The record 

shows classroom type training also occurred in November, 2012 during which safety was 

discussed. (Tr. 704-05, 961, 998-1001, 1027; Exs. R-F, R-G, R-H, R-EEEE, at pp. 12-13). 

According to Ms. Nelson, “[g]roup training in safety is important because the subject is 

intimidating to many people.” Ms. Nelson believed that “the most effective training occurs when 

workers share their experiences and feelings with their peers. Beyond building camaraderie, 

they gain practical safety ideas and learn about real-life encounters to help expand their 

knowledge base.” Ms. Nelson characterized the ‘shadowing’ done at the onset of the job as brief 

and insufficient given the isolating nature of the SC’s virtual workplace. She testified that the 

113 There is no record showing [redacted] attended any part of the Florida Orientation Training Integra conducted 

from August 27 through September 7, 2012. Ms. Cooney testified that she never met [redacted]. (Tr. 800; Exs. C27, at p. 5, R-Y). 114 The Court notes that the assigned readings in the Neumann training before December 10, 2012 did not include 

articles entitled “Social Worker Safety Tips” or “Staying Safe on Home Visits.” Session 8 of the Neumann training 

included an assignment to read material entitled “Home Safety.” In rebuttal, CO Prymmer testified that on May 14, 

2013, Ms. Brown told him that Integra did not start using the article entitled “Social Worker Safety Tips” as part of 

the Neumann training until after [redacted]’ death. CO Prymmer also testified that Integra had not provided to him 

the material entitled “Staying Safe on Home Visit” during his investigation even though he had asked Integra to 

provide him with the complete version of the Neumann training materials. The Court finds that the article entitled 

“Social Worker Safety Tips” was not the material referred to in the Session 8 of the 2012 Neumann training as 

“Home Safety.” The Court further finds that, on August 28, 2012, Dr. Arnott posted material with the “Topic: 

Safety Tips” that included all of the material; i.e. 10 steps, included within the article entitled “Staying Safe on 

Home Visits.” (Tr. 1086-91, Exs. C-15, C-35, at pp. 2-3, R-EEEE, at pp. 12-13). 

81 
 

 

 

 

 

 

 

 

 

 

face-to-face training Integra provided was consistent with worker isolation. Ms. Nelson believed 

that Integra management did not prioritize safety. Ms. Nelson pointed out that, despite workers’ 

concerns communicated to management, Integra lacked a standardized workplace violence 

prevention program, ignored worker’s requests for better safety training, and lacked an 

established safety committee to consider employee concerns and assure that safety protocols 

were being followed.115 (Tr. 644-46, 697-98; Ex. C-27). 

The Court finds Integra’s face-to-face safety training to be inadequate. It was short in 

time and safety content, and was not mandatory before going out into the field (even for 

inexperienced new hires). In one instance, it was included as one of the many topics addressed 

in a 45 minute overview. Ms. Cooney served as Coordinator of Program Implementation and 

Training. She provided face-to-face training to the SCs in the fall of 2012. Ms. Cooney was not 

qualified to train or mentor SCs. She lacked any academic credential and did not meet Integra’s basic 

requirement that SCs have a bachelor’s degree. Her answers to questions concerning her academic 

achievements were evasive. She did not know how many credits she had earned while taking 

community college courses. The record also does not establish to what extent, if at all, [redacted] was 

trained by Ms. Cooney in the field. Ms. Cooney never met [redacted]. Some SCs began visiting 

115 Integra claims that Ms. Nelson’s testimony regarding Integra’s approach to safety was “called into question” 

because she was neither aware of “the nature of the face-to-face meetings” nor the topics during the weekly rounds 

when she composed her report. Ms. Nelson, however, was at the hearing and heard all of the testimony regarding 

Integra’s approach to safety. After reading the depositions of Dr. Arnott and Ms. Brown and listening to the testimony 

regarding the Neumann training, face-to-face field training, weekly rounds, buddy system, hotline, and universal 

precautions, Ms. Nelson did not change her opinion that Integra’s approach to safety for its workers was inadequate. 

(Tr. 589, 687-89, 744-46; Resp’t Br., at p. 14 n5). 

