No. 14-1077 IN THE SUPREME COURT OF TEXAS

In re CHRISTUS Santa Rosa Health System d/b/a CHRISTUS Santa Rosa Hospital – New Braunfels

On Petition for a Writ of Mandamus from Cause No. C-2013-0566C From the 274th Judicial District Court of Comal County, Texas The Honorable Dib Waldrip, presiding

SUPPLEMENTAL RECORD TO RELATOR’S REPLY BRIEF ON THE MERITS

KROGER | BURRUS Edward J. Kroger State Bar No. 11729700 Leah A. Greene State Bar No. 24012729 Meredith Massey State Bar No. 24077190 3100 Weslayan, Suite 300 Houston, Texas 77027 Telephone: 713-961-7952 Facsimile: 713-961-7953 E-mail: [email protected] COUNSEL FOR RELATOR Supplemental Record Index

Tab 1 – Documents

1. Documents Responsive to Real Party’s Requests for Production R. 1:1 2. Objections & Answers to Real Party’s First Interrogatories R. 1:55 3. Excerpts of Deposition of Pamela Holden R. 1:65 4. Excerpts of Deposition of Cassie McKeen R. 1:68 REQUEST FOR PRODUCTION NOs. 1, 6, 7, 8

R. 1:1 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review ADMINISTRATION LEADERSHIP CO-AD-01-01 5/21/10 Mission, Core Values And Vision 5/20/13 CO-AD-01-04 11/30/2012Policy on Policies & Procedures 11/30/15 CO-AD-01-05 12/30/2011Administrative Call Coverage 12/29/14 CO-AD-01-06 9/30/2011Transaction Approval Levels 9/29/14 CO-AD-01-07 10/1/2011Patient Visitation 9/30/14 CO-AD-01-09 3/1/2011Intermediate Sanctions 2/28/14 Event Scheduling(Room scheduling,Catering Room Set- CO-AD-01-11 1/29/2010 Up, Audio-Visual Equipment) 1/28/13 CO-AD-01-14 9/1/2013 Paging- Overhead 8/31/16 CO-AD-01-15 1/31/2012 Meetings Of The Directors 1/30/15 CO-AD-01-16 1/31/2012 Board Of Directors Orientation Program 1/30/15 CO-AD-01-18 5/1/2012 Plan For Provision Of Care And Hospital Services 5/1/15 CO-AD-01-19 6/1/2011 Leadership Values- Based Decisions Making Process 5/31/14 CO-AD-01-20 1/1/2014 Contract Management 12/31/16 CO-AD-01-21 9/28/2009 Sponsorship, Contribution, Donation Guidelines 9/27/12 Governance- Governing Boards And Other Governance CO-AD-01-23 10/15/2010 Principles 10/14/13 CO-AD-01-25 3/1/2012 Emergency Service Diversions Policy 3/1/15 CO-AD-01-26 1/1/2011 In- House Catering 12/31/13 CO-AD-01-27 1/1/2011 Alcohol Service at Catering Events 12/31/13 CO-AD-01-28 10/1/2013 Contract Management Rose 9/30/16 CO-AD-01-29 10/1/2013 Access to Regional Contract Database 9/30/16 CO-AD-01-30 10/1/2013 Entering and Uploading Contract in Contract Database 9/30/16 CO-AD-01-31 10/1/2013 Storage and Security of Contract Documents 9/30/16 BUSINESS OFFICE CO-FM-02-02 9/11/2009 Petty Cash 9/10/12 Approval Of Company-Sponsored And Company Directly CO-FM-02-03 1/1/2008 Paid Credit Cards 12/31/10 CO-FM-05-07 12/1/2010 Chaplain Housing Allowance 11/30/13

R. 1:2 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review FINANCE Reimbursement of Business Expenses to CHRISTUS Santa CO-AD-03-01 10/1/2012 Rosa Health Care Associates 10/1/15 CO-FM-01-01 4/1/2012 Charity Care 4/1/15 Professional Courtesy And Prompt Pay Discounts For CO-FM-01-02 4/1/2012 Health Services 4/1/15 CO-FM-01-03 2/28/2011 Patient Charge Capture And Reconciliation 2/27/14 CO-FM-01-05 11/29/2010 Awarding Construction Projects 11/28/13 CO-FM-01-07 3/31/2011 Cost-Capitalization 3/30/14 ADVOCACY ORGANIZATIONAL DEVELOPMENT AD-01-03 12/30/2011 CSRHS FULL ORG CHART DEC 2011 12/29/14 1 12/30/2011 ORG CHAR - AH 12/29/14 1 12/30/2011 ORG CHART - CH of SA 12/29/14 1 12/30/2011 ORG CHART - MC 12/29/14 1 12/30/2011 ORG CHART - NB 12/29/14 1 12/30/2011 ORG CHART - WH 12/29/14 FUNDRAISING CO-FM-04-02 1/4/2011 Use Of Charitable Gifts 1/3/14 CO-FM-04-03 1/31/2011 Charitable Raffles 1/30/14 PUBLIC AND COMMUNITY RELATIONS STRATEGIC PLANNING ADMITTING ADMINISTRATION CO-FM-06-16 12/1/2011 Red Flag Policy 11/30/14 CASH HANDLING CO-FM-06-04 12/1/2011 ED Collections 11/30/14 CO-FM-06-12 12/1/2011 Cash Management 11/30/14 CO-FM-06-15 12/1/2011 Cash Drawer Policy 11/30/14 REGISTRATION CO-FM-06-01 12/1/2011 Inpatient Requirements 11/30/14 CO-FM-06-02 12/1/2011 Pre-Admission Process 11/30/14 CO-FM-06-05 12/1/2011 Medicare Secondary Payer Questionaire 11/30/14

R. 1:3 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review 1 CO-FM-06-06 12/1/2011 Consent Signatures, Obtaining 11/30/14 1 CO-FM-06-07 12/1/2011 Medical Necessity Standards 11/30/14 1 CO-FM-06-08 12/1/2011 Protected Health Information, Use and Disclosure of 11/30/14 1 CO-FM-06-09 12/1/2011 Confidential Communication, Patient Request for 11/30/14 1 CO-FM-06-10 12/1/2011 Requiest for Restricting or Revoking Consent 11/30/14 1 CO-FM-06-11 12/1/2011 Privacy Practices, Notice of 11/30/14 1 CO-FM-06-13 12/1/2011 Care Givers, Non-Staff 11/30/14 1 CO-FM-06-14 12/1/2011 Room and Board Transfer Process 11/30/14 1 CO-FM-06-17 12/1/2011 Outpatient Registration Process 11/30/14 1 CO-FM-06-18 12/1/2011 Patient Identification 11/30/14 1 CO-FM-06-19 12/1/2011 Downtime Policy 11/30/14 SCHEDULING 1 CO-FM-06-03 12/1/2011 Ancillary Scheduling 11/30/14 CARE MANAGEMENT CASE MANAGEMENT 1 Care Management Plan - Adult 2014 1 CO-CM-01-05 9/1/2013 Code 44, Inpateint Admission Changed to Observation 8/31/16 Clinical Determination of Patient Status and Level of Care 1 CO-CM-01-07 9/1/2013 Guidelines 8/31/16 1 CO-PM-06-12 1/5/2012 Documentaion in Meditech UR Module 1/4/15 1 CO-PM-06-19 1/1/2012 Ordering Durable Medical Equipment 12/31/14 1 CO-PM-06-21 1/1/2012 Documentaion Discharge Plan in Medical Record 12/31/14 Notifying Medicare Beneficiaries of Their Discharge 1 CO-PM-06-26 1/1/2012 Appeal Rights 12/31/14 1 CO-PM-06-27 1/1/2012 Financial Referral 12/31/14 1 CO-PM-06-28 1/1/2012 Denials: Insurance Notification 12/31/14 1 CO-PM-06-29 1/1/2012 Potential Avoidable Day Opportunity 12/31/14 1 CO-PM-06-31 2/1/2012 Multidisciplinary Care & Discharge Planning 1/31/15 1 CO-PM-06-32 1/1/2012 Acute Care Readmissions 12/31/14 1 CO-PM-06-33 1/1/2012 Patient Right to Choice in Community Resources 12/31/14 1 CO-PM-06-35 1/1/2012 Advance Beneficiary Notice of Non-Coverage/ABN 12/31/14

R. 1:4 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review CO-PM-06-41 1/1/2012 Case Management Patient Status Determination Protocol 12/31/14 SOCIAL WORK Emergency Possession of Certain Abandoned CO-PM-06-1A 11/1/2011 Children/Baby Moses Laws 10/31/14 CO-PM-06-02 11/1/2011 Mental Health Commitments 10/31/14 CO-PM-06-05 11/1/2011 Suspected Elderly Abuse/Neglect 10/31/14 CO-PM-06-5A 11/1/2011 Domestic Violence 10/31/14 CO-PM-06-6A 11/1/2011 Physical Child Abuse 10/31/14 CO-PM-06-11 2/1/2012 Guardianship 1/31/15 CO-PM-06-14 1/5/2012 Discharge Transportation 1/4/15 CO-PM-06-15 1/1/2012 Meal Tickets 12/31/14 CO-PM-06-17 1/1/2012 Discharge Planning Skilled Nursing Facility Placement 12/31/14 CO-PM-06-20 1/1/2012 Patient/Family Conference 12/31/14 CO-PM-06-30 1/1/2012 Discharge Planning: Long Term Acute Care Placement 12/31/14 PATIENT INTAKE CENTER CO-PM-06-39 1/1/2012 Patient Intake Center Operations 12/31/14 CO-PM-06-40 1/1/2012 Record-Keeping for Patient Intake Center 12/31/14 CO-PM-06-42 1/1/2012 Patient Intake Center Admit Screening Policy 12/31/14 Transfer from Outlying Hospitals to Medical Center CO-PM-06-47 1/1/2012 Campus 12/31/14 CLINICAL DOCUMENTATION IMPROVEMENT UTILIZATION REVIEW CHRISTUS TRANSPLANT INSTITUTE ADMINISTRATIVE CHECKLISTS Competency Checklist CTI-A-01 3/1/2011 Policy For Transplant Regulatory Compliance 2/28/14 CTI-A-03 3/1/2011 Final Transplant Compatibility Protocol 2/28/14 CTI-A-04 3/1/2011 Documentation And Medical Record Components 2/28/14 CTI-A-05 3/1/2011 Clinical Nutritional Services Protocol 2/28/14 Policy For Quality Assessment and Performance CTI-A-06 11/1/2011 Improvement And Adverse Event Follow Up 10/31/14

R. 1:5 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review Policy For Patient And Living Donor Nutritional CTI-A-07 11/1/2011 Management 10/31/14 CTI-A-09 11/1/2011 CTI Onsite Program Coverage Plan 10/31/14 CTI-A-10 11/1/2011 Organ Procurement Organ Recovery 10/31/14 CTI-A-12 11/1/2011 ABO Compatibility Verification Donor-Recipient 10/31/14 CTI-A-13 11/1/2011 After Hours Accessibility 10/31/14 CTI-A-14 11/1/2011 Standard Operating Procedure Clinical Drug Monitoring 10/31/14 CTI-A-15 3/1/2011 Clinical Transplant Coordinator Competency Testing 2/28/14 CTI-A-16 3/1/2011 Continuity Of Care 2/28/14 CTI-A-18 3/1/2011 Financial Coordinator Core Competencies 2/28/14 CTI-A-19 3/1/2011 Financial Coordinator Flow Process 2/28/14 CTI-A-20 3/1/2011 Fire Protection 2/28/14 CTI-A-22 3/1/2011 Medicare Certification For Active Transplant Programs 2/28/14 CTI-A-23 3/1/2011 Organ Acquisition Billing 2/28/14 CTI-A-24 11/1/2011 Patient Disposition 10/31/14 CTI-A-25 11/1/2011 Patient Family Education 10/31/14 CTI-A-26 11/1/2011 Patient Referral 10/31/14 CTI-A-27 11/1/2011 Patient Selection Committee Meeting 10/31/14 CTI-A-32 11/1/2011 Provision Of Arranged Services 10/31/14 CTI-A-33 3/1/2011 Quality Indicatory Monitoring 2/28/14 CTI-A-35 3/1/2011 Scope Of Patient Family Assessment 2/28/14 Securing Of Medical Records Involved Litigation Or CTI-A-36 3/1/2011 Potential Litigation 2/28/14 CTI-A-37 11/1/2011 Time Study Documentation 10/31/14 CTI-A-38 11/1/2011 Transfer Into - Out Of CTI Transplant Program 10/31/14 CTI-A-39 11/1/2011 Transplant Adminstrative Director 10/31/14 CTI-A-40 11/1/2011 Agreements 10/31/14 CTI-A-41 3/1/2011 Transplant Staff Core Competencies 2/28/14 CTI-A-42 3/1/2011 Signature Policy 2/28/14 CTI-A-43 3/1/2011 Departmental Emergency Preparedness 2/28/14 CTI-A-44 9/1/2011 Transplant Program Disaster Emergency Plan 8/31/14

R. 1:6 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review Transplant Specific Sentinel Event and Significant CTI-A-45 1/1/2012 Adverse Event Reporting 12/31/14 CTI-A-46 6/1/2012 Protection Of Confidentiality Of Deceased Donor Identitiy 6/1/15 CTI-A-47 9/1/2012 Student Residents Guidelines 9/1/15 CLINICAL PRACTICE Renal, Renal Pancreas, and Pancreas Transplant Selection CTI-KP-01 8/1/2012 Criteria 8/1/15 CTI-KP-02 1/1/2012 Renal Pancreas Organ Selection Criteria 12/31/14 CTI-KP-03 12/1/2011 Independent Donor Advocate Team, Policy For 11/30/14 Membership Requirements For Renal And Pancreas CTI-KP-04 1/1/2012 Transplant Selection And Quality Oversight Meeting 12/31/14 Renal Pancreas Transplant Patient Education And CTI-KP-05 1/1/2012 Evaluation Informed Consent, Policy For 12/31/14 CTI-KP-06 1/1/2012 Living Renal Donor Transplant Psychosocial Protocol 12/31/14 CTI-KP-07 1/1/2012 Renal Pancreas Transplant Psychosocial Protocol 12/31/14 CTI-KP-08 1/1/2012 Renal Pancreas Transplant On Call Event Setup 12/31/14 Protocol For Ureteral Stent Removal In Renal And Renal CTI-KP-09 1/1/2012 Pancreas Recipients 12/31/14 CTI-KP-10 12/1/2012 Living Kidney Donor Evaluation and Selection Criteria 12/1/15 CTI-KP-11 12/1/2011 Living Donor Informed Consent 11/30/14 Guidelines For Acute Renal And Renal- Pancreatic CTI-KP-12 7/1/2012 Cellular Rejection 7/1/15 Lymphocyte Depleting Induction + Tacrolimus+Steroids + CTI-KP-13 7/1/2012 Mycophenolate Mofetil (MMF) 7/1/15 CTI-KP-14 7/1/2012 Standard Immunosuppression Guidelines 7/1/15 CTI-KP-15 7/1/2012 Treatment Of Acute Humoral Rejections Guidelines 7/1/15 Guiedlines For Maintenance Immunosuppression Using CTI-KP-16 7/1/2012 Cyclosporine In Renal Transplant Recipients 7/1/15 Guidelines For Initiation And Maintenance Immunosuppression Using Tacrolimus In Renal And Renal- CTI-KP-17 7/1/2012 Pancreas Transplants 7/1/15

