Guam Memorial Hospital Authority Aturidat Espetat Mimuriat Guahan 850 Go\, C,Arfos CJ

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Guam Memorial Hospital Authority Aturidat Espetat Mimuriat Guahan 850 Go\, C,arfos CJ. ('a1nachn Road rfarnuning, CilJ 96913 Phone: (671) 047-23.i0/2444 I Fax: (671) 649-0145

October 19. 2015

Honorable Judith T. Won Pat. Ed.D. S/;eaker r~ll A1inarreruai T'res jVa l,ihcslaturan (;udhan 155 Hesler Place Hagiitfia. GU 96910

RE: REPORTING REQUIREMENTS FOR BOARDS AND COMMISSIONS

Dear Speaker Won Pat:

In accordance with Ch .8 of Title 5 GCA, Section 38, §8113. l. Reporting Requirements for Boards and Conunissions. enclosed is a cornpact disc containing electronic copies of aH n1ateriaJs presented and discussed during the GMHA Board of Trustees meeting held on September 24, 2015 at 6:00 p.m. in the GMHA D.L Webb Conference Room.

Please contact me directly at 647-2 l 04 if you have any questions.

Senserarnente,

Theo M _Pangelinan Administrative Assistant - Board Office cc: Hospital Administrator/CEO File

0970

GUAM MEMORIAL HOSPITAL AUTHORITY Board of Trustees Regular Meeting

AGENDA Thursday, September 24, 2015 | 6:00 p.m. D. L. Webb Conference Room

I. Call meeting to order and determination of quorum II. Medical Staff President’s report III. Executive Session IV. Approval of regular session minutes A. July 30, 2015

V. Board Sub-committee reports A. Human Resources 1. Res. 15-74 through 15-79 Relative to Retirements 2. Res. 15-80 Relative to Commending Dr. Walter Chris Perez 3. Res. 15-81 Relative to Commending Dr. Debra Ericson

B. Joint Conference and Professional Affairs 1. Res. 15-66 & 71 Relative to Appointments/Reappointments

C. Facilities, Capital Improvement Projects, and Information Technology 1. Res. 15-65 Relative to Complying with PL 32-179 & 32-204 in Order to Effectively Complete GMHA’s Family Birth Center Renovation Project 2. Facility Master Plan: “Designing & Building the Best Guam Hospital”

D. Governance, Bylaws, and Strategic Planning E. Quality and Safety 1. Performance Improvement Dashboard – Month 2 (CY-2015, 2Q) 2. Skilled Nursing Unit (CY-2015, 2Q) 3. EEO Report (CY-2015, 2Q)

F. Finance and Audit 1. Res. 15-72 Relative to the Consent to Adjust Hospital Rates to Reflect Current Year Medicare Reimbursements Under PL 26-66 2. Res. 15-73 Relative to the Approval of Fourteen (14) New Fees 3. Financials: August 2015

VI. Administrators’ reports A. Associate Administrator of Medical services B. Chief Financial Officer C. Hospital Administrator/CEO

VII. Old Business VIII. New Business IX. Public Comment X. Adjourn

Doc. No. 33GL-15-0970

Doc. No. 33GL-15-0970 GUAM MEMORIAL HOSPITAL AUTHORITY

“Designing & Building the Best Guam Hospital”

A Facility Master Plan (September of 2015)

Organizational Background

The Guam Memorial Hospital, a component of the Government of Guam (GovGuam), a government entity created on July 26, 1977 under Public Law No. 14-29 as an autonomous agency of GovGuam. Preceding the creation of the Guam Memorial Hospital Authority (GMHA), the United States Government provided free hospital and health care services to the people of Guam. At the turn of the 20th century, the United States took formal possession of Guam with the United States Naval forces assuming responsibility for the island’s health needs. Post World War II, responsibility to provide for the island’s health care needs was assumed by the Government of Guam’s Department of Public Health and Welfare with the donation of the first hospital facility. In 1977, GMHA was created as a public corporation administered under the governance of a Board of Trustees. GMHA achieved full autonomy through Bill No. 386-30, which became Public Law 30-190 when it was signed into law by Felix P. Camacho, the Honorable Governor of Guam, on 8/28/2010.

As the Guam Memorial Hospital is the exclusive “public” provider of hospital-based services for the civilian population of the community of Guam, GMHA is mandated to deliver medical care notwithstanding one’s financial ability to pay for the provision of services. GMHA’s mission is “to provide quality patient care in a safe environment” twenty-four (24) hours, three hundred sixty-five (365) days a year by way of two medical facilities located in Tamuning and Barrigada. The Tamuning facility is an acute care hospital responsible for the delivery of acute and emergency care, as well as a wide array of non-acute and outpatient services; and the Barrigada facility is a Skilled Nursing Unit responsible for the delivery of skilled nursing care and associated services. GMHA is accredited and/or certified by the following standards/guidelines setting healthcare entities:

The Joint Commission (TJC);

The Centers for Medicare and Medicaid Services (CMS);

The College of American Pathologists (CAP) and the Food and Drug Administration (FDA) accreditation/certification for Laboratory Services; and

GMHA’s Education Department is American Heart Association accredited as a Training Facility to provide certification programs for Basic and Advanced Cardiac Life Support, thus covering the Guam community’s patient population with respect to cardiac life support; and is also accredited, by the Hawaii Medical Association and California Board of Registered Nurses, to provide education credits for both Continuing Medical Education (CME) and Continuing Nursing Education (CNE) respectively.

Doc. No. 33GL-15-0970 Clinical Bed Capacities

GMHA’s current bed capacities are as follows:

161 hospital acute care beds; 97 hospital non-acute care beds; and 40 skilled nursing unit residential treatment beds.

The availability or utilization of the above listed beds, for actual admissions, varies from time to time in accordance with the availability of fully trained and licensed staff.

Mission, Core Values and Vision

As reflected in its 2013 Strategic Plan, GMHA’s mission is “To provide quality patient care in a safe environment.” Its core values were determined to be as follows:

Accountability; Cost Efficiency; Excellence in Service; Safety; plus Quality.

Based upon these core values, GMHA determined that its vision is to “To achieve a culture and environment of safety and quality patient care meeting national standards and addressing the needs of the Community in a fiscally responsible, autonomous hospital.”

