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LHH’s Delayed Inspections Delays Admissions

Laguna Honda Hospital’s Endless Waiting Game

Anonymous Complaints Under State Review
Staff Report Their Personal Trauma
Health Commission Claims it Has No “Levers to Pull”

• • • • • • • • • • November 28, 2023 • • • • • • • • • •

San Franciscans remain pretty concerned about what may be taking so long, having Laguna Honda Hospital’s (LHH) Medicare recertification site visit inspections begin. At this rate, the resumption of admissions to LHH is probably four months away. San Franciscans will be lucky if admissions restart before April 2024.

Somewhat shocking — on November 14, San Francisco's Health Commission president — herself a physician — asserted the Commission has no “levers to pull” to move recertification along to resume admissions to LHH.

LHH’s CEO and San Francisco’s Health Commission keep asserting they are at the mercy of federal inspectors showing up to conduct sequential facility inspection surveys to become recertified in the Medicare reimbursement program and become fully recertified. LHH’s CEO and Health Commission seem to have thrown in the towel, feigning their hands are tied. That has resulted in their collective impotence.

It's worth remembering that Laguna Honda was decertified in April 2022. It's also worth remembering the inspection process LHH is waiting to have started involves a four-month process from the date of the first site survey, which is supposed to be a full extended inspection. That's followed by a mandatory, 90-day reasonable assurance waiting period [to ensure corrective actions are  sustained long term], followed by a second complete inspection survey to ensure that Laguna Honda Hospital remains in “substantial compliance.”  That will stretch over a probable four-month period before LHH gains full certification and is allowed to resume admitting patients.

At this point, it's highly probable that Laguna Honda may not gain full recertification — allowing for admissions to the facility to resume again — until April of 2024. A full two-year decertification period is both almost unheard of and shameful. 

It’s shameful because the halt of new admissions for a full two years forces the dumping of vulnerable San Franciscans needing skilled nursing facility level of care at Laguna Honda into out-of-county placements for what now seems like an eternity. LHH's admissions policy, finally revised in September 2023, now contains a provision to re-admit patients forcibly evicted and exiled under mandatory discharges in the summer of 2022 during the botched, then aborted "LHH Closure Plan,” as the first priority for re-admission to LHH (provided they didn’t die) when admissions are allowed to resume.

We'll wait to see if LHH and the Health Commission actually make concerted efforts to reach out to those patients who have been evicted and offer them priority to return to LHH.

But for the hundreds of San Francisco residents denied admission to LHH during the past two years (but not actually evicted, since they were never admitted and placed out-of-county, instead), they may fall into the fifth category of admissions priority — but only if there is some meaningful and effective outreach effort made to identify the patients dumped out of county while LHH admissions were halted.

What’s the Inspection Hold-Up?

It’s worth revisiting the recent timeline of events.

It took the Health Commission until August 1, 2023, to approve a resolution allowing Laguna Honda to begin reapplying for recertification as a Medicare and/or Medicaid (Medi-Cal) provider. At that point, LHH had been decertified for 15 months and 18 days. And at that point, LHH had been awarded $40.4 million to hire outside consultants to come in and fix Laguna Honda's mismanagement problem. Problems that dated back for almost 20 years of running LHH as an acute-care hospital rather than as a Skilled Nursing Facility (SNF).

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… Governor Gavin Newsom, Mayor London Breed, and San Francisco’s 11-member Board of Supervisors may all have taken a hands-off “waiting game” approach to helping kick-start LHH’s Medicare recertification site visits and inspection process that will take four months to complete — once the magic bouncing ball starts rolling.”

On August 11, LHH submitted its Medi-Cal recertification application to the California Department of Public Health (CDPH), which surprisingly quickly approved it. LHH was recertified as a Medi-Cal (only) provider on August 16, 2023.

Then, on August 23 LHH submitted a “change of information application” for Medicare recertification to the Centers for Medicare and Medicaid Services (CMS), with the legal assistance of San Francisco City Attorney David Chiu’s staff. LHH informed its governing body, the Health Commission, on September 12 that “[LHH is] subject to a full survey by CMS, which could happen at any time, and without notice:”

But it was the wrong type of application, which Chiu and his staff should have had the legal competence to have known. So, LHH had to go back to the drawing board and submit the correct Medicare recertification forms. On September 15, LHH submitted the correct application, losing almost a month in the process. On October 10, LHH again informed the Health Commission that "[LHH is] subject to a full survey by CMS, which could happen at any time, and without notice:”

Sadly, LHH informed the Health Commission's LHH-JCC (Joint Conference Committee consisting of three Health Commissioners and LHH's senior management team) on Tuesday, November 14, that LHH is still waiting for the first recertification inspection survey to begin. 

