Centers for Medicare & Medicaid (CMS) Isn't Playing Around as Managers May Believe
Temporary Reprieve on Evictions, But Harsh Warnings
CMS Orders Laguna Honda Hospital to Expedite Hiring Nursing Home Administrators
•••••••••• February 22, 2023 ••••••••••
One day after a relatively useless Board of Supervisors hearing about LHH held on January 31st, Centers for Medicare & Medicaid Services (CMS) approved — on February 1st — a temporary extension of the pause on transfers and discharges scheduled to end on February 2nd, to May 19th.
The reprieve to May 19th from CMS is good news, particularly for LHH residents facing the potential transfer trauma and death resulting from mandatory, forced eviction from LHH.
But in the same letter, CMS issued several dire warnings and other bad news to LHH.
As the Westside Observer reported in January, a fire alarm went off during the “90-day Monitoring Survey” to regain recertification. That resulted in an “Immediate Jeopardy” citation, imposed when there are immediate risks to residents' health or safety, which are one step higher than “actual harm” violations.
Still, the fire alarm debacle triggered an “Extended Survey” and a second separate “Fire Life Safety Survey.” Thus the contingent of surveyors grew from 14 to “over” 25, who hung around until December 16th, and a myriad of other problems surfaced.
Pickens misinformed the Supervisors that the June '22 “Mock Survey” conducted by in-house consultants had identified 300 “milestones” that might prevent recertification.
As the Westside Observer noted, the recertification “Mock Survey” uncovered 101 deficiencies, not 300. Of those 101 deficiencies, only 63 had been fully resolved by November 18th, with 38% remaining.
Why were additional expensive consultants needed to train employees on Fire Life Safety? CMS had only cited a handful of employees who didn't know ... where the nearest fire extinguishers were. ”
Unfortunately, Pickens' misstatements do not serve to inform the Board. They may have no idea that 38% of the deficiencies identified during the June “Mock Survey” still hadn't been fixed as of November 18th.
LHH's fire alarm 81-page “Plan of Correction” (PoC) was resubmitted to the California Department of Public Health (CDPH) on January 8th. Since the first version may have proposed insufficient remedies and corrections.
Pickens “Immediate Jeopardy” version
“So, for example, when the fire alarm went off there should be an overhead [public address system] announcement “Fire alarm, fire detected such-and-such part of the building.” Well, that overhead announcement didn't happen.” Nor did the requirement that everyone exit the building. “If an alarm goes off right now in this building [City Hall] we all need to exit. Well, when that happened, in December, not all of the staff exited appropriately. And so, the surveyors saw that.
“So, it's unfortunate that everything that should have happened with that fire alarm system didn't happen. So, the good thing is that it was identified, and we were able to respond to it immediately.”
No “good” thing happened as a result of the failed fire alarm announcement, Pickens added:
“... we had to quickly do several things. One was, we brought over the Fire Life Safety expert from Zuckerberg San Francisco General (SFGH) … deployed him to Laguna Honda as a Disaster Service Worker, and made him exclusively responsible for improving and enhancing the Fire Life Safety program at Laguna. We also brought on additional consultants, because one of the findings was that we need to do a better job of training staff so that they can understand exactly what their role was for Fire Life Safety.”
Doesn't LHH have a Fire Life Safety expert of its own? Why isn't LHH's Building and Grounds Maintenance Supervisor, Arnold Brunswick, qualified to do Fire Life Safety inspections and repairs? What about Diana Kenyon, Building and Grounds Maintenance Superintendent? Isn't she required to perform Fire Life Safety inspections and repairs?
A public records request revealed that the SFGH fire safety “expert” Gregory Chase — like Kenyon — has a job classification code of “7120 Building and Grounds Maintenance Superintendent.” His title at SFGH is “Facilities Services Director.” However, deemed an “expert” for LHH, it's unknown if he's getting paid extra. Kenyon and Chase each earned $160,007 in regular pay (excluding fringe benefits). Still, Chase snapped up an additional $75,390 between overtime pay and “other pay” (perhaps for carrying a pager), for total of $235,398 in FY21–22.
Why were additional expensive consultants needed to train employees on Fire Life Safety? CMS had only cited a handful of employees who didn't know what RACE is (Rescue, Alarm, Contain, Extinguish/Evacuate) despite its prominence on their ID cards nor where the nearest fire extinguishers were.
The violation didn't just involve the public address system.
In fact, the Fire Life Survey PoC revealed 24 deficiencies in CMS' citation of the survey results, including smoke detectors — turned off for six months, faults with the beam smoke detectors in the Pavilion Building, fire sprinklers not appropriately maintained, obstructed fire sprinklers, uninspected portable fire extinguishers and smoke beam detectors, smoke barrier doors didn't close fully sometimes not at all, an elevator out of order, an untested emergency (EPS) generator, daisy-chained surge protectors (forbidden by the Fire Code), among other more minor issues. Pickens withheld this crucial information from the Board of Supervisors.