Current Scope of Services

In support of its mission and in striving to achieve its vision, GMHA offers a wide scope of services. These services currently include acute and non-acute care, skilled nursing, emergency care, surgical services, diagnostic, therapeutic, and a host of professional support services as follows:

The acute care units provide all customary acute care services such as pediatric and adult medical services; pediatric and adult intensive care services; adult progressive care and telemetry; obstetrics ward services; and non-acute units provide obstetrics services to include labor & delivery, nursery, postpartum, and birthing.

The Skilled Nursing Unit provides skilled nursing and intermediate care at an off-site facility.

Emergency care is a 24-hour service for trauma cases, full spectrum of medical and surgical emergencies, and extended emergency services such as short stay observation.

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Doc. No. 33GL-15-0970 Comprehensive inpatient and outpatient surgical services are available in the operating room with four surgical suites, one cystoscopy room, one endoscopy unit, a post anesthesia recovery area, and one room in Labor & Delivery (L & D) for C-Sections. In August 2015, GMHA completed the A/E Design Phase to upgrade its L & D Unit in order for it to become a state-or-the-art Family Birthing Center to include multi-purpose Labor, Delivery, Recovery, and Postpartum Rooms, as well as a state-of-the-art Nursery.

Inpatient and outpatient diagnostic and therapeutic services include laboratory and comprehensive blood bank services, that are CAP accredited and FDA registered, radiology, nuclear medicine, nuclear cardiology, thallium stress tests, CT scan, mammography, ultrasonography, and angiography imaging services; inpatient pharmacy, respiratory and cardiopulmonary services; physical, speech, occupational, cardiac, and recreational therapies; and inpatient hemodialysis.

Other professional support services include dietary/nutritional counseling; spiritual care; medical social services; patient/family education; staff education, guest relations and special services which includes echocardiogram, stress test, EKG, EEG, cardiac MIBI and neurology, cardiology and orthopedic Consultations.

Telemedicine and Teleradiology services are available for specialty consultations and follow-ups; as well as distance education programs for physicians, nursing staff, and allied health professionals.

“Best Guam Hospital” Additional Future Scope of Services

GMHA’s near future “Best Guam Hospital” Scope of Services shall also include, as examples, the following hospital-based, state-of-the-art Medical Centers of Excellence:

Wound Care Services; Oncology Care Services; Neurology & Stroke Care Services; Surgical Arts & Trauma Care Services; Magnetic Resonance Imaging (MRI) Services; and Cardiac Care Services (to include an independent Catheterization Lab).

“Best Guam Hospital” Capital Outlay Needs

Project #1: Consolidated “Best Guam Hospital” A/E Design-Build Package

Scope of Work: Contract the professional A/E Design and Construction Services required to complete a Consolidated Package to include multiple, phased Capital Improvement Projects (CIPs) that do not disrupt GMHA Operations during the Construction Phases. Those multiple, phased CIPs are as follows:

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Doc. No. 33GL-15-0970 Phased Removal / Replacement of Existing Hospital Electrical Distribution Panel and one (1) 1.6 Meg Emergency Generator to include road development behind the Hospital that will effectuate GMHA’s Traffic Improvement Plan for small and large emergency transport vehicles. This is a “shovel ready” CIP, as A/E Designs are complete It is critical that this CIP proceed on the front end of this Consolidated “Best Guam Hospital” A/E Design-Build Package in order for GMHA to meet and sustain it mission “to provide quality patient care in a safe environment” (Construction Cost Est. $3M).

Z-Wing Abatement & Demolition Phase will enable GMHA to safely and effectively abate the asbestos contained underneath the floor tiles of the Z-Wing followed by safe and effective building demolition (Z- Wing Abatement & Demolition Phase Cost Est. between $500,000 to $700,000 depending on the discovery of any unforeseen challenges inside, around and beneath the Z-Wing Building).

New Z-Wing A/E Design & Construction Phase will provide GMHA with a long overdue, newly constructed Z-Wing that shall include at least 3 Floors and ≈ 65,000 – 80,000 sq. feet that will include the following “Best Hospital on Guam” Services:

o Medical Arts, Fiscal Services & Operations Wing (Design & Construction Cost Est. $25M).

o Professional Support Services Upgrades to include the following capital improvements:

. Radiology Department (A/E Design & Construction Cost Est. $12M);

. Laboratory Department (A/E Design & Construction Cost Est. $10M);

. Special Services Department to include development of a Neurology and Stroke Center (A/E Design & Renovation Cost Est. $8M).

o Medical & Nursing Services Upgrades to include the following capital improvements:

. Operating Room Unit Expansion & Upgrade (A/E Design & Renovation Cost Est. $12M); and

. Telemetry & Pediatric Units Expansion & Upgrade (A/E Design & Construction Cost Est. $10M).

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Doc. No. 33GL-15-0970

o Furnishings, Fixtures & Equipment (FF&E) Package to support this Consolidated “Best Guam Hospital” A/E Design-Build Package (FF&E Package Cost Est. $25M).

o Hospital Expansion Utility Systems Upgrades (A/E Design & Construction Cost Est. $10M in support of New Z-Wing).

Parking Structure Development Project, which is depicted as a “design concept” within GMHA’s Hospital Expansion Feasibility Study completed by Provido • Tan • Jones Architects Inc. in April of 2012 (Design & Construction Cost Est. $10M).

o Note: Pending the availability of funds to complete the Parking Structure Development Project summarized above, the BOT Facilities/CIP/IT Subcommittee recommends that GMHA conduct a “Paid Parking Test” in order to gauge the possibility and potential to allow the Community and GMHA Employees the opportunity to pay for parking in a small portion of the front parking rows/stalls of the Hospital. Individuals would have an opportunity, for example, to buy a one month permit for a predetermined fee that shall be based upon national market research of U.S. Mainland Hospitals. GMHA’s lessons learned from the “Paid Parking Test” can eventually be applied to either additional parking rows/stalls within the existing Parking Lots, as well as applying them to the Parking Structure Development Project once it comes to fruition.

Purpose: GMHA’s Hospital Expansion Feasibility Study confirmed that it is very possible for GMHA to build the “Best Guam Hospital” at its current campus by completing several capital improvement opportunities in a phased manner in such a way that there is minimal disruption to GMHA’s Operations. The intent of this Consolidated “Best Guam Hospital” A/E Design-Build Package is to enable GMHA to provide the above outlined “Best Hospital on Guam” Services in a State-of-the-Art Environment that will generate and earn the pride and respect of the Guam Community.