R. 1:7 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review Guidelines For Initiation And Maintenance Immunosuppression Using Cellcept In Renal And Renal- CTI-KP-18 7/1/2012 Pancreas Transplants 7/1/15 Guidelines For Initiation And Maintenance Immunosuppression Using Sirolimus In Renal and Renal- CTI-KP-19 7/1/2012 Pancreas Transplants 7/1/15 Guidelines For The Use Of Antithymocyte Globulin As Induction Immunosuppresion And/Or For Treatment Of CTI-KP-20 7/1/2012 Rejection 7/1/15 Guidelines For Routine Infectious Disease Prophylaxis In CTI-KP-22 7/1/2012 Renal and Renal-Pancreas Transplants 7/1/15 Guidelines For Management Of Hypertension Post Renal CTI-KP-23 7/1/2012 and Renal-Pancreas Transplant 7/1/15 Protocol For Health Care Maintenance Post Renal And CTI-KP-26 1/1/2012 Renal-Pancreas Transplant 12/31/14 CTI-KP-27 1/1/2012 Response To Decline In Renal Function 12/31/14 Communication With Dialysis Center And/Or Referring CTI-KP-28 1/1/2012 Physician 12/31/14 CTI-KP-29 7/1/2012 Steroid Elimination Guidelines 7/1/15 CTI-KP-30 1/1/2012 Karnofsky Performance Status Scale 12/31/14 CTI-KP-31 1/1/2012 Management Of The Deceased Donor Transplant List 12/31/14 CTI-KP-32 3/1/2013 Post Transplant Recipient Follow Up 2/29/16 Potential Candidate Evaluation Process Flow (Recipient CTI-KP-33 12/1/2011 And Live Donor) 11/30/14 CTI-KP-34 1/1/2012 PRA (Panel - Reactive Antibody) Monitoring 12/31/14 CTI-KP-35 1/1/2012 Preoperative Education For The Live Donor 12/31/14 CTI-KP-36 1/1/2012 Solid Organ Transplant Criteria Guidelines 12/31/14 CTI-KP-37 9/1/2011 Transplant Body Mass Index Protocol 8/31/14 CTI-KP-38 1/1/2012 Wait List Management Of Transplant Patients 12/31/14 CTI-KP-39 1/1/2012 Expanded Donor Informed Consent 12/31/14 CTI-KP-40 12/15/2011 TIEDI Data Entry and Maintenance 12/14/14 Organ Identification and Verfication Upon Arrival To CTI-KP-41 12/1/2011 Transplant Hospital 11/30/14

R. 1:8 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review CTI-KP-42 12/1/2011 Preoperative Work-Up For Living Kidney Donors 11/30/14 CTI-KP-43 1/1/2012 Bariatric Referral 12/31/14 CTI-KP-44 4/1/2012 Status Changes for Waitlisted Kidney Transplant Patients 4/1/15 CTI-KP-45 4/1/2012 Kidney and Pancreas Evaluation Testing 4/1/15 Evaluation For Tuberculosis Infection In Renal Transplant CTI-KP-46 8/1/2012 Candidates 8/1/15 CTI-KP-47 1/4/2012 Contacting Donor For TEIDI Follow Up 1/3/15 FINANCIAL GUIDELINES CLINICS/COMMUNITY HEALTH SERVICES CHILDREN'S MOBILE CLINIC 1 1 8/1/2009 Vaccine Ordering, Handling, and Storage 7/31/12 1 5 8/1/2009 Pediatric Mobile Clinic Emergency Preparedness Plan 7/31/12 1 CO-CL-01-02 4/1/2013 Emergency Kit 3/31/16 1 CO-CL-01-04 4/1/2013 Nursing Procedure Reference Book 3/31/16 1 CO-CL-01-06 4/1/2013 Immunization Policy 3/31/16 ADULT CLINICS WIC CLINIC CO-CL-03-01 9/1/2012 Informing Associates of Formula in Stock 9/1/15 CO-CL-03-02 9/1/2012 Income Screening As A Certification Requirement 9/1/15 CO-CL-03-03 9/1/2012 Coordination of Program Operations 9/1/15 CO-CL-03-04 9/1/2012 Thinning of Client Records 9/1/15 CO-CL-03-05 4/1/2013 Filing of Client Records 3/31/16 CO-CL-03-06 9/1/2012 Provision of Services to Individuals with Disabilities 9/1/15 Policy For Screening, Documenting and Reporting Child CO-CL-03-07 3/1/2013 Abuse 2/29/16 CO-CL-03-08 9/1/2012 Identification of WIC Applicant 9/1/15 CO-CL-03-09 9/1/2012 Staff Fraud and Abuse Policy 9/1/15 CO-CL-03-10 9/1/2012 Quality Assurance Plan 9/1/15 CO-CL-03-11 9/1/2012 Dual Participant (DP) and Transfer Locks (TR) 9/1/15 CO-CL-03-12 9/1/2012 Physical Presence 9/1/15 CO-CL-03-13 9/1/2012 Referral Agencies Resource Directories 9/1/15

R. 1:9 Most Recent Binder Review Date Due No. Policy No. Date Title Column1 for Review CO-CL-03-14 9/1/2012 LA Orientation Training 9/1/15 Limited English Proficiency (formerly CO-CL-03-15 9/1/2012 Translation/Interpretation Policy) 9/1/15 CO-CL-03-16 9/1/2012 Orientation Training 9/1/15 CO-CL-03-17 9/1/2012 Calibration of Scales 9/1/15 CO-CL-03-18 9/1/2012 Client Grievance 9/1/15 CO-CL-03-19 9/1/2012 Discrimination Complaints 9/1/15 CO-CL-03-20 9/1/2012 Confidentiality Policy 9/1/15 CO-CL-03-21 9/1/2012 Transfer of Participants within Project #89 9/1/15 CO-CL-03-22 9/1/2012 Management of Adverse Outcomes 9/1/15 CO-CL-03-23 9/1/2012 Transporting Client Records 9/1/15 CO-CL-03-24 9/1/2012 Contingency Plan For Certifying Authority Coverage 9/1/15 CO-CL-03-25 9/1/2012 Scheduling Missed Appointments 9/1/15 CO-CL-03-26 9/1/2012 End of Month Procedures 9/1/15 CO-CL-03-27 2/1/2013 Order of WIC Program Records 2/1/16 CO-CL-03-28 9/1/2012 High Risk Referrals 9/1/15 CO-CL-03-29 9/1/2012 Record Retention and Proper Disposal 9/1/15

R. 1:10 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. EMERGENCY PREPAREDNESS CO-EC-04-06 6/1/2013 Emergency Color Codes 5/31/16 ETHICS, RIGHTS, AND RESPONSIBLITIES , PATIENT RIGHTS PATIENTS RIGHTS CO-ET-01-01 3/1/2013 Patient's Rights and Responsibilities 2/29/16 CO-ET-01-02 2/1/2013 Use of Medical Interpreters 2/1/16 CO-ET-01-03 5/1/2013 Patient Complaint/Grievance 4/30/16 CO-PM-01-03 2/1/2012 Human Research Protection Oversight 1/31/15 CO-PM-01-05 6/1/2011 Organ and Tissue Donation 5/31/14 Photographing of Patients for Educational - Performance CO-PM-01-32 4/10/2010 Improvement Purposes 4/9/13 CO-PM-02-01 10/1/2011 Advance Directives 9/30/14 CO-PM-02-02 1/1/2012 Physician - Family Medical Care 12/31/14 CO-PM-02-02- 01 6/9/2010 CSRHS Ethics Committee 6/8/13 CO-PM-02-03 6/9/2010 Do not Resuscitate/Allow Natural Death 6/8/13 CO-PM-02-04 10/1/2011 End of Life Care 9/30/14 CO-PM-02-07 4/1/2012 Withdrawal Of Medical Treatments 4/1/15 ETHICS CO-ET-02-01 11/1/2012 Determination of Brain Death for Adults & Children 11/1/15 CO-ET-02-02 5/1/2013 Misconduct In Science 4/30/16 CO-PM-02-02- 04 1/1/2012 Ethical Considerations For Life Threatening Pg. 12/31/14 CO-PM-02-02- 05 1/1/2012 Direct Sterilization 12/31/14 CO-PM-02-02- 08 1/1/2012 Donation After Cardiac Death 12/31/14 CO-PM-02-02- 09 4/1/2011 Contraceptives 3/31/14

R. 1:11 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. FACILITIES,MAINTENANCE & PLANT OPS HAZARDOUS MATERIALS CO-EC.02.02.01 7/1/2012 Hazardous Materials Management Plan 7/1/15 CO-EC-01-02 1/1/2014 SDS Management 12/31/16 CO-EC-03-8 6/1/2011 Hazardous Spills 5/31/14 CO-EC-03-10 6/1/2011 Pharmaceutical Waste Disposal Management Program 5/31/14 FIRE AND LIFE SAFETY MEDICAL EQUIPMENT 2 0 2/4/2013 EC Compliance Manual 2/4/16 2 1 11/1/2013 Biomedical Engineering Overview 10/31/16 2 800.01 2/22/2013 Medical Equipment Inventory 2/22/16 2 800.02 2/22/2013 Management, Inspection, and Repair of Medical Equipme 2/22/16 2 800.03 2/22/2013 Medical Equipment Selection 2/22/16 2 800.4 1/26/2012 Retirement and Disposal of Medical Equipment 1/25/15 EC-02.04.01 7/1/2012 Medical Equipment Program Management Plan 7/1/15 12/30/02 2 1000 3/1/2010 Table Of Contents 2/28/13 2 1001 3/1/2010 Equipment Management Plan 2/28/13 2 1002 3/1/2010 Medical Equipment Management Program Criteria 2/28/13 2 1003 3/1/2010 Medical Equipment Management Program Inventory 2/28/13 2 1004 3/1/2010 Initial Inspection 2/28/13 2 1005 3/1/2010 Equipment Contract Coverage Additions and Deletions 2/28/13 2 1006 11/2/2011 Device Recalls and Alerts 11/1/14 2 1007 3/1/2010 Safe Medical Devices Act 2/28/13 2 1008 3/1/2010 Record Keeping and Documentation 2/28/13 2 1008a 3/1/2009 End of Month Processing 2/29/12 2 1009 3/1/2010 Service Codes 2/28/13 2 1010 3/1/2010 Clinical Rounds 2/28/13 2 1011 3/1/2010 Unscheduled Work Requests 2/28/13 2 1012 3/1/2010 Scheduled Maintenance 2/28/13 2 1013 3/1/2010 Vendor Service 2/28/13 2 1014 3/1/2009 In-Service Training 2/29/12 2 1014a 3/1/2010 Maintainer Training 2/28/13

R. 1:12 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. 2 1015 3/1/2010 Life Cycle Analysis 2/28/13 2 1016 3/1/2010 Electrical Safety Inspections 2/28/13 2 1016a 3/1/2010 Lock Out Tag Out 2/28/13 2 1017 3/1/2010 General Shop Safety 2/28/13 2 1018 3/1/2009 Equipment Assessment Reports 2/29/12 2 1019 3/1/2010 Quality Assurance and Improvement 2/28/13 2 1020 3/1/2010 Service Manuals, Software and Specialized Test Equipmen 2/28/13 2 1021 3/1/2010 Inspection Labels 2/28/13 2 1022 3/1/2010 Non-Hospital Owned Medical Equipment 2/28/13 2 1023 3/1/2010 Environmental Sweep 2/28/13 2 1024 3/1/2010 Test Equipment 2/28/13 2 1025 3/1/2010 Employee Training Records 2/28/13 UTILITIES MANAGEMENT CO-EC-07-2 1/1/2012 Standard on Hot Water Temperature 12/31/14 CO-EC.02.05.01 7/1/2012 Utility Sytems Management Plan 7/1/15 MAINTENANCE /PLANT OPERATIONS 2 1000 1/1/2012 Mission 12/31/14 2 1001 1/1/2011 Statement of Accountability and Responsibility 12/31/13 2 1002 1/1/2012 Functions 12/31/14 2 1004 1/1/2012 Hours of Service 12/31/14 2 1005 1/1/2012 Staff Meetings 12/31/14 2 1006 1/1/2012 Disaster Plan 12/31/14 2 1006.1 1/1/2012 Department Response To A Disaster (Code Gray) 12/31/14 2 1007 1/1/2012 Blue Prints 12/31/14 2 1008 1/1/2012 Fire Plan 12/31/14 2 1009 1/1/2012 Fire Watch 12/31/14 2 1010 1/1/2012 Access Key Control 12/31/14 2 2000 1/1/2012 Environmental Maintenance 12/31/14 2 2000.4 1/1/2012 Environmental Maintenance- Non- Patient Care Area 12/31/14 2 2000.5 1/1/2012 Environmental Maintenance - Patient Care Area 12/31/14 2 2000.6 1/1/2012 Environmental Maintenance - Mechanical Area 12/31/14 2 2000.7 1/1/2012 Environmental Maintenance - Grounds 12/31/14 2 2000.8 1/1/2012 Interim Life Safety Measures 12/31/14

R. 1:13 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. 2 2000.9 1/1/2012 Department Infection Control 12/31/14 2 2000.9A 1/1/2012 Infection Control - Airborne / Ventilation 12/31/14 2 2000.9B 1/1/2012 Infection Control - Operating Room Ventilation 12/31/14 2 2000.9C 1/1/2012 Infection Control - Waterborne 12/31/14 2000.9D-1 1/1/2012 Infection Control - Decontamination 12/31/14 2 2000.9E 1/1/2012 Infection Control - Cooling Towers 12/31/14 2000.9G 1/1/2012 Infection Control - Ice Machines 12/31/14 2 2000.9F 1/1/2012 Infection Control - Dialysis Water 12/31/14 2 2001 1/1/2012 Maintenance and Inspection: Fire Warning and Safety Sys 12/31/14 2 2001.1 1/1/2012 Fire Alarm System Reset 12/31/14 2 2001.2 1/1/2012 Maintenance and Inspection: Fire Protection System 12/31/14 2 2002 1/1/2012 Maintenance & Inspection: Electrical Distribution System & 12/31/14 2 2002.1 1/1/2012 Electrical Generator Procedure 12/31/14 2 2003 1/1/2012 Maintenance & Inspection: Vertical & Horizontal Transpor 12/31/14 2 2004 1/1/2012 Maintenance & Inspection: HVAC System 12/31/14 2 2004.1 1/1/2012 Christus Santa Rosa Health Care Chiller Operation Proced 12/31/14 2 2004.3 1/1/2012 Air Filter P.M. Procedure 12/31/14 2 2005 1/1/2012 Maintenance & Inspection: Water Distribution/Plumbing S 12/31/14 2 2005.1 1/1/2012 Softner Operation Procedure on Units in Center for Childr 12/31/14 2 2005.2 1/1/2012 Softner Operation Procedure Outside CTRC (Formerly Ot 12/31/14 2 2006 1/1/2012 Maintenance & Inspection: Boiler/Steam System 12/31/14 2 2006.1 1/1/2012 Christus Santa Rosa Health Care Boiler Operation Procedu 12/31/14 2 2007 1/1/2012 Medical Gas System 12/31/14 2 2008 1/1/2012 Maintenance & Inspection: Medical / Surgical Air and Vac 12/31/14 2 2009 1/1/2012 Domestic Water Temperature 12/31/14 2 2010 1/1/2012 Scheduled Equipment Maintenance 12/31/14 2 2010.1 1/1/2012 Plant Maintenance Shift Operations 12/31/14 2 2011 1/1/2012 Equipment / Furniture Repair 12/31/14 2 2011.1 1/1/2012 Identification of Repaired Equipment (Form 00117537) 12/31/14 2 2011.2 1/1/2012 Monthly Report on Abuse & Operator Error 12/31/14 2 2012 1/1/2012 Pre-Purchase Evaluations 12/31/14 2 2013 1/1/2012 Service Request / Work Order Control 12/31/14 2 2014 1/1/2012 ICRA - Renovation and Contstruction 12/31/14

R. 1:14 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. 2 2015 1/1/2012 Relocation of Equipment and Furniture 12/31/14 2 2016 1/1/2012 Interior Furnishings, Finishes and Floors 12/31/14 2 2017 1/1/2012 Equipment Inventory and Preventive Maintenance 12/31/14 2 2017.1 1/1/2012 Equipment Critical to Patient Care 12/31/14 2 2017.2 1/1/2012 Building Maintenance Program 12/31/14 2 2017.3 1/1/2012 Regulatory Preventive Maintenance 12/31/14 2 2018 1/1/2012 Computerized Maintenance Management Improvement 12/31/14 2 3000 1/1/2012 Job Descriptions 12/31/14 2 3005 1/1/2012 Time and Attendance Collection System (KRONOS) 12/31/14 2 3006 1/1/2012 Absenteeism and Tardiness (Call In Procedure) 12/31/14 2 3007 1/1/2012 Dress Code 12/31/14 2 3008 1/1/2012 Performance Evaluation 12/31/14 2 4000 1/1/2012 Tool, Storage, Distribution and Inventory 12/31/14 2 4001 1/1/2012 Use of Personal Tools 12/31/14 2 4003 1/1/2012 Use of Vehicles for Hospital Business 12/31/14 2 5000 1/1/2012 Emergency Call Procedure 12/31/14 2 5001 1/1/2012 Loss of Electrical Power 12/31/14 2 5002 1/1/2012 CPSB Power Cubicles - City Centre 12/31/14 2 5003 1/1/2012 Elevator Failure and Passenger Evacuation 12/31/14 2 5004 1/1/2012 Failure of Heating, Ventilation, A/C (HVAC) System 12/31/14 2 5004.1 1/1/2012 System Failure on Chillers 12/31/14 2 5005 1/1/2012 Failure of Water Distribution System 12/31/14 2 5006 1/1/2012 Failure of Plumbing System / Flooding 12/31/14 2 5007 1/1/2012 Failure of Boiler / Steam Equipment 12/31/14 2 5008 1/1/2012 Failure of Medical Gas System - Oxygen 12/31/14 2 5009 1/1/2012 Failure of Medical Air System 12/31/14 2 5010 1/1/2012 Failure of Medical Vacuum System 12/31/14 2 5011 1/1/2012 Ethylene Oxide Leakage 12/31/14 2 5012 1/1/2012 Toxic Eternal Atmosphere 12/31/14 2 5013 1/1/2012 Failure of Pneumatic Tube System 12/31/14 2 5014 1/1/2012 Maintenance of Plant Operations in Freezing Temperature 12/31/14 2 5015 1/1/2012 Clean Up of Chemical Spills 12/31/14 2 5015.1 1/1/2012 Clean Up of Chemical Spills SLUG Control Plan 12/31/14