Now, just after Thanksgiving, and given the end-of-year and New Year holidays are just weeks away, it's improbable to imagine site visit inspections happening before January 1, 2024. The four-month process may begin then.

Dan Bernal
Dan Bernal

Essentially, LHH sat by idly for over two months without attempting to get local, State, and Federal legislators to intervene and move the entire survey inspection process along expeditiously.

Of interest, former San Francisco Health Commission President Daniel Bernal — who had simultaneously been former House Speaker Nancy Pelosi’s Chief of Staff for two decades and should have had an inside track exerting federal pressure — took no action to try to speed up the Medicare inspection survey process before he recently stepped down from the Health Commission to take a Vice Chancellor job at UCSF, doubling his salary to approximately $350,000.

[Bernal had to seek a San Francisco Ethics Commission waiver to take the UCSF gig, crying poor that he would face “an extreme financial hardship" without being granted the Ethics waiver, which he needed for retirement purposes to avoid “incurring more debt,” apparently given he had only earned $174,058 working for Pelosi during 2022. Ethics Commission staff had determined Bernal would not have faced “extreme financial hardship,” but Ethics Commission appointees approved his waiver request, anyway. Observers wondered whether Pelosi had greased some wheels at Ethics, as many other San Francisco politicians reportedly had done by submitting letters supporting Bernal's cries.]

[As for me, I have a hard time empathizing with Bernal’s whine that his retirement based on his $174,000 salary servicing Pelosi was a “hardship.”  After all, my own City employment retirement is based on a third of that, at a final salary after 16 years of about $60,000. I haven't whined about facing a "financial hardship.”  But I’ve never pretended or aspired to be part of the gay “A-Crowd” Castro community. And I waste no time contemplating a pension based on earning a $350,000 salary.]

At the very least and at a bare minimum, Bernal could have simply picked up the phone and reached his boss, Pelosi, asking her to intervene to get the U.S. Health and Human Services Secretary Xavier Becerra, California Health and Human Services Agency Secretary Dr. Mark Ghaly, or the California Department of Public Health Director Dr. Tomás Aragón — the latter two of whom are both Newsom appointees — to get LHH’s Medicare survey inspection ball bouncing or rolling!

Also of concern, although District 7 Supervisor Myrna Melgar had taken the lead previously in trying to light fires under San Francisco's congressional delegation to initiate and spur action, Melgar herself has been curiously missing in action on advocating for a prompt start to CMS' inspections of Laguna Honda. San Franciscans may need Melgar's rapid interventions now more than ever.

Are Anonymous Complaints Slowing Inspections?

As a reminder for readers, LHH was warned at least three times after it was decertified in April 2022 that it should not get any more "Immediate Jeopardy” inspection violation citations (that pose a potentially severe risk of jeopardizing residents' health) and that LHH should additionally reduce the number of “Actual Harm” citations it had been receiving (a step lower on the severity scale). Unfortunately, LHH did rack up another “Immediate Jeopardy” citation on May 8, 2023, that put LHH at risk of not gaining Medicare recertification.

Also, regrettably, LHH’s Quality Management Department presented its monthly “Regulatory Affairs Report” for the period ending in October to the LHH-JCC Commissioners on November 14. The report — which summarizes so-called “facility-reported incidents” (FRI’s) nursing homes are required to report to California’s Department of Public Health — was potentially more worrisome.

Among other details, the “Survey Updates” section of the report showed three “Facility Reported Incidents” were investigated on-site at LHH on October 20 and October 30 — all involving “Anonymous Complaints” that are apparently still under review by CDPH’s District Office as of November 14. The news was somewhat alarming.

It's unknown whether LHH staff, residents, or their family members are filing anonymous complaints or why they feel compelled to file them anonymously.

Ten months into the calendar year 2023 (through October 31), LHH had reported 31 anonymous complaints, up admittedly by just one more than in the calendar year 2022. But there are still two months to go, and LHH has averaged 4.4 anonymous complaints per month so far in 2023.

Most on-site investigations are typically resolved on-site, rather than involving District Office review and decision-making. So, it’s potentially concerning that the three anonymous complaints investigated in October were not resolved during the October site visits but were instead elevated to review by CDPH's District Office. And it's unknown if the three anonymous complaints investigated all occurred during October or had perhaps occurred earlier, and CDPH had just gotten around to investigating them due to backlogs in CDPH.