Project Budget: The total estimated cost to complete the Z-Wing Abatement, Demolition and Consolidated A/E Design-Build Package is ≈ $125,000,000.

Timeline: Approximately three and one half (3.5) years are needed to complete the Project’s various phases to include Abatement, Demolition, A/E Design and Construction without any disruption to GMHA’s Operations. The following projection provides a total project timeline:

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Doc. No. 33GL-15-0970 Design-Build RFP Phase 4 months Contract Award 2 months A/E Design Phase 12 months Construction Phase 24 months

Project #2: Fully Integrated Organization-Wide Information Technology System

Scope of Work: Contract the purchase, installation, implementation and end-user training to implement a fully Integrated Organization-Wide Information Technology System featuring clinical, ancillary and financial applications designed for today’s healthcare environment with the adaptability to accommodate the challenges of the future. The system connects clinicians and administrators with shared patient information and workflow to advance accuracy, efficiency and safety across healthcare settings, departments, locations and other Government of Guam agencies that are critical partners within Guam’s Healthcare System. The Installation Phase shall require migration of existing electronic and hardcopy patient information to the new Information Technology System.

Purpose: The intent of such an Information Technology System solution is to enable GMHA to provide better patient care, enhance patient safety, productivity and profitability while staying current with complex and changing regulatory environment. GMHA’s new Information Technology System will be a unified suite of digital solutions proven to streamline administration, reduce costs and improve patient care and patient safety which shall fully automate and integrate the entire organization’s processes, including order entry, analytic operations, information distribution, billing and business performance management. This new Information Technology System will provide for fully integrated modalities such as electronic medical record, clinical imaging, CPOE, Laboratory, Radiology, Pharmacy, Emergency Department, Perioperative, revenue cycle, general financials, supply chain, materials management, medication history, enterprise content management, document management, maintenance management, medical devices, point of care, mobility, interoperability, quality and performance improvement, reporting and outcomes, workforce management, JC compliance, CMS compliance and HIPAA compliance. Some of the System’s features and benefits shall include:

Must be CCHIT Certified; Provide real-time access to patient results and clinical information across care disciplines; Enable healthcare organization(s) to meet The Joint Commission requirements for patient confidentiality;

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Doc. No. 33GL-15-0970 Access patient information securely from wherever and whenever it is most convenient for the care team; Improve patient care as clinicians can focus on the patient’s overall health and not just the encounter; Increase efficiency by placing real-time, updated information with the care team in time to make fast and effective decisions; Increase access to information from multiple venues in the health system; Single registration screen across hospital, practice and clinic; Centralized billing across enterprise from one location in the system; Ability to schedule lab and radiology orders from a physician practice or clinic to a hospital; Single patient record for registering and billing patients; Enterprise scheduling across acute-care and ambulatory settings; Patient education; Health maintenance support; Reduce maintenance overhead managing disparate systems; Provide an improved user experience as module is built in Paragon, reduce potential user training time; Reduce the cost and hassle associated with paper/faxed lab and radiology results between the physician practice and the hospital; Improve physician and provider workflow; Save time by reducing the need to rekey data from the hospital or clinic; Advanced lab-pharmacy-clinical integration; Management Reporting of workflow and results timeliness, productivity reports, and physician ordering summaries; Quality Controls for entries, acknowledgements, results, and out-of- range controls; Patient Access; Case Management; Health Information Management; Patient Accounting; Ensuring Documentation Integrity; Automating Discharge Planning; Real-time edits, medical necessity, references and look-up embedded in the application screens; Clinically and financially driven workflow; Seamless integration to physician’s message center; Single patient record in clinic and hospital venues; Schedule, collect payment and check balances on a single screen; and Must be certified ready to meet Meaningful Use Stage 1 and Stage 2 and beyond.

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Doc. No. 33GL-15-0970 Project Budget: The total estimated cost to complete the Information Technology System Procurement, Installation and End-User Training is ≈ $20,000,000.

Timeline: Two (2) years are needed to complete the System’s Procurement, Installation, Implementation, and Interface Phases to include End-User Training, Testing and Go-Live. The following projection provides a total project timeline:

ITS Procurement 4 months ITS Installation and Data Migration 4 months Technical Staff Training 4 months End-User Training 4 months Systems and Applications Testing 4 months Phased Go-Lives 4 months

Project #3: Hospital Roof Systems/Rainwater Runoffs/Facility Paint Project

Scope of Work: Contract the professional A/E Design and Construction Services required in completing GMHA’s Hospital Roof Systems, Rainwater Runoffs & Facility Paint Upgrade Project. This project shall involve upgrading all of GMHA’s roof systems and rainwater runoffs prior to repainting the Hospital exterior at all wings except for the Z-Wing, which will be completed as reflected in Project #1 of this document.

Purpose: GMHA’s Hospital Expansion Feasibility Study, completed by Provido • Tan • Jones Architects Inc. in April of 2012, indicated the following about GMHA’s hospital roof and underside of roof slab systems and rainwater runoffs that will be helpful relative towards planning for the required Project Scope of Work to include appropriate A/E Design Features and Mitigation Measures needed to ensure GMHA receives a long term solution to this existing opportunity for improvement:

The built-up roofing system at A, B, E-Wing appeared to be in a poor and severely worn-down state. It consisted of 24” x 24” built-up rigid roof insulation boards coated with a roof coating. Widespread failures and cracks in the dark, severely worn down, and highly mildewed roof coating could be found. The joints between rigid insulation boards had separated. Vegetation could be seen in various locations. The rigid roof insulation tapered to low points at various locations on the roof. At those low points, roof drains were located. Some roof drains appeared to be clogged with debris. Many roof drains had missing strainer covers which would allow debris to clog the downspout lines inside the building. If left unchecked, these conditions would encourage prolonged moisture presence and deterioration under the insulation boards and the concrete roof substrate below.

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Doc. No. 33GL-15-0970 The roof conditions below the rigid roof insulation were concealed and could not be verified. This unknown condition should be field-verified before performing any repair work. Invasive removal of roof insulation boards and review of the top side of the roof slab would be highly recommended to verify that spalling had not occurred on that concealed top side.

A possible recommendation for a long term solution would be to remove the insulation/top coat in its entirety to expose and verify the concealed concrete substrate conditions, and to repair and replace it with a new built-up insulated roof system with a durable protective concrete topping and a roof coating. The slope to the roof drain could be made steeper to promote drainage flow and mitigate ponding.