Three Dire Warnings
“Yes Men,” dispatched from SF General Hospital and the Department of Public Health, comprise the management at LHH. Those senior managers have no experience managing any skilled nursing facility, which concerns CMS deeply.
During 2004-5, after the closure of the Mental Health Rehabilitation Facility (MHRF), when the “flow project” moved behavioral health patients from SFGH, they also removed “long-term care” from LHH's mission statement.
The extended pause on transfers to May 19th only extends Federal reimbursement for current residents to the November 13th deadline. That's when Federal funding ends. CMS warned, “manage its resources, including plans to safely discharge and transfer residents, accordingly with that date in mind.”
Second, CMS warned that during follow-on 90-day Monitoring Surveys, more “Immediate Jeopardy” findings would not be tolerated.
There were also findings alleging actual harm to LHH's residents and “multiple quality of care concerns,” including individualized care planning violations, which Pickens withheld from the Board of Supervisors.
CMS implied that any more “Immediate Jeopardy” or “actual harm” findings might trigger CMS to potentially end the “LHH Settlement Agreement” entirely, making recertification all but impossible.
The phantom “Revised Closure Plan”
CMS had a more direct warning regarding the resumption of mandatory evictions to resume on May 19th.
It's unknown when LHH submitted its “Revised Closure Plan” — mentioned in the Settlement Agreement 18 times, but they refused multiple records requests from the Westside Observer. It was required when 12 patients died under the Initial Closure Plan.
Fed up with LHH's delay, CMS wrote: “For any resident transfer/discharge, Laguna Honda must follow the approved, revised closure plan process, in order to continue to receive extended federal funding. At this time, Laguna Honda's draft revised closure plan has not been approved. CMS, CDPH, and the California Department of Health Care Services provided feedback on Laguna Honda's plan on January 13 and 18, 2023, and we have not yet received a revised version in response.
“If Laguna Honda does not timely complete its revised closure plan, CMS reserves the right to pursue all remedies and enforcement measures under the settlement/systems improvement agreement. CMS further reserves all its rights under the settlement/systems improvement agreement, including its right to terminate the agreement pursuant to Paragraph 3.”
Failure to Respond
CMS could terminate its reimbursement for current residents through November 23rd. There would be no Medicare and Medicaid funding at all.
Footdragging: Nursing Home Administrator
Exasperated with LHH's footdragging to hire a licensed Nursing Home Administrator and a licensed Assistant Nursing Home Administrator, CMS noted that plans to post job vacancy announcements for the two positions on April 30th, are insufficient.
“LHH should prioritize efforts to expeditiously install permanent leadership with appropriate experience in nursing home administration.”
CMS set two deadlines: 1. demonstrate “tangible progress” toward hiring leadership with nursing home experience by May 19, and 2. provide a detailed timeline by February 15th about hiring and onboarding licensed Nursing Home Administrators.
An Administrator would face an uphill internal struggle. LHH's last licensed Nursing Home Administrator was Larry Funk in 2004, who also served as CEO.”
Acting CEO, Roland Pickens provided an organization chart on June 30th, on 36-inch paper. It was unprintable and illegible when zoomed in to read. Irritated, Health Commissioner Chow requested a readable copy.
The Nursing Home Administrator position is buried two layers down in the chart. An Administrator would face an uphill internal struggle. LHH's last licensed Nursing Home Administrator was Larry Funk in 2004, who also served as CEO.
The new Nursing Home Administrator should also be the CEO. Most nursing homes do not have a CEO and a Nursing Home Administrator.
San Francisco Health Network's Baljeet Sangha has no experience in skilled nursing facilities. He told the Health Commissioners the goal was to add sustainable City positions to take over the work of consultants and consultant nurse administrators. By the end of 2022, the new leadership positions would be evaluated to determine if the model is effective. Commissioner Guillermo asked for evaluation data of the leadership model and a timeline for recruiting LHH positions. Sangha claimed job postings might be posted by the end of the year 2022.
SFDPH has “no responsive records” for either the evaluation data Guillermo requested or the evaluation analysis report on the model's effectiveness due by year's end.
CMS expects LHH to fast-track the hiring with a detailed timeline.
Joining California Association of Health Facilities
CMS requires LHH to join the California Association of Health Facilities (CAHF), and staff needs to enroll in its “Leadership Academy” to “install permanent leadership with appropriate experience in nursing home administration.”
Why did CMS require affiliation with CAHF, rather than the National Association of Directors of Nursing Administration of Long-Term Care [NADONA] — a more traditional Skilled Nursing Facility (SNF) association? CAHF does not focus on SNFs. Instead, its main focus is legislative advocacy.
CAHF is a trade organization with an extensive history of legislative advocacy for California nursing homes, according to its website. It “strives, through advocacy, to provide a credible, respected voice for long-term care with elected officials, state agencies, stakeholder organizations, print, broadcast, and social media.”
Beyond that, CAHF has no focus on developing nursing home administrators other than through its “Leadership Academy.”
The Leadership Academy
“... an enriching experience designed to grow leadership skills ...” Leadership students will develop a “Quality Assurance Performance Improvement” (QAPI) for their organization's facility.
