INSLEE ANNOUNCES EDUCATION RECOMMENDATIONS FOR 2020–2021 SCHOOL YEAR

Gov. Jay Inslee today announced new recommendations from the Washington State Department of Health for resuming in-person instruction in public and private K-12 education for the upcoming 2020–2021 school year. Inslee was joined by Chris Reykdal, state Superintendent of Public Instruction at a press conference.

Similar to the state’s county-by-county phased approach to reopening, the plan allows local health departments and school districts decide if and how they will allow students back in the classroom.

“We know the uncertainty surrounding school reopening is a source of extraordinary anxiety for parents and educators — anxiety not just about whether it’s safe to go back to school in person, but also about the impacts to children if they don’t return to the classroom,” Inslee said.

The plan includes several different considerations for deciding whether or not to return to in-person learning, but no matter the county, when COVID-19 infection rates are high, the state strongly recommends school districts move to mostly online or remote learning.

Read the rest of the story on the governor’s Medium page.

INSLEE ANNOUNCES ROLLBACKS TO SOME ACTIVITIES TO SLOW COVID-19 EXPOSURE

COVID-19 WEEKLY UPDATE JUNE 30, 2020

This update is published each Tuesday following the report by County Medical Director, Dr. Thomas Locke, to the County Commissioners and summarizes significant points from that meeting and other information that has not been previously reported in PLVC eBlasts. Topics are listed in summary form with links to Web pages such as PLVC at www.plvc.org/covid-19 or Washington State Hotline at Phone: 800-525-0127 – at prompt press #.
Roadmap to Reopening: (We are now in Phase II – have applied for Phase III)
  • JeffCo forwarded its Phase III re-opening application to the Washington State Department of Health on 06/29/20 – see PLVC website above for Board of Health details. Increased numbers of individuals allowed for various activities are included. Some additional limits on indoor gatherings may be imposed when Phase III is actually implemented.
  • It is expected that the turnaround response will not be as quick as the Phase II application and will take up to 7 to 10 business days to hear back
  • It is expected that we will be in Phase III, at minimum, through the balance of 2020 – or perhaps longer
  • Dr. Locke’s ongoing messaging:
  • Masking Protocols – must be followed
  • Distance – Social Distancing Protocols must be followed both indoors and outdoors
  • Hand Hygiene – wash hands frequently
  • No face touching
More information on Safe Start Washington can be found via this link:
Advisories:
  • New testing procedures being explored:
  • Pool testing – this is group testing
  • A sample of individuals in the pool is tested
  • If tests come back negative – all is good
  • If tests come back positive, then everyone in that pool (group) is tested individually to find out which one(s) are positive
  • The pool testing procedure will allow a greater quantity of testing to be completed with faster contact tracing opportunities
  • Masking:
  • Research has found face shields to be effective
  • Suggested to be used with some sort of bandana for absorption benefit of moisture and airborne particles
  • In combination with face mask – more effective than shield alone
  • Use of face shields would be considered following the WA State masking orders/directives
Department of Emergency Management (DEM) Updates (Willie Bence):
  • State EOC has been contacted about support on face shield or clear face masks for those with disabilities that require lip reading, etc.
  • There is a need for smaller sized face masks for children outside of the exempted age range
  • Jefferson Health is in good supply of PPE and bed capacity should a surge occur
  • It was also noted that masking compliance in the county is good and getting better
  • However, there are residents that are not properly wearing their masks
  • To keep yourselves and others safe, the mask needs to fully cover both the nose and mouth

Rayonier Spraying Around Teal Lake

Toxicity

Triclopyr herbicide products are labeled by the EPA with the signal word “Caution” which translates to low toxicity.  It is also a Group D chemical which means it is not classifiable as a carcinogen. It is non-toxic to bees but highly toxic to fish.

Mode of Action

The effects of Triclopyr mimic that of plant growth hormones, interfering with the normal growing process.  It is absorbed by leaves, roots, cut stems or green bark and moves through the plant to accumulate in the growth region of plant where it is able to disrupt further growth.

Uses

Triclopyr is registered for use on rice, pasture and rangeland, lawns, right-of-ways, and forests.