The underside of concrete roof slab at A and B Wing appeared to be in a much better condition than anticipated. Viewed from the ceiling space below, the underside of the roof slabs looked like new. There appeared to be dry with no signs of roof cracks or moisture penetration. These were surprising considering the severely deteriorated roof conditions above at A, B, and E-Wing. Exactly why moisture had not penetrated the roof slabs would remain a mystery, and could be due to a variety of reasons. Invasive removal of roof insulation boards and a review of the top side of the roof slab would be highly recommended to verify that spalling had not occurred on that concealed top side.

At the roof of 2nd floor B-Wing (over the housekeeping/ surgery hallways), the elastomeric roof coating membrane around roof drains was exposed to prolonged ponding, and had failed. The membrane had been punctured. The concrete roof slab was exposed to water and moisture related problems. Viewed from the ceiling below, the bottom of the roof slab appeared to be in an unexpected dry condition. However, if left unchecked, this ponding would lead to eventual moisture seepage through the slab and long term deterioration.

Some abandoned roof openings capped with either dry-rotted plywood boards or rusting sheet metal covers could also be seen. If left unchecked, these abandoned units and roof openings would deteriorate further and potentially allow water leakage. During a typhoon, they could fail and allow winds and large volumes of water into the building, or become flying debris. The abandoned units needed to be disposed. The abandoned roof openings should be covered and sealed with appropriate materials suited for the local humid and high wind environment.

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Doc. No. 33GL-15-0970 At the roof of C-Wing, the roof slab had an elastomeric coating and appeared to be in good condition with normal wear and tear. The roof drains were located at low points. Limited ponding is found around the roof drains. Some missing roof drain strainers had to be replaced. At C-Wing, the insulation in the form of blanket type batt insulation was located below the slab. The blanket type batt insulation had been disturbed, and some had fallen out of place, or were missing. To mitigate potential condensation problems below the roof slab, the batt insulation should be maintained properly and kept in place.

At D-Wing, the roof coating appeared to be in average condition. However its future condition would not be known as it was being used as a staging area for construction materials for the A-Wing wall hardening project. From the underside of D-Wing steel supported concrete slab, water leaks located below the roof expansion joint were reported. There, the damaged and falling gypsum wallboard would need to be replaced. Although the origins of the leak at the roof were not located due to the construction materials, the roof expansion joint assembly was suspected.

At the roof of Generator, P, S, G-Wing, the roof slab was covered with an elastomeric roof coating. As these buildings were naturally ventilated and have no air-conditioning, the roofs were not insulated. The roof slab appeared to be in good condition with normal wear and tear conditions, except for the following:

o At Generator Wing, roof ponding could be seen. The ponding could be due to lack of proper drainage slope to roof drains or clogged roof drains. If this ponding became prolonged, the standing water could damage the roof membrane, leading to potential long term problems. Monitoring and subsequent preventive measures could be needed.

o At P-Wing, an abandoned roof opening had been covered with metal decking and plastic sheet appeared to be leaking and would need repair. Appropriate measures would be needed to address the potential deterioration of the metal cover. The turnbuckles of tie- downs for the steam stack showed signs of severe rust. At underside of P-Wing roof slab, a small concrete spall was found and could be an isolated incident.

o At the roof of S and P-Wing, multiple cracks were found at the inverted roof beams. If left unchecked, these cracks could expose the rebars to moisture, rust and related spalling.

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Doc. No. 33GL-15-0970 o At the lower roof G-Wing, the backup air-cooled chiller and its steel supports showed sign of prolonged rust and severe deterioration. During typhoons, these units could pose a severe threat as flying debris. These mechanical units would need to be maintained or replaced. If abandoned, they needed to be disposed.

o At G-Wing, the majority of the recent second floor roof appeared to be in a good condition with minimal wear and tear. However, at the roof of the second floor chiller pump room, (next to the roof backup chiller) the concrete roof slab is bare and exposed. It would need a roof coating.

To mitigate long term problems associated with runoff of rainwater at the exterior walls, proper design and maintenance of rainwater runoff systems should encourage the flow of rainwater away from the exterior walls. With proper roof protective coatings, adequate roof slopes to prevent roof ponding, the locations of roof drain at the low points of roofs/balconies, and the use of strainers and overflow drains to prevent clogging, this design measure could prevent long term deterioration of building exterior walls. Together with a proper maintenance program, this could prolong or enhance the lifespan of the building.

Project Budget: The total estimated cost to complete the Hospital Roof Systems, Rainwater Runoffs & Facility Paint Upgrade Project is ≈ $5,000,000.

Timeline: Approximately two (2) years are needed to complete the Project’s various phases to include A/E Design and Construction Services. The following projection provides a total project timeline: A/E Design RFP Phase 4 months Contract Award 2 months A/E Design Phase 6 months IFB Construction Phase 4 months Contract Award 2 months Construction Phase 6 months

 Total Cost Est. for Projects #1, #2 & #3 is ≈ $150M. 

