St Joseph Memorial Hospital

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34824 Based on document review and interview, it was determined that the Critical Access Hospital failed to comply with the Condition of Participation 42 CFR 485.614, Patient Rights. Findings include: 1. The Hospital failed to ensure that least restrictive restraints were used in accordance with an order from a physician/licensed practitioner as required. See deficiency at C-2551. 2. The Hospital failed to ensure documentation of a one-hour face to face evaluation was completed as required by policy. See deficiency at C-2553 A. 2. The hospital failed to ensure that a chemical restraint order was obtained as required by policy. See deficiency cited at See deficiency at C-2553 B.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 45565 A. Based on observation, documentation, and interview, the CAH failed to ensure emergency carts and medication boxes were checked daily to ensure safe functioning per policy. This has the potential to affect all patients who receive care by the CAH emergency department. Findings Include: 1. During the observational tour of the Emergency Department on 01/30/24 at 10:30 AM, the following was identified: - 2 of 2 adult crash cart checks were not completed on 01/22/24. - 1 of 1 pediatric crash cart check was not completed on 01/22/24. - 1 of 1 neonatal airway box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24. - 1 of 1 stat heart box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24. - 1 of 1 Narcan box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24. 2. The policy “Crash Cart (& Emergency Stock Maintenance, Cleaning, etc.) SY-NG-037” (revised 10/18/22) notes, “ ... III. Responsibilities. 1. Designated Staff: 1. Checks the crash cart daily as indicated ... V. Procedure. 1. Crash cart shift checks are done per crash cart check sheet. The designated department staff conducting the crash cart check completes the checklist posted in the department ... 2. Other outer contents and locks as per Checksheet such as oxygen, suction, where applicable, backboard, needle boxes, etc.” 3. An interview with the ED director (E#5) during the tour was conducted. E#5 reviewed the checklists and verbally verified checks had not been completed as required per policy on the dates noted above. E#5 also stated, “a nurse on shift is responsible for performing and documenting crash cart checks were completed.” B. Based on observation and staff interview, it was determined the Facility failed to ensure open sterile supplies were not available for patient use. This failure has the potential to affect all patients who receive care by the CAH procedures area. Findings include: 1. During the observational tour of the OR on 01/31/24 at approximately 11:00 AM, it was identified that open sterile supplies on the anesthesia cart were available for immediate patient use to include the following: - One (1) Endotracheal Tube, open with contents still inside and available for use. - One (1) Suction Catheter, open with contents still inside and available for use. - Two (2) Oral Airways, open with contents still inside and available for use. 2. An interview with Quality Improvement Registry Coordinator (E#8) and OR Supervisor (E#9) was conducted during the observational tour. E#8 vebally agreed the items should have been disposed of. E#8 stated, “expired supplies and open sterile supplies should not be available for patient use. We have spoken to anesthesia about this before.””

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 45539 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on February 6, 2024, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 34824 Based on document review and interview, it was determined for 2 of 2 (Endo Room #1 and Endo Room #2) procedure rooms (rooms that pain procedures utilize radiation) that required a dosimetry monitoring, the Hospital failed to ensure the dosimeter badges were monitored per policy. This has the potential to affect all patients and staff who are exposed to radiation. Findings include: 1. An observational tour was conducted on 1/31/24 at approximately 11:30 AM with Quality Improvoment Registry Coordinator (E #8) and OR Supervisor (E #9). E #9 stated, “We monitor the dosimetry by the badges on the wall in procedure room #1 and room #2. Those rooms do not get much exposure so the staff do not get individual badges, unless they request it. The radiation exposure is monitored through the badges that are mounted on the wall. They are monitored monthly. The staff in the rooms have no other radiation exposure so they would not require the individual badges.” 2. The policy titled, “Radiation Safety in the OR, SY-OR-023 (revised 6/6/23)” was reviewed on 1/31/24. The policy stated, “... III Responsibilities... 2. RSO (Radiation Safety Officer) 1. Determines the appropriate type of monitoring for radiation exposure based on the employee job duties. 2. Provides the appropriate monitor. 3. Collects and replaces monitoring devices on a regular basis (monthly, quarterly).... V. Procedures:... 2. Radiation monitoring devices (film badges)... 1. Surgical Services personnel who are (hospital) employees, are considered non-radiation workers and have the potential of receiving an exposure of 500m/Yr or higher are provided with radiation monitoring devices (film badges) by the RSO. Some areas will be monitored by using Area Monitors...” 3. The Dosimeter Reports from October 23 to present was requested. The reports were reviewed on 2/1/24 at approximately 9:00 AM. The Radiation Dosimetry Reports were provided were dated as follows: Endo Room #1 dated - 10/24/23, 11/29/24, and 1/5/24 Endo Room #2 dated - 10/24/23 The reports lacked monitoring for Room #1 in December and Endo #2 November, December and January. 4. An interview was conducted with the System Director of Regulatory and Accreditation Compliance (E #1) on 2/1/24 at 9:30 AM. E #1 reviewed the reports and verbally agreed the dosimeter reports are not conducted monthly as required for the procedure rooms.”