R. 1:15 Most Recent Date Binder Review Due for Former No. Policy No. Date Title Review Policy No. 2 5016 1/1/2012 Failure of Fire Alarm System 12/31/14 2 5017 1/1/2012 Failure of Fire Protection System 12/31/14 2 5100 1/1/2012 Utility Shutdown 12/31/14 2 5200 1/1/2012 Utility Incident Reporting 12/31/14 2 6000 1/1/2012 Performance Improvement Procedure 12/31/14 2 6000.1 1/1/2012 Maintenance / Engineering Performance: Improvement M 12/31/14 2 6000.2 1/1/2012 Energy Curtailment Program 12/31/14 2 7000 1/1/2012 General Safety 12/31/14 2 7001 1/1/2012 Electrical Safety - General appliances, Tools, TV, DVD, an 12/31/14 2 7001.1 1/1/2012 Electrical Safety - Lockout Procedure 12/31/14 2 7003 1/1/2012 Hazardous Chemicals 12/31/14 2 7004 1/1/2012 Asbestos Control Program 12/31/14 2 7004.1 1/1/2012 Removal of Asbestos Containing Materials 12/31/14 2 7005 1/1/2012 Handling and Use of Compressed Gas Cylinders 12/31/14 2 7006 1/1/2012 Radiation Protection Regulations: Guidelines for Maintena 12/31/14 2 7007 1/1/2012 Life Safety Program / Inspection and Surveys 12/31/14 2 8001 1/1/2012 Isolation Room Precautions 12/31/14 2 8002 1/1/2012 Decontamination of Equipment 12/31/14 FOUNDATION

R. 1:16 Most Recent Date Binder Review Due for No. Policy No. Date Title Review HIPAA HIM/MEDICAL RECORDS CO-IM-04-01 6/1/07 Concurrent Review Of Patient Records By Non-Hospital Em 5/31/10 CO-IM-04-03 3/8/2011 Medical Staff Suspensions Policy-Medical Records Delinqu 3/7/14 CO-IM-04-04 11/1/2006 Confidentiality And Release Of Medical Information 10/31/09 CO-IM-04-05 3/1/2011 Maintenance And Security Of Patient Medical Records 2/28/14 CO-IM-04-06 3/1/2011 Retrievel Of Requested Patient Medical Records 2/28/14 CO-IM-04-07 3/1/2011 Individuals Authorized To Document In The Medical Reco 2/28/14 CO-IM-04-08 3/1/2011 Approved/Unapproved Abbreviations And/Or Symbols 2/28/14 CO-IM-04-09 10/1/2006 Forms Management 9/30/09 CO-IM-04-10 3/1/2011 Patient Information Change 2/28/14 CO-IM-04-11 3/1/2011 Thinning Charts 2/28/14 CO-IM-04-13 1/6/2011 Resolution of Correct Documentation on Abstract (ABS) Ho 1/5/14 CO-IM-04-14 12/15/2010 Chart Completion 12/14/13 CO-IM-04-15 12/31/2010 Administrative Closure of an Incomplete Medical Record 12/30/13 CO-IM-04-16 5/1/2011 Legal Health Record 4/30/14 CO-IM-04-17 4/1/2011 Medical Identity Theft or Red Flag Rules 3/31/14 CO-PM-01-20 3/1/2011 Accounting of Disclosures of Protected Healthcare Inform 2/28/14 HUMAN RESOURCES INTRODUCTION CO-HR-01-01 4/1/2012 Human Resources Guidelines 4/1/15 CO-HR-01-02 7/1/2011 Labor Statement 6/30/14 EMPLOYMENT IMFORMATION CO-HR-02-02 5/1/2012 At Will Employment 5/1/15 CO-HR-02-03 12/1/2012 Equal Opportunity Employment 12/1/15 CO-HR-02-05 4/1/2012 Pre-Employment Verification 4/1/15 CO-HR-02-07 12/1/2011 Diversity and Inclusion 11/30/14 CO-HR-02-08. 12/1/2012 Government Postings 12/1/15 CO-HR-02-13 4/1/2012 Associate Employment Record 4/1/15 CO-HR-02-15 6/1/2011 Confidentiality Of Information/HIPAA 5/31/14 CO-HR-02-17 9/1/2012 Rehiring Of Terminated Associates 9/1/15

R. 1:17 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 3 CO-HR-02-21 4/1/2012 Employment Of Relatives 4/1/15 3 CO-HR-02-22 4/13/2010 Employment Eligibility Compliance 4/12/13 3 CO-HR-02-23 11/1/2010 Employment Of Minors 10/31/13 3 CO-HR-02-29 11/1/2010 Classification Of Associates 10/31/13 3 CO-HR-02-37 4/1/2012 Quoting Of Entry Wages 4/1/15 3 CO-HR-02-40 9/1/2012 Severance Plan (previously titled Severance Transition) 9/1/15 3 CO-HR-02-41 1/1/2012 HR- Allied Health Professionals 12/31/14 WORKING CONDITIONS 3 CO-HR-03-01 9/1/2013 Solicitation And Distributions 8/31/16 3 CO-HR-03-04 9/1/2012 Assignment Of Work 9/1/15 3 CO-HR-03-06 4/1/2010 Entry Period Of Employment 3/31/13 3 CO-HR-03-10 7/31/2011 Staff Requests Involving Patient Care 7/30/14 3 CO-HR-03-13 4/1/2012 Attendance and Punctuality 4/1/15 3 CO-HR-03-15 5/31/2011 Time And Attendance System 5/30/14 3 CO-HR-03-18 4/1/2012 Inclement Weather 4/1/15 3 CO-HR-03-24 4/1/2012 Moonlighting 4/1/15 3 CO-HR-03-27 6/30/2011 Transfers- New Facility 6/29/14 3 CO-HR-03-28 6/30/2011 Transfers- Internal (CSR) 6/29/14 3 CO-HR-03-29 4/1/2012 Promotion/Demotion 4/1/15 3 CO-HR-03-30 12/31/2011 Performance Plans And Evaluations 12/30/14 3 CO-HR-03-31 10/31/2010 Associate Competency Assessment 10/30/13 3 CO-HR-03-32 11/1/2012 Termination Voluntary-Resignation 11/1/15 3 CO-HR-03-34 4/1/2012 Termination-Involuntary 4/1/15 3 CO-HR-03-36 6/1/2011 Associate Clearance Upon Termination Of Unemployment 5/31/14 3 CO-HR-03-40 4/1/2012 Final Paychecks 4/1/15 3 CO-HR-03-42 12/1/2012 Dress Code/Uniforms Standards 12/1/15 3 CO-HR-03-44 7/31/2011 Personal Electronic Devices 7/30/14 3 CO-HR-03-62 6/3/2011 Transitional Duty 6/2/14 3 CO-HR-03-66 4/1/2012 Failure Of State Board Nursing Examination 4/1/15 3 CO-HR-03-74 6/1/2012 Associate Licenses 6/1/15 3 CO-HR-03-76 6/1/2012 Contractors 6/1/15 Student Educational Experience Reporting and 3 CO-HR-03-77 7/31/2012 Orientation Policy 7/31/15

R. 1:18 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 3 CO-HR-03-78 11/1/2010 Tranfers (Christus-wide) 10/31/13 3 CO-HR-03-83 1/1/2013 New Associate Orientation 1/1/16 3 CO-HR-03-97 1/31/2012 Language Competency For Associates 1/30/15 Wage And Salary Administration 3 CO-HR-04-01 4/1/2012 Wage And Salary Administration 4/1/15 3 CO-HR-04-04 4/1/2012 Non-Exempt Compensation 4/1/15 3 CO-HR-04-06 4/1/2012 Exempt Compensation 4/1/15 3 CO-HR-04-12 4/1/2012 On Call And Call Back Pay 4/1/15 3 C0O-HR-4-18 9/1/2012 Merit Increases 9/1/15 3 CO-HR-04-20 2/1/2013 Pharmacist Incentive Pay Plan 2/1/16 3 CO-HR-04-22 1/31/2010 Extracorporeal Membrane Oxygenation (ECMO) Hourly P 1/30/13 3 CO-HR-04-23 3/11/2012 Holiday Differential 3/11/15 3 CO-HR-04-38 4/1/2012 Job Descriptions 4/1/15 3 CO-HR-04-46 4/1/2012 Job Evaluation 4/1/15 3 CO-HR-04-51 1/1/2013 Interim Department Directors, Managers, And Supervisor 1/1/16 3 CO-HR-04-52 3/1/2012 Education Hours 3/1/15 3 CO-HR-04-54 7/1/2012 Emergency Staffing Pay (formerly ESI) 7/1/15 3 CO-HR-04-55 4/1/2012 Direct Deposit 4/1/15 3 CO-HR-04-56 5/31/2011 Secondary Job/Dual Job 5/30/14 3 CO-HR-04-58 7/31/2011 Disaster Pay Practices 7/30/14 3 CO-HR-04-59 3/1/2012 Shift Differential Pay 3/1/15 3 CO-HR-04-60 3/1/2012 Overtime Pay 3/1/15 3 CO-HR-04-61 3/1/2012 Daylight Savings Time 3/1/15 BENEFITS 3 CO-HR-05-01 3/1/2013 Paid Time Off (PTO) 2/29/16 3 CO-HR-05-10 5/1/2012 Payroll Deduction For Meals 5/1/15 3 CO-HR-05-15 3/31/2010 Meal and Rest Breaks 3/30/13 3 CO-HR-05-17 8/31/2012 Short Term Absences (Jury Duty,Funeral Leave, Witness R 8/31/15 3 CO-HR-05-18 7/31/2012 Leave Of Absence 7/31/15 3 CO-HR-05-30 12/31/2011 Success Sharing 12/30/14 3 CO-HR-05-62 4/30/2011 Health And Welfare Benefits 4/29/14 3 CO-HR-05-69 10/31/2010 ADCAP Tuition Assistance 10/30/13 3 CO-HR-05-70 1/31/2012 Tuition Reimbursement 1/30/15

R. 1:19 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 3 CO-HR-05-71 2/25/2010 National Nursing Certification Program 2/24/13 3 CO-HR-05-72 4/1/2012 Recognition Of Associates At Retirement 4/1/15 3 CO-HR-05-95 1/15/2010 Mother-Friendly Distinction For Breastfeeding Associates 1/14/13 CONDUCT AND ETHICS 3 CO-HR-06-1 1/1/2012 Code Of Ethics For Associates 12/31/14 3 CO-HR-06-2 2/1/2012 Associate Standards Of Conduct 1/31/15 3 CO-HR-06-3 6/1/2012 Disciplinary And Corrective Action Process 6/1/15 3 CO-HR-06-10 4/1/2012 Performance Probation 4/1/15 3 CO-HR-06-19 5/31/2011 Workplace Principles (Harassment And Retaliation) 5/30/14 3 CO-HR-06-21 11/1/2010 Violence- Free Workplace 10/31/13 3 CO-HR-06-24 9/30/2010 Drug Free Work Place 9/29/13 3 CO-HR-06-25 9/1/2013 Tobacco-Free Environment 8/31/16 3 CO-HR-06-26 4/1/2012 Consumption Of Alcoholic Beverages At CSRHC 4/1/15 COMMUNICATIONS 3 CO-HR-07-02 9/1/2013 Problem Solving Process For Associates 8/31/16 3 CO-HR-07-20 10/31/2010 Educational Requirements and Resource Support for CSRH 10/30/13 3 CO-HR-07-26 9/1/2012 Exit Surveys 9/1/15 GENERAL INFORMATION 3 CO-HR-08-05 4/1/2012 Endorsements, Referrals, And/Or Recommendations 4/1/15 3 CO-HR-08-09 12/31/2011 Conflict Of Interest 12/30/14 3 CO-HR-08-10 2/28/2011 Associate Consent To Record Or Film 2/27/14 ASSOCIATE HEALTH 3 CO-HR-09-03 9/1/2013 Vaccine Preventable Diseases and Immunizations 8/31/16 3 CO-HR-09-04 5/1/2012 Post Offer Health Screen 5/1/15 3 CO-HR-09-05 3/1/2012 Tuberculosis Screening For Volunteers And External Staff 3/1/15 3 CO-HR-09-06 10/1/2010 Tuberculosis Screening For Associates 9/30/13 3 CO-HR-09-07 12/1/2011 Tuberculosis Screening For Physicians 11/30/14 3 CO-HR-09-09 9/30/2011 Hepatitis B Vaccination For Associates 9/29/14 3 CO-HR-09-10 9/1/2012 Post Exposure And Follow Up To Blood And Other Infectio 9/1/15 3 CO-HR-09-15 6/30/2011 Employee Assistance Program (EAP) 6/29/14 3 CO-HR-09-16 5/1/2012 Work Restrictions Related To Communicable Disease 5/1/15 3 CO-HR-09-17 4/30/2012 Texas Occupational Injury Assistance Plan (TOIAP) 4/30/15

R. 1:20 Most Recent Date Review Due for Binder Policy No. Date Title Review INFECTION CONTROL AND PREVENTION OVERVIEW CO-IC-01-2 2/1/2012 Goals Of The Infection Control and Prevention Program 1/31/15 CO-IC-01-3 2/1/2012 Infection Control Committee 1/31/15 CO-IC-01-4 2/1/2012 Policy Review - Procedures With A High Infection Potent 1/31/15 CO-IC-01-5 2/1/2012 Occupational Health / Infection Control Interaction 1/31/15 PATIENT MANAGEMENT CO-IC-01-01 2/1/2012 Role Of Our Associates In Infection Control 1/31/15 CO-IC-04-01 5/1/2012 Guidelines For Patient Placement 5/1/15 CO-IC-07-01 5/1/2012 Patient Teaching - Communicable Diseases (State Law) 5/1/15 CO-IC-07-02 2/1/2012 Hand Hygiene 1/31/15 CO-IC-07-08 2/1/2012 Patient Cultures 1/31/15 CO-IC-07-09 5/1/2012 Portable Fans / Celing Fans 5/1/15 CO-IC-08-02 5/1/2012 Management Of Patients With Lice Or Scabies 5/1/15 DISEASE SPECIFIC AND EXPOSURE MANAGEMENT CO-IC-05-04 5/1/2012 Care Of The Body After Death Of Person With A Commu 5/1/15 CO-IC-07-13 8/31/2012 Chemoprophylaxis For Occupational Exposure To HIV 8/31/15 CO-IC-07-14 2/1/2012 Investigation Of Suspected Outbreaks 1/31/15 CO-IC-08-05 5/1/2012 Prevention Of Transmission Of HIV and HBV By Infected 5/1/15 CO-IC-08-06 10/1/2012 Tuberculosis Prevention And Control Plan 10/1/15 CO-IC-08-07 11/1/2012 Bloodborne Pathogens - Exposure Control Plan 11/1/15 CO-IC-08-08 5/1/2012 Legionella Prevention And Control 5/1/15 CO-IC-08-09 5/1/2012 Infection Control Precautions For Patients With Cystic Fi 5/1/15 CO-IC-08-12 2/1/2012 Pandemic Respiratory Infectious Disease Plan 1/31/15 ISOLATION PRECAUTIONS CO-IC-02-01 2/1/2012 Standard Precautions 1/31/15 CO-IC-06-01 2/1/2012 Isolation Precautions (Transmission-Based Precautions) 1/31/15 CO-IC-08-03 2/1/2012 Protective Precautions 1/31/15 CO-IC-08-04 2/1/2012 Vancomycin-Resistant Organisms 1/31/15 CO-IC-08-11 2/1/2012 Emerging MDRO Precautions 1/31/15 CO-IC-08-13 5/1/2012 C.difficile Precautions 5/1/15 CO-ICP-04-01 2/1/2012 MRSA Precautions 1/31/15