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Doc. No. 33GL-15-0970

Doc. No. 33GL-15-0970 ATTENDANCE Board Members: Hospital Leadership: Minutes of the regular meeting of the Lee P. Webber Theodore Lewis Frances Mantanona Zennia Pecina, RN Guam Memorial Hospital Authority (GMHA) Edna Santos, MD Benita Manglona Rose Grino, RN Dr. Florencio Lizama Board of Trustees Ricardo Terlaje, MD Dr. Hoa Nguyen Valentino Perez Joygemma Villaruel, RN June Perez July 30, 2015 | 6:00 p.m. Evelyna Akimoto – Excused Guest(s): D.L. Webb Conference Room Jonathan Kriegel – Docomo Pacific Marilyn Borja – Docomo Pacific I. CALL TO ORDER AND DETERMINATION OF QUORUM – After notices were duly and timely issued pursuant to Title 5 Guam Code Annotated, Chapter 8 Open Government Law, Section 8107(a) and with a quorum present, Chairman Lee Webber called to order the regular meeting of the GMHA Board of Trustees at 6:12 PM on Thursday, July 30, 2015 in the D. L. Webb Conference Room of the GMHA located in Tamuning, Guam. RESPONSIBLE REPORTING ISSUE/TOPIC/DISCUSSIONS DECISION(S)/ACTION(S) STATUS PARTY TIMEFRAME II. MEDICAL STAFF PRESIDENT’S REPORT Dr. Nguyen reported that the Medical Executive The MEC will be sending a letter to the Guam Dr. Nguyen Updates to be Informational Committee remained concerned about Dr. Board of Medical Examiners to address the provided at the Friedman’s practice of referring his patients to GMH matter. next regular for a procedure that he is unable to perform. He meeting stated that both the pediatricians and internists at A letter will also be written to the GMH were uncomfortable performing this particular Commonwealth Healthcare Corporation in procedure whenever a patient presented at GMH. Saipan notifying them that Dr. Friedman is not able perform this particular procedure and to reconsider referring their patients to him, because of his practice. III. EXECUTIVE SESSION – At the written request of Legal Counsel, Chairman Webber called the meeting into Executive Session. Trustee Santos motioned and it was seconded by Trustee Perez to move to Executive Session. Motion carried with all ayes.  The minutes of the Executive Session are confidential and kept under separate cover in accordance with Title 5 Guam Code Annotated, Chapter 8 Open Government Law, Section 8111(c)(7). IV. APPROVAL OF REGULAR SESSION MINUTES – The minutes of the May 28, 2015 regular meeting were reviewed. Trustee Perez motioned and it was seconded by Trustee Grino to approve the minutes as printed. Motion carried with all ayes. V. BOARD SUB-COMMITTEE REPORTS A. Human Resources Sub-committee 1. Trustee Mantanona presented Board Res. Trustee Grino motioned and it was seconded Trustees Updates to be Informational 15-61 relative to commending Dr. Michael by Trustee Perez to approve this resolution as Mantanona and provided at Robinson for his dedication and commitment printed. Motion carried with all ayes. Grino each meeting to GMHA.

Dr. Robinson was invited to the meeting and The Board and all who were present provided brief remarks before his departure. applauded him for his services during his tenure at the hospital.

Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 1 of 7

Doc. No. 33GL-15-0970 2. Trustee Mantanona reported that the Search The search committee will meet on August 20, Search Committee continued recruiting for the 2015 to review the applications received. Committee hospital administrator/CEO position and that Members four applications were received.

3. Trustee Mantanona reported that Jason Boyd This position will be removed from the list of was hired permanently as Chief Pharmacist critical positions. which was a position he had been detailed to for a period of time.

4. Dr. Santos suggested for the Medical Dr. Nguyen would bring this matter to the Dr. Nguyen Executive Committee to prepare an action MEC for action. commending doctors Walter Chris Perez and Debra Ericson similar to the resolution for Dr. Robinson.(HR item #1) B. Joint Conference and Professional Affairs Trustees Reports to be Informational Sub-committee (JCPA) Webber and provided at Dr. Lizama presented the following resolutions Santos each meeting relative to appointments/reappointments for hospital privileges: Medical Director 1. Res. No. 15-62, Relative to the Trustee Grino motioned and it was seconded Reappointment of Active Medical Staff by Trustee Perez to approve this resolution as Medical Staff Privileges (exp. 06/30/17) for: presented. Motion carried with all ayes. Office  Insaf Ally, MD

Dr. Ally was placed on Focused Professional Practice Evaluation (FPPE) to address concerns reported against him. The details of the reports were not provided for confidentiality purposes.

2. Res. No. 15-63, Relative to the Appointment Trustee Mantanona motioned and it was of Provisional Medical Staff Privileges (exp. seconded by Trustee Santos to approve this 06/30/16) for: resolution as presented. Motion carried with  Clarissa Hammer, DO all ayes.  Theodore Mayer, MD  Ben Thebaut, MD  Jeffrey Shay, MD  Eric Wong, MD C. Facilities, Capital Improvement, and Reports to be Deferred Information Technology Sub-committee provided at The sub-committee did not meet during the No decisions or actions taken. each meeting month of July 2015. Meetings would be scheduled on an as needed or quarterly basis. Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 2 of 7

Doc. No. 33GL-15-0970 D. Governance, Bylaws and Strategic Planning Trustee Terlaje Reports to be Deferred Sub-committee provided at The sub-committee did not meet during the Note: The Board of Trustees bylaws will be Theo each meeting month of July 2015. Meetings would be forwarded to legal counsel for review. Pangelinan scheduled on an as needed or quarterly basis E. Quality and Safety Subcommittee Trustees Santos Reports to be Informational  Trustee Santos reported that the Hospital and Grino provided at maintained its accreditation status; however, each meeting it had to successfully address requirements for improvement for 7 Evidence of Standards Compliance within 45 days.

Excessive overtime, waiting time in the As for excessive overtime, management will emergency department, titration for a certain assess the needs on a daily basis and would medication, medical record documentation, request for volunteers to work the additional and inconsistencies with policies and hours instead of pre-scheduling them. protocols were among the surveyors’ observations.

 Trustee Santos reported that the sub- committee had discussed applying for deemed status with the Joint Commission.

However, it was agreed that the hospital was not financially and resourcefully prepared.

 Trustee Santos reported that the CAP accreditation for the laboratory was a standing agenda item for the sub-committee. A representative from the lab was requested to attend future meetings until all the citations are resolved.

Mr. Lewis stated that the hospital responded to the last correspondence from CAP, requesting for additional documentation, and awaited their response.

 Trustee Santos reported that departments continued to perform fairly well with their PI activities. Some areas for improvement included: visitation policies in pediatrics, infection control practices in NICU when there is a shortage of supplies, securing Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 3 of 7

Doc. No. 33GL-15-0970 signatures for MD time study, and employees wearing their badges.

 Trustee Santos reported that the hospital had As per Mr. Lewis, management was in the been without a Patient Safety Officer for the process of recruiting a Patient Safety Officer. past several months. She stated that the Patient Safety Committee had not met since then to address patient safety matters and to collect and analyze data.

 Dr. Santos reported that by January 2016 the As requested by Trustee Santos, Mr. Lewis Mr. Lewis hospital would be required to fully implement would prepare a letter to all medical its electronic health records as required by departments requesting for them to develop CMS. order sets which would be inputted into the system. A thorough discussion took place regarding the current status and what remained to be done order to comply with CMS requirements.

Ms. Pecina commented that the process was very tedious and required every department within the hospital to build modules. She expressed that the current systems being utilized were not integrated and was one reason nurses struggled to comply with documentation requirements. F. Finance and Audit Sub-committee Trustee Grino Reports to be Informational 1. Trustee Grino reported that the hospital provided at awaited a decision from CMS relative to the Trustee each meeting hospital’s request to rebase its TEFRA Mantanona reimbursements.