82 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

members without having first received any shadow training and some SCs never shadowed anyone.116 

(Tr. 122-23, 702-03, 800; Ex. C-27). 

3. Weekly Telephone Training: The “weekly rounds” were telephone conference calls 

among the SCs, team leads, and Drs. Arnott and Krajewski. These phone calls typically 

occurred on Wednesdays and lasted up to about one hour. Accounts differed on whether roll was 

taken. There are no written attendance sheets in the record. Dr. Krajewski testified that during 

these calls, “cases are presented. We go through scenarios. We talk about, uh, patients who are 

making people, you know, feel uneasy, uh. Patients who are – you know, we said, well, what 

kind of services do they need? We talked about safety issues.” Ms. Rochelle also held some 

staff meetings on Wednesdays at 11:00 a.m. that lasted up to about one hour. They discussed 

issues similar to the telephone calls with Dr. Krajewski. These telephone calls primarily focused 

on how SCs were to provide care to members, and not SC safety. Mr. Schneider testified that 

they did not discuss safety issues during the weekly rounds until after [redacted]’ death. None of 

the three witnesses who led these calls testified to the specific content of the safety message 

given to the SCs during these weekly rounds. Rather, the message given to the SCs was to leave 

a situation if the SC felt unsafe. The Court finds that this message is conclusory and empty of 

specific content regarding prevention and detection of potential violence by a member at the 

Integra workplace. (Tr. 96, 98, 196 -97, 289-91, 483-84, 767, 818-21, 914, 1027, 1030). 

4. Buddy System: Integra had a loosely-defined buddy system. Ms. Nelson recalled 

Dr. Arnott and Ms. Brown mentioning the buddy system as Integra’s primary safety policy. 

Integra’s buddy system was developed for both safety and back up reasons, i.e., “if you’re going 

on vacation, or you’re out, there’s a backup person who can step in.” Buddies were not assigned. 

116 CO Prymmer testified that new SCs were not required to shadow anyone. (Tr. 122-23), 

83 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Integra did not have a written procedure for requesting a buddy. Dr. Arnott testified that 

Integra’s buddy system policy was that “if a Service Coordinator felt unsafe, he should ask a 

colleague to go with him.”117 Before [redacted]’ death, Integra did not require SCs to take a 

buddy to a member’s house if the SC thought there was a danger. SCs allegedly complained to 

Dr. Arnott that “they didn’t want to do it [buddy up] because their days were so long.” Dr. 

Arnott could not recall whether Integra had ever disciplined a SC for visiting a member without a 

buddy before [redacted]’ death. (Tr. 127, 348, 353-55, 698-700, 898, 942-43). 

According to Ms. Nelson, Integra’s buddy system was poorly implemented. It was not 

standardized “with specific procedures on how to double team,” allowing workers to be 

“unprepared to deal with a violent situation.” It was also discretionary, when it should have been 

mandatory, and it was ineffective because “Integra did not have workers discuss, role-play, 

identify code words, non-verbal signals and practices scenarios in order to be an effective 

team.”118 (Tr. 741-42, Ex. C-27, at p. 11). 

The Court agrees with Ms. Nelson and finds that Integra’s buddy system was ineffective 

and in the case of [redacted] of no real safety value. Before [redacted]’ death, SCs relied on 

themselves to arrange for another SC to accompany them. Dr. Arnott testified that a mandatory 

buddy system was started, but then stopped, previously in the Philadelphia Integra office because 

the work load was inconsistent with it. As a solution, Integra made the buddy system 

discretionary, which, the Court finds, conveyed the message that the workload was more 

important than a buddy. (Tr. 114, 354-56). 

117 Based upon her cavalier demeanor at trial, the Court gave little weight to Ms. Cooney’s testimony concerning 

Integra’s buddy system.

118 CO Prymmer testified that before [redacted]’ death, SCs relied on themselves to arrange for another SC to 

accompany them. (Tr. 114). 