Products Containing Triclopyr

Battleship III Herbicide – 2.5 gallon
Fertilome Brush Killer and Stump Killer
Confront Herbicide
Crossbow Herbicide

JEFFERSON COUNTY LOCAL HEALTH OFFICER DIRECTIVE REGARDING COVID-19; REQUIRING THE WEARING OF CLOTH FACE COVERINGS 05/28/2020

NOW, THEREFORE, I, Thomas Locke, MD, MPH, Local Health Officer for Jefferson County, under the authority of RCW 70.05.070, RCW 43.20.050, and WAC 246-100-036, make the following DIRECTIVE:

  1. Use of Cloth Face Coverings. All individuals must wear face coverings over their noses and mouths when they will be at (1) indoor public settings, or (2) outdoor public locations and cannot maintain distancing of approximately six feet from another individual who does not share their household. Because there is still a shortage of medical-grade or N95 respirators for health care workers, unless a particular health reason requires it, individuals should use fabric coverings, such as cloth face masks, scarves and bandana coverings or other material as recommended by CDC. Cloth face masks must be worn properly in order to avoid contaminating the hands or face of the user. Before putting on a mask and after removing a mask, an individual should clean their hands with alcohol-based hand rub or soap and water and change masks when moist and wash after use. While in use, avoid touching the mask. Worn masks may be contaminated with infectious agents. Wearing of cloth face coverings should not be required for the following individuals: (a) any child under two years of age; (b) any child who is at least two and less than twelve years of age unless a parent or caregiver supervises the use of cloth face coverings by children to avoid misuse; (c) any individual who is unable to remove the cloth face covering without assistance; (d) any individual who is deaf and uses facial and mouth movements as part of communication; or (e) any individual who has been advised by a medical professional that wearing a face covering may pose a risk to that individual for health reasons.
  2. Cloth Face Coverings Required. Owners and operators of businesses in Jefferson County shall not permit or allow any non-employee to enter or remain inside a building owned or operated by the business unless the non-employee is wearing a cloth face covering over their mouth and nostrils. This does not apply to a restaurant, tavern, or bar patron while eating or drinking. Further, businesses that sell food, medicine, or medical supplies shall provide a method for customers to purchase these items without entering a building, such as curbside pick-up or delivery. 3. Notice by Businesses, Ports, and Marina Facilities. Owners and operators of all businesses, ports, and/or marina facilities in Jefferson County shall post notice at entry points indicating that the wearing of cloth face coverings is required inside businesses in Jefferson County. Said notice shall be posted no later than 7 days after Jefferson County begins full implementation of Phase II of the Safe Start Washington plan as authorized by the Governor or Washington Secretary of Health. This paragraph does not require posting of notice by a business that is not open to the public.
  3. Notice by Businesses, Ports, and Marina Facilities. Owners and operators of all businesses, ports, and/or marina facilities in Jefferson County shall post notice at entry points indicating that the wearing of cloth face coverings is required inside businesses in Jefferson County. Said notice shall be posted no later than 7 days after Jefferson County begins full implementation of Phase II of the Safe Start Washington plan as authorized by the Governor or Washington Secretary of Health. This paragraph does not require posting of notice by a business that is not open to the public.

JEFFERSON COUNTY IN PHASE 2 OF “SAFE START” REOPENING PLAN 05/26/2020

Jefferson County in Phase 2 of “Safe Start” Reopening Plan
On May 23, Jefferson County received approval to move into Phase 2 of Governor Inslee’s “Safe Start” phased approach for resuming recreational, social and business activities, subject to conditions. Every phase will still require social distancing and appropriate health precautions including the use of personal protective equipment in a number of workplaces. Use of a cloth face covering is strongly recommended. Guidance and safety criteria for reopening can be found on the “Safe Start” webpage. Camping and indoor retail sales in Jefferson County remain prohibited until additional neighboring counties also enter Phase 2. See the tables below for what’s open and what’s not.

What’s Open, What’s Closed?