“RESTRAINT AND SECLUSION CFR(s): The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 34824 Based on document review and interview, it was determined that for 2 of 3 violent restraint records (Pt #4 and Pt #13) reviewed, the Hospital failed to ensure that least restrictive restraints were used in accordance with an order from a physician/licensed practitioner as required. This has the potential to affect all patients that require violent restraints. Findings include: 1. The Hospital’s policy titled, “Restraints, Use of, SY-DR-010 (3/28/2023),” was reviewed. The policy stated, “... III. Responsibilities 1. Physician: 1. Provides the restraint orders... 3. RN: ... Attempts to alternatives to restraints or less restrictive restraint methods...” 2. The clinical record of Pt #4 was reviewed on 1/31/24. Pt. #4 arrived to the ED on 1/14/24 as 12:25 AM with a chief complaint of “suicidal.” The ED nursing note at 12:50 AM stated, “... Pt became agitated and angry that (Pt #4’s) phone was taken and tried to leave the room.... (ED MD) agreed to use soft restraints to obtain labs, place pt in paper scrubs and keep (Pt #4) in the hospital safe for evaluation).” The nursing flowsheet noted Pt #4 was placed in 4-point “locking” restraints. A physician order was noted at 1:31 AM for “Soft limb” 4-point (left lower, left upper, right lower, and right upper) restraints due to “Danger to others.” 3. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of “Altered mental status and smoke inhalation.” Pt #13 was placed in 4 point locked restraints due to being a danger to self on 12/3/23 from 11:17 PM. The right wrist and left ankle locking restraint was discontinued on 12/3/23 at 2:00 AM. The left wrist was discontinued at 3:30 AM with the Right ankle restraint being discontinued at 4:00 AM. Pt #13 was put back into 4 point locking restrains at 8:44 AM. The locking restraints were discontinued at 11:12 AM. Physician orders for violent-restraints, dated 12/2/23 at 11:17 PM and 12/3/23 at 8:44 AM, were reviewed. The orders were for 4- point (extremity) “Soft Limb” restraints due to “Danger to self.” 4. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24, at approximately 3:30 PM. E #4 reviewed the records and stated that “the restraints ordered were soft restraints and the flowheets indicated the nurse utilized locking restraints. The staff should have followed the order and used the correct type of least restrictive restraints.””

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 34824 A. Based on document review and interview, it was determined for 1 of 3 patient’s (Pt #13) clinical records reviewed for violent restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints. Findings include: 1. The Hospital’s policy titled, “Restraints, Use of, SY-DR-010 (3/28/2023),” was reviewed. The policy stated, “... III Responsibilities 1. Physician: ... 2. Does a face-to-face assessment within one (1) hour for violent or self-destructive restraint application per episode....” 2. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of “Altered mental status and smoke inhalation.” Pt #13 was placed in 4 point locked restraints due to being a danger to self on 12/3/23 from 11:17 PM. The right wrist and left ankle locking restraint was discontinued on 12/3/23 at 2:00 AM. The left wrist was discontinued at 3:30 AM with the Right ankle restraint being discontinued at 4:00 AM. Pt #13 was put back into 4 point locking restrains at 8:44 AM. The record lacked documentation of a 1 hour face-to-face after Pt #13 was placed back in restraints at 8:44 AM. 3. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24 during the record review. E #4 verbally agreed the 1-hour face-to-face documentation was not documented on the second restraint event and stated “I thought the face-to-face only had to be done once in 24 hours. I train staff and have been training them wrong.” B. Based on document review and interview, it was determined for 1 of 2 patient’s (Pt #13) clinical records reviewed for chemical restraints, the Hospital failed to ensure a chemical restraint order was placed as required by policy. This has the potential to affect all patients placed in chemical restraints. Findings include: 1. The Hospital’s policy titled, “Restraints, Use of, SY-DR-010 (3/28/2023),” was reviewed. The policy stated, “... V Procedure... 7. Physicians or Advanced Practice Professionals in the Emergency Department. 1. The order for the use of restraints are based on the identification of clinically justified behaviors. Orders include: A. Indication for use. B. Type of restraint....” 2. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of “Altered mental status and smoke inhalation.” Pt #13 was given Ativan (anti-anxiety) 0.5mg at 9:37 PM and Geodon (anti-psychotic) 10mg at 10:35 PM as Pt #13 was “agitated/restless.” The record lacked a chemical restraint order. 3. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24 during the record review. E #4 reviewed the record and stated, “the provider should have ordered a chemical restraint and did not.””

