Executive Offices

April 10, 2019

Mr. Robert Gordon

Director
Michigan Department of Health and Human Services
333 South Grand Avenue
Lansing, MI 48909

Dear Director Gordon:

Please accept this response to your letter of April 5th. It is unfortunate that McLaren Flint’s efforts
to establish a trusting and collaborative relationship with you have apparently failed. When you
first reached out to me in January, you requested a meeting and made it clear that the only
alternative was your referral of our hospital to LARA for disciplinary action (the basis for which was
never explained). Before and after the meeting, you made it clear you were not receptive to
hearing from us about our history with MDHHS, but instead would accept information only as
presented to you by MDHHS staff. Imagine our confusion that you now want to revisit sixteen
months of history with us as a basis for an order that you and the Assistant Attorney General
previously said could only come from LARA.

If you question McLaren Flint’s caution with regard to MDHHS, we encourage you to study that
history and consider our perspective. When McLaren Flint provided information to MDHHS in 2017
and 2018 as part of a “collaborative” and “cooperative” process for “public health assurance”,
MDHHS used that information to generate its “chart book” report that was released to the media
in May 2018 with great fanfare. That report omitted important facts and data and ignored the
published peer-reviewed scientific articles that examined the link between Flint water quality after
the switch and the surge in Legionnaires’ disease that followed. The Attorney General’s office used
that report to support the defense of your predecessor Mr. Lyon in both the criminal and civil
proceedings, and it appears to have been created solely for that purpose.

When we met with you on February 21st, we were told that you intended to re-engage in a
“collaborative” and “cooperative” process to negotiate a new “public health assurance”
agreement, but in subsequent discussions your words and actions made it clear that there was, in
fact, no room for collaboration. When we asked for information about MDHHS’s “public health
assurance” efforts at other hospitals and healthcare facilities in the county, your staff claimed the
information was confidential. Yet MDHHS and the Attorney General’s office widely published
information about McLaren Flint’s operations in court filings and in the press. When we allowed
your team to study our water program data and question our consultant about it in February and
March of 2019, CDC and GCHD representatives expressed satisfaction with our approach and our

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April 10, 2019
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performance. MDHHS’s representative, Ms. Lyon-Callo, did not convey any level of concern about
the program. Yet your most recent letter indicates you refuse to accept those views.

So now comes your order for McLaren Flint to provide current and future information to MDHHS,
and to generate new information and take certain additional actions that are not part of our water
management program—actions not required of any other healthcare facility in our state, to our
knowledge. The statute cited in your letter does not authorize MDHHS to order the actions
described; the statute authorizes MDHHS to collect only existing information.

Accordingly, McLaren Flint agrees to provide existing water management program data for
February and March 2019. Julie Borowski will forward this data to Ms. Lyon-Callo and Mr. Collins,
as you had requested.

Other aspects of your letter are addressed below.

Program Performance

Your letter refers to MDHHS’s review of McLaren Flint clinical and environmental data over the
past sixteen months as a basis for your action. During that period, though, state and county public
health officials expressed favorable views of McLaren Flint’s water management program. In July
of 2018, MDHHS issued a “close out” report for the May 2017 Cooperative Strategy Agreement. In
that report, MDHHS confirmed that McLaren Flint had substantially complied with the terms of the
CSA and the efforts had been effective. In December of 2018, GCHD asked to conduct water
sampling at our hospital. We agreed to that request. The results demonstrate that our water
management program is effective. All 36 samples collected by GCHD were non-detect for Lp1. One
of 36 samples collected by McLaren Flint’s consultant was positive for Lp1, at 1 cfu/mL—a finding
considered entirely negligible by all water quality guidelines. In January 2019, Jim Henry at GCHD
(the public health agency that we are supposed to report to) indicated that GCHD has no issues
with the effectiveness our water management program. Mr. Henry has been our primary point of
contact for GCHD’s and MDHHS’s questions about water management at McLaren Flint and he is
familiar with plan and program data, including the results of the December 2018 sampling.

All of this data supports that our water management plan is effective. The water management
team monitors the environmental and clinical data on a regular basis, and in consultation with
outside experts. There are no indications of legionella growth (amplification) in our hospital’s
plumbing system.

On the clinical side, we are aware that MDHHS believes two of the twenty-seven LD cases reported
in Genesee County in 2018 were possibly associated with McLaren Flint Hospital. Neither our
internal investigation, nor the review of our external consultants, nor the available clinical data
support that conclusion. We welcome the opportunity to engage in a meaningful dialogue with
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April 10, 2019
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MDHHS about the alleged association of those cases with our hospital. To date, MDHHS has not
been receptive to hearing from McLaren Flint staff about these cases. Instead, MDHHS has
attempted to shift the definition of “hospital-associated LD” that it applies to cases reported by
McLaren Flint so that it demonstrates an association where no association would exist under the
standard definition.