Mrs. Manglona informed the Board of other efforts being made to improve the hospital’s finances, including, working with the Department of Public Health and Social Services to revise the Medicaid State Plan and requesting for legislation to adjust all fees that fall below Medicare cost to at least Medicare cost.

2. April 2015 Financials This item was deferred to the Chief Financial Officer’s report. Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 4 of 7

Doc. No. 33GL-15-0970 VI. ADMINISTRATORS’ REPORTS A. Hospital Administrator/CEO’s Report  Mr. Lewis reported that the condition of the To ensure the safety of staff and visitors, Theodore Lewis Reports to be Informational Z-wing was unsafe for occupancy and that departments within the Z-wing will be provided at there were future plans to demolish the relocated to other areas within the main each meeting building. facility and SNU.

 Mr. Lewis distributed a proposed draft for the renovation of the C-wing (admin/ops offices). The renovation would create a medical staff lounge and conference room in the administration office. He awaited a cost proposal from the contractor.

 Mr. Lewis reported that the MCH renovation project was moving forward.

He also mentioned that the operating room and radiology were other major renovations to look forward to, because they were the biggest of competitors with Guam Regional Medical City.

 Mr. Lewis distributed copies of Part II Nursing of the cooperative agreement (Draft I, as of 06/30/15) between GMHA and the Department of Corrections (DOC) for the Board’s review.

He reported that the agreement was developed in collaboration with DOC and the Office of Attorney General. B. Associate Admin. of Medical Services’ Report Dr. Lizama Reports to be Informational Dr. Lizama reported that he was in the process of No decisions or actions taken. provided at evaluating physician compensation. each meeting C. Chief Financial Officer’s Report Mrs. Manglona Reports to be Informational 1. A draft of the June 2015 financials was Mrs. Manglona answered clarifications from provided at distributed for the Board’s review. the Board. each meeting

Mrs. Manglona reported that she had compared the hospital’s current payables to 5 years ago. She noted that in September 2014, payables were slightly lower due to

Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 5 of 7

Doc. No. 33GL-15-0970 proceeds from a $25M loan used to pay vendors. Overall, payables over the years averaged $18M.

She considered working with vendors to discuss outstanding balances and negotiating interest charges assessed.

2. Mr. Perez followed-up on an executive summary of the financials, which he had requested from the CEO to be provided (moving forward) at the May 28, 2015 Board meeting.

An executive summary of the financials was not available.

3. Mrs. Manglona reported that NTT conducted No decisions or actions taken. a conversion of the hospital’s general ledger in June 2015. VII. OLD BUSINESS A. Res. 15-64, Relative to honoring the GMHVA Trustee Grino motioned and it was seconded Board of None Closed for their hard work, dedication, and by Trustee Santos to approve the resolution Trustees contributions to GMHA as presented. Motion carried with all ayes. VIII. NEW BUSINESS Mr. Lewis invited Mr. Jonathan Kriegel and Ms. The Board thanked Docomo Pacific for the None None None Marilyn Borja to speak on the partnership he opportunity to develop the partnership. developed with Docomo Pacific to provide wireless capability at the hospital.

Mr. Kriegel briefly explained Docomo Pacific’s island-wide vision to provide wireless capabilities for the community and tourists.

He stated that installation at the hospital would benefit patients and visitors by providing them a means of communicating with loved ones afar.

He stated that a total of the 48 access points were available throughout the hospital with the exception of restricted areas.

Ms. Borja expressed the company’s gratitude for the

Minutes of the Board of Trustees Regular Meeting Thursday, July 30, 2015 Page 6 of 7

Doc. No. 33GL-15-0970

Doc. No. 33GL-15-0970 Guam Memorial Hospital Authority Performance Improvement Dashboard - Divisions Month 2

CORE DEPT. INDICATORS / MEASURES GOAL CY2014 1Q 2Q 3Q 4Q VALUES 2015 NURSING SERVICES DIVISION - Specialty Units - APRIL-MAY-JUNE 2015 Q HEMO, ER Pain Management 90% 94% 94% 86% 90% Q Weight Monitoring 93% 93% 98% 97% 98% A, Q HEMO Infection Control Monitoring Tool 95% 100% 100% 100% 100% A, Q Disinfection Monitoring 98% 100% 100% 100% 100% A, Q Surgical Site Infection SURVEY RESPONSE 95% 96% 100% ND 100% A, S Surgical Site Infection - Cases WITHOUT Infection 95% new for CY2015 99% ND 99% OR A, S Intra-Operative Counts 100% 100% 100% 100% 100% A, S Nitrous Oxide Monitoring 95% 100% 100% 100% 100% A, S ER Annex Crashcart Checklist 90% 79% 100% 100% 100% ER S Suicide Risk Management 90% 92% 84% 89% 87% Smoking Cessation Counseling (overall) 85% 73% 97% 94% 96% A, Q PATIENT EDUCATION GMHA Patient Education Teaching (overall) 93% 96% 96% 97% 97% SNU Patient Education Teaching (overall) 98% 100% 100% 100% 100% FISCAL SERVICES DIVISION - APRIL-MAY-JUNE 2015 Claims Final Billed (Current and Prior month Billed out of Current ??? new for CY2015 89% 73% 81% and Prior month Claims Received) Denial Management (total # of denials/returns due to ??? new for CY2015 232 622 854 wrong/missing codes or not meeting filing dates) PATIENT AFFAIRS Post-Payment Denial Report (total # reviewed and total # 226 - reviewed 109 - reviewed A, C ??? new for CY2015 #DIV/0! (BUSINESS OFFICE) received) 238 - received 183 - received Accounts Receivables - Self Pay (# of statements generated and 30,248 and 23,457 and ??? new for CY2015 #DIV/0! # of statements NOT mailed due to errors) 1,942 1,962 Accounts Receivables - Insurance/Others (total # of payments ??? new for CY2015 59 61 120 posted received in 7 days and received by remittance) OPERATIONS DIVISION - APRIL-MAY-JUNE 2015 Weekly Testing of Emergency Generators 90% 94% 100% 100% 100% A, S FACILITIES MAINTENANCE Equipment with Completed Preventative Maintenance 90% 72% 79% 100% 90% Utilities with Completed Preventative Maintenance 90% 91% 97% 96% 97% Bi-Weekly Inspection Submission 90% 92% 89% 93% 91% A, S SAFETY Respiratory Protection Program (% of fit-tested employees - 90% new for CY2015 62% 72% 72% cumulative tracking) TAT Regular Discharge Room (cleaned & released ≤ 30 mins) 90% new for CY2015 82% 87% 85%