HEALTH OFFICER RECOMMENDATIONS RE: VARIANCE REQUEST TO MOVE FROM PHASE 1 TO PHASE 2 OF GOVERNOR INSLEE’S STAY HOME – STAY HEALTHY PROCLAMATION 5/14/2020

Background: For the past 10 weeks, Washington State has been dealing with an unprecedented public health emergency – the SARS-CoV-2 Pandemic. Lacking either a vaccine or effective antiviral medications and facing severe limitations in personal protective equipment and adequate testing resources, Washington State implemented an increasingly restrictive set of community mitigation strategies. These mitigation strategies started with isolation and quarantine of know cases and contacts and progressed to school closures and, on March 23, 2020, a state-wide closure of all non-essential businesses, a stay at home order, and a ban on all non-essential travel. These extreme measures were successful in stopping the exponential spread of the pandemic coronavirus and preventing the demand for hospital care from exceeding the capacity to deliver that care. This “flattening of the curve” has dropped the number of new cases of COVID-19 infection from almost 600 per day in late March to around 250 per day. Demand for hospital services is also slowly declining. The success of this effort is precarious and the most recent data shows that case rates may be climbing upwards again. Washington State has not set a numerical target for suppression of new COVID-19 infections. The CDC has recommended 0.7 cases/100,000 population. This would translate into 50 cases/day in Washington State and 7-8 cases per month in Jefferson County.

The Way Forward: Indefinite closures of non-essential business and home isolation are neither desirable nor sustainable. These extreme measures were designed to prevent a medical catastrophe and save lives that would have otherwise been lost for lack of advanced medical care. This goal has been achieved. Washingtonians have had over 6 weeks to learn social distancing, hand hygiene, and other mitigations designed to limit spread of coronavirus. On May 3, 2020 Governor Inslee renewed his emergency proclamation with significant modifications. The new plan authorizes a set of Phase 1 activities to begin on May 5th and last until at least May 31st.  10 rural counties with populations less than 75,000 and with very low levels of Covid-19 activity (as evidenced by no diagnosed cases for 3 weeks or longer) were authorized to seek a variance to move from Phase 1 to Phase 2 activities before the rest of the state. This variance request could seek authorization to adopt all Phase 2 activities or could request a subset of these activities. The formal process starts with a recommendation from the county health officer to the local board of health. If a majority of board of health members supports the variance request (either as submitted by the health officer or as modified by the board), it advances to the board of county commissioners for final approval. The application must provide information on 5 essential metrics and contain a certification from the local hospital that it has adequate bed capacity and PPE to respond to an increase in COVID-19 cases.

Jefferson County Response: On Thursday, May 7, a joint videoconference meeting was held with the Jefferson County Board of Commissioners, the Jefferson County Board of Health, and the Port Townsend City Council. After a presentation by the health officer and considerable discussion, it was decided to move forward with a deliberative process to gather public comment and carefully consider each option on the list of Phase 2 activities for possible early implementation in Jefferson County. This process would involve a special meeting of the Jefferson County Board of Health on May 14 and a final vote at the Board’s regularly scheduled meeting on May 21.

New Developments and Status of Variance Requests in Washington State: At the time of the May 7th meeting, Jefferson County had not recorded a confirmed case of COVID-19 for 28 days and was clearly eligible to submit a variance application. On May 9th, a Jefferson County resident was diagnosed with COVID-19. The source of her infection is unknown as is the date the infection was acquired and is the subject of an ongoing case investigation requiring additional specialized testing at the University of Washington. Last week 5 rural counties in Eastern Washington (Columbia, Garfield, Lincoln, Ferry, and Pend Oreille) were granted variances to move to Phase 2 activities. Three additional eligible counties (Stevens, Skamania, and Wahkiakum) were approved on May 11. After submitting their application, Kittitas County experienced a large outbreak of COVID-19 at a meat packing plant and their application review has been “paused”. In addition to the 10 counties deemed eligible by virtue of their population size and >3 weeks of no new cases, 2 other counties have expressed interest in obtaining variances despite a small number of COVID-19 cases in the past 3 weeks. It is reported that Mason county has applied for a variance and asked that alternate measures of low COVID prevalence be utilized. The legislative representatives from Clallam County have made a similar request for consideration. It is unclear whether Jefferson County remains eligible for a Phase 2 variation and this eligibility will need to be determined by the Secretary of Health, Dr. Wiesman.