R. 1:21 Most Recent Date Review Due for Binder Policy No. Date Title Review DISINFECTION AND ENVIRONMENTAL MANAGEMENT CO-IC-07-03 2/1/2012 Sharps - Handling And Disposal 1/31/15 CO-IC-07-04 7/1/2011 Special Medical / Infectious / Regulated Waste 6/30/14 CO-IC-07-05 5/1/2012 Sanitary Storage And Dispensing Of Ice 5/1/15 CO-IC-07-06 5/1/2012 Environmental Microbiologic Monitoring 5/1/15 CO-IC-07-07 5/1/2012 Handling And Prevention Of Soiled Documents (Charts) 5/1/15 CO-IC-07-10 6/1/2012 Management Of Contaminated Work Clothes 6/1/15 CO-ICP-05-01 3/1/2013 Disinfection and Sterilization Plan For Medical Equipme 2/29/16 INFECTION CLASSIFICATION AND REPORTING CO-IC-03-01 2/1/2012 Determining The Presence Of Health Care-Associated In 1/31/15 CO-IC-05-01 2/1/2012 Reporting Conditions - "Notifiable Conditions" In Texas 1/31/15 CO-IC-05-02 5/1/2012 Reporting Infections-Healthcare Associated Infection, C 5/1/15 CO-IC-05-03 2/1/2012 Notification Of Possible Exposure By A Peace Officer, Fi 1/31/15 CO-IC-05-05 4/1/2012 Autopsy Reports - Undiagnosed Ante Mortem Infections 4/1/15 CO-IC-07-11 5/1/2012 Status / VIP Codes For Infection Control 5/1/15 INFORMATION MANAGEMENT INFORMATION SERVICES PROTECTED HEALTH INFORMATION (PHI) PUBLIC RELATIONS CO-PM-04-1 5/1/2011 Communications, Promotions, & Public Relations 4/30/14 CO-PM-04-2 5/1/2011 Release of Information to the News Media 4/30/14 CO-PM-04-3 5/1/2011 Entertainer/ Media Visitors in Children's Hospital 4/30/14 CO-PM-04-4 5/1/2011 Identity, Graphic Standards, Naming of Entities or Servic 4/30/14 CO-PM-04-5 5/1/2011 News Media / Public Relations 4/30/14 LABORATORY CO-LAB-01-01 5/1/2013 Regional Morgue Management 4/30/16 MATERIALS MANAGEMENT CO-FM-03-02 3/1/2001 Capital Budget Policy 2/29/04 CO-FM-03-03 3/1/2011 Ordering Business Cards - Santa Rosa Health Care Facil 2/28/14 CO-FM-03-04 8/1/2012 Purchase of Supplies Non-Captial Equipment and Servic 8/1/15 CO-FM-03-05 3/1/2011 Disposal Of Excess Furnishings And Equipment (Assets) 2/28/14 CO-FM-03-07 2/1/2011 Contract Confidentiality 1/31/14 CO-FM-03-08 3/1/2011 Guidelines For Inventory Products 2/28/14

R. 1:22 Most Recent Date Review Due for Binder Policy No. Date Title Review 4 CO-FM-03-09 3/1/2011 Group Purchasing 2/28/14 4 CO-FM-03-19 3/1/2011 Purchase And Management Of Capital Equipment And F 2/28/14 4 CO-FM-03-21 9/17/2010 Inventory Cycle Counting 9/16/13 4 CO-FM-03-22 3/1/2011 Damaged Goods 2/28/14 4 CO-FM-03-23 1/1/2012 Vendor Representative Appointment Process 12/31/14

R. 1:23 Most Recent Date Binder Review Due for No. Policy No. Date Title Review NURSING NURSING CLINICAL PRACTICE 5 12/1/2011 Transfer of Patients to or from Another Facility 11/30/14 CO-NU-00-01 9/1/2012 Code Blue Response For Clinic Services, Diagnostic And T 9/1/15 CO-NU-00-02 4/1/2013 Use of Restraints 3/31/16 CO-NU-00-04 6/4/2012 Tissue Management 6/4/15 CO-PM-01-06 5/1/2012 Animal Assisted Therapy 5/1/15 CO-PM-07-06 2/28/2012 Closure (Temporary) Of Nursing Unit 2/27/15 CO-PM-07-08 5/1/2012 Service Animals 5/1/15 CO-PM-07-09 5/7/2012 Management Of The Suicide/Overdose Patient 5/7/15 CO-PM-07-10 10/24/2011 Death, Autopsy, And Post - Mortem Care 10/23/14 CO-PM-07-11 1/1/2012 Discharge Procedure 12/31/14 CO-PM-07-13 1/1/2012 Skin Testing 12/31/14 CO-PM-07-15 2/1/2012 Sedation During Diagnostic And Therapeutic Procedures 1/31/15 CO-PM-07-17 12/1/2011 Patient Controlled Analgesia (PCA) 11/30/14 CO-PM-07-17C 8/21/2008 Epidural Analgesia Management 8/21/11 CO-PM-07-18 2/1/2012 Pain Management 1/31/15 CO-PM-07-21 4/1/2012 Nursing Process 4/1/15 CO-PM-07-24 6/1/2008 Informed Consent For HIV Testing 6/1/11 CO-PM-07-25 11/1/2008 Physician Orders, Receiving, and Transcribing 11/1/11 CO-PM-07-27 1/1/2007 Off Unit Privileges for Patients 12/31/09 CO-PM-07-30 8/7/2009 Latex Sensitivity Program 8/6/12 CO-PM-07-32 1/1/2012 Blood Administration 12/31/14 CO-PM-07-33 11/12/2008 "Hand Off" Communications 11/12/11 CO-PM-07-37 10/1/2007 MyTime Extra Shift Program 9/30/10 CO-PM-07-38 12/1/2010 Critical Test/ Critical Value Reporting 11/30/13 CO-PM-07-39 4/1/2012 Wound Assessment Using Photography and E-Z Graph 4/1/15 CO-PM-07-40 5/1/2012 Preoperative NPO Status And HCG Testing 5/1/15 CO-PM-07-41 5/1/2012 Blood Cultures 5/1/15 CO-PM-07-43 4/1/2012 Parenteral Nutrition 4/1/15 CO-PM-07-45 8/13/2008 Hypo-Hyperthermia Blanket, Use of the 8/13/11 CO-PM-07-47 8/11/2008 In-Line Filter Use 8/11/11 CO-PM-07-48 8/13/2008 Clearing an Occluded Central Venous Catheter 8/13/11

R. 1:24 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 5 CO-PM-07-49 7/28/2008 Patient Transport - In Facility 7/28/11 5 CO-PM-07-50 4/1/2012 Refrigerator / Freezer Temperature 4/1/15 5 CO-PM-07-51 3/20/2008 Medication Extravasation 3/20/11 5 CO-PM-07-52 2/1/2012 Resuscitation Cart Maintenance 1/31/15 5 CO-PM-07-53 1/1/2008 Immunizations 12/31/10 5 CO-PM-07-55 5/1/2011 Rapid Response Team (RRT) - Adult and Pediatrics 4/30/14 5 CO-PM-07-57 6/1/2010 LVN Administration Of IV Bolus Medications 5/31/13 5 CO-PM-07-59 11/1/2010 Adult Code Blue 10/31/13 5 CO-PM-07-60 5/1/2011 Central Venous Catheter/PICC Management: Insertion 4/30/14 5 CO-PM-07-65 3/18/2010 Therapeutic Phlebotomy 3/17/13 5 CO-PM-07-68 12/1/2011 Medication Administration Process 11/30/14 5 CO-PM-07-72 2/1/2012 Central Venous Catheter/PICC Management: Care and M 1/31/15 5 CO-PM-07-73 2/1/2012 Central Venous Catheter/PICC Management: Blood Samp 1/31/15 5 CO-PM-07-153 5/1/2009 Acute MI and STEMI Patients (Heart Alert) 4/30/12 5 CO-PM-07-162 6/1/2012 Monitoring of Blanket Warmers 6/1/15 6/1/2012 Tissue Supplier Certificates ADMINISTRATION 5 CO-NU-01-01 11/1/2012 Peer Review Plan - Incident Based 11/1/15 5 CO-NU-01-03 11/1/2012 Peer Review Plan - Safe Harbor 11/1/15 5 CO-PM-07-01 12/1/2010 Scopes Of Practice For Registered Nurses (RN) And Licen 11/30/13 5 CO-PM-07-02 1/1/2012 RN Professional Recognition Program (PReP) 12/31/14 5 CO-PM-07-03 9/1/2007 Reassignment Of Staff (Floating) 8/31/10 5 CO-PM-07-07 1/1/2012 Lifesaver Program In Patient Care Services 12/31/14 5 CO-PM-07-12 1/1/2012 PRN Pool Program In Patient Care Services 12/31/14 5 CO-PM-07-19 6/3/2011 Nursing Administration Chain of Command 6/2/14 5 CO-PM-07-20 12/15/2010 Standards Of Nursing Practice 12/14/13 5 CO-PM-07-26 8/5/2009 Student Nurses 8/4/12 5 CO-PM-07-29 4/1/2012 Required School Support For Patients 4/1/15 5 CO-PM-07-36 5/1/2012 Resuscitation Training Expectations Of Personnel 5/1/15 5 CO-PM-07-42 5/1/2012 Use of Nursing Procedure Manuals 5/1/15 5 CO-PM-07-58 4/27/2010 Nurse Staffing Committee 4/26/13 CARDIOLOGY - CATH LAB 5 Heart Alert - Flow Chart

R. 1:25 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 5 Heart Alert - Transfer Flow Chart 5 CO-PM-07-95 1/1/2012 Assessment / Reassessment Of The Cath Lab Patient 12/31/14 5 CO-PM-07-96 1/1/2012 Equipment In The Cath Lab 12/31/14 5 CO-PM-07-97 1/1/2012 Hours Of Operation 12/31/14 5 CO-PM-07-98 1/1/2012 Traffic Patterns - Infection Control 12/31/14 5 CO-PM-07-99 1/1/2012 Dress Code For Cath Lab Staff 12/31/14 5 CO-PM-07-100 1/1/2012 Intra Procedure Montoring 12/31/14 5 CO-PM-07-101 1/1/2012 Pediatric Cardiac Catheterization Laboratory Scheduling 12/31/14 5 CO-PM-07-102 1/1/2012 Recovery Of The Invasive Procedure Patient 12/31/14 5 CO-PM-07-103 1/1/2012 Contrast Reaction 12/31/14 5 CO-PM-07-104 1/1/2012 Education / Competency In The Cardiac Cath Lab 12/31/14 5 CO-PM-07-105 1/1/2012 Arterial And Venous Sheath Removal 12/31/14 CARDIOLOGY - NON INVASIVE ECHOCARDIOGRAPHY 5 E04 4/1/2012 Adult Transthoracic Echocardiogram:2D and M-Mode Vie 4/1/15 5 E05 4/1/2012 Dobutamine Stress Echocardiogram 4/1/15 5 E07 4/1/2012 Bubble Contrast Study 4/1/15 5 E08 5/1/2012 Transesophagel Echocardiogram 5/1/15 5 E13 4/1/2012 Processing of Echocardiogram Procedures 4/1/15 5 E15 5/1/2012 Guidelines for Echocardiogram Interpretations 5/1/15 5 E16 4/1/2012 Definity Contrast Echocardiogram 4/1/2015 ELECTRODIAGNOSTICS 5 A01 2/1/2011 Cardio-Neurodiagnostics Scope of Care 1/31/2014 5 A02 2/1/2011 EKG Administrative Procedure 1/31/2014 5 A03 2/1/2011 Electrocardiogram Adult - Pediatric Lead Placement 1/31/2014 5 A04 3/1/2011 Process for Performing EKG's 2/28/2014 5 A05 3/10/2011 Critical Test Values 3/9/2014 5 A06 3/1/2011 Cleaning EKG machines and Stress Equip 2/28/2014 5 A07 3/1/2011 Isolation Technique for EKG and EEG 2/28/2014 5 A08 3/1/2011 Ordering Procedures for Non-Invasive Cardiology Exams 2/28/2014 5 A09 3/1/2011 Scheduling Outpatient Cardiovascular Neurodiagnostic E 2/28/2014 5 A10 11/1/2008 Inpatient Scheduling 11/1/2011 5 A11 3/1/2011 Procedure of Ordering Supplies 2/28/2014

R. 1:26 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 5 A12 3/1/2011 ER and EKG Reading Roster Qualifications 2/28/2014 5 A13 3/1/2011 Responsibilities of the EKG Weekly Reader 2/28/2014 5 A14 3/1/2011 STAT EKG Interpretations 2/28/2014 5 A15 3/1/2011 Cardiology Department EKG Discrepancy Reporting 2/28/2014 5 A16 3/1/2011 Department Disaster plan for Non-Invasive Cardiology 2/28/2014 5 A17 3/1/2011 Code Blue 2/28/2014 5 B01 3/1/2011 Transportation of Patients 2/28/2014 5 B02 2/1/2011 Exercise Adenosine Stress with Nuclear isotope 1/31/2014 5 B03 2/1/2011 Adenosine Stress with Nuclear Medicine Imaging 1/31/2014 5 B04 2/1/2011 Dobutamine Stress with Nuclear Medicine Imaging 1/31/2014 5 B05 2/1/2011 Elective Electrical Cardioversion 1/31/2014 5 B06 2/1/2011 Lexiscan Stress Test with Nuclear Medicine Imaging 1/31/2014 5 B07 2/1/2011 Metabolic Exercise Test without Nuclear Imaging 1/31/2014 5 B08 2/1/2011 Persantine Stress Test with Nuclear Medicine Imaging 1/31/2014 5 B09 2/1/2011 Tilt-Table Testing 1/31/2014 5 B10 2/1/2011 Exercise Stress Test with Radio-Isotope Nuclear Medicine 1/31/2014 5 B11 2/1/2011 Exercise Stress Test without Nuclear Medicine Imaging 1/31/2014 5 B12 2/1/2011 Standing Delegation Orders for Nuclear Stress Testing 1/31/2014 5 B13 2/1/2011 Thirty Minute Rule 1/31/2014 5 B14 3/1/2011 Crash Cart 2/28/2014 NEURODIAGNOSTICS 5 A02 5/20/2010 General Policies, Neurodiagnostics 5/19/2013 5 A06 5/26/2010 Routine Adult EEG for Inpatients and Outpatients 5/25/2013 5 A08 5/20/2010 Scheduling for Long-Term Video EEG 5/19/2013 5 A09 5/25/2010 Long-Term Monitoring with Video EEG 5/24/2013 5 A10 5/20/2010 Editing Video EEG's 5/19/2013 5 A12 5/26/2010 Record Storage and Retrieval 5/25/2013 5 A15 6/23/2010 On-Call, Call-Back, STAT, and Routine Orders 6/22/2013 5 A16 5/25/2010 Cleaning Gold Disc Electrodes for Neurodiagnostic Proce 5/24/2013 CO-NU-03-01 6/1/2013 Designation of Interpreting Physician 5/31/2016 CO-NU-03-02 6/1/2013 Brain Death EEG Procedures (ECS) 5/31/2016 CO-NU-03-03 6/1/2013 International 10-20 System of Measurement 5/31/2016 CO-NU-03-04 6/1/2013 Unattended Patient Policy 5/31/2016