Regardless, concerned observers are worried about whether those anonymous complaints may have slowed CMS commencing the Medicare recertification inspection survey, since it may take some length of time before we learn from potential CMS Form 2567 inspection reports become public, just what problems the anonymous complaints may have uncovered, and whether LHH received additional serious State deficiency violation citations and/or fines — again.

Observers know that “exit survey” de-briefing procedures traditionally used during site visits typically involve informing LHH about what particular “F-Tag” inspection code standards may have been involved, investigated, or violated — and whether violations involved substandard patient care by definition. Have LHH and the Health Commission already been de-briefed in closed session on what problems the anonymous complaints uncovered during an exit meeting — information LHH and the Health Commission may have decided to keep secret temporarily?

Again, the concern is that the investigations of anonymous complaints may be slowing down the start of LHH’s Medicare recertification site survey inspections, delaying and exacerbating the resumption of new patient admissions.

Other Clues in the “Regulatory Affairs Reports

There were other clues in the “Regulatory Affairs Report” presented to the LHH-JCC on November 14.

A preliminary analysis of the data reveals that there have been a few significant changes in some of the “Facility Reported Incidents” (FRIs) LHH has reported to CDPH over the past two calendar years after it was decertified.

Although there were 65 fewer facility-reported “abuse incidents” overall in 2023 (albeit with two more reporting months to go), there was a concomitant offsetting increase of 31 additional “serious incident" FRI, including more injuries of unknown source, major injuries, other adverse events, and disease outbreaks, for a net decrease of 34 FRIs across the two years.

I am not a clinician and have no clinical training. It is difficult to draw sound conclusions without a longer baseline since the types of incidents reported vary from year to year.

Some observers rightly wonder whether LHH staff had been spending so much time trying to “manage” residents with behavioral health problems that staff didn't have the "bandwidth” to help prevent other types of serious incidents.

The subcategory of “resident-to-resident abuse” in the facility-reported “abuse incidents” category is clearly significant, having dropped from 94 incidents reported in 2022 to just 44 such incidents in 2023. It seems clear the decline was probably due to the cessation of LHH admissions in April 2022, particularly of younger, behaviorally-disruptive patients dumped out of SFGH into LHH for ease of discharge from an acute hospital setting.  

Across the seven categories in the “serious incidents” section, the increase of 31 additional incidents in 2023 (from 40 to 71 such incidents in 2023) is significant, even when comparing just two calendar years in the baseline of years compared.

As for the “other serious incidents” category, the data shown will probably rise further in the next two months when the November and December data are eventually released.

The 71 total incidents in 2023 may be presumptive indicators of both distracted and overburdened LHH staff and potentially enhanced reporting requirements under CMS's and CDPH's watchful eyes. For example, the rise in “major injuries” from 4 to 8 in 2023 could have been due to staff distraction or, alternatively, understaffing in some nursing job classification codes. Major injuries are always fully reported, so it’s unlikely the increase would have been due to enhanced reporting requirements.

The doubling of “major injuries" is worrisome and may have perhaps been even more worrisome to CMS in deciding when to begin LHH's Medicare recertification inspection process.

By contrast, the rise in the vague subcategory of “staff neglect” incidents to six in 2023 — when there had been zero in 2022 — might be due to more stringent reporting requirements. (It’s not yet known if reporting of this type of incident had been required in years prior to 2022, or if it's an entirely new F-Tag category of incidents introduced during recent CMS "Phase 3" regulatory changes applicable to skilled nursing facilities.)

Reasonable clinical observers suspect the overall increase in the seven “serious incidents” category types may likely be due to both staff distraction — caused by the chaos from repeated inspection surveys, external consultants hovering over staff, the influx of new and additional clueless interim administrators brought over from SFGH and the San Francisco Health Network (SFHN) to act as decertification “incident response commanders” but who lacked actual experience working in skilled nursing facility settings, and the resulting pressure from increased staff meetings and incessant monitoring of staff to regain certification — plus potentially enhanced reporting of the “abuse incidents” subcategories.

If staff shortages occurred in some job classifications, that might have been a factor. Having to guide and orient per diem registry service nurses could also have been a distraction from focusing on direct patient care, even though staffing may have been temporarily boosted.

Still, it’s fair to report on these trends, without drawing overly firm conclusions, given just the two years of data.