Special Considerations for Jefferson County: Jefferson County scores favorably on several metrics for pandemic preparedness: adequate public health and hospital capacity to provide prompt case investigation and contact tracing and to meet the medical needs of diagnosed COVID-19 patients, either through hospitalization or medical case management in an outpatient setting. PPE supplies although hardly optimal, do meet state standards for adequacy. A major concern for Jefferson County is its high percentage of residents at risk for the complications of COVID-19 infection. U.S. census projections are that 36.9% of Jefferson Counties 32,221 residents were 65 years of age or older as of April 1, 2020. This is the highest population percentage in Washington State. Mortality risk increases with age for COVID- 19 with 90% of Washington deaths due to this infection occurring in those 60 years of age or older. An additional serious consideration is Jefferson County’s proximity to Seattle and the urban centers of the I- 5 corridor where COVID-19 infection remains prevalent. The Phase 1 openings of State and National parks to day use and permitting of recreational fishing have already dramatically increased travel to the Olympic Peninsula. Any Phase 2 openings that further encourage tourism and travel will likely increase this trend. This risk is especially acute if Jefferson County is perceived as the closest “open” county to Seattle and thus an attractive day trip to escape the restrictions of the urban “lockdown”.

Basis of Health Officer Recommendations: As the appointed Health Officer for Jefferson County since 1996, my duties are clearly defined in statute. RCW 70.O5.070 (3) assigns the health officer the duty to “Control and prevent the spread of any dangerous, contagious or infectious diseases that may occur within his or her jurisdiction”. Additional statutes and rules assign specific powers and duties to control communicable diseases, including broad isolation and quarantine powers. A health officer’s prime directive is to prevent the spread of infectious diseases. This is not to minimize the importance of other social determinates of health – jobs, civil liberties, economic and food security, education, and more.

Public health is always a balancing act between community health and individual liberty. As in many other health-related activities, the risks and benefits of specific choices must be carefully balanced.

Risk/Benefit Analysis of Phase 2 Activities: Phase 2 activities modify physical distancing measures in 4 key areas: recreation, gathering size, travel, and business/employer activity. There is still much that is

unknown about SARS-CoV-2 transmission and the proportionate risk of different behaviors and activities. Models are being developed by the Institute of Disease Modeling (https://www.idmod.org/ ) and others to better quantify these risks but are not yet available. One early finding is that manufacturing and construction activities have high economic benefit and low disease transmission risk. Conversely “leisure activities” have low economic benefit and comparatively higher transmission risk.

Given the greater likelihood that strict physical distancing, hand hygiene, Covid-specific occupational health standards, and restriction of ill workers can be best accomplished in the structured environment of a construction site or a manufacturing facility, these findings appear plausible. Leisure activities, by their nature, are less structured and more likely to violate physical distancing standards. Activities that promote tourism increase coronavirus transmission risk by encouraging travel from high prevalence areas to low prevalence areas. This effect is magnified when these activities are not available in adjacent counties.

Another important consideration is enforcement. While Governor Inslee’s proclamation is backed by the force of law and violations carry gross misdemeanor penalties, there is no active enforcement of travel or gathering sizes. To be effective, citizens must be motivated to follow physical distancing requirements by a mix of personal benefit and the desire to protect others. Some activities are readily enforceable. Isolation and Quarantine orders have specific enforcement mechanisms. Licensed food establishments (like grocery stores and restaurants) have licenses issued by the local health department which can be suspended or revoked for violation of public health codes. Individual businesses can enforce physical distancing restrictions by setting conditions for entry (e.g. number of customers or an indoor masking requirement). Salons, barbers, and pet groomers can limit appointments to local clients only.

Benefit/Risk Ranking of Phase 2 activities:

 High benefit/low risk: Manufacturing (non-essential repair, maritime industry, and others), additional construction phases, in-home domestic services (nannies, housecleaning, etc.), professional services/office-based business [non-tourism oriented, telework strongly encouraged], pet grooming [local customers only]

Medium benefit/medium risk: Outdoor activity with 5 or fewer people outside your household (no overnight camping), indoor gathering with 5 people outside your household per week, hair and nail salons/barbers [local customers only]

Lower benefit/ higher risk: Outdoor activity with 5 or fewer people involving overnight camping (RV or campgrounds), Restaurants with sit down service, real estate (beyond current permitted activities), pet grooming (out-of-area clients), hair and nail salons/barbers (out-of-area clients), retail (in-store purchases)

Jefferson County Health Officer Recommendations Phase 2 Variance Activities Recommended:

Recreation: Outdoor recreation involving fewer than 5 people outside your household excluding all overnight camping.

Gatherings: Gather with no more than 5 people outside your household per week, masking encouraged if social distancing cannot be maintained. Visitors from high prevalence areas strongly discouraged.

Travel: Essential travel and limited non-essential travel for Phase 1 and 2 permissible activities. Out-of- area tourism strongly discouraged (ferry signage, advertising, local governmental directives) until statewide Phase 2 implementation.

