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Blind men and the elephant
Despite our sunshine laws and management's feckless promises, LHH managers kept this key document under wraps. This report finally gives us a complete picture of LHH's problems and the path to recoveryGraphic Courtesy of

The Secret Report DPH Kept Hidden for Nine Weeks

“Laguna Honda Debacle - Root Cause Analysis

Dr. Derek Kerr & Dr. Maria Rivero
Dr. Derek Kerr & Dr. Maria Rivero

••••••• February 23, 2023 •••••••

Laguna Honda Hospital (LHH) had to hire an outside Quality Improvement Expert to conduct a Root Cause Analysis as part of its Settlement Agreement with federal and state regulators. That analysis, performed by the Health Services Advisory Group (HSAG) consultants, has identified causal factors that resulted in its decertification from the Medicare Program. It has also induced an Action Plan to fix the hospital's deficiencies.

Because LHH is paying HSAG $7 million, and because the group is certified by the federal Centers for Medicare & Medicaid Services (CMS), its analysis could have slanted toward LHH - or CMS. Turns out, the Root Cause Analysis concedes the deficiencies cited by regulators. Its exhaustive recommendations - including for more consultants – emerge from this concession.

quote marks

Knowledgeable executives committed to the long-term care of the elderly and disabled were purged and replaced by Flow-friendly managers from SFGH – an acute care hospital. These occupying managers lacked the experience to operate in compliance with skilled nursing regulations.”

Hidden History

 HSAG issued its Root Cause Analysis on December 1st, 2022. But LHH kept it secret for nine weeks, despite a public promise by Interim CEO, Roland Pickens, to uphold transparency — and despite dogged records requests by the Westside Observer’s Patrick Monette-Shaw. Now we know why. The analysis exposes the ignorance and mismanagement that befell the hospital. So, instead of revealing the full report, CEO Pickens gingerly offered this morsel to the Heath Commission; 
“The theme throughout the RCA (Root Cause Analysis) is that over time, Laguna Honda policies and practices have become out of sync with high-performing skilled nursing homes, and we often operated more like an acute care hospital."

OK, but why did our Skilled Nursing Facility (SNF) start operating like “an acute care hospital”? No explanation. SNFs/Nursing Homes are fundamentally different from Acute Care Hospitals like SFGH. Patients in SNFs are called "residents" because they live there long-term, often for the rest of their lives.

Laguna Honda Hospital Bldg.
Laguna Honda Hospital

The ill-fated transformation occurred once the 2004 Department of Public Health (DPH) Flow Project pumped younger, behaviorally disruptive, hard-to-place patients from SF General Hospital (SFGH) into the LHH's population. At the start of the Flow Project, LHH had administrators, nursing and medical executives who were competent in long-term care and familiar with regulations governing SNFs. But the Flow Project commandeered Laguna Honda, stripping it of its skilled nursing mission, identity, and expertise.

Knowledgeable executives committed to the long-term care of the elderly and disabled were purged and replaced by Flow-friendly managers from SFGH – an acute care hospital. These occupying managers lacked the experience to operate in compliance with skilled nursing regulations.

Indeed, they viewed these regulations as barriers to repurposing Laguna Honda Hospital.

LHH devolved into a subsidiary of SFGH, marketed as a “leader in Post-acute care” that provides short-term rehabilitation and support to patients coming from Acute Care Hospitals. Since post-acute patients aren’t long-term SNF residents, their care isn’t as all-encompassing. Forced to prioritize younger, short-term patients, the new occupiers reduced admissions of older San Franciscans requiring chronic care. This cultural shift affected the elderly women in particular. Their presence dropped from around 54% before the Flow Project to 37% in 2021.

Eventually, the take-over agenda corrupted the hospital's Quality Assurance programs. SNF standards were disregarded. Employees who challenged these lapses were silenced. The Root Cause Analysis omits this foundational history, but covers its grim outcome. Here, we summarize five of the eight problem areas analyzed in the report.