However, CMS and CDPH obviously have access to 10 or more years of the facility-reported incidents LHH has been reporting, and CMS knows this data better than anyone (although LHH and the Health Commission should have access to this data at their fingertips, too).

Of interest, the preliminary FRI analysis also showed there has been a significant increase in the number of FRIs at LHH still awaiting investigation and resolution by CDPH staff. The data shows that at the end of December 2022, 185 FRIs were awaiting CDPH review. That climbed to 289 unreviewed FRIs by the end of October 2023, an increase of 104 over ten months. In other words, there are now almost 100 more uninvestigated FRIs (289) than the 192 FRI's LHH had reported in the first ten months of 2023.

This is an indicator of how far behind CDPH is in investigating facility-reported incidents in nursing facilities all over the State of California!

Any reasonable observer would have to wonder whether LHH's history of FRIs has also contributed to the delay in CMS even beginning LHH's Medicare recertification inspections that continue delaying the resumption of new admissions.

Is Another Factor LHH’s Medical Director Vacancy?

Perhaps another factor contributing to the delay in beginning LHH’s Medicare survey inspections is the unwarranted delay in hiring a new Medical Director for Laguna Honda.

Back on February 1, 2023, CMS "Regional Survey and Operations Group” located in Sacramento wrote a letter to LHH’s acting CEO, Roland Pickens, essentially ordering LHH to “prioritize efforts expeditiously" to install permanent leadership and demonstrate progress in doing so no later than May 19. CMS expected LHH's new Medical Director to join the California Association of Long-Term Care Medicine (CALTCM) to receive “coaching” before February 28, 2023.

In response, LHH posted a job opening announcement online on February 10 to recruit a Medical Director, listing an annual salary of up to $306,878 plus a fringe benefits package worth 32.2% above the base salary.

In addition, LHH entered into a $92,071 contract with Berkeley Search Consultants as far back as October 1, 2020 — two years before it was decertified in April 2022 — to recruit an LHH Medical Director. As of July 11, 2023, LHH had been billed by Berkeley Search Consultants for a second invoice, bringing the costs to $46,035. It's not yet known if LHH has been invoiced and paid Berkeley Search Consultants for two more invoices on the remaining balance of $43,065 for hiring a Medical Director for LHH or if LHH switched to a different executive recruiting company.

That LHH hadn't completed hiring and onboarding its new Medical Director by November 14, 2023, probably has not escaped CMS and CDPH's attention. Can that also be contributing to the delay of starting LHH’s first Medicare inspection survey?

Health Commission Claims It’s Powerless to Help

Sandra Simon
Sandra Simon

During the LHH-JCC November meeting the Health Commission's newly-elected president, Laurie Green, MD stated at 0:20:17 on audiotape:

"I think it would be helpful for us to kind of review this whole issue with CMS [and State] surveyors coming [for LHH’s Medicare recertification inspection] because if I understand correctly, we have no levers to pull [to initiate the survey inspection process], including we tried our darnedest at the very beginning, at the very outset of all of this to have some of the … um … our very connected politicians intervene, and even that did not yield great results. I don't think the surveyors will come out this week … and next week is Thanksgiving.

So, it’s hard to know when they will be here [show up to conduct the first Medicare inspection], and if I understand correctly, hopefully [they’ll show up] by the end of the year. But they prioritize [when they'll show up], and all we can do is ask [that they start the inspections]. What is our ability to reach out and try to give them a little nudge [to move this along]?”

An LHH staff member, possibly  Laguna Honda’s new CEO, Sandra Simon, replied to Green saying:  “You're correct in that we don't really … have no way to know. There's really no way for us to influence … after that, it's just a waiting game.”

Here we are 19 months following LHH decertification in April 2022, and the Health Commission is still claiming it is powerless, without political levers to pull. The Commission seems content to just sit back and idly play the “waiting game.”

That's not good enough.

After all, LHH has been awarded $40.4 million in consultant contracts in the 19 months since decertification in April 2022 and has the approval to spend another $8 million on consultants. Then there's the $37 million currently approved to repair LHH's facilities (which is outrageous because the replacement hospital that opened in 2010 is only 13 years old). Additional facility repair costs needed haven't been fully disclosed.

All told known expenses to position LHH for Medicare recertification have reached at least $120 million, not including the $8 million approved for more consultants. The $120 million is projected to grow even higher. San Franciscans are tired of the expenses that keep accruing during this endless “waiting game” — not to mention the unknown costs of human suffering.