“On February 6, 2024, the Life Safety Code portion of the Re-Certification Survey was conducted. The surveyor was accompanied during all or portions of the survey walk-through and document review portions of the survey by one or more of the following provider representatives: The System Director Regulatory Compliance The Facility Engineering Manager (FEM) The System Director Facilities Engineering The System Emergency Management and Environment of Care Coordinator (EM/EOC) The survey consisted of the main hospital located on a single site described as follows: St. Joseph Memorial Hospital (Main Building), constructed in 1957, was indicated to be of Type II (222) construction. The facility is fully protected by an automatic sprinkler system. The facility was surveyed as an Existing Health Care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 485.623 are NOT MET as evidenced by the deficiencies cited under the following K-Tags.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 45539 . Based on document review, the facility failed to establish a proper Fire Watch Training of staff for procedures that must conducted when the “Fire Alarm System” is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect an indeterminable number of patients, staff and visitors in all Smoke Zones, if staff did not conduct the proper procedures when the fire alarm system was inoperable. Findings include: A. On 02/06/24 at 11:28 AM, Document Review revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of LSC; Section 9.6.1.6. B. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the fire alarm system has been returned to service in accordance with NFPA 101, 2012 Edition, Section 9.6.1.8. Examples of missing Key Directives: 1. Facility provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuated effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6. 2. The Authorities Having Jurisdiction (AHJ) shall be notified including: (1) The local fire department (2) IDPH Regional Office. 3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: “The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104 (1) The fire watch is continuous (2) The personnel conducting the fire watch has no other duties. (3) Method of recording and documenting the fire watch (4) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (5) Identification of Staff performing the Fire Watch (6) Access to all spaces provided to Fire Watch Staff This finding was reviewed at the Exit Conference with E-1, E-2, E-3 and E-4. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 45539 . Based on an observation, the facility failed to provide proper maintenance, required clearance at devices, or required maintenance of the automatic sprinkler system. This deficient practice could affect an indeterminable number of patients, staff and visitors in the Lobby Smoke Zone, if the sprinkler system failed to operate properly due to improper maintenance. Findings include: On 02/06/24 at 2:15 PM, while accompanied by E-1, E-2, E-3 and E-4., an observation revealed that the Lobby Smoke Zone - Entrance Canopy had one (1) dirty sprinkler head. The sprinkler head cover was missing, the sprinkler head was covered with dirt and lint and was not in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.1 and NFPA 101; 2012 Edition, Section 9.7. This finding was reviewed at the Exit Conference with E-1, E-2, E-3 and E-4. .”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 45539 . Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the “Sprinkler System” is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect an indeterminable number of staff and visitors in all Smoke Zones, if staff did not conduct the proper procedures when the sprinkler system was inoperable. Findings include: A. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6. B. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6). Examples of missing Key Directives: 1. Impairment Coordinator is established. NFPA 25, 2011 Edition Section 15.2.1 2. Impairment tags are posted at each fire department connection and control valves. NFPA 25, 2011 Edition Section 15.3.2 3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following: NFPA 25, 2011 Edition Section 15.5.2(4): (1) Evacuation of the building or portion of the building affected by the service outage (2) An approved Fire Watch 4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: “The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104.: (1) The fire watch is continuous (2) The personnel conducting the fire watch has no other duties (3) Method of recording and documenting the fire watch (4) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (5) Identification of Staff performing the Fire Watch (6) Access to all spaces provided to Fire Watch Staff 5. When the sprinkler is out of service the facility shall notify the local fire department has been notified. NFPA 25, 2011 Edition Section 15.5.2(5) 6. When the sprinkler is out of service the facility shall notify the following: NFPA 25, 2011 Edition Section 15.5.2(6): (1) The insurance carrier (2) The alarm company (3) IDPH Regional Office (4) All other authorities having jurisdiction are notified 7. Restoring System to Service the following provided: (1) Necessary inspections and tests have been conducted to verify that the effected systems are operational (2) Supervisors are notified (3) Fire Department is notified (4) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified (5) Impairment tags removed. These findings were reviewed at the Exit Conference with E-1, E-2, E-3 and E-4. .”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45539 . Based on observations the facility failed to install electrical wiring to ensure the safety of the staff and residents. This deficient practice could affect an indeterminable number of patients, staff and visitors in the Support Core 1, 2 and 5 Smoke Zones, if the electrical wiring started a fire from overloading electrical circuits or electrical shock occurred due to the failure. Findings include: A. On 02/06/24 at 1:28 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 1 Smoke Zone - Hospitalist’s office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM’S S & C Memo 14-46-SC. B. On 02/06/24 at 1:29 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 1 Smoke Zone - Infusion Manager’s office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM’S S & C Memo 14-46-SC. C. On 02/06/24 at 1:47 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 5 Smoke Zone - Lab Director’s office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM’S S & C Memo 14-46-SC. D. On 02/06/24 at 1:56 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 5 Smoke Zone - Same Day Surgery Educator’s office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM’S S & C Memo 14-46-SC. E. On 02/06/24 at 2:43 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 2 Smoke Zone - Lab Director’s office, was using six (6) surge-protected power strips, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strips were lying on the floor where they could pose a tripping hazard and were not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM’S S & C Memo 14-46-SC. These findings were reviewed at the Exit Conference with E-1, E-2, E-3 and E-4. .”