84 
 

 

 

 

 

 

 

 

 

 

 

 

 

5. Hotline: Integra set up a telephone hotline to be used when “somebody’s in a bind 

and they need to have information right away.” The hotline was set up so that the first call was 

to the team lead, the second call to Dr. Arnott, and the third call to Dr. Krajewski. With regard 

to the hotline, Ms. Nelson testified: “I was aware of two different things. That [Drs. Arnott and 

Krajewski] said they were available and that the workers said they had trouble getting a hold of 

them.” Ms. Nelson’s testimony is consistent with the SC testimony in this case regarding trying 

to get in touch with management. Even if the SC got in touch with management, the standing 

advice was to get out of the situation if they felt uncomfortable. If the hotline was to be used 

when the SC was “in a bind,” and needed something “right away,” the SC was already face-toface with a member. Integra’s hotline was of limited practical use when the “bind” was 

workplace violence by a member at Integra. (Tr. 725, 1027). 

6. Universal Precautions: Integra says it directed its employees to use “universal 

precautions,” and treat all members as if they had violent tendencies. Integra says SCs were 

allowed to “get out” of or leave any situation they were currently in if they felt in danger. Dr. 

Krajewski explained that “universal precautions” means to “[a]ssume everybody you deal with 

could have the potential for harm. And you need to have that healthy sense of awareness [] so 

that when you go out there, you want to be aware.” Ms. Nelson testified that she did not view 

testimony by Dr. Arnott and Ms. Brown alluding to SCs exiting when feeling unsafe or to 

meeting members in a public place as part of Integra’s workplace safety program because they 

were not mandated strict policies. At best, Integra’s message to its SCs was mixed. Managers 

say they said leave any dangerous situation. The Neumann training test questions sought 

answers that were correct and different. Practicing “universal precautions” was plainly 

85 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

inadequate when, as here, the SC was inexperienced, naïve, untrained, and already face-to-face 

with the member with a history of a violent behavior. (Tr. 700, 924, 1030-31; Exs. C-16, C-27). 

For these reasons, the Court finds that Integra’s approach to safety was inadequate. One 

more point is by far more persuasive in illustrating Integra’s inadequate approach to safety. The 

SC’s goal was to complete the assessment of the member. The assessment contained 

information necessary to gauge potential violence from the member, including previous history 

of violence, living habits, substance abuse, and whether they are compliant with their 

medication. Before assessing these “predictors of violence,” the SC was forced to meet face-toface with a member multiple times. The record shows that in many instances Integra directed its 

SCs to cold-call members, and if unsuccessful, go to their homes unannounced, to make an initial 

contact. After obtaining a member’s written consent to accept Integra’s services, SCs had up to 

thirty days to complete their assessment of the member and determine his needs. Before making 

their assessment, SCs generally did not know how non-compliant the member had been with his 

doctor’s orders, whether he had any substance abuse addictions, and whether he had any criminal 

behavior or history. And during this time before the assessment, SCs were charged by Integra to 

chase down members and obtain this information, all while not knowing how dangerous they 

actually are. (Ex. C-34, at p. 3; Sec’y Br., at p. 37). 

The case of [redacted] showcases Integra’s inadequacy. [redacted] was hired sometime 

during the period from August through September 8, 2012. By September 8, 2012, Integra had 

assigned [redacted] to [redacted] as a member in her caseload. [redacted] attempted to contact 

[redacted] three times in September: September 9, September 16, and September 23. The 

discussion notes associated with the Neumann training indicate that [redacted] did not complete 

the safety portion of the Neumann training before September 27, 2012. [redacted] met with 

86 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

[redacted] for the first time in October 2012, the same month that she was awarded her certificate 

for completing the Neumann training. In the paper she prepared as part of the Neumann training, 

she stated: “Lastly knowing how to act in a crisis situation is not a skill that is easily learned, 

and I know that it will be difficult when I encounter it for the first time.” Despite Integra’s 

approach to safety, Integra’s own practices and policies exposed [redacted] to a hazard she 

should not have been required to confront while working for Integra. (Tr. 136, 141-42, 992-93, 

1015-16; Exs. C-7, R-JJ, at p. 1, R-VVV, R-RRRR, at p. 11). 

b. The Secretary Has Established Feasible Means of Abatement 

After establishing that the employer’s existing means of abating the hazard are 

inadequate, “[t]he Secretary must [then] specify the proposed abatement measures and 

demonstrate both that the measures are capable of being put into effect and that they would be 

effective in materially reducing the incidence of the hazard. The Secretary must also show that 

her proposed abatement measures are economically feasible.” Beverly, 19 BNA OSHC 1161, 