Your letter refers to “anomalies” in performance of the secondary treatment systems and
monitoring procedures. These “anomalies” are actually instances of normal and expected
variability in water quality. Your questions about the water quality data were discussed at length
and were fully addressed at the February 21st meeting and in subsequent communications. It is
clear to us from this exchange that MDHHS’s stated concerns are based on disagreements or
misunderstandings about the program and program data. Your contractors, who are relatively new
to this process, are entitled to their views; however, MDHHS does not have any authority over the
design or implementation of our water management program or evaluation of our program
performance. The CMS water management policy places all responsibility for water management
on the facility and its water management team.

The suggestion that McLaren Flint was unwilling to collaborate with MDHHS is patently false. In
February 2019, MDHHS requested a new “collaborative agreement” to facilitate an exchange of
information about McLaren Flint’s water management program. MDHHS and the Assistant
Attorney General indicated that there would be a collaborative process, as had been the case in
2017. McLaren Flint was willing to engage in a collaborative process to resolve MDHHS’s stated
concerns. MDHHS’s initial draft agreement imposed requirements on McLaren Flint that are not
consistent with the laws, policies, and protocols that apply to all hospitals and healthcare facilities
in our state. Such an agreement was not acceptable to McLaren Flint. A “public health assurance”
effort directed exclusively at McLaren Flint does not promote the public health in Genesee County.
If “public health assurance” was the goal, MDHHS’s efforts would be directed at all hospitals and
healthcare facilities, including those other than McLaren Flint that have reported multiple LD cases
into MDSS, that have detected Legionella pneumophila as a result of investigative water testing
conducted by or at the direction of public health agencies, or that have no water management
program and conduct no water testing at all. Additionally, MDHHS would direct meaningful
attention to the cases of LD with no association to McLaren Flint, and there are many. A “public
health assurance” effort focused exclusively on McLaren Flint Hospital would leave our community
at risk and would bias the resulting data against our hospital.

Because of our ongoing concern about MDHHS’s singular focus on McLaren Flint—an approach
that leaves our community at risk—McLaren Flint stands by the request for information about
MDHHS’s “public health assurance” efforts at other healthcare facilities in the state, including
information about the number of diagnosed cases of LD—and deaths—reported by other facilities
which have occurred and that have not been reported to the public. If you are unwilling to provide

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April 10, 2019
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the information to us, please identify the custodian of records for a Public Information Act
request.

In response to your initial draft agreement, we proposed an agreement that reinforced both
parties’ commitment to follow the existing water management program and the applicable laws,
policies, and protocols that apply to all hospitals and health care facilities in our state, such as the
clinical guidelines and MDHHS’s Legionellosis Surveillance and Investigation Protocol. MDHHS
rejected that proposal and demanded that we sign on to MDHHS’s initial proposal as written.
Faced with that demand and the threat of a LARA referral, McLaren Flint agreed to almost all
provisions of MDHHS’s initial proposal. Negotiations broke down because MDHHS refused to
accept any changes to that proposal, making it clear that MDHHS did not intend for this to be a
“collaborative process”. MDHHS then sought LARA’s involvement but apparently bypassed LARA
by issuing the letter of April 5th.

The assertion that MDHHS “cannot be assured that the hospital is actively minimizing the risk of LD
transmission” does not align with the facts. In the four years since the water crisis began, McLaren
Flint has invested close to $2,000,000 in our water management program to reduce the risk of
legionella in our hospital. MDHHS is well aware of the extraordinary measures McLaren Flint has
implemented. Those efforts consist of the following:

1. We retained Dr. Janet Stout of Special Pathogens Laboratory in 2016 to conduct a risk
assessment and design a water management program for legionella risk management.

2. We installed multiple monochloramine units to boost the concentration of disinfectant in

the incoming municipal water before it is circulated in the hospital’s plumbing system.

3. We implemented the water management plan designed by Dr. Stout, which includes –

(a) Regular monitoring of the monochloramine systems;

(b) Periodic water testing for many waterborne pathogens including legionella;
(c) Corrective actions in response to specific events;
(d) The use of water restrictions when warranted;
(e) Regular communications between infection control and facilities staff; and
(f) Regular consultation with outside technical experts.

McLaren Flint has tested its water on at least a monthly basis since September 2014. The program
covers all areas of the hospital and provides state-of-the-art water quality control.

McLaren Flint also provides drinking fountains, filtered bottle-filling stations, and bottled water for
patient care, staff and visitors.

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April 10, 2019
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McLaren Flint is in the process of installing a point-of-entry filter to remove debris and organic
matter from the incoming municipal water before it enters the hospital’s plumbing system. Test
results from late 2018 indicated that the city water had high concentrations of particulates and
organic material, as indicated in our March 13, 2019 letter to you. As we reported to you, the city’s
water was visibly discolored when samples were collected in December 2018, as shown in this
photo of a water sample taken from the city’s water pipes just before it enters the hospital:

These external conditions can promote legionella growth, so we are making the additional
investment in the point-of-entry filter. The water infrastructure conditions documented in the
MDEQ’s Administrative Consent Order against the City, and the construction work required to
correct those conditions (which is scheduled to take place in the months and years ahead) also is a
concern.