R. 1:27 Most Recent Date Binder Review Due for No. Policy No. Date Title Review CO-NU-03-05 6/1/2013 Technical Standards of EEG Recordings for Nonates up to 5/31/2016 CO-NU-03-06 6/1/2013 Therapeutic Hypothermia for Infants 5/31/2016 CO-NU-03-07 6/1/2013 Routine Pediatric EEG for Inpatient and Outpatient 5/31/2016 5 F11 5/25/2010 Interpretation of Long-Term Video EEG 5/24/2013 EMERGENCY SERVICES CO-NU-04-01 12/1/2012 Emergency Department Medical Screening Examination 12/1/15 CO-PM-07-77 3/1/2012 Admission to Emergency Services 3/1/15 CO-PM-07-78 9/1/2012 Blood Alcohol Sample For Medical And/Or Legal Purpose 9/1/15 CO-PM-07-79 3/1/2012 Care Of The Sexual Assault Victim 3/1/15 CO-PM-07-80 3/1/2012 Culture Reports and Lab Discrepancies 3/1/15 CO-PM-07-81 3/1/2012 Post Exposure Prophylaxis and Reporting Of Rabies Expo 3/1/15 CO-PM-07-82 3/1/2012 Emergency Services Computer Downtime 3/1/15 CO-PM-07-83 3/1/2012 Emergency Services Patient Flow (EDM Tracker) 3/1/15 CO-PM-07-84 3/1/2012 Exposures To EMS and Public Safety Officers 3/1/15 CO-PM-07-85 3/1/2012 Management Of Boarded Patients In The Emergency Depa 3/1/15 CO-PM-07-86 9/1/2012 Notification Of Private Physician 9/1/15 CO-PM-07-87 3/1/2012 Patient Belongings 3/1/15 CO-PM-07-88 3/1/2012 Emergency Services Pediatric Reference Texts 3/1/15 CO-PM-07-89 3/1/2012 Rapid Medical Examination and Discharge 3/1/15 CO-PM-07-90 1/1/2012 Visitors In The Emergency Department 12/31/14 FAMILY MEDICINE, HYPERBARICS AND WOUND CARE INTENSIVE CARE UNIT CO-NU-06-01 8/1/2012 Patient Care Standards - Intensive Care Units 8/1/15 CO-NU-06-02 8/1/2012 Continuous Telemetry and Bedside Cardiac Monitoring 8/1/15 CO-NU-06-03 8/1/2012 Standard Of Care: Care Of The Patient With An Arterial Li 8/1/15 CO-NU-06-04 8/1/2012 Normal Saline Use In Disposable Transducer Systems 8/1/15 CO-NU-06-05 8/1/2012 External Cardiac Pacing 8/1/15 CO-NU-06-06 8/1/2012 Temporary Transvenous Pacing 8/1/15 CO-NU-06-07 8/1/2012 Standard Of Care: Care Of The Patient Receiving Continuo 8/1/15 MEDICAL , SURGICAL NEONATAL SERVICES CO-NU-08-01 3/1/2013 Misadministration of Expressed Breast Milk(EBM) 2/29/16

R. 1:28 Most Recent Binder Review Date Due for Former No. Policy No. Date Title Review Policy No. Extra #1 NURSING SENIOR BEHAVIORAL HEALTH CENTER CO-NU-09-01 6/1/2013 Admission Criteria 5/31/16 CO-NU-09-02 6/1/2013 In-House Transfers to and from Senior Behavioral Health C 5/31/16 CO-NU-09-03 6/1/2013 Assault on Patients and Staff 5/31/16 CO-NU-09-04 6/1/2013 Patient Orientation to Community Rules 5/31/16 CO-NU-09-05 6/1/2013 Continuity of Care 5/31/16 CO-NU-09-06 6/1/2013 Contraband and Search of Patient Belongings and Visitors' 5/31/16 CO-NU-09-07 6/1/2013 Crisis Management 5/31/16 CO-NU-09-08 6/1/2013 Denial of a Patient's Rights 5/31/16 CO-NU-09-09 6/1/2013 Discharge Criteria 5/31/16 CO-NU-09-10 6/1/2013 Duty to Warn 5/31/16 CO-NU-09-11 6/1/2013 Nutritional Assessment 5/31/16 CO-NU-09-12 6/1/2013 Patient Dress Code 5/31/16 CO-NU-09-13 6/1/2013 Patient Grievance Process 5/31/16 CO-NU-09-14 6/1/2013 Patient Laundry Service 5/31/16 CO-NU-09-15 6/1/2013 Patient Mail 5/31/16 CO-NU-09-16 6/1/2013 Levels of Observation 5/31/16 CO-NU-09-17 6/1/2013 Meal Supervision 5/31/16 CO-NU-09-18 6/1/2013 Medical Rehabilitation Services 5/31/16 CO-NU-09-19 6/1/2013 Multidisciplinary Treatment Planning 5/31/16 CO-NU-09-20 6/1/2013 Neurological Examination 5/31/16 CO-NU-09-21 6/1/2013 Patient Orientation 5/31/16 CO-NU-09-22 6/1/2013 Patient's Rights 5/31/16 CO-NU-09-23 6/1/2013 Program Safety 5/31/16 CO-NU-09-24 6/1/2013 Therapeutic Treatment Schedule 5/31/16 CO-NU-09-26 6/1/2013 Documentation 5/31/16 PERIOPERATIVE, TRANSPLANT GI LAB OPERATING ROOM CO-NU-10-01 1/1/2012 Respiratory Airborne and Droplet Precautions For Patients 12/31/14 CO-NU-10-02 1/1/2012 Aseptic Technique And Applications 12/31/14 CO-NU-10-03 1/1/2012 Procedure For Use Of Biological Monitoring System 12/31/14 CO-NU-10-04 7/1/2012 Blanket And Fluid Warmer Monitoring 7/1/15 CO-NU-10-05 4/1/2011 Modified Block Scheduling Of Perioperative Procedures 3/31/14 CO-NU-10-06 1/1/2012 Code Blue / Cardiopulmonary Arrest In The Operating Roo 12/31/14 CO-NU-10-07 4/1/2012 Duties And Responsibilities Of The On-Call Personnel 4/1/15 CO-NU-10-08 4/1/2012 Duties Of The Circulating Nurse 4/1/15 CO-NU-10-09 4/1/2012 Duties Of The Scrub Personnel 4/1/15 CO-NU-10-10 12/1/2011 Emergency "Bump" Guidelines 11/30/14 CO-NU-10-11 6/1/2012 Environmental Cleaning Of The Operating Room 6/1/15 CO-NU-10-12 4/1/2012 Event Related Sterility 4/1/15 CO-NU-10-13 6/1/2012 Hair Removal At Operative Site 6/1/15 CO-NU-10-14 4/1/2012 Handling Of Sharps 4/1/15 CO-NU-10-15 12/1/2011 Implant Record 11/30/14 CO-NU-10-16 12/1/2011 Latex Allergy Precautions 11/30/14 CO-NU-10-17 12/1/2011 Malignant Hyperthermia 11/30/14 CO-NU-10-18 4/1/2012 Monitoring The Local Anesthesia Patient In The OR 4/1/15 CO-NU-10-19 12/1/2011 New Perioperative Associate Unit Specific Information 11/30/14 CO-NU-10-20 12/1/2011 Organ Harvest 11/30/14 CO-NU-10-21 3/1/2012 Perioperative Metrics - Co Management 3/1/15 CO-NU-10-22 4/1/2012 Perioperative Patient Care Standards 4/1/15 CO-NU-10-23 4/1/2012 Personal Protective Equipment 4/1/15 CO-NU-10-24 4/1/2012 Philosophy 4/1/15 CO-NU-10-25 4/1/2012 Positioning The Surgical Patient 4/1/15 CO-NU-10-26 4/1/2012 Resterilization Of Single-Use Items 4/1/15 CO-NU-10-27 3/1/2012 Smoke Evacuation 3/1/15 CO-NU-10-28 4/1/2012 Special Precautions (Oxygen Cylinders & Manifolds) 4/1/15 CO-NU-10-29 4/1/2012 Standard Precautions 4/1/15 CO-NU-10-30 4/1/2012 Standards Of Perioperative Clinical Practice 4/1/15 CO-NU-10-31 4/1/2012 Steam Sterilization - Use Of The Autoclave 4/1/15 CO-NU-10-32 6/1/2012 Surgical Attire - Dress Code (Sterile Environment) 6/1/15 CO-NU-10-33 9/1/2011 Care And Disposition Of Surgical Specimens 8/31/14 CO-NU-10-34 12/1/2011 Transplant Protocol 11/30/14 CO-NU-10-53 8/1/2013 Surgical Lasers, Use of 7/31/16 PACU CO-PM-07-106 1/1/2012 Discharge Criteria From PACU 12/31/14 CO-PM-07-109 1/1/2012 Criteria For Discharging Patient From PACU And Admitting 12/31/14 CO-PM-06-110 1/1/2012 Emergency Transfer of Patients from PACU to an ICU 12/31/14 CO-PM-07-112 1/1/2012 Criteria For Post - OP Admit To An ICU Bypassing PACU 12/31/14 CO-PM-07-113 1/1/2012 ICU Overflow Patients In PACU 12/31/14 CO-PM-07-114 1/1/2012 Visitors In PACU 12/31/14 CO-PM-07-115 1/1/2012 Call Guidelines / Call Back Implementation 12/31/14 PSU CO-NU-10-46 1/1/2012 Admissions To The Perioperative Support Unit (PSU) 12/31/14 CO-NU-10-47 1/1/2012 PSU Charges 12/31/14 CO-NU-10-48 1/1/2012 Discharge Instructions 12/31/14 CO-NU-10-49 1/1/2012 Post Operative Follow-Up Evaluation / Post OP Calls 12/31/14 CO-NU-10-50 1/1/2012 Post-Op Nursing Care For SDS Patients 12/31/14 CO-NU-10-51 1/1/2012 Pre-operative Work Up 12/31/14 CO-NU-10-52 1/1/2012 Receiving The Patient Directly From Surgery 12/31/14 CO-NU-10-54 1/1/2012 Transfer From Outpatient To Inpatient Status 12/31/14 CO-NU-10-55 1/1/2012 Visitors In PSU 12/31/14 SPD TELEMETRY, INTERMEDIATE CARE CO-PM-07-156 5/1/2012 Admissions and Discharge Guidelines For Telemetry And 5/1/15 TRANSPORT SERVICES TRAUMA SERVICES CO-TS-01-01 6/1/2011 Burn Protocol For Trauma Care In Emergency Department 5/31/14 CO-TS-01-02 5/1/2011 Patient Who Presents to the Emergency Department That i 4/30/14 CO-TS-01-03 7/1/2011 Resuscitation and Treatment of the Trauma Patient 6/30/14 CO-TS-01-04 5/1/2011 Santa Rosa System Trauma Services Performance Improvem 4/30/14 CO-TS-01-05 6/1/2011 Spinal Cord Trauma Care In Emergency Department 5/31/14 CO-TS-01-06 5/1/2011 Utilization Of Medcom For Trauma Transfer Cases 4/30/14 CO-TS-02-01 5/1/2011 Acceptance Of Trauma Patients By Transfer To Santa Rosa C 4/30/14 CO-TS-02-02 5/1/2011 Acceptance Of Trauma Patients By Transfer To Santa Rosa L 4/30/14 CO-TS-02-03 5/1/2011 Admission Of Injured Patients To Santa Rosa Healthcare Le 4/30/14 CO-TS-02-05 6/1/2011 Trauma Team Activation Policy-City Centre 5/31/14 CO-TS-02-08 5/1/2011 Trauma Team Roles And Responsibilites - Level IV Facilitie 4/30/14 CO-TS-02-09 5/1/2011 Trauma Team Roles And Responsibilites - Level III Facilitie 4/30/14 CO-TS-03-01 6/1/2011 Pediatric Trauma Care In Emergency Department 5/31/14 WOMEN'S SERVICES CO-NU-14-01 1/31/2012 Obstetrics Emergencies 1/30/15 CO-NU-14-03 12/1/2011 Operating Room Responsibilites 11/30/14 CO-NU-14-04 8/31/2012 Intermediate Care of the Newborn 8/31/15 CO-NU-14-05 8/31/2012 Antepartum Care 8/31/15 CO-NU-14-06 8/31/2012 Care of the Post Partum Patient 8/31/15 CO-NU-14-07 8/31/2012 Care of the Patient in the OR-Preoperative nad Postoperati 8/31/15 CO-NU-14-08 8/31/2012 Care Of Patients With Post Partum Complications 8/31/15 CO-NU-14-09 3/31/2012 Discharge of the Well Newborn 3/31/15 CO-NU-14-10 8/31/2012 Admission, Physician Notification And Discharge Criteria O 8/31/15 CO-NU-14-11 8/31/2012 Hypoglycemia Protocol 8/31/15 CO-NU-14-12 8/31/2012 Patient Care Standards - Obstetric Patient 8/31/15 CO-NU-14-13 8/31/2012 Patient Care Standards: Newborn 8/31/15 CO-NU-14-14 4/30/2012 Newborns Requiring Transfer 4/30/15 CO-NU-14-15 8/31/2012 Management of Pre-eclampsia and Magnesium Sulfate 8/31/15 CO-NU-14-16 8/31/2012 Intrapartum Care Of Patient With Vaginal Delivery 8/31/15 CO-NU-14-17 8/31/2012 Visitation In Women's Services 8/31/15 CO-NU-14-18 11/1/2013 Fetal Demise 10/31/16 CO-NU-14-19 12/1/2012 Induction Of Labor 12/1/15 CO-NU-14-20 1/21/2013 Fetal Monitoring 1/21/16 CO-NU-14-21 9/1/2012 Newborn Procedures 9/1/15 CO-NU-14-22 8/1/2012 Admission of Newborn to Level I Nursery 8/1/15 CO-NU-14-23 2/1/2013 Breastfeeding Policy For Late Preterm Infants 2/1/16 CO-NU-14-24 2/28/2011 Limited Third Trimester Ultrasound in the OB Setting 2/27/14 CO-NU-14-25 2/28/2011 Nursing Competency for Third Trimester Ultrasound in the 2/27/14 CO-NU-14-26 4/15/2010 Surrogacy/Gestational Agreement Cases 4/14/13 CO-PM-07-61 7/1/2011 Labor Epidural Anesthesia 6/30/14 CO-PM-07-63 7/31/2011 Infant Security (Code Pink) Policy 7/30/14 CO-PM-07-64 6/30/2011 Medical Screening Exam for the Obstetrical Patient 6/29/14 CO-PM-07-66 12/30/2011 Breastfeeding Policy For Full Term Infants 12/29/14 CO-PM-07-69 11/30/2011 Operative Assistive Delivery 11/29/14 CO-PM-07-70 11/30/2011 VBAC (Vaginal Birth after Cesarean) 11/29/14 NEONATAL INTERMEDIATE CARE CO-NU-08-02 6/1/2013 Administration of Blood Products in High-Risk Infants 5/31/16 CO-NU-08-03 6/1/2013 Guidelines for Infants and Families with CPS Involvement 5/31/16 CO-NU-08-04 6/1/2013 Hearing Screening 5/31/16 CO-NU-08-05 6/1/2013 Hepatitis B Prophylaxis and Management 5/31/16 CO-NU-08-06 6/1/2013 Kangaroo Care 5/31/16 CO-NU-08-07 6/1/2013 Neonatal Circumcision 5/31/16 CO-NU-08-08 6/1/2013 Newborn Car Seat Angle Challenge 5/31/16 CO-NU-08-09 6/1/2013 Newborn Screening in Neonatal Intermediate Care 5/31/16 CO-NU-08-10 6/1/2013 Neonatal Intermediate Care Admission and Discharge 5/31/16 CO-NU-08-11 6/1/2013 Phototherapy Administration 5/31/16 CO-NU-08-12 6/1/2013 Placement and Use of Gastric Tube in NIMC 5/31/16 CO-NU-08-13 6/1/2013 Pulse Oximetry Screening for Congenital Heart Disease 5/31/16 CO-NU-08-14 6/1/2013 Referrals to Pediatrix Developmental Services and Clinic 5/31/16 CO-NU-08-15 6/1/2013 Re-warming Hypothermic Infants(using Infant Warmer) 5/31/16 CO-NU-08-16 6/1/2013 Safe Sleep for Infant in Neonatal Intermediate Care 5/31/16 CO-NU-08-17 6/1/2013 Sucrose Use in Infants 5/31/16 CO-NU-08-18 6/1/2013 Teaching Parents/Caregivers Cardiopulmonary Resuscitat 5/31/16 CO-NU-08-19 6/1/2013 Thermoregulation and Weaning to an Open Crib 5/31/16 HEMATOLOGY, ONCOLOGY FORENSIC NURSE EXAMINER CO-NU-16-01 9/1/2012 Patient Declining Forensic Examination 9/1/15 CO-NU-16-02 9/1/2012 Consent for Medical Forensic Examination 9/1/15 CO-NU-16-03 9/1/2012 Digital Photography Of Physical Injuries 9/1/15 CO-NU-16-04 9/1/2012 FNE Quality Improvement Process 9/1/15 CO-NU-16-05 9/1/2012 FNE Nursing Process 9/1/15 CO-NU-16-06 9/1/2012 Physician Consultation 9/1/15 CO-NU-16-07 9/1/2012 Medical Forensic Examination Policy 9/1/15 CO-NU-16-08 1/1/2012 Chain of Custody - Release of Medical Forensic Evidence 12/31/14 CO-NU-16-09 4/1/2012 Laboratory Test Standards 4/1/15 CO-NU-16-10 2/1/2012 Post-Exposure Prophylaxis for Patients of Sexual Abuse or 1/31/15 CO-NU-16-11 4/1/2012 Standard Medication Orders for Prophylaxis Related to Sex 4/1/15