Business/Employers: Manufacturing (non-essential repair, maritime industry, and others), additional construction phases, in-home domestic services (nannies, housecleaning, etc.), professional services/office-based business [non-tourism oriented, telework strongly encouraged], pet grooming (local customers only), hair and nail salons/barbers (local customers only)

Phase 2 Variance Activities NOT Recommended:

Recreation: Outdoor activity with 5 or fewer people involving overnight camping (RV or campgrounds)

Business/Employers: Restaurants with sit down service, real estate (beyond current permitted activities), pet grooming (out-of-area clients), hair and nail salons/barbers (out-of-area clients), retail (in- store purchases allowed with restrictions), professional services/office-based business (tourism focused)

Note: The Governor’s Safe Start Washington plan (https://www.governor.wa.gov/sites/default/files/SafeStartWA_4May20_1pm.pdf ) contains detailed physical distance and infection control requirements for individuals and businesses. These apply to all phases of the State’s reopening plan and are critical for the prevention of coronavirus transmission.

Failure to rigorously adhere to all of these community interventions will constitute grounds to revoke Phase 2 status for individuals or businesses.

Signed

Thomas Locke, MD, MPH
Jefferson County Health Officer

WASHINGTON REOPEN PHASES

Phase 1

  • Some restrictions could be lifted in mid-May, including retail curbside pickup, auto sales, car washes and drive-in church services.
  • The ban on large gatherings remains in effect, even gatherings where participants think they can socially distance.

Phase 2

  • Increase in outdoor recreation, including camping.
  • Small gatherings of five people or less could return
  • New construction and in-store retail purchases with health restrictions.
  • Barber shops and salons could reopen.
  • Restaurants could reopen with 50% capacity and table size no larger than five people.
  • Some professional services and offices could open as well, even though teleworking would remain strongly encouraged.
  • Pet care services including grooming could resume.

Phase 3

  • Gatherings of 50 people or less could resume, including sports activities.
  • Restaurants and bars could increase their capacities to 75% and gyms and movie theaters could reopen at 50% capacity.
  • Retail, libraries, museums and government buildings could reopen.
  • Recreational facilities including pools could open at 50% capacity.

Phase 4

  • The majority of public interactions could resume and gatherings of more than 50 people would be allowed, but still while practicing social distancing.
  • Bars, restaurants and entertainment venues could return to allow the maximum licensed capacity of their venues.
  • Worksites could reopen, but with physical distancing continuing.

 

INTERPRETIVE STATEMENT RELATED TO PROCLAMATION BY THE GOVERNOR 20-24, RESTRICTIONS ON NON-URGENT MEDICAL PROCEDURES

INTERPRETIVE STATEMENT RELATED TO PROCLAMATION BY THE GOVERNOR 20-24, RESTRICTIONS ON NON-URGENT MEDICAL PROCEDURES

TO: Interested Stakeholders

FROM: Governor Jay Inslee

DATE: April 29, 2020

SUBJECT:     Interpretive Statement Related to Proclamation by the Governor 20-24, Restrictions on Non-Urgent Medical Procedures

Background. On March 19, 2020 Governor Inslee issued Proclamation 20-24 with the goal of ensuring hospitals and the health system would have enough surge capacity and personal protective equipment to manage an influx of patients with COVID-19. The Proclamation applies to services delivered in hospitals, ambulatory surgical facilities, dental, orthodontic, and endodontic offices in Washington State. The Proclamation will remain in effect through May 18, 2020.

As providers across the state have significantly adjusted operations in response to the Proclamation, the need for additional guidance has been identified. The purpose of this statement is to provide that guidance.

It is the position of the State that the Proclamation allows performance of all services considered to be “emergent” or “urgent” for which delay would result in worsening a life-threatening or debilitating prognosis. Clinicians should use clinical judgment to determine performance of procedures considered to be non-urgent or “elective.”

In addition, given the evolving and fluid nature of pandemics in general, and COVID-19 in particular, clinical judgments regarding non-urgent or “elective” procedures need to be viewed through the lens of relative harm to patients of treatment versus deferment, in terms of potential patient and provider contraction of COVID-19.

The remainder of this document pertains to health care services, procedures, and surgeries falling into the non-urgent or “elective” category.