San Francisco General Hospital
San Francisco General Hospital

Competent Staff and Training

Starkly, the consultants identified LHH’s problem as follows; “Leadership, management, facility staff, and medical staff do not have knowledge of SNF (Skilled Nursing Facility) regulations and do not know how to operationalize the regulations in a very large SNF… how to manage staff, and how to educate staff to ensure sustainable, substantial compliance.”

This dearth of Skilled Nursing Facility experience results in “limited staff competencies.” And, because LHH executives and physicians did not join traditional Skilled Nursing associations, they lost touch with industry best practices and regulations. “This results in regulations and best practices not being implemented and LHH not operating in alignment with SNF industry standards of care.”

Line staff did not escape scrutiny. Surprisingly, the consultants found “low compliance” with mandatory training programs. Worse, “There are no consequences for employees and medical staff not completing mandatory education, resulting in some staff providing care without the tools and knowledge necessary for optimal resident outcomes.”

No one was minding the store.

Quality Assurance & Performance Improvement

Quality Assurance and Performance Improvement (QAPI) programs are; “ineffective in including direct-care staff members in addressing the full range of complex care and services provided by LHH and is unable to signal deficiencies at an early onset.”

How did this happen?

Well, “The QAPI structure is designed to align with LHH’s affiliated acute care hospital within the San Francisco Network…resulting in a QAPI Program that is not tailored toward the SNF setting…This increases the risk that performance goals are not met and the necessary care to residents related to SNF regulations is not delivered.” (Bolding added) In addition, while LHH did track performance lapses, the analysis – asking why they occurred - fell short.

Also lacking was participation in Quality Assurance activities by direct caregivers and medical staff: "This results in a culture of silence and indifference, increasing the likelihood that quality concerns are not raised and addressed, which places residents at risk for harm.”

Omitted here is that professional survival at LHH calls for silence.

Laughably, the consultants advised, "To address staff concerns regarding retaliation for speaking up, the CEO and CNO will provide their direct phone number to staff for confidential conversations.” But, when the CEO and Chief Nursing Officer are unqualified to run a nursing home, they are most likely to feel threatened – and to retaliate when staffers expose their failings.

SF Department of Public Health
SF Department of Public Health

In a damning section titled; "Lack of QAPI competencies by middle-management and staff," the report notes, "Middle managers and staff members across all LHH departments are not properly trained and coached on the QAPI process, roles, expectations, basic data competency, and how to implement and participate in quality improvement (QI) activities.”

Left unsaid is that LHH managers have, especially since 2004, been selected for obedience rather than competence.

So, when it comes to Quality Assurance meetings, there's "an established trend where committee members at the meetings provide little to no engagement in the presentation of the data, analytics review of the data, and feedback for robust follow-up actions."

It gets worse. “The four new hires in the QM (Quality Management) Department do not have SNF or healthcare quality experience, a common hiring practice throughout LHH. This nursing home knowledge and experience gap contribute to the staff not being properly qualified or competent.” (Bolding added).

Behavioral Health and Substance Abuse

After two near-fatal drug overdoses in July 2021, State inspectors found uncontrolled drug use and smuggling at LHH during two follow-up surveys. That led to a grave “Immediate Jeopardy” citation in March 2022. The last straw for decertification came in April 2022 when inspectors found widespread sloppiness in hand-washing and applying personal protective equipment. CEO Pickens has dissembled, claiming that these infection control deficiencies led to LHH's decertification. That's like saying that the bombardment of Fort Sumter caused the Civil War. Back-stories matter.

The consultants determined that; “LHH has historically admitted residents with complex needs regarding behavioral health (BH) and substance use disorder (SUD). LHH staff are not well trained nor do they have the expertise to properly treat and manage these complex needs.”

Accordingly, "LHH will review and update its…admission protocol to accurately reflect LHH’s ability to provide adequate care to residents who are admitted for SNF care.” They also recommended more funding to recruit and train staff. Notably, “LHH will also retain a consultant to investigate alternative models for a focused SUD care and BH unit.”