1190 (No. 91-3144, 2000) (consolidated) (citations omitted). “‘Feasible’ means economically 

and technologically capable of being done.” Id. “[F]easible 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.” Arcadian, 20 BNA OSHC at 2011 citing 

Pepperidge Farm, Inc., 17 BNA OSHC 1993, 2032 (No. 89-0265, 1997) citing Nat’l Realty & 

Const. Co., Inc., 489 F.2d at 1257. “[T]he Secretary need only show that the abatement 

method would materially reduce the hazard, not that it would eliminate the hazard.” MorrisonKnudsen, 16 BNA OSHC at 1122. 

As previously discussed herein, the Secretary identified many feasible means of 

abatement in Citation 1, Item 1, and during trial that Integra could use to reduce the likelihood of 

87 
 

 

 

 

 

 

 

 

 

 

 

 

 

the workplace violence described herein.119 Ms. Nelson testified that performing background 

checks, implementing certain administrative and engineering controls, including assigning 

member/caseloads considering member risk,120 and providing employee training in de-escalation 

and non-harming self-defense techniques, would be low-cost to Integra and would materially 

reduce the risk of the workplace violence described herein. She also testified that the abatement 

recommended by OSHA was feasible and would materially reduce instances of workplace 

violence. This portion of Ms. Nelson’s testimony was unchallenged by Integra, which provided 

neither lay nor expert opinion testimony claiming that these abatement measures were infeasible 

or would not reduce the hazard of workplace violence described herein.121 (Tr. 617, 644-66, 

672-75, 1094-95; Exs. C-1, at pp. 6-8, C-27, at p. 12; Sec’y Br., at pp. 34-35). 

Integra does not claim that the methods proposed by the Secretary are infeasible 

technologically or economically. Indeed, the record shows that Integra has already implemented 

some of the Secretary’s proposed means of abatement. For instance, Integra now has a written 

workplace violence prevention program with mandatory reporting requirements. They had no 

such plan prior to [redacted]’ death. Integra now regularly performs background checks on all 

members before assigning them to a SC. If a member has a criminal history, Integra initiates a 

“red flag” on that member’s chart, notifying anyone reading about that member about the 

criminal history. Typically, Integra now “rolls off” that member, so an Integra employee would 

119 See Nat’l Realty, 489 F.2d at 1268 (“Only by requiring the Secretary, at the hearing, to formulate and defend his 

own theory of what a cited defendant should have done can the Commission and the courts assure evenhanded 

enforcement of the general duty clause.”); Baroid Div. of NL Indus., Inc., 660 F.2d at 449 (“While an inadequate 

citation may be cured through actual notice at the hearing, the employer must at least at the hearing stage receive 

adequate notice of what particular steps it should have taken to avoid citation.”). 

120 Examples of such controls include establishing a safety committee; assigning the committee to write field safety 

procedures; developing safety plans and practice them; race, gender, language and culture; having home visit 

itineraries and call-in requirements to monitor location of employees; establishing a system to communicate to 

employees all incidents of threats or violence; and developing code words to indicate when there is a problem. 121 Integra presented no expert testimony in its defense. 

88 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

never come into contact with that person while on the job. This evidence supports a finding that 

the Secretary’s first three proposed means of abatement are feasible technologically and 

economically for Integra. SeaWorld, 748 F.3d at 1215 (finding that evidence of post-citation 

methods of abatement taken by SeaWorld support finding that the proposed means were feasible 

and did not fundamentally alter SeaWorld’s business.). (Tr. 126, 166-67, 377, 389, 410, 810; Ex. 

R-R). 

Integra claims that the Secretary failed to show that any of these abatement measures 

would be effective in abating the hazard. Integra bases its claim on the fact that Ms. Nelson 

could not quantify how effective the abatement measures could be and could not promise that the 

hazard would be completely eliminated. It is not necessary that the hazard be eliminated, only 

that it be materially reduced. Morrison-Knudsen, 16 BNA OSHC at 1122. OSHA itself notes in 

its “Guidelines for Preventing Workplace Violence for Health Cate & Social Service Workers,” 

that “[a]lthough not every incident can be prevented, many can, and the severity of injuries 

sustained by employees can be reduced.” (Ex. C-32, at p. 7; Resp’t Br., at pp. 13-14; Resp’t 

Reply Br., at pp. 7-9). 