 Considerations in determining “harm” to the patient. The Proclamation limits, “healthcare services, procedures, and surgeries that, if delayed, are not anticipated to cause harm to the patient within the next three months…” The Proclamation goes on to provide examples of procedures to delay, which include, “most joint replacements, most cataract and lens surgeries, non-urgent cardiac procedures, cosmetic procedures, some endoscopy and some interventional radiology services.”

The Proclamation does not provide a definition of “harm.” To clarify, the Governor leaves assessment of harm up to the individual clinician. In order to assess harm, clinicians should consider if a patient’s illness or injury is: causing significant pain, significant dysfunction in their daily life or work, or is either progressing, or at risk to progress. Additionally, clinicians should assess the risk of harm that could be experienced by a patient as a result of undertaking the surgery or procedure during the COVID-19 pandemic.

The decision to perform any surgery or procedure in hospitals, ambulatory surgical facilities, dental, orthodontic, and endodontic offices, including examples of those that could be delayed in the Proclamation, should be weighed against the following criteria when considering potential harm to a patient’s health and well-being as described above:

  • Expected advancement of disease process
  • Possibility that delay results in more complex future surgery or treatment
  • Increased loss of function
  • Continuing or worsening of significant or severe pain
  • Deterioration of the patient’s condition or overall health
  • Delay would be expected to result in a less-positive ultimate medical or surgical outcome
  • Leaving a condition untreated could render the patient more vulnerable to COVID-19 contraction, or resultant disease morbidity and/or mortality
  • Non-surgical alternatives are not available or appropriate per current standards of care
  • Patient’s co-morbidities or risk factors for morbidity or mortality, if inflicted with COVID-19 after procedure is performed

Furthermore, diagnostic imaging, diagnostic procedures or testing should continue in all settings if disease is suspected, based on clinical judgement that uses the same definition of harm and criteria as listed above.

Prerequisites to performance of healthcare services, procedures and surgeries. Foundational to the performance of any healthcare service, procedure, or surgery permitted under Emergency Proclamation 20-24 is the ability to meet infection prevention and control standards, maintain

appropriate personal protective equipment supplies, as well as following Department of Health (DOH)- issued guidance on use of personal protective equipment (PPE). For permitted procedures requiring an overnight stay, hospitals will not exceed 80% of available bed (licensed and staffed beds) capacity.

Specifically, the following PPE prerequisites are required before facilities can perform procedures, surgeries, or services permitted under Emergency Proclamation 20-24:

  • Facilities must provide health care workers (direct patient care and affected ancillary staff) with appropriately sized and sufficient quantities of PPE to perform essential job
  • Facilities must be aligned with Washington State Department of Health’s PPE Usage Guidelines – PPE Conservation Strategies (Yellow), which says personal protective equipment is discarded and replaced when it is soiled, damaged, or hard to breathe
  • Facilities must follow the Washington State Department of Health’s Guidance on Extended and Re-use of PPE by Healthcare Personnel (HCP).
  • Facilities must have on-hand and in the facility 7 days of appropriate
  • Facilities must report accurate counts of PPE available and in the facility daily, as well as PPE on order, to the WA Health
  • Facilities must report following required DOH guidelines for PPE use and conversation to the WA Health
  • Health care workers have access to COVID-19 testing and to timely notification (within eight

(8) hours of awareness) of exposure to COVID-19.

  • Facilities must report on COVID-19 positive health care workers by facility and profession/position to the WA Health

Outpatient clinic visits. The Proclamation permits outpatient clinic visits, both in hospital-based clinics and other outpatient clinic settings. While not addressed in the Proclamation, the Governor encourages clinicians to weigh the benefits and risks of such visits to patients given the active presence of COVID-19 in our communities. He also encourages clinicians to use telehealth visits where possible. If a clinician determines an outpatient clinic visit is necessary, all steps possible should be taken to promote social distancing measures and reduction of infection risk by appropriate use of hand hygiene and PPE-use protocols.

Penalties and enforcement. The Proclamation states, “Violators of this order may be subject to criminal penalties pursuant to RCW 43.06.220(5),” making anyone found to be in willful violation of the order guilty of a gross misdemeanor. The department finds that documented clinical decision- making reflecting application of the Proclamation and this statement to the clinical matter(s) or case(s) under consideration will serve as evidence that performance of the health care services, procedures or surgeries was not a willful violation of the Proclamation.