TAT Isolation Discharge Room (cleaned & released ≤ 45-60 mins) 90% new for CY2015 49% 67% 58% ENVIRONMENTAL A, C, E SERVICES TAT Tele-PCU Transfer Room (cleaned & released ≤ 15-20 mins) 90% new for CY2015 79% 86% 83% Public Restrooms Monitoring Checklists PASSED 90% new for CY2015 100% 97% 99% Housekeeping Staff Hand Hygiene Compliance 90% new for CY2015 85% 90% 88%

Doc. No. 33GL-15-0970 CORE DEPT. INDICATORS / MEASURES GOAL CY2014 1Q 2Q 3Q 4Q VALUES 2015 PRO-SUPPORT DIVISION - APRIL-MAY-JUNE 2015 Missing Medications from Patient Cassettes < 0.5% 0.51% 0.60% 0.60% 0.60% A, C, S PHARMACY Medication Errors per 100 dispensed medications < 0.5 0.06 0.06 0.07 0.07 Drug Interventions < 0.2% 0.13% 0.24% 0.24% 0.24% Patient/Family Education on FDI 90% 90% 92% 98% 95% A, E, S, Q DIETARY Enteral Feedings NOT held inappropriately 90% 88% 90% 88% 89% Infection Control - Sanitation 90% 96% 97% 96% 97% A, S, Q Transcription Report Turn Around Time (within 24 hours) 90% 83% 97% 99% 98%

A, E, S, Q Patient/Family Education on Central Line Insertion 90% 94% 95% 97% 96% RADIOLOGY Infection Control Central Line Checklist 90% 93% 97% 95% 96% A, S Radiation Safety - Staff Dosimeters within acceptable limits 90% 100% 100% 100% 100% Radiation Exposures - Pregnant Patients 0 exposures 1 0 0 0 MEDICAL SERVICES DIVISION - APRIL-MAY-JUNE 2015 A Medical Staff Scheduled Meetings held as scheduled 90% 92% 81% 93% 87% Physicians trained on iMed 70% 73% 70% 93% 93% Monitoring - Completion of FPPE for New Applicants (less 90% 82% 77% 86% 82% than 3 months timeframe) Monitoring - Completion of FPPE for New Applicants (greater MEDICAL STAFF OFFICE 90% 67% n/a 80% 80% A, S, Q than 3 months timeframe) Monitoring - Completion of FPPE for New Privileges 90% N/A n/a n/a #DIV/0! Monitoring - Completion of FPPE for Quality Concerns 90% 50% 0% 0% 0% Monitoring - OPPE Response submissions 90% 33% 100% n/a 100% Appropriateness of Admission - Medicare, Medicaid, MIP & Self- 90% 99% 99% ND 99% pay (based on Interqual Guidelines) Timeliness of Consults - seen within 24 hours 90% 98% 96% ND 96% A,C,E,S,Q UTILIZATION REVIEW Timeliness of Procedures - completed as scheduled 90% 99% 94% ND 94% Level of Care Appropriateness 90% 97% 100% ND 100% TAT for UR Worksheets (submission to Patient Affairs) ??? new for CY2015 ND ND Barriers to Discharge/Transfer to SNU ??? new for CY2015 ND ND #DIV/0! SKILLED NURSING UNIT - PLEASE SEE ATTACHED DASHBOARD EEO-EXIT INTERVIEW REPORT (January through June 2015) - PLEASE SEE ATTACHED  based on 1Q & 2Q data only (3Q & 4Q not submitted)  based on 1Q data only (no data for other quarters)  based on 1Q, 2Q & partial 3Q data only (remaining CY data not submitted) lacks June data

Doc. No. 33GL-15-0970 Guam Memorial Hospital Authority Aturidåt Espetåt Mimuriåt Guåhan 850 Governor Carlos G. Camacho Road Tamuning, Guam 96911 P: (671)647-2104/2367 F: (671)649-0145

Guam Memorial Hospital Authority (GMHA) Board of Trustees Meeting

MEDIA ADVISORY: FOR IMMEDIATE RELEASE DATE: September 19, 2015 CONTACT: Theo M. Pangelinan Administrative Assistant (P) 647-2104

In accordance with Public Law 24-109, relative to notice of meetings, and in addition to the published notice in the Pacific Daily News on September 17, 2015, this serves as public notice for the regular meeting of the GMHA Board of Trustees.

Date: Thursday, September 24, 2015 Time: 6:00 p.m. Place: GMHA – Daniel L. Webb Conference Room 1st Floor, “C” Wing

Persons requiring special accommodations, auxiliary aids, or services may contact Toni Tenorio, EEO Officer/ADA Coordinator at 647-2218/2418.

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Doc. No. 33GL-15-0970

Doc. No. 33GL-15-0970 GUAM SKILLED NURSING UNIT MEMORIAL HOSPITAL DASHBOARD AUTHORITY CY 2015 - 2nd Quarter Apr May June 2015 REPORT DATE: August 17, 2015

Note: Operational Definitions can be viewed in the trending sheet.

TARGET KEYS: Better than Expected Expected Needs More Work Worse Than Expected

TARGET TARGET PERFORMANCE MEASURES KEYS GOAL 1Q 2Q 3Q 4Q COMMENTS >95 >85 RESIDENT'S PRIVACY >75

<75 >85% 95% 93% 100 PRESSURE ULCER >90 MANAGEMENT >80 <80 >90% 99% 96% 100 We averaged 72% on our fall compliance rate this quarter which is an >90 improvement from last quarter's 57%. The whole hospital is reevaluating the fall FALL PREVENTION >80 policy and even establsihed a fall team hospital wide. Problem includes the failure of the nurses to have a consistent environmental checklist and fall <80 >90% 57% 72% assesments. >90 MEDICAL RECORDS (2014 CMS >80 CITATION) >70 <70 >80% 68% 89% 100 >90 PAIN MANAGEMENT >80 <80 >90% 95% 96% 100 >90 ADMISSION DOCUMENTATION >80 <80 >90% 96% 98%

Doc. No. 33GL-15-0970 TARGET KEYS: Better than Expected Expected Needs More Work Worse Than Expected