So, why hasn’t LHH separated patients with active drug and mental disorders from the general population? After all, LHH created special wards for Hospice, AIDS and Dementia, as well as Asian and Hispanic patients. Recall that the DPH Behavioral Health division had a catchphrase for situating its hard-to-place patients; “Any door is the right door.”  Thus, any vacant bed at LHH is the right destination. But, creating a special Behavioral Health ward would confine placements to that site, impeding placements into any open LHH bed. That would inhibit patient flow from SFGH.

 Then there’s the high cost of adequately caring for these unpredictable, medically complex patients. They’ll need specially-trained staff, 1 to 1 supervision by psychiatric technicians, ongoing psychiatric therapy, plus enhanced security measures. It’s been cheaper to scatter them around LHH and let untrained caregivers cope with them.

The analysis concludes, “The SFDPH system is a designated safety net for the San Francisco community. Therefore, LHH responds to this by admitting individuals with complex SUD/BH conditions, weakening its compliance with admission criteria.” This admission policy has produced a complex population of residents with specialized needs for which staff are not trained to support in the SNF environment.”

That’s slick. LHH may be a safety-net facility, but it does not admit children, patients on ventilators, and others for whom it cannot safely care. Previously, LHH did not “respond” to its safety-net status by admitting behaviorally unsafe patients. It was coerced - by the DPH Flow Project - to violate its own Admissions Policy.

Infection Prevention and Control

One cause of the shortcomings in its Infection Prevention and Control (IPC) program is that its infection risk assessment “was developed for the acute care setting, resulting in priorities that are misaligned with SNF infection control regulatory requirements and best practice..." Further, “A common practice for LHH is to hire individuals without nursing home background who do not know SNF regulations. This often results in the spread of inaccurate information specific to nursing home care.”

Unsurprisingly, the consultants recommended; "…an appropriately staffed IPC team with SNF-appropriate certification and/or SNF working knowledge…"

The consultants also identified why LHH is still struggling for recertification. “Leadership at LHH is a group of individuals that have been redeployed from… (SFGH). While these individuals are extremely adept in hospital-based QI and care, their knowledge of nursing home requirements/expectations/best practices is lacking. The facility does not have a nursing home administrator on staff, which also contributes to the lack of knowledge specific to nursing home regulations and operations.” 

Care Plans and Quality of Care

As we know from the State review of 12 patients who died after being transferred from LHH, their care plans were more cookie-cutter than individualized assessments. Per the consultants, "The (Interdisciplinary Care Team), including the medical staff, does not demonstrate an understanding of its role and the appropriate knowledge or training to develop and modify effective SNF resident care plans.” Additionally, “…the majority of the nursing staff at LHH are not assigned to a specific unit. Furthermore, consistent nursing assignment is not a widespread practice at LHH, resulting in staff not working with the same residents daily.”

Besides, “Nurse leaders (e.g., directors and managers) have inconsistent and ineffective participation in the care plan process.”

This dearth of nursing engagement and consistency - as well as supervision - factored into a 2019 LHH patient abuse scandal. Over three years, rogue nurses drugged and overdosed restless patients with pilfered medications and abused dozens more - without anyone reporting the violations.

The root cause of this debacle is the colonization of Laguna Honda Hospital by SF General via the DPH Flow Project. Economics played a role. But hubris drove the deformation of LHH. The “best and the brightest” from DPH and SFGH devalued long-term care for the elderly.

Now, outside experts affirm that even LHH’s newly-installed “leaders” don’t know what they’re doing. It’s shameful that federal and state regulators had to force the DPH to redress the incompetence it rammed into LHH.

Dr. Derek Kerr is a San Francisco investigative reporter for the Westside Observer and a member of SPJ-NorCal. Both he and Dr. Maria Rivero were on the staff at Laguna Honda Hospital when it had a qualified Nursing Home Administrator. Contact:

February 23, 2023

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