Ms. Nelson testified specifically to these methods of abatement and that they do decrease 

the risk of physical assault in the Integra workplace. See Williams Enters., Inc., 7 BNA OSHC 

1247, 1250 (No. 4533, 1979) (“The Secretary must establish hazard recognition by reference to 

the level of awareness or knowledge in the industry or by the employer himself, but the required 

abatement is determined by reference to feasibility rather than industry custom or knowledge.”); 

Wheeling-Pittsburgh Steel Corp., 10 BNA OSHC at 1245 (“[S]ection 5(a)(1) may require that 

feasible protective measures be taken even though such measures are not considered customary 

in a particular industry.”). The Court finds that Ms. Nelson’s opinion as an expert in personal 

89 
 

 

 

 

 

 

 

 

 

 

 

 

safety, and visiting people in the field, is persuasive evidence that the Secretary provided for this 

issue. 

The Court is persuaded by Ms. Nelson’s opinion that “[t]he key variables in workplace 

safety training are identifying ‘who, what and where.’ The ability to assess the person, their 

situation and the setting is paramount.” (Ex. C-27, at p. 9). The Court finds that preparation is 

essential to reduce the risk of physical assault in the Integra workplace by a member with a 

violent history. A written workplace violence prevention program decreases the risk of assault 

by helping prepare the SC for the possibility of a violent situation. Ms. Nelson testified that: 1) 

a written document is an established resource for trainees, preventing experienced workers from 

taking all of their knowledge with them if they leave the company; 2) the safety program also 

provides “scenarios” to make trainees aware of possible safety situations like a member with a 

weapon, dogs, trespassing signs, and other people in the member’s house; and 3) the safety 

program will then list ways to identify, prevent, and escape from those scenarios. (Tr. 646-49). 

The Court agrees with Ms. Nelson that a background check gives more information to the SCs so 

that they know who they are meeting with and can prepare themselves appropriately. (Ex. C-27, 

at p. 11). It is undisputed that a history of violent behavior, which could be uncovered in a 

background check, is one of the top predictors of future violence. Flagging a potentially violent 

member with a history of violence decreases the risk of assault because it allows the SCs to 

know who may have a propensity for violence so that they may prepare themselves or 

alternatively assign the member to a SC based on client risk, rather than geographic or 

scheduling concerns. (Tr. 618-19). The Court finds that “rolling off” a member with a history of 

violent behavior decreases the risk of assault because the SC would not be required by Integra to 

meet with that member. The Court also agrees with Ms. Nelson that mandatory reporting 

90 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

requirements decrease the risk of assault because: 1) by making it mandatory, it decreases the 

chance that Integra SCs will not report it for fear of looking like they are not doing their job, and 

2) it allows all the SCs to know what is going on so that they can all help and prepare for the 

possibility of a violent situation with a particular member. (Tr. 661-62). 

The record shows that Integra’s approach to containing this hazard was plainly 

inadequate. The measures Integra has adopted since [redacted]’ death are consistent with Ms. 

Nelson’s expert testimony,122 as well as OSHA’s recommendations as noted in its Guidelines. 

The Secretary has met his burden in establishing feasible means of abatement for this general 

duty citation. 

This citation item is affirmed.123 

b. Characterization 

The Secretary characterizes this citation item as serious. A violation is “serious” if there 

was a substantial probability that death or serious physical harm could have resulted from the 

violative condition. 29 U.S.C. § 666(k). The record shows that [redacted], a novice employee 

who Integra hired and trained inadequately, died as a result of an attack by member [redacted]. 

The violation is properly characterized as serious.

124 

122 See Tampa Shipyards, Inc., 15 BNA OSHC 1533, 1536 (No. 86-360, 1992) (finding proposed means of 

abatement were materially reduced based on expert testimony.).