TARGET TARGET PERFORMANCE MEASURES KEYS GOAL 1Q 2Q 3Q 4Q COMMENTS >95 We are striving to satisfy our custumer needs especially on timely answering of CALL LIGHT RESPONSE TIME >90 call lights and its functionality. We are trying to pilot a program to start a partner AND CALL LIGHT >80 approach among CNAs and license nurses to improve call light response time. FUNCTIONALITY <80 >85% 87% 80% We also improved our CNA staffing in all 3 shifts. >90 Care plan formulation specifically making it interdisciplinary and indiviualize has >80 been challenging for nurses despite numerous trainings given to them. With the INTERDISCIPLINARY CARE PLAN >70 new optimum being established we are working closely with the iMED team to - NURSING change the care plan formulation to make it more user friendly. Unit Supervisor has assigned a staff to conduct weekly audits on care plans especially on <70 >80% 65% 76% individualize care plans. 100 >95 MEDICATION STORAGE >85 <85 >95% 95% 96% 100 EXPIRED AND RESIDENT OWN >90 MEDICATIONS (2014 CMS >80 CITATION) <80 >90% 100% 100% >95 This is a CMS citation. For better compliance, all NSS and Dakin solutions are PROPER DATING AND LABELING >85 being provided now in 500cc bottles. Consistent reminders were also given to (2014 CMS CITATION) >75 the nurses for proper labeling and dating of solution to prevent cross <75 >85% 63% 69% contamination. >90 >80 BOWEL MOVEMENT PROTOCOL >70 <70 >80% 98% 96% >90 INDEPENDENT URINARY >80 ELIMINATION >70 <70 >80% 92% 98% >90 INFECTION CONTROL - CROSS >85 CONTAMINATION (WOUND >70 CARE) <70 >85% 92% 93% >90 CONTACT ISOLATION AND >85 FAMILY COMPLIANCE >70 <70 >80% 96% 94%

Doc. No. 33GL-15-0970 TARGET KEYS: Better than Expected Expected Needs More Work Worse Than Expected

TARGET TARGET PERFORMANCE MEASURES KEYS GOAL 1Q 2Q 3Q 4Q COMMENTS >95 >90 HAND HYGIENE >80 <80 >90% 100% 99% >90 The assigned person to monitor this PI had April and May months specifically >80 PATIENT OUTCOMES - PATIENT targeted for dates only on the 1st and 15th without looking at the three days >70 WEIGHT grace period, thus indicating it as non-compliant. Unit Supervisor personally did a review observation with the assigned person for the month of June and the <70 >80% 88% 72% compliance was 100%. >90 EMERGENCY FOOD AND WATER >80 SUPPLY (2014 CMS CITATION) >70 <70 >80% 78% 83% >90 INTERDISCIPLINARY CARE PLAN >80 Communication error of assigned areas of care plans for rotating staff and part- - DIETARY >70 time Dietary Tech. <70 >80% 77% 78% >90 KITCHEN SANITATION - REVISED >80 (2014 CMS CITATION) >70 <70 >80% 96% 99% >90 INTERDISCIPLINARY CARE PLAN >80 - REHAB SERVICES >70 <70 >80% 88% 85% >90 SNU Social Workers researched the audit findings and results show that in the INTERDISCIPLINARY CARE PLAN >80 month of April #187461 was admitted for only four days and #2113025 pt. - SOCIAL SERVICES >70 expired within seven work days. For the month of May, #2014200 pt. was <70 >80% 63% 78% admitted on 05/27/15, assessment was done on 06/04/15 within 7 work days. >90 MOOD AND BEHAVIOR CARE >80 PLAN (2014 CMS CITATION) >70 <70 >80% 96% 100% NON-PHARMACOLOGICAL >90 COMPLIANCE - REVISED >80 PSYCHOTROPIC DRUG USE >70 (2014 CMS CITATION) <70 >80% 100% 91%

Doc. No. 33GL-15-0970 TARGET KEYS: Better than Expected Expected Needs More Work Worse Than Expected

TARGET TARGET PERFORMANCE MEASURES KEYS GOAL 1Q 2Q 3Q 4Q COMMENTS >90 >80 PHARMACY REVIEW >70 <70 >80% 93% 100% <10 This includes all medication not renewed on time, medication that's not verified NON ACCOUNTED MEDICATION <20 after faxing, and medication not filled in time after renewing. There is missed (MISSING MEDICATION) <30 medication on this quarter caused by non-accounted medication. We need to >30 < 10% 29% 28% work more on our system for better accountablity of prescribed medication. >90 >80 CLEANING AND DISINFECTING >70 <70 >80% 92% 90% ENVIRONMENTAL ROUNDS (Leak >90 Free, Courtyard/Exterior Window >80 Algae Free, Courtyard Animal Free, >70 Courtyard Oder Free) <70 >80% 88% 80% 100 PATIENT IDENTIFIERS-- >95 LABELING SPECIMENS >85 <85 >95% 95% 100% <1.5 <3.5 FALL RATE <5.0 >5.0 <3.5% 2% 1% <5.0 PRESSURE ULCER INCIDENCE <7.0 RATE <10.0 >10.0 <7.0 1% 0% >90 >80 SUICIDE PRECAUTIONS >70 <70 >80% N/A N/A 100 >90 RESTRAINT USE >80 <80 >90% N/A N/A

Doc. No. 33GL-15-0970 TARGET KEYS: Better than Expected Expected Needs More Work Worse Than Expected

TARGET TARGET PERFORMANCE MEASURES KEYS GOAL 1Q 2Q 3Q 4Q COMMENTS 100 >90 FIRE SAFETY-R.A.C.E >80 <80 >90% 100% 100% 100 >90 FIRE SAFETY DRILL >80 <80 >90% 100% 100% VOLUME INDICATORS SECURITY # OF THEFTS 2 0 0 # OF ASSAULTS/HARRASSMENTS 0 0 0 # OF VANDALISMS - 0 0 0 # OF DISTURBANCES/CODE 60s 0 0 0 # OF SMOKING VIOLATORS 0 0 0 # OF ALCOHOL CONSUMPTION VIOLATION 0 0 0 # OF UNSECURED AREAS REPORTED 2 0 0 # OF LOST AND FOUND 0 0 0

# ELOPEMENT RESIDENTS INDICATORS VOLUME 0 0 0

Doc. No. 33GL-15-0970