McLaren Flint also implemented a proactive clinical surveillance protocol to support efforts to
quickly identify cases of LD, consistent with the Legionellosis clinical protocols issued by GCHD.

In addition to these practical risk management measures, McLaren Flint has shared clinical and
environmental data with MDHHS and GCHD. We have allowed MDHHS and GCHD to communicate
with our staff and consultants about the program and the program data. As you may not know,
there is an extensive history of communications on these issues that occurred before you joined
MDHHS. That written record, including our March 2017 letter to your predecessor, the
information provided under the May 2017 CSA, MDHHS’s August 2018 “close out report”, and
subsequent letters and emails, will reflect MDHHS’s knowledge that McLaren Flint is “actively
minimizing the risk of LD transmission at its hospital.” MDHHS is not only well aware of McLaren
Flint’s efforts, MDHHS and GCHD acknowledged that our efforts are effective. LARA recognized our
plan as consistent with national best practices.

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Director Robert Gordon
April 10, 2019
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We have reason to believe that our water management program is among the most proactive and
comprehensive in the county, if not the state.

Information Requested

MDHHS Request No. 1: The current version of [McLaren Flint’s] Water Management Plan and
any further editions of that document as they are implemented.

McLaren Flint Response: MDHHS has a current version of McLaren Flint’s Water Management Plan.
If the document is updated, the revised edition will be shared with MDHHS.

MDHHS Request No. 2: The following data per the Water Management Plan water monitoring
schedule, from February 7, 2019 to present, and on an ongoing basis moving forward:

a. Hot water generation temperature (weekly);

b. How water distal outlet temperature (quarterly);
c. Monochloramine concentrations (weekly);
d. Free ammonia concentrations (weekly);
e. Legionella distal site positivity (quarterly);
f. Incoming and distal outlet cold-water temperature (as available);
g. Incoming and distal outlet cold-water free chlorine concentration (quarterly);
h. Incoming cold-water heterotrophic plate count concentration (quarterly);
i. Monitoring of ice machines (per guidelines).

McLaren Flint Response: This requested data is encompassed by our existing Water Management
Plan. McLaren Flint agrees to provide MDHHS the program data for the months of February and
March 2019.

MDHHS Request No. 3: All water management program team/consultant/facility management

responses to aberrations in water quality measures.

McLaren Flint Response: McLaren Flint’s Water Management Plan does not call for corrective
actions to be taken for “aberrations” in water quality measures. The plan defines operational goals
and control limits. Results outside of control limits are reviewed by the water management team.
Data is trended and put into context with other clinical and environmental operational factors for
precision. Corrective actions are taken when called for by the water management plan.

MDHHS Request No. 4: All water management program team/consultant/facility management

responses to environmental Legionella positives and/or LD cases or suspected cases of LD in
persons identified as having possible healthcare association with the hospital.

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April 10, 2019
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McLaren Flint Response: McLaren Flint will continue to take corrective actions in accordance with
the water management plan and it will maintain a corrective action log, as called for in the plan.
We will make the corrective action log available to MDHHS or GCHD (whichever is the designated
lead agency) in the event of a public health investigation of Legionellosis conducted in accordance
with MDHHS’s Legionellosis Surveillance and Investigation Protocol.

McLaren Flint was encouraged by your stated commitment to science, the public interest, equal
treatment of all Michigan residents, and fiscal responsibility. We looked forward to MDHHS’s
transformation under your leadership. However, it is clear now that you are adopting the same
approach as your predecessor. With this in mind, as well as the data that shows that McLaren
Flint’s water management program is effective and very likely the most proactive and
comprehensive in the county, if not the state, McLaren Flint must disagree with your comments.
McLaren Flint is willing to engage with you about the public health aspects of water quality when
we can be assured that MDHHS is applying the same standards, criteria and protocols to McLaren
Flint as it applies to all healthcare facilities in the state, and when we have confidence that the
requests for information are driven by genuine science-based public health considerations instead
of legal defense strategies.

In closing, please be assured that McLaren Flint is committed to the health and safety of our
patients, staff, and the community we serve. We will continue to follow our water management
program, the clinical Legionellosis guidelines, and the laws, policies, and protocols that apply to all
healthcare facilities in our state. We look forward to a time when we can be assured that MDHHS
is applying the same standards, criteria and protocols to McLaren Flint as it applies to all other
hospitals, and when we have confidence that MDHHS’s recommendations and requests for
information are guided by objective, science-based criteria. We also look forward to a time when
our respective organizations can work together toward achieving the common goal of promoting
public health in Genesee County.

Respectfully,

Chad M. Grant
President and CEO

cc: Orlene Hawks, Director, Michigan Department of Licensing and Regulatory Affairs
John McKellar, Health Officer, Genesee County Health Department

401 S. Ballenger Highway, Flint, MI 48532