123 Despite raising it in its Answer, Respondent has not claimed the UEM defense in its post hearing briefs. L&L 

Painting Co., 23 BNA OSHC 1986, 1989 n. 5 (No. 05-0055, 2012) (finding item not addressed in post-hearing 

briefs deemed abandoned); Midwest Masonry Inc., 19 BNA OSHC 1540, 1543 n. 5 (No. 00-0322, 2001) (noting 

arguments not raised in post-hearing briefs generally deemed abandoned); Jersey Steel Erectors, 16 BNA OSHC 

1162, 1168 (No. 90-1307, 1993), aff'd, 19 F.3d 643 (3d Cir. 1994) (unpublished) (holding that to establish UEM 

defense, employer must show that it had a “thorough safety program, which was adequately communicated and 

enforced, and that the violative conduct of the employee was idiosyncratic and unforeseeable.”). 

124 Respondent argues that the violation can not be characterized as serious because it had no knowledge that its 

actions were in violation of the general duty clause. As the Secretary notes, there is no “knowledge” component to a 

violation’s characterization. Respondent’s argument goes to the recognition/ knowledge prong of the merits of the 

general duty violation, not to its characterization. As discussed above in that section, the Court finds that 

Respondent’s arguments in this regard are without merit. (Sec’y Br., at p. 9, Resp’t Br. at 16-18; Resp’t Reply Br., 

at pp. 10-11). 

91 
 

 

 

 

 

 

 

 

 

 

 

 

II. Serious Citation II, Item I – Alleged Reporting Violation 

a. Merits 

The Secretary claims that Integra violated the reporting standard at 29 C.F.R. 

§ 1904.39(a) because it did not report [redacted]’ death within eight hours of its occurrence to 

OSHA. To prove a violation of an OSHA standard, the Secretary must show by a preponderance 

of the evidence that: (1) the cited standard applies, (2) there was a failure to comply with the 

cited standard, (3) employees had access to the violative condition, and (4) the employer knew or 

could have known of the condition with the exercise of reasonable diligence. Astra Pharma. 

Prods., 9 BNA OSHC 2126, 2129 (No. 78-6247, 1981), aff’d in relevant part, 681 F.2d 69 (1st 

Cir. 1982) (Sec’y Br., at p. 38). 

It is undisputed that [redacted] was an employee of Integra, that she died as a result of a 

work-related incident, and that Integra did not report her death to OSHA within eight hours of its 

occurrence. 29 C.F.R. § 1904.39(a); see also 29 C.F.R. § 1904.5(a) (an injury is work-related if 

an event or exposure in the work environment either caused or contributed to the resulting 

condition). It is undisputed that Integra failed to report [redacted]’ death to OSHA because of 

the mistaken assumption that its responsibility extended only to “Work[er’s] Compensation.” 

Although initially contested, Integra states in its post-hearing brief that it no longer contests this 

citation item.125 See Charles A. Gaetano Constr. Corp., 6 BNA OSHC 1463, 1465 (No. 14886, 

1978) (noting ignorance of the requirements of the law generally does not excuse 

noncompliance). (Tr. 86; Resp’t Br., at p. 18). 

This citation item is affirmed. 

b. Characterization 

125 In its Post-Hearing Brief, Respondent admits “it did not also report the fatality to OSHA.” (Resp’t Br., at p. 7, n 

3). 

92 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Secretary characterizes this citation item as other-than-serious. A violation is “otherthan-serious” if the evidence in the record does not support a finding that failure to comply with 

the cited standard would likely result in death or serious physical harm. 29 U.S.C. § 666(k); 

Miniature Nut & Screw Corp., 17 BNA OSHC 1557, 1559 (No. 93-2535, 1996). The Secretary 

has not claimed that Integra’s failure to report [redacted]’ death would likely result in another 

Integra employee death or serious physical harm. The record also does not support such a 

finding. The Court finds that the violation is properly characterized as other-than-serious. 

III. Penalties 

“Section 17(j) of the [OSH] 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, gravity of the violation, good faith, and prior history of violations.” Hern 

Iron Works, Inc., 16 BNA OSHC 1619, 1624 (No. 88-1962, 1994). When determining gravity, 

typically the most important factor, 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. Id. When evaluating good faith: 

the Commission focuses on a number of factors relating to the employer's actions, 

‘including the employer's safety and health program and its commitment to assuring 

safe and healthful working conditions[,]’ in determining whether an employer's 

overall efforts to comply with the OSH Act and minimize any harm from the 

violations merit a penalty reduction. 