Surely, the Health Commission can pull some levers and beg San Francisco’s congressional delegation — and our Governor, U.S. Senators, and Mayor — to demand that CMS expedite the survey inspections so that admissions to Laguna Honda can resume by April 2024. Vulnerable San Franciscans needing admission to LHH deserve no less.

LHH Staff Report Their Personal Trauma

Another report dated March 10, 2023 — but only released in response to a public records request on November 17 — pointed to a potentially complicating issue facing LHH’s staff.

The report was prepared by Health Management Associates (HMA), which has been awarded at least $5.9 million in consulting contracts since May 2022 to help Laguna Honda prepare to submit its application to obtain Medicare recertification. HMA was "engaged” (a.k.a., “commissioned’ or “hired”) to conduct seven focus groups among LHH staff to assess staff training and educational needs to care for residents with behavioral health and substance use disorders.

The report revealed, somewhat surprisingly, that LHH staff have been suffering from their self-reported “trauma.”

Of interest, the “Themes” sub-paragraphs on numbered page 6 of HMA’s report states:

A consistent theme across all focus groups was the compounded trauma the LHH staff have experienced over the past four years. LHH has been locally and nationally identified by the horrific abuse scandal in 2019 …”

And this gem:

Several staff noted the ongoing negative publicity with LHH means they [staff, not patients] can never escape the trauma, and it impacts all areas of their lives.”  Anonymized quotes from staff also included these gems:  “There is stigma and layers of trauma.”  “We never healed from the abuse scandal; EAP never showed up.” … “We were abandoned [by the CMO, CNO, CEO, Quality who had left, all gone].”

Mivic Hirose
Mivic Hirose

“EAP” refers to an “Employee Assistance Program,” that typically provides counselors to help care for staff.

Imagine how LHH’s abused and traumatized LHH’s residents felt — especially since residents may not have had access to their own EAP, and had to turn to suing Laguna Honda and the City, instead.

Some LHH staff behaved horrifically during the 2019 sexual abuse scandal. Only a handful were fired, and Laguna Honda’s CEO, Mivic Hirose, and other senior staff were let go. Despicably, Hirose held onto a still-financially lucrative "golden parachute” transfer within SFDPH working in “medical informatics,” despite having no training or experience beyond surgical nursing training.

Any staff “trauma” brought on by the patient sexual abuse and cover-up scandal that occurred was a direct result of bad management and outright mismanagement, which flourished under Hirose. Period.

Any staff trauma so severe that it’s mentioned by staff four years later suggests LHH had become a truly dangerous place for anyone to work. And it identifies the major cruelty and cluelessness on the part of management. Direct care staff are typically the most vulnerable caregivers on the totem pole. But bashing the staff is what management always does to cover up the cruelty and neglect of their staff.

It's somewhat shocking to learn in 2023 of the trauma LHH staff endured four years ago, which appears to have gone unaddressed — when not ignored altogether — by senior leadership of San Francisco's Department of Public Health, SFHN managers, and even the Health Commission.

San Francisco Congressional Delegation’s Inaction

Are San Francisco City Hall officials in cahoots with San Francisco’s congressional delegation claiming their impotence to move LHH's Medicare recertification inspection process along? (Think former House Speaker Nancy Pelosi, U.S. Senator Diane Feinstein’s replacement stand-in (Laphonza Butler), and California’s other U.S. Senator, Alex Padilla.)

They may not be alone, given that Governor Gavin Newsom, Mayor London Breed, and San Francisco’s 11-member Board of Supervisors may all have taken a hands-off “waiting game” approach to helping kick-start LHH’s Medicare recertification site visits and inspection process that will take four months to complete — once the magic bouncing ball starts rolling.

As we've seen time and time again ever since decertification, those most obviously harmed by these ongoing problems are the residents, and the ever-increasing number of San Franciscans dumped into out-of-county facilities — denied admission to Laguna Honda.

Our Congressional delegation's inaction is almost as sadistically obscene as CMS initial decertification itself.

Will LHH’s admissions resume by May 2024, if we’re lucky? Or, will this keep dragging out indefinitely, ad nauseum?

This seemingly endless “waiting game” must end!

Monette-Shaw is a columnist for San Francisco’s Westside Observer newspaper, and a member of the California First Amendment Coalition (FAC) and the ACLU. He operates stopLHHdownsize.com. Contact him at monette-shaw@westsideobserver.com.

November 28, 2023

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