R. 1:29 Most Recent Binder Review Date Due No. Policy No. Date Title for Review PHARMACY CO-PM-03-00 9/1/11 Medication Management Policy 8/31/14 CO-PM-03-01 1/1/2012 Administration And Handling Of Medications 12/31/14 CO-PM-03-02 7/31/2011 Antidote and Poison Control 7/30/14 CO-PM-03-03 7/1/2011 Automatic Stop Of Medication Orders 6/30/14 CO-PM-03-04 3/1/2012 Controlled Sustance Distribution Administration 3/1/15 CO-PM-03-05 7/1/2011 Crash Cart Medication Re-Supply 6/30/14 CO-PM-03-06 9/1/2010 Medication Orders 8/31/13 CO-PM-03-07 2/1/2012 Controlled Substance Infusion - Documentation 1/31/15 CO-PM-03-08 9/30/2011 Drug Use Evaluation Process 9/29/14 CO-PM-03-10 1/1/2012 Formulary Process 12/31/14 CO-PM-03-11 9/30/2011 Generic And Therapeutic Substitution 9/29/14 CO-PM-03-13 2/1/2012 Floor-Stock Medication Distribution 1/31/15 CO-PM-03-14 1/1/2012 Potassium Chloride (KCL) Administration Guidelines 12/31/14 CO-PM-03-15 9/30/2011 Investigational Medications 9/29/14 CO-PM-03-16 9/1/2011 Medication Information Services 8/31/14 CO-PM-03-17 2/1/2012 Medication Delivery Process 1/31/15 CO-PM-03-18 9/1/2011 Medication Error Reporting 8/31/14 CO-PM-03-19 12/1/2011 Drug Product Problem Reporting 11/30/14 CO-PM-03-20 7/1/2011 Automated Medication Dispensing Systems (PYXIS) 6/30/14 CO-PM-03-20B 9/1/2011 Medication Override Guidelines 8/31/14 CO-PM-03-21 7/31/2011 Adverse Drug Reaction Reporting Process 7/30/14 CO-PM-03-22 7/1/2011 Reconciliation Of Medications 6/30/14 CO-PM-03-23 9/1/2011 Methadone Use 8/31/14 CO-PM-03-24 12/1/2011 Nurse / Pharmacy Medication Communication Form 11/30/14 CO-PM-03-25 12/1/2011 Outpatient Prescription Services 11/30/14 CO-PM-03-26 1/1/2012 Medication Labeling 12/31/14 CO-PM-03-27 2/1/2012 Patient Own Medications 1/31/15 CO-PM-03-29 9/1/2011 Medication Management - Minimum Patient Data Set 8/31/14 CO-PM-03-30 1/1/2012 Medication Adminstration Record 12/31/14 CO-PM-03-31 5/1/2012 Storage Of Pharmaceuticals 5/1/15 CO-PM-03-32 12/1/2011 Pharmacy & Therapeutic Committees 11/30/14 CO-PM-03-33 12/1/2011 Recall Of Medications 11/30/14 CO-PM-03-34 2/1/2012 Safe Handling Of Cytotoxic Drugs 1/31/15 R. 1:30 Most Recent Binder Review Date Due No. Policy No. Date Title for Review 7 CO-PM-03-35 12/1/2011 Pharmaceutical Sales Representatives 11/30/14 7 CO-PM-03-36 9/30/2011 Medication Samples 9/29/14 7 CO-PM-03-37 12/1/2011 Security Of Medications In Patient Care Areas 11/30/14 7 CO-PM-03-38 3/1/2012 Medication Administration Time Standards 3/1/15 7 CO-PM-03-39 12/1/2011 Standarized Concentrations For Medications 11/30/14 7 CO-PM-03-40 1/1/2012 Food-Medication Interaction Monitoring and Education 12/31/14 7 CO-PM-03-41 2/1/2012 High Alert Medications 1/31/15 7 CO-PM-03-44 12/1/2011 Vincristine (Intravenous) Preparation, Delivery, And Adm 11/30/14 7 CO-PM-03-45 2/1/2011 Look-alike, Sound-alike Medication Names (a.k.a. Confuse 1/31/14 7 CO-PM-03-47 12/1/2011 Contrast Media As Medication 11/30/14 7 CO-PM-03-48 12/1/2011 Pharmacy Closure 11/30/14 7 CO-PM-03-49 12/1/2011 Surgery Pharmacy Services 11/30/14 7 CO-PM-03-50 5/1/2012 Pharmacist-Managed Drug Therapy Protocol For Vancomy 5/1/15 7 CO-PM-03-51 5/1/2012 Hospital Protocol. For Parenteral Nutrition (PN) in Adult Pa 5/1/15 7 CO-PM-03-52 7/31/2011 Anticoagulation Management Program 7/30/14 7 CO-PM-03-53 1/1/12 Storage and Use of Concentrated Potassium Chloride and 12/31/14 PHYSICIAN SERVICES MEDICAL STAFF ADMINISTRATION 7 1/16/09 Membership, Credentialing, Privileging, And Due Proces 1/16/12 7 1/16/09 Organizational Manual 1/16/12 7 3/26/12 Rules and Regulations 3/26/15 7 1/14/2011 Medical Staff Bylaws 1/13/14 7 CO-AD-02-05 11/30/2011 Sexual Harassment Involving Medical Staff 11/29/14 7 CO-AD-02-10 11/30/2011 Disclosure Of Medical Errors 11/29/14 7 CO-AD-02-14 11/30/2011 Disclosure Of Unanticipated Outcomes 11/29/14 7 CO-AD-02-15 11/30/2011 Emergency Room On-Call Schedule Process 11/29/14 7 CO-AD-02-16 11/30/2011 Emergency Room On-Call Physician Response 11/29/14 7 CO-AD-02-20 11/30/2011 Professional Practice Evaluation Policy 11/29/14 7 CO-AD-02-21 11/30/2011 Conflict Of Interest For Medical Staff Policy 11/29/14 7 CO-AD-02-25 4/1/12 Physician Attribution Policy 4/1/15 7 CO-MS-01-01 11/1/2012 Practitioner Peer Review Guidelines 11/1/15 7 CO-MS-01-02 11/1/2012 Professional Code Of Conduct Policy 11/1/15 7 CO-MS-01-03 5/1/13 Medical Staff Chain of Command 4/30/16

R. 1:31 Most Recent Binder Review Date Due No. Policy No. Date Title for Review PHYSICIAN RECRUITMENT MEDICAL EDUCATION (CME) QUALITY, PI, & NPSG CO-PI-01-03 7/1/11 Performance Improvement and Patient Safety Plan 6/30/14 CO-PI-01-26 3/26/2009 Patient Flow and Bed Capacity 3/25/12

R. 1:32 Most Recent Date Binder Review Due for No. Policy No. Date Title Review RADIOLOGY ADMINISTRATION CO-PM-08-02 12/1/2011 Assessment for Central Venous Device Insertion 11/30/14 CO-PM-08-03 2/6/2012 Care of Critically Ill Patients 2/5/15 CO-PM-08-04 12/29/2011 Diagnostic Imaging Guidelines 12/28/14 CO-PM-08-14 12/31/2011 Diagnostic Imaging Quality Control 12/30/14 CO-PM-08-15 7/1/2012 Use of Power Injectors in the Radiology Department 7/1/15 CO-PM-08-16 2/13/2012 Rectal Tube Insertions 2/12/15 CO-PM-08-17 2/6/2012 Radiology Medical Records 2/5/15 CO-PM-08-18 2/13/2012 Radiology Department Chairperson 2/12/15 CO-PM-08-19 2/13/2012 Radiology Services Provided by Outside Agency 2/12/15 CO-RD-01-01 4/1/2013 Reporting Patient Complaing and/or Grievance in Radiolo 3/31/16 CO-RD-01-06 1/31/2013 Radiation Safety Program and Procedures 1/31/16 CAT SCAN (CT) INTERVENTIONAL RADIOLOGY (IR) MAGNETIC RESONANCE IMAGING (MRI) CO-PM-08-07 1/31/2012 Patient Protection in MRI 1/30/15 CO-PM-08-08 1/31/2012 MRI Associates/Non-MRI Associate Zone Restriction 1/30/15 CO-PM-08-09 2/1/2012 Time Varying Gradient and Radiofrequency Magnetic Fie 1/31/15 CO-PM-08-10 1/31/2012 Monitoring Critically Ill Patients 1/30/15 CO-PM-08-12 1/31/2012 Safety in the MRI Suite due to an Emergent Situation 1/30/15 CO-PM-08-13 2/9/2012 Cyrogen Safety 2/8/15 MAMMOGRAPHY NUCLEAR MEDICINE (NM) NM - ADMINISTRATION CO-PM-08-36 2/14/2012 Medical Director of the Nuclear Medicine Department 2/13/15 CO-PM-08-51 2/17/2012 Radiation Safety Committee Responsibilites 2/16/15 CO-PM-08-52 3/6/2012 Radiation Safety Officer 3/6/15 NM - OPERATIONS CO-PM-08-20 2/13/2012 Administration of Radionuclides by Non-Physician 2/12/15 CO-PM-08-21 2/13/2012 Assurance of Correct Injections in Nuclear Medicine 2/12/15 CO-PM-08-24 2/13/2012 Collection and Re-Injection of Blood Products 2/12/15 CO-PM-08-25 2/13/2012 Compliance with Regulatory Agencies 2/12/15

R. 1:33 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 8 CO-PM-08-27 2/13/2012 Disposition of Examination Report 2/12/15 8 CO-PM-08-31 2/14/2012 General Instructions for Obtaining Nuclear Medicine Proc 2/13/15 8 CO-PM-08-32 2/14/2012 Informed Consent to Nuclear Medicine Procedures 2/13/15 8 CO-PM-08-33 2/14/2012 Leaking or Contaminated Source 2/13/15 8 CO-PM-08-34 2/14/2012 Lost or Stolen Radiation Sources 2/13/15 8 CO-PM-08-35 2/14/2012 Mandatory Review for I-131 RX Physician Ordered Proced 2/13/15 8 CO-PM-08-37 2/15/2012 Nuclear Medicine Hours of Operation 2/14/15 8 CO-PM-08-42 2/17/2012 Ordering and Receipt of Radiopharmaceuticals 2/16/15 8 CO-PM-08-43 2/17/2012 Orientation and Review 2/16/15 8 CO-PM-08-46 2/17/2012 Venous Blood Collection, Policy and Procedure for 2/16/15 8 CO-PM-08-54 2/21/2012 Records Maintenancefor Nuclear Medicine 2/20/15 8 CO-PM-08-57 2/21/2012 Supervision of Therapeutic Neclear Medicine Procedures 2/20/15 NM - QUALITY CONTROL 8 CO-PM-08-22 2/13/2012 Calibration of Nuclear Medicine Intstruments 2/12/15 8 CO-PM-08-28 2/14/2012 Dose Calibrator Quality Control 2/13/15 8 CO-PM-08-45 2/17/2012 Performance Monitoring in Nuclear Medicine 2/16/15 8 CO-PM-08-48 2/17/2012 Quality Control Program 2/16/15 NM - RADIATION SAFETY 8 CO-PM-08-38 2/15/2012 Nursing Instructions for Gold Seed Implants 2/14/15 8 CO-PM-08-39 2/15/2012 Nursing Instructions for I-131 Therapy 2/14/15 8 CO-PM-08-40 2/17/2012 Nursing Instructions for Permanent Radioactive Seed Impl 2/16/15 8 CO-PM-08-49 2/17/2012 Radiation Protection in Nuclear Medicine 2/16/15 8 CO-PM-08-50 2/17/2012 Radiation Protection Principles for Attending Personnel 2/16/15 8 CO-PM-08-53 2/21/2012 Radiation Safety Program Review 2/20/15 NM - SAFETY 8 CO-PM-08-23 2/13/2012 Care of Critically Ill Patients 2/12/15 8 CO-PM-08-26 2/13/2012 Equipment Safety Guidelines, Nuclear Medicine 2/12/15 8 CO-PM-08-55 2/21/2012 Sharps Disposition and Disposal 2/20/15 Picture Archive Communications System (PACS) 8 CO-PM-08-58 2/13/2012 Archiving of Studies 2/12/15 8 CO-PM-08-59 2/10/2012 CHRISTUS Network Downtime Procedures 2/9/15 8 CO-PM-08-60 2/1/12 Control Station Operation in PACS 1/31/15 8 CO-PM-08-61 2/9/2012 Diagnostic Imaging CR System 2/8/15

R. 1:34 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 8 CO-PM-08-62 2/9/2012 Digitizing of Hard Copy Radiographs 2/8/15 8 CO-PM-08-63 2/9/2012 ER Physician User Role 2/8/15 8 CO-PM-08-64 2/10/2012 Exporting of Exams to CD-ROM 2/9/15 8 CO-PM-08-65 2/10/2012 Hospital Information System Downtime Procedures 2/9/15 8 CO-PM-08-66 2/10/2012 ICU - Ward Staff User Role 2/9/15 8 CO-PM-08-67 2/10/2012 Outside Physician User Role 2/9/15 8 CO-PM-08-68 2/9/2012 Audit Procedures 2/8/15 8 CO-PM-08-69 2/9/2012 Downtime Procedures 2/8/15 8 CO-PM-08-70 2/10/2012 Quality Assurance 2/9/15 8 CO-PM-08-71 2/10/2012 User Account Inactivation 2/9/15 8 CO-PM-08-72 2/10/2012 User Account Request 2/9/15 8 CO-PM-08-73 2/10/2012 Purpose and Philosophy of PACS 2/9/15 8 CO-PM-08-74 2/10/2012 Radiologist User Role 2/9/15 ULTRASOUND X-RAY REHAB SERVICES PROCEDURES 8 CO-RE-00-01 8/31/2012 Prosthetic/Orthotic Services for Rehabilitation Patients 8/31/15 8 CO-RE-00-02 8/31/2012 Traction Pelvic-Motorized 8/31/15 8 CO-RE-00-03 8/31/2012 VitalStim Electrical Stimulation 8/31/15 8 CO-RE-00-04 8/31/2012 Bedside Swallowing Evaluations 8/31/15 8 CO-RE-00-05 8/31/2012 Tilt Table 8/31/15 8 CO-RE-00-06 8/31/2012 Deep Pharyngeal Neuromuscular Stimulation (DPNS) 8/31/15 8 CO-RE-00-07 8/31/2012 Referral For Audiological Assessment 8/31/15 9 CO-RE-00-08 8/31/2012 Phonophoresis 8/31/15 8 CO-RE-00-09 8/31/2012 Cryotherapy 8/31/15 8 CO-RE-00-10 8/31/2012 Joint Mobilization 8/31/15 8 CO-RE-00-11 8/12/2012 Biofeedback Myofeedback 8/12/15 8 CO-RE-00-12 8/31/2012 Driving 8/31/15 8 CO-RE-00-13 8/31/2012 Treatment Procedure: Fluidotherapy 8/31/15 8 CO-RE-00-14 8/31/2012 Hydrocollator - Hot Packs-Moist Heat Packs 8/31/15 8 CO-RE-00-15 8/31/2012 Intermittent Compression Unit - Instructions 8/31/15 8 CO-RE-00-17 8/31/2012 Cleaning Of Equipment & Supplies Used For Patient's 8/31/15