LHH already has Quality Management and Nursing Education departments to help employees develop QAPI programs. And the consultants — hired at $26.7 million — are teaching staff to develop QAPI projects. So why more QAPI projects?
Pickens' reported that LHH had joined CAHF, which had accepted six staff to the Leadership Academy.
The six employees are:
- Prasanthi Patel, MPH; Administrative Director of Operations, LHH Operations Department, 2593 Health Program Coordinator III, typically not considered senior managers of nursing facilities.
- Arnold Brunswick;-Facility Services, LHH Facilities Department, 7203 Bldg. & Grounds Maintenance Supervisor.
- Elvis Lavarreda, CDM, CFPP; Food Service Director, Food and Nutrition Services Department, 0923 Manager II.
- Lucia Angel, MHA; LHH Chief of Staff, LHH Administration, 2593 Health Program Coordinator III.
- Susan Duong, RN; Director of Nursing, South Tower, LHH Nursing Department, 2324 Nursing Supervisor.
- Rowena Patel, MSN, BSN, RN, GNP-BC; Director of Nursing North Tower/Pavilion, LHH Nursing Department, 2324 Nursing Supervisor.
Only three of the six — Lavarreda, Duong, and Rowena Patel — are indicated on the “Leadership Organizational Chart,” linked above and midlevel on LHH's organizational structure.
A public records request revealed the fees to join CAHF include $78,359 to date, including a membership application fee ($833), membership dues July to December 2022 ($23,746), membership dues January to December 2023 ($46,655), and CAHF’s Spring 2023 “Leadership Academy” enrollment for five LHH staff members ($7,125), given one complimentary Academy enrollment scholarship.
Going forward, LHH must pay annual membership dues of approximately $53,000 annually, based on the $78 per-bed fees if LHH retains licensure for all its 769 beds, plus additional $1,425 per student “Leadership Academy” registration fees.
Pickens and Sangha should get the boot, too, and now — before CMS pulls the plug.
Fed up with the delay of SFDPH, LHH, and Pickens to release the initial “Root Cause Analysis” (RCA) report to CMS on December 1 — which CMS had accepted and approved by December 12 apparently as LHH had originally submitted it — this author, on behalf of the Westside Observer, submitted a formal FOIA complaint in the afternoon of Thursday, February 2 to CMS and the California Department of Public Health alleging LHH was potentially violating a key stipulation of the LHH Settlement Agreement.
Paragraph 41 of the Agreement — titled “Public Disclosure” — explicitly provides that all parties (CMS, CDPH, and LHH as signatories) had agreed that the Settlement Agreement was “subject to public disclosure in accordance with the FOIA and/or in accordance with applicable [local] laws and processes.”
That seemed to have done the trick in prying loose the RCA and several other documents out of SFDPH and Pickens’ clutches they’d been stalling on releasing. Three working days later in the morning of Wednesday February 8, SFDPH finally released the RCA. Separately, SFDPH also provided the full two-phase “First Mock Survey” reports.
Phase 1 of the First Mock Survey was conducted between June 22 and June 28. Phase 2 was conducted between July 11 and July 21.
A preliminary secondary detailed analysis under way by this author assessing the combined phases of the Mock Survey revealed a total of 123 deficiencies, including deficiencies that occurred multiple times — not the 101 deficiencies Pickens and LHH’s consultant, Health Management Associates (HMA), have tried to palm off on the San Francisco Health Commission and members of the public to minimize LHH’s problems.
Similarly, although Pickens keeps asserting the initial “Action Plan” produced from the findings of the initial RCA report had yielded 300 “milestones” (i.e., corrective actions that must be taken) across initially eight major problem categories at LHH, he again minimized the scope of necessary corrective steps. There were actually 353 milestones in the Action Plan related to the first RCA.
Then came along the first 90-Day Monitoring Survey during which the disastrous fire alarm fiasco happened. LHH did not receive just one “immediate jeopardy” citation related to the Fire Life Safety survey, it received four of them from CDPH — all at the highest severity-and-scope of “L” immediate jeopardies, not just one citation.
The 90-day Survey made necessary a second RCA, with a separate follow-on Action Plan (tacked on to the first Action Plan). That resulted in an additional 90 “milestones” in three newly identified additional major problem categories at LHH, plus 11 more “milestones” uncovered as additional necessary corrective actions from the first RCA.
So far, there have been 454 “milestones” identified — not 300 as Pickens keeps trying to pass off. And LHH hasn’t yet had its second 90-Day Monitoring Survey, expected in March. Along the way, the consultants hired at over $26 million to date abandoned holding a second Mock Survey last September before applying to regain CMS re-certification.
Members of the public — and LHH’s frail residents — must be told honestly that the problems at LHH are not insignificant. They’re major, pointing to sheer mismanagement at LHH by unqualified SFDPH managers over the past 18 years, most recently by Pickens and Sangha, given the continuing failure to hire a qualified and licensed Nursing Home Administrator.
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 Contact him at firstname.lastname@example.org.
February 22, 2023