Monroe Drywall Constr., Inc., 24 BNA OSHC 1209, 1211 (No. 12-0379, 2013) (citations 

omitted). The Commission is the “final arbiter” of penalties. Hern Iron Works, 16 BNA OSHC 

at 1622 (citation omitted). 

For Citation 1, Item 1, the workplace violence violation, the Secretary proposed the 

maximum statutory penalty for a serious violation, $7,000. See 29 U.S.C. § 666(b). The Court 

finds that the gravity of the violation is high. Due to its inadequate approach to safety in the SC 

93 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

workplace, Integra exposed essentially all of its SCs to an increased likelihood of workplace 

violence by a member with a history of violence. Some of these exposures lasted for hours while 

alone with a violent person in a private home or vehicle. The record establishes that Integra 

could have taken precautions preventing injury by hiring, training, performing, and assigning 

work appropriately, but chose not to in the interest of saving money and time. The record also 

establishes that an encounter at the home of a dangerous member resulted in a fatality. Integra 

has no prior history with OSHA. OSHA never inspected Integra before [redacted]’ death. The 

record shows that Integra had about 62 employees at the time of [redacted]’ death. OSHA had 

initially calculated a 30% reduction in penalty due to size, but revised it to 0% “to achieve the 

appropriate deterrent effect.” OSHA did not recommend a good faith reduction because it is 

only given “if there’s an adequate safety and health program.” The Court agrees with the 

Secretary’s proposed penalty recommendations. Integra also does not address the proposed 

penalty amount for this citation item in its post-hearing briefs.126 The Court finds that the 

proposed penalty is appropriate for this affirmed citation item. (Tr. 168-69; Exs. C-2, C-6, at p. 

2; Sec’y Br., at p. 39). 

For Citation 2, Item 1, the reporting violation, both parties agree that the proposed $3,500 

penalty is appropriate. The statutory maximum civil penalty for an other-than-serious violation 

of the OSH Act is $7,000. 29 U.S.C. § 666(c). The Court finds that the gravity for this otherthan-serious violation is low as there was little, if any, risk of injury as a result of this violation. 

The Court also agrees with the Secretary’s proposal for a reduction for size, but no reduction for 

126 In this respect, Respondent only addresses the characterization of the general duty violation. (Resp’t Br., at pp. 

16-18; Resp’t Reply Br., at p. 11). As found above, the Secretary has established that the violation is properly 

classified as serious. Furthermore, any argument not included in Respondent’s brief is deemed abandoned. L&L 

Painting Co., 23 BNA OSHC at 1989 n. 5 (noting item not addressed in post-hearing briefs deemed abandoned); 

Midwest Masonry Inc., 19 BNA OSHC at 1543 n. 5 (finding arguments not raised in post-hearing briefs generally 

deemed abandoned). 

94 
 

 

 

 

 

 

 

 

 

 

 

good faith or history. The Court finds that the proposed $3,500 penalty is appropriate for this 

affirmed citation item.127 (Tr. 169-70; Sec’y Br., at p. 40; Resp’t Br., at p. 22). 

FINDINGS OF FACT AND CONCLUSIONS OF LAW 

All findings of fact and conclusions of law relevant and necessary to a determination of 

the contested issues have been made above. See Fed. R. Civ. P. 52(a). All proposed findings of 

fact and conclusions of law inconsistent with this decision are denied. 

ORDER 

Based on these findings of fact and conclusions of law, it is ordered that: 

1) Item 1 of Citation 1, alleging a serious violation of section 5(a)(1) of the OSH Act, is 

AFFIRMED and a penalty of $7,000 is ASSESSED. 

2) Item 1 of Citation 2, alleging an other-than-serious violation of 29 C.F.R. § 1904.39(a), is 

AFFIRMED and a penalty of $3,500 is ASSESSED. 

/s/ 

The Honorable Dennis L. Phillips 

U.S. OSHRC Judge 

Date: June 22, 2015_____ 

Washington, D.C. 

127 In its brief, Integra proposes that “the $3,500 penalty identified by the Secretary is appropriate.” (Resp’t Br., at p. 

22). 

95