R. 1:35 Most Recent Date Binder Review Due for No. Policy No. Date Title Review 8 CO-RE-00-18 1/31/2012 Pain Management 1/30/15 8 CO-RE-00-19 1/31/2012 Treatment Plan Development 1/30/15 8 CO-RE-00-20 1/31/2012 PCS Documentation: General Guidelines 1/30/15 8 CO-RE-00-21 1/31/2012 Written Documentation: General Guidelines 1/30/15 8 CO-RE-00-22 8/31/2012 Use of Safety Devices 8/31/15 8 CO-RE-00-23 8/31/2012 Ultrasound 8/31/15 8 CO-RE-00-24 8/31/2012 Ultrasound And Electrical Stimulations - Combined 8/31/15 8 CO-RE-00-25 8/31/2012 Patient Transportation 8/31/15 8 CO-RE-00-26 8/31/2012 Neuromuscular Electrical Stimulation (Vital Stimulation) 8/31/15 8 CO-RE-00-27 8/31/2012 Contrast Baths, Procedure 8/31/15 8 CO-RE-00-28 8/31/2012 Electrical Stimulation 8/31/15 8 CO-RE-00-29 8/31/2012 Monitoring of Modality Safe Temperatures 8/31/15 ACUTE CARE 8 CO-RE-01-01 1/31/2012 Discharge Criteria For Acute Therapy Services 1/30/15 8 CO-RE-01-02 1/31/2012 Assessment: Initial/Discharge 1/30/15 8 CO-RE-01-03 1/31/2012 Acute Hospital Patient Reassessment 1/30/15 OUTPATIENT REHAB 8 CO-RE-02-01 2/28/2012 Patient Safety/Fall Prevention Program 2/27/15 8 CO-RE-02-02 1/31/2012 Admission Criteria 1/30/15 8 CO-RE-02-03 1/31/2012 Discharge Criteria 1/30/15 8 CO-RE-02-04 1/31/2012 Discharge Planning 1/30/15 8 CO-RE-02-05 1/31/2012 Discharge Summary 1/30/15 8 CO-RE-02-06 1/31/2012 Exclusionary Criteria 1/30/15 8 CO-RE-02-07 1/31/2012 Initial Evaluation - PT/OT/ST 1/30/15 8 CO-RE-02-08 1/31/2012 Medical and Therapeutic Holds 1/30/15 8 CO-RE-02-09 1/31/2012 Patient Admission Information 1/30/15 8 CO-RE-02-10 1/31/2012 Patient And Family Education 1/30/15 8 CO-RE-02-11 1/31/2012 Patient Case Conferences 1/30/15 8 CO-RE-02-12 1/31/2012 Patient Referrrals For Outpatient Rehabilitation Services 1/30/15 8 CO-RE-02-13 1/31/2012 Plan Of Care 1/30/15 8 CO-RE-02-14 1/31/2012 Reassessment 1/30/15 8 CO-RE-02-15 8/1/2012 OFF Grounds Treatment with Patient/Therapist 8/1/15 8 CO-RE-02-16 8/1/2012 Multidisciplinary Community Re-Entry Outings 8/1/15

R. 1:36 Most Recent Date Binder Review Due for No. Policy No. Date Title Review INPATIENT REHAB CO-RE-03-01 8/31/2012 Discharge Planning Inpatient 8/31/15 CO-RE-03-02 8/31/2012 Ordering Special Equipment - Other Than Prosthetics and 8/31/15 CO-RE-03-03 8/31/2012 Family Conferences 8/31/15 CO-RE-03-04 8/31/2012 Treatment for Patients Who Have Experienced A Change 8/31/15 CARDIAC REHAB CO-RE-04-01 5/1/2011 Cardiac Rehab Services And Referral Process 4/30/14 CO-RE-04-02 5/1/2011 Cardiac Rehab Program Goals 4/30/14 CO-RE-04-03 5/1/2011 Cardiac Rehab Safety 4/30/14 CO-RE-04-04 5/1/2011 Cardiac Rehab Termination Of Exercise Session 4/30/14 CO-RE-04-05 5/1/2011 Cardiac Rehab Patient Risk Stratification 4/30/14 CO-RE-04-06 5/1/2011 Cardiac Rehab Patient Education Program 4/30/14 CO-RE-04-07 5/1/2011 Cardiac Rehab Initial Assessment And Orientation 4/30/14 CO-RE-04-08 5/1/2011 Cardiac Rehab Inclusionary & Exclusionary Criteria 4/30/14 CO-RE-04-09 5/1/2011 Cardiac Rehab Exercise Prescription 4/30/14 CO-RE-04-10 5/1/2011 Cardiac Rehab Assessment 4/30/14 CO-RE-04-11 5/1/2011 Discharge Criteria, Cardiac Rehab 4/30/14 CO-RE-04-12 5/1/2011 Cardiac Rehab Patient Assessments 4/30/14 CO-RE-04-13 5/1/2011 Phase I Cardiac Rehab Services 4/30/14 CO-RE-04-14 5/1/2011 Role Of The Medical Director 4/30/14 CO-RE-04-15 5/1/2011 Cardiac Rehab Guidelines For Exercise In Diabetic Patien 4/30/14 PULMONARY REHAB CO-RE-05-01 6/1/2011 Pulmonary Rehab Patient Referral 5/31/14 CO-RE-05-02 6/1/2011 Pulmonary Rehab Admission Criteria 5/31/14 CO-RE-05-03 6/1/2011 Pulmonary Rehab Initial Assessment 5/31/14 CO-RE-05-04 6/1/2011 Pulmonary Rehab Six Minute Walk Assessment 5/31/14 CO-RE-05-05 6/1/2011 Pulmonary Rehab Reassessment 5/31/14 CO-RE-05-06 6/1/2011 Pulmonary Rehab Patient Safety 5/31/14 CO-RE-05-07 6/1/2011 Pulmonary Rehab Patient Exercise Prescription 5/31/14 CO-RE-05-08 6/1/2011 Pulmonary Rehabilitation Patient & Family Education 5/31/14 CO-RE-05-09 6/1/2011 Pulmonary Rehab Goals 5/31/14 CO-RE-05-10 6/1/2011 Pulmonary Rehab Documentation 5/31/14 CO-RE-05-11 6/1/2011 Pulmonary Rehab Discharge Guidelines 5/31/14

R. 1:37 Most Recent Date Binder Review Due for No. Policy No. Date Title Review CO-RE-05-12 6/1/2011 Pulmonary Rehab Individualized Treatment Plan 5/31/14 General Administration CO-RE-06-01 8/31/2012 Pool Rules and Regulations 8/31/15 CO-RE-06-02 1/31/2012 Educating Patient And Family 1/30/15 CO-RE-06-03 8/31/2012 Scheduling Patients for Therapy Treatments 8/31/15 CO-RE-06-04 8/31/2012 Safety - Limited Use Of Extension Cord in the Therapy Dep 8/31/15 CO-RE-06-05 8/31/2012 Safety - IV's, Oxygen, Catheter Bags - Guidelines for Ther 8/31/15 CO-RE-06-06 8/31/2012 Safety Guidelines And Records 8/31/15 CO-RE-06-07 8/31/2012 Infection Control With Kitchen Activities 8/31/15 CO-RE-06-08 8/31/2012 Infection Control: Cleaning Of Modality Equipment 8/31/15 CO-RE-06-09 8/31/2012 Infection Control : Sanitizing of Adaptive Eating Equipmen 8/31/15 CO-RE-06-10 8/31/2012 Wheelchair and Seating Clinic Services 8/31/15 PEDIATRICS FORMS

R. 1:38 Most Recent Date Binder Review Due for No. Policy No. Date Title Review RESPIRATORY CARE ADMINISTRATION CO-RC-01-01 7/1/2012 Medical Direction Of Respiratory Care 7/1/15 CO-RC-01-02 8/1/2012 Performance Improvement for Respiratory Care 8/1/15 CO-RC-01-03 9/1/2012 Orientation, Training & Education Of Respiratory Therapy Associates 9/1/15 CO-RC-01-04 9/1/2012 State License And CPR Certification 9/1/15 CO-RC-01-05 9/1/2012 Responsibilities of the Cardiopulmonary Department 9/1/15 CO-RC-01-06 9/1/2012 General Responsibilities Of The Respiratory Care Department 9/1/15 CO-RC-01-07 11/1/2013 Staffing, Absences and Punctuality 3/31/16 CO-RC-01-08 9/1/2012 Management of External Agrency Respiratory Care Practitioners 9/1/15 Documentation and Meditech Downtime Procedures For Respiratory CO-RC-01-09 9/1/2012 Care 9/1/15 CO-RC-01-10 9/1/2012 Respiratory Student Policy 9/1/15 RESPIRATORY CARE 9 4/1/2012 Safe Handling - Use of Metricide OPA PLUS Solution and Test Strips 4/1/15 CO-RC-02-01 9/1/2012 Criteria For Undesirable Therapeutic Side Effects 9/1/15 CO-RC-02-03 9/1/2012 Respiratory Care Services Respiratory Care Plan 9/1/15 CO-RC-02-04 9/1/2012 Initiation & Timelines Of Therapy 9/1/15 CO-RC-02-05 9/1/2012 Respiratory Care Orders 9/1/15 CO-RC-02-06 9/1/2012 Shift Report 9/1/15 CO-RC-02-07 9/1/2012 Transfers of RC Patients Between ICU's, General Floors And ER's 9/1/15 CO-RC-02-08 9/1/2012 Pulse Ox Monitoring on the Floors 9/1/15 CO-RC-02-09 9/1/2012 Oxygen Rounds 9/1/15 CO-RC-02-10 9/1/2012 Oxygen Administration 9/1/15 CO-RC-02-11 9/1/2012 Continuous Aersol Therapy 9/1/15 CO-RC-02-12 5/1/2012 Aersol Therapy Treatments 5/1/15 CO-RC-02-13 9/1/2012 Pentamidine Isethionate Aersol Therapy Treatments 9/1/15 CO-RC-02-14 9/1/2012 Pulse Oximeter Trending 9/1/15 CO-RC-02-15 10/1/2012 Intermittent Positive Pressure Breathing 10/1/15 CO-RC-02-16 7/1/2012 Sputum Specimen Collection 7/1/15

R. 1:39 Most Recent Date Binder Review Due for No. Policy No. Date Title Review CO-RC-02-17 7/1/2012 Aerosol Medication Delivery Via Meter Dose Inhaler And Aero-chamber 7/1/15 CO-RC-02-18 7/1/2012 Nasal Wash For The Detection Of Respiratory Syncytial Virus 7/1/15 CO-RC-02-19 7/1/2012 Chest Physical Therapy 7/1/15 CO-RC-02-20 7/1/2012 Nasopharyngeal Or Oropharyngeal Suctioning 7/1/15 CO-RC-02-21 7/1/2012 Suctioning Endotracheal Tube Or Tracheotomy Tube 7/1/15 CO-RC-02-22 7/1/2012 Use Of The Demistifier Scavenging Isolation Unit 7/1/15 CO-RC-02-23 7/1/2012 Initiation Of Pulse Oximeter 7/1/15 CO-RC-02-24 7/1/2012 Cystic Fibrosis Therapy Protocol 7/1/15 CO-RC-02-25 7/1/2012 Administration of Pulmozyme(Dornase Alpha) 7/1/15 CO-RC-02-26 7/1/2012 Administration of Aerosolized Tobi(Tobramycin Solution) 7/1/15 CO-RC-02-27 7/27/2012 Use of The Vest Percussive Unit 7/1/15 CO-RC-02-28 12/1/2012 Acapella(airway mucus clerance device) 12/1/15 CO-RC-02-29 12/23/2012 EzPAP(Positive Airway Pressure System) 12/1/15 CO-RC-02-30 12/23/2012 Surfactant Administration in Nicu 12/1/15 CO-RC-02-31 12/23/2012 Intrapulmonary Percussive Ventilation 12/1/15 CO-RC-02-32 12/1/2012 Administration of Hypertonic Saline 12/1/15 CO-RC-02-33 12/23/2012 Pediatric Asthma Protocol 12/1/15 CO-RC-02-34 12/1/2012 Colistin Antibiotic Aerosol Therapy 12/1/15 CO-RC-02-35 12/1/2012 Cough Assist Mechanical In-Exsufflator Device 12/1/15 CO-RC-02-36 11/1/2013 Bronchiolitis Protocol 12/1/15 CO-RC-02-37 12/12/2012 Reactive Airway Disease Protocol 12/12/15 CO-RC-02-39 12/1/2012 Mechanical Ventilation 12/1/15 CO-RC-02-40 1/17/2013 Use of the Passy-Muir Tracheostomy Speaking Valve(Pmtsv) 1/1/16 CO-RC-02-41 1/17/2013 Evita 4 Mechanical Ventilator Set-Up & Implementation 1/1/16 CO-RC-02-42 1/17/2013 Tracheostomy Replacement 1/1/16 CO-RC-02-43 1/17/2013 Endotracheal Intubation 1/1/16 CO-RC-02-45 1/1/2013 Bilevel Positive Airway Pressure Ventilation 1/1/16 CO-RC-02-46 1/17/2013 Bronchoscopy Assistance 1/1/16 CO-RC-02-47 1/17/2013 Continuous Bronchodilator Therapy Administration 1/1/16 CO-RC-02-48 1/1/2013 Plumonetic System LTV Ventilator 1/1/16 CO-RC-02-60 11/1/2013 Bunnell Jet Ventilator 10/31/16 H-18 3/1/2012 Negative Pressure Ventilation 3/1/15

R. 1:40 Most Recent Date Binder Review Due for No. Policy No. Date Title Review BLOOD GASES PULMONARY FUNCTION TESTS SLEEB LAB RISK MANAGEMENT 9 Risk Management and Loss Prevention Regional Plan FY2013 CO-PI-01-07 7/1/2012 Informed Consent 7/1/15 CO-PI-01-12 1/1/2012 Authorized Drivers of CSRHC Owned Vehicles Policy 12/31/14 CO-PI-01-16 9/1/2012 Records Retention and Destruction Policy 9/1/15 CO-PI-01-17 10/19/2012 RM and Loss Prevention Management Plan 10/19/15 CO-PI-01-18 1/1/2012 Patient Personal Property And Valuables 12/31/14 Emergency Medical Treatment & Active Labor Act (EMTALA) And CO-PI-01-23 9/1/2012 Patient Transfer Policy 9/1/15 CO-PI-01-24 1/1/2012 EMTALA Violation Reporting 12/31/14 CO-PM-01-33 12/1/2009 Response to Patient Abuse Allegations Made Against Staff 11/30/12 CO-RM-01-02 4/1/2013 Variance Reporting (Risk Management Notification) 3/31/16 CO-RM-01-03 7/1/2013 Associates Serving As Notary Public To Legal Instruments 6/30/16 CO-RM-01-06 7/1/2013 Elopement Policy 6/30/16 CO-RM-01-15 1/1/2014 Against Medical Advice-Refusal of Treatment and Discharge(AMA) 12/31/16 Sequestering of Medical Devices, Equipment, and Products Following CO-RM-01-25 6/1/2013 an Actual or Potential Adverse Event 5/31/16 Associates Witnessing Signatures on Wills, Deeds for Asset or Property 9 CO-RM-01-26 7/1/2013 Transfers, and Durable Power of Attorney 6/30/16 CO-RM-01-27 9/1/2013 Emergency Detention and Involuntary Mental Health Services 8/31/16 SAFETY CO-EC-01-02 1/1/2012 Electrical Safety 12/31/14 CO-EC-01-03 1/1/2012 Extension Cords and Adaptors 12/31/14 CO-EC-01-04 1/1/2012 Portable Heating Devices 12/31/14 CO-EC-01-11 1/1/2012 Safe Medical Device Act Reporting 12/31/14 Construction Related Environmental Safety And Infection Control CO-EC-01-14 12/1/2010 Procedures 11/30/13 CO-EC-01-15 7/1/2012 Eyewash Stations and Emergency Showers 7/1/15 CO-EC-03-04 5/1/2013 Respiratory Protection Program 4/30/16 CO-EC-05-02 1/1/2012 Report on Open Flame Fires - Code Red 12/31/14

R. 1:41 Most Recent Date Binder Review Due for No. Policy No. Date Title Review CO-EC-05-04 1/1/2012 Portable Fire Extinguisher Inspection 12/31/14 Flammability / Combustibility of Purchased Furniture, Furnishings, and CO-EC-05-05 1/1/2012 Decorations 12/31/14 CO-EC-05-07 1/1/2012 General Fire Prevention Duties 12/31/14 CO-EC-05-08 4/1/2012 Compressed Gas Cylinders 4/1/15 CO-SA-01-06 4/1/2013 Fire Alarm and Fire Drills 3/31/16 EC.02.03.01 LS. 7/1/2012 Fire and Life Safety Management Plan 7/1/15 EC.01.01.01 7/1/2012 Environmental Safety Management Plan 7/1/15 SECURITY EC-02.01.01 7/1/12 Security Management Plan 7/1/15 CO-EC-02-02 3/1/11 Parking At Christus Santa Rosa Health Care Facilities 2/28/14 CO-EC-02-08 4/1/2011 Package Inspection 3/31/14 CO-EC-02-17 5/1/2013 Patient Valuables Policy 4/30/16 CO-EC-02-20 11/1/2010 Patient (Forensic) Prisoner Policy 10/31/13 CO-EC-02-21 2/28/2013 Mobile Telephone and Pager Service 2/28/16 CO-SC-01-02 7/1/2013 Key Control 6/30/16 CO-SC-01-03 7/1/2013 Helipad Procedure 6/30/16 CO-SC-01-05 7/1/2013 Prevention of Workplace Violence 6/30/16 CO-SC-01-06 7/1/2013 Disoderly Conduct 6/30/16 CO-SC-01-07 7/1/2013 Bomb Threat (Code Black) 6/30/16 CO-SC-01-08 7/1/2013 Closed Circuit Television (CCTV) 6/30/16 CO-SC-01-09 7/1/2013 Regional Access Control 6/30/16 CO-SC-01-10 7/1/2013 Regional Weapons 6/30/16 CO-SC-01-12 8/1/2011 Active Shooter Policy (Code White) 7/31/14 CO-SC-01-13 7/1/2013 Identification Badges 6/30/16 CO-SC-01-16 7/26/2013 Disaster Phone Procedures 7/25/16 CO-SC-01-17 7/1/2013 Management of Dangerous or Combative Patients 6/30/16 CO-EC-02.01.0 7/1/2012 Security Program Management Plan 7/1/15 SPIRITUAL CARE

R. 1:42 REQUEST FOR PRODUCTION NOs. 3, 4, 5

R. 1:43 R. 1:44 R. 1:45 R. 1:46 R. 1:47 R. 1:48 R. 1:49 R. 1:50 R. 1:51 R. 1:52 R. 1:53 R. 1:54 Cause No. C-2013-0566-C LESLIE BAIRD § IN THE DISTRICT COURT § v. § OF COMAL COUNTY, TEXAS § GERALD MARCUS FRANKLIN, MD AND § G. MARCUS FRANKLIN, MD § ASSOCIATES, P.A. D/B/A THE ENT § CENTER OF NEW BRAUNFELS § 274th JUDICIAL DISTRICT

DEFENDANTS CHRISTUS HEALTH AND CHRISTUS SANTA ROSA HEALTH SYSTEM D/B/A CHRISTUS SANTA ROSA HOSPITAL — NEW BRAUNFELS’ OBJECTIONS AND ANSWERS TO DEFENDANTS GERALD MARCUS FRANKLIN, MD AND G. MARCUS FRANKLIN, MD & ASSOCIATES, PA D/B/A THE ENT CENTER OF NEW BRAUNFELS’ FIRST INTERROGATORIES TO: Gerald Marcus Franklin, MD and G. Marcus Franklin, MD & Associates, P.A. d/b/a The ENT Center of New Braunfels, by and through its attorney of record, Richard J. Kasson, Gonzalez, Chiscano, Angulo & Kasson, PC, 613 N.W. Loop 410, Suite 800, San Antonio, Texas 78216.

CHRISTUS Health and CHRISTUS Santa Rosa Health System d/b/a CHRISTUS Santa Rosa Hospital — New Braunfels, pursuant to the Texas Rules of Civil Procedure, make the following Objections and Answers to Defendants Gerald Marcus Franklin, MD And G. Marcus Franklin, MD & Associates, PA D/B/A The ENT Center Of New Braunfels’ First Interrogatories.

R. 1:55 Respectfully submitted, KROGER | BURRUS

By: ___________________________ Edward J. Kroger State Bar No. 11729700 [email protected] Leah A. Greene State Bar No. 24012729 [email protected] 3100 Weslayan, Suite 300 Houston, Texas 77027 Telephone: 713.961.7952 Telecopier: 713.961.7953 Counsel for Defendants CHRISTUS Health and CHRISTUS Santa Rosa Health System d/b/a CHRISTUS Santa Rosa Hospital – New Braunfels

R. 1:56 CERTIFICATE OF SERVICE This Pleading was served in compliance with the Texas Rules of Civil Procedure by the methods designated, or if not designated, by United States Postal Service First Class Mail, on this, the 4th day of April 2014.

Mr. Michael Sawicki Via CM-RRR and Fascimile Sawicki & Lauten, LLP (214) 468-8845 4040 N. Central Expressway, Suite 850 Dallas, Texas 75204 Mr. Charles Soechting Via CM-RRR and Fascimile Soechting Law Firm (512) 392-6204 3331 Ranch Rd., 12, Suite 107 San Marcos, Texas 78666 Mr. Richard Kasson Via CM-RRR and Fascimile Gonzalez Chiscano Angulo & Kasson, PC (210) 569-8490 NW Loop 410, Suite 800 San Antonio, Texas 78216

____________________________ Leah A. Greene

3 R. 1:57 DEFENDANTS CHRISTUS HEALTH AND CHRISTUS SANTA ROSA HEALTH SYSTEM D/B/A CHRISTUS SANTA ROSA HOSPITAL — NEW BRAUNFELS’ OBJECTIONS AND ANSWERS TO DEFENDANTS GERALD MARCUS FRANKLIN, MD AND G. MARCUS FRANKLIN, MD & ASSOCIATES, PA D/B/A THE ENT CENTER OF NEW BRAUNFELS’ FIRST INTERROGATORIES INTERROGATORY NO. 1: Identify by name, address and phone number each and every employee, including but not limited to, all nurses, surgical coordinators, surgical assistants, pathology department technicians, of the Hospital who worked in the surgical department and the pathology department within the Hospital on March 5, 2012.

ANSWER: The health care providers whose names, signatures, or initials appear in the medical records for Leslie Baird’s March 5, 2012 procedure at CHRISTUS Santa Rosa Hospital — New Braunfels include but may not be limited to: CHRISTUS Santa Rosa Hospital — New Braunfels Treating Facility c/o Counsel Edward J. Kroger and Leah A. Greene Kroger | Burrus 3100 Weslayan, Suite 300 Houston, Texas 77027 Telephone: 713.961.7952 Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated healthcare providers currently employed and/or employed at the time of the incident made the basis of this lawsuit, including but not limited to: Angleton, Gareth G., RN PACU Bonner, Joe, RN OR Supervisor Brammeier, Vanessa, RN Farrow, Martha Garcia, Carmela Holden, Pamela Lab Supervisor La Roque, B., Nerve stimulator McKeen, Cassie, RN Circulator Moya, Susie S., RN Path-Jente, Lori A., RN Phillips, Patricia Certified Scrub Tech Skehan, Laura S, RN Post Op Physicians on staff at CHRISTUS Santa Rosa Hospital — New Braunfels Franklin, Gerald Marc, MD ENT Surgeon Hensley, Richard, MD Pathologist Perches, David, MD Anesthesiologist Rodriguez, Richard First Assistant

4 R. 1:58 INTERROGATORY NO. 2: Identify each and every Hospital employee you contend informed Dr. Franklin BEFORE he started his thyroidectomy surgery on Plaintiff on March 5th, 2012, that the cryostat a/k/a frozen section machine was not available and/or out of service for Plaintiff’s surgery.

ANSWER: CHRISTUS Santa Rosa Hospital — New Braunfels Treating Facility c/o Counsel Edward J. Kroger and Leah A. Greene Kroger | Burrus 3100 Weslayan, Suite 300 Houston, Texas 77027 Telephone: 713.961.7952 Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated healthcare providers currently employed and/or employed at the time of the incident made the basis of this lawsuit, including but not limited to: Bonner, Joe, RN OR Supervisor McKeen, Cassie, RN Circulator

INTERROGATORY NO. 3: Identify by name, address and phone number of each pathologist who was on duty and in charge/supervising the operations of the pathology department of the Hospital on March 5, 2012 and indicate the start and ending time of each pathologist.

ANSWER: Berardo, Melora, MD Chief Pathologist N. Union Ave New Braunfels, Texas 78130 830.643.5189 Dr. Berardo was responsible for Clinical Pathology services from 5:00 PM on March 5, 2012 through the conclusion of her shift on March 6, 2012.

Hensley, Richard, MD Pathologist N. Union Ave New Braunfels, Texas 78130 830.606.9111 Dr. Hensley was responsible for the Histology Department from 7:45 AM to 5:00 PM on March 5, 2012.

5 R. 1:59 INTERROGATORY NO. 4: Identify by name, address and phone number who was serving as Chief of Pathology for the Hospital on March 5, 2012.

ANSWER: Berardo, Melora, MD Chief Pathologist N. Union Ave New Braunfels, Texas 78130 830.643.5189

INTERROGATORY NO. 5: Identify by name, address and phone number Chief of Surgery for the Hospital on March 5, 2012.

ANSWER: Metzger, Nicholas, MD Chief of Surgery N. Union Avenue New Braunfels, Texas 78130 830.627.9229

INTERROGATORY NO. 6: Identify by name, address and phone number the pathology department personnel, technician and/or pathologist who you contend called and/or informed the surgical department on March 5, 2012 to tell them the cryostat a/k/a frozen section equipment was down due to contamination and need for cleaning.

ANSWER: CHRISTUS Santa Rosa Hospital — New Braunfels Treating Facility c/o Counsel Edward J. Kroger and Leah A. Greene Kroger | Burrus 3100 Weslayan, Suite 300 Houston, Texas 77027 Telephone: 713.961.7952 Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated healthcare providers currently employed and/or employed at the time of the incident made the basis of this lawsuit, including but not limited to: Bonner, Joe, RN OR Supervisor Holden, Pamela, HT Lab Supervisor McKeen, Cassie, RN Circulator

6 R. 1:60 INTERROGATORY NO. 7: Identify any and all Pathology Policies and Procedures manuals and/or guidelines that were in effect on March 5, 2012, which address and/or pertain in any manner to proper communication to various departments/personnel within the Hospital if any pathology equipment, including but not limited to cryostat a/k/a frozen section machine(s) are not available for use for any reason.

ANSWER: Please see the attached CHRISTUS Santa Rosa Hospital — New Braunfels Guidelines. Please highlight the sections you would like to review, and Defendant will forward the same to you.

INTERROGATORY NO. 8: Identify any and all Surgical Department Policies and Procedures manuals and/or guidelines that were in effect on March 5, 2012, which address and/or pertain in any manner to the proper course of action and/or communication to physicians, surgeons and/or surgical technicians if any pathology equipment, including but not limited to cryostat a/k/a frozen section machine(s) are not available for use for any reason.

ANSWER: Please see the attached CHRISTUS Santa Rosa Hospital — New Braunfels Guidelines. Please highlight the sections you would like to review, and Defendant will forward the same to you.

7 R. 1:61 Pamela Holden 1 1 NO. C-2013-0566-C LESLIE BAIRD, ) IN THE DISTRICT COURT ) 3 Plaintiff, ) ) VS. ) COMAL COUNTY, TEXAS ) GERALD MARCUS FRANKLIN, ) M.D., AND G. MARCUS ) FRANKLIN, M.D. & ) ASSOCIATES, P.A. D/B/A THE ) ENT CENTER OF NEW ) BRAUNFELS, CHRISTUS ) HEALTH; AND CHRISTUS SANTA ) ROSA HEALTH CARE ) CORPORATION D/B/A CHRISTUS ) SANTA ROSA HOSPITAL - NEW ) BRAUNFELS, ) ) 11 Defendants. ) 274TH JUDICIAL DISTRICT ----------------------------------- ORAL AND VIDEOTAPED DEPOSITION OF PAMELA HOLDEN JULY 16, 2014 ----------------------------------- 17 ORAL AND VIDEOTAPED DEPOSITION OF PAMELA HOLDEN, produced as a witness at the instance of the DEFENDANT, and duly sworn, was taken in the above-styled and numbered cause on July 16, 2014 from 9:08 o'clock a.m.

21 to 1:46 o'clock p.m., before DEBBIE S. LONGORIA, CSR in and for the State of Texas, reported by machine shorthand, at the COURTYARD MARRIOTT NEW BRAUNFELS, pursuant to the Texas Rules of Civil Procedure and the provisions stated on the record or attached hereto.

DepoTexas, Inc. / Sunbelt Reporting & Litigation Services R. 1:62 Pamela Holden 158 1 A. I've just always called directly to the OR and told them that the cryostat will be down, no more frozens.

4 Q. Generally, that's usually all the cryostat is 01:09 5 used for is by the OR department, correct?

6 A. Correct. Well, we also get tissue from the surgery center on Commons and we drive down there, pick it up as fast as we can, get it back and perform a frozen.

01:09 10 Q. But, within regards to the hospital setting, it's -- cryostat is used by the pathologists when requested by surgeons in the OR?

13 A. Correct.

14 Q. And do you -- do you remember what you did in 01:10 15 this case with respect to this particular tissue and who you contacted?

17 A. For this one, as soon as I handed it to Dr. Hensley, he said, "Possible granulomas," and I said, "Okay. What does that mean possible? Yea or nay, are 01:10 20 we shutting it down?" And he said, "Yes." I said, "Okay." I called directly into the OR and I said, "The cryostat will be down." I spoke with Joe Bonner on this.

24 Q. All right. And is it your testimony you made 01:10 25 that phone call immediately after getting instructions DepoTexas, Inc. / Sunbelt Reporting & Litigation Services R. 1:63 Pamela Holden 159 or information from Dr. Hensley that the cryostat is to be shutdown?

3 A. Yes, sir.

4 Q. And this is a phone call that you had with 01:11 5 him, you didn't tell him in person, correct?

6 A. Correct.

7 Q. And am I right to assume that this is a phone call that lasted a very short period of time?

9 A. Correct.

01:11 10 Q. Do you know for a fact that you specifically remember sitting here today making that phone call?

12 A. Yes, sir.

13 Q. And what was Mr. Bonner's response?

14 A. He -- he repeated what I said. I said, "The 01:11 15 cryostat's shutdown, no more frozens." And he said, "No more frozens?" And I said, "No, sir. We are down for the day." 18 Q. Did you tell him because of suspected TB?

19 A. Yes.

01:11 20 Q. Any other information you gave him other than what you've told me already?

22 A. No, not that I remember.

23 Q. Not that you remember?

24 A. Correct.

01:11 25 Q. All right. Did you have any subsequent DepoTexas, Inc. / Sunbelt Reporting & Litigation Services R. 1:64 R. 1:65 R. 1:66 R. 1:67 Cassie McKeen 1 1 NO. C-2013-0566-C 2 LESLIE BAIRD, ) IN THE DISTRICT COURT ) 3 Plaintiff, ) ) 4 VS. ) COMAL COUNTY, TEXAS ) 5 GERALD MARCUS FRANKLIN, ) M.D., AND G. MARCUS ) 6 FRANKLIN, M.D. & ) ASSOCIATES, P.A. D/B/A THE ) 7 ENT CENTER OF NEW ) BRAUNFELS, CHRISTUS ) 8 HEALTH; AND CHRISTUS SANTA ) ROSA HEALTH CARE ) 9 CORPORATION D/B/A CHRISTUS ) SANTA ROSA HOSPITAL - NEW ) 10 BRAUNFELS, ) ) 11 Defendants. ) 274TH JUDICIAL DISTRICT ----------------------------------- ORAL AND VIDEOTAPED DEPOSITION OF CASSIE McKEEN JULY 16, 2014 ----------------------------------- 17 ORAL AND VIDEOTAPED DEPOSITION OF CASSIE McKEEN, 18 produced as a witness at the instance of the DEFENDANT, 19 and duly sworn, was taken in the above-styled and 20 numbered cause on July 16, 2014 from 2:22 o'clock p.m.

21 to 4:59 o'clock p.m., before DEBBIE S. LONGORIA, CSR in 22 and for the State of Texas, reported by machine 23 shorthand, at the COURTYARD MARRIOTT NEW BRAUNFELS, 24 pursuant to the Texas Rules of Civil Procedure and the 25 provisions stated on the record or attached hereto.

DepoTexas, Inc. / Sunbelt Reporting & Litigation Services R. 1:68 Cassie McKeen 69 1 A. I don't really understand that.

2 Q. Sure.

3 A. It went on too long.

4 Q. You -- you are -- you are testifying under 5 oath that you told Dr. Franklin, prior to him doing the 6 surgery, that the cryostat was down?

7 A. That's correct.

8 Q. And that he proceeded, despite knowing that 9 information, that's your testimony, correct?

10 A. Yes.

11 Q. My question is, have you ever had that 12 experience before with another physician on a 13 thyroidectomy where, for whatever reason, the cryostat 14 was down, you informed that surgeon that it was down, 15 yet, that surgeon went forward with the thyroidectomy, 16 even though it wasn't -- even -- even though that 17 equipment was not available to them?

18 A. I cannot.

19 Q. This is the only case that you can remember?

20 A. This is the only case I can remember a 21 thyroidectomy. Other cases, I can remember where we 22 proceeded.

23 Q. I'm sorry, what?

24 A. Where we proceeded if there wasn't frozen 25 available.

DepoTexas, Inc. / Sunbelt Reporting & Litigation Services R. 1:69 R. 1:70 R. 1:71 R. 1:72