Donate Image

Your Donations Count Donate Graphicat the Westside Observer!


April 14, 2023 is the first anniversary of LHH's decertification.

A Secondary Analysis of LHH’s “Root Cause” Problems
Pre-Mortem of a Hospital: One-Year Anniversary

Root Cause Factors Refute DPH Claims Minimizing LHH’s Violations

Help Save 120 Beds at Laguna Honda Hospital

Laguna Honda Puzzle

Please Sign My Petition

Given our severe shortage of Skilled Nursing beds, DPH claimed it would do “everything it can” to save LHH’s 120 beds. But it hasn’t submitted a written waiver request yet!

Please share this petition widely with your contacts, I’d really appreciate your help.

•••••••••• April 10, 2023 ••••••••••

It’s taken two months to wade through reading, digesting, and reflecting on the two root causes analysis (RCA) reports Laguna Honda Hospital (LHH) commissioned to uncover the underlying factors that led to LHH's decertification from the Medicare Program, along with other documents released on February 8. Background material for this article totals 669 pages, hence this in-depth article.

[Note: I ask for readers’ indulgence with this necessarily long article meant to help preserve the historical record of LHH’s mismanagement.]

LHH's residents deserve to have this history told. And read. And preserved. They deserve to be cared for safely.

It was shocking to learn of the 63 detailed root causes uncovered. These causes now require 454 corrective actions to resolve 138 citations LHH has received. LHH violated 78 separate patient care-related “F-Tags” — many multiple times each — plus an additional 20 “K-Tag” violations of facility “physical plant” deficiencies across the three years and four months since the sexual abuse of patients scandal at LHH surfaced in 2019. The 98 various types of "Tag" deficiencies led to those 138 citations.

The sheer volume of the 138 citations involving the 78 F-Tag violations was even more shocking to the cadre of dedicated current employees and alums who served at LHH over the years. They are mostly not responsible for the current sad situation at LHH and will suffer from the negative publicity. They are people who feel proud of their work providing LHH’s residents with high levels of care.

The alums don't have to be present at LHH today to surmise the origins of these citations. Most remain shocked because citations had never been so severe, with so many basic patient care regulations violations.

Dr. Kerr, Dr. Rivero and Patrick Monette-Shaw
"Dr. Kerr, Dr. Rivero and Monette-Shaw"

When interloping managers from San Francisco General Hospital (SFGH) and the San Francisco Health Network (SFHN) began running LHH in the past three years like an acute care hospital instead of a skilled nursing facility, the citations mushroomed. The inept managers are principally responsible for the current mess at LHH, not LHH's caring and dedicated staff.

Even more shocking are the bald attempts by San Francisco City officials, including the Board of Supervisors, who have tried desperately to diminish the scope and severity of the 138 deficiencies and citations, and the causal factors that led to them.

To dispel attempts to diminish the severity of LHH's patient care violations falsely, consider a few numbers.

One-hundred and thirty-eight. One-hundred and twenty-three. Two-hundred and sixty-one.

Those may not sound like huge numbers, but 138 is the shocking number of actual substandard patient care violations plus facility physical plant citations LHH has racked up as a result of State survey inspectors during the three-year, four-month period following the patient sexual abuse scandal that first rocked the hospital in July 2019. That's a lot of violations over a short period.

Add in another 123 substandard care violations uncovered during an unofficial inspection conducted by LHH’s in-house consultant, Health Management Associates (HMA), during LHH’s first “mock survey” done in June 2022 to prepare LHH for an official recertification survey by the California Department of Public Health (CDPH). There was no explanation why a planned second "Mock Survey" was never held.

quote marks

When interloping managers from SF General Hospital and SF Health Network began running LHH in the past three years like an acute care hospital instead of a skilled nursing facility, the citations mushroomed. The inept managers are principally responsible for the current mess at LHH, not LHH's caring and dedicated staff.”

LHH tried to minimize the 123 “Mock Survey" findings by claiming there were only 101 unduplicated F-Tag violations, creatively excluding 22 repeated F-Tags.

That totals 261 patient care and facility violations of Federal regulations, suggesting severe problems with regulatory compliance provided to LHH's vulnerable residents. At every opportunity LHH, the Board of Supervisors, and City officials have minimized the severity and scope of the violations.

But there's no escaping that 261 problems — requiring up to 454 corrective actions identified as necessary — can't simply be brushed off as outliers or “minimal,” as the “minimizers” have asserted. The problems were primarily due to inept management brought into LHH, who had no experience whatsoever managing a skilled nursing facility.

It isn't about LHH's ability to walk and chew gum at the same time, as Supervisor Myrna Melgar cavalierly asserted, along with her pal, Supervisor Hillary Ronen.

LHH has been in the throes of potential closure, for now, a full year following its decertification on April 14, 2022, as a participating provider in the Federal government's Centers for Medicare and Medicaid (known as Medi-Cal in California) Services (CMS) participation program for skilled nursing facilities (SNF’s).

To receive reimbursement from CMS, SNF's must substantially comply with approximately 211 "F-Tags" required by various Federal regulations designed to protect nursing home residents and other regulations. LHH was found to have extensively violated those regulations during the past three years.

It wasn't always this way. LHH was typically in substantial compliance with CMS regulations and routinely passed State inspections with few, if any, regulatory violations. What is new is the recent massive mismanagement of LHH.

When a trove of records was released belatedly on February 8, we began learning the severity and scope of just how severe LHH's violations have been. The documents read like a pre-mortem of a hospital's potential death spiral.

Doctors Derek Kerr and Maria Rivero published a terrific article on February 23 in the Westside Observer summarizing a portion of the root causes that led to LHH’s decertification in a report the Department of Public Health had kept secret for nine weeks. Their article is a must-read for anyone interested in the fate of LHH and its dwindling resident population.

Kerr and Rivero have been an investigative whistleblower and watchdog team for the Observer for approaching 20 years. [Disclosure: When Dr. Rivero served as LHH’s Medical Director, she extended my job offer when I was hired at LHH in 1999. A decade later, I helped proofread and format their seminal "Critical Analysis of the Ja Report” in 2009 about a behavioral health program proposed for LHH.]

LHH’s Institutional Comorbidities

Kerr’s and Rivero’s article in February covered the initial 48-page Root Cause Analysis (RCA) Report prepared by Health Services Advisory Group (HAG). This consultant has been paid $17.3 million to date to assist LHH in obtaining recertification from CMS. That report was released on February 8 following drawn-out public records requests to obtain it.

I only take slight issue with an editor’s caption to an illustration accompanying their article that suggests the initial RCA report dated December 1, 2022 finally gives us a complete picture of LHH's problems and the path to recovery. A complete picture is premature, given that there was a second 36-page RCA report describing LHH’s first “90-Day Monitoring Survey” dated January 31, 2023, and a 49-page “Action Planreport listing 454 corrective actions needed to fix LHH’s mismanagement.

A second 90-Day Monitoring Survey that began on March 13 planned to take a week, but that was concluded on March 17. It will be followed by a third RCA report and a potential additional “Action Plan.” I’m hesitant to conclude we’ve seen a complete picture of LHH’s problems decades-long in the making.

Just as individual patients often have multiple, co-existing, long-term medical conditions — known as comorbidities that may develop independently of one another but may not directly cause each other — hospitals, institutions, and skilled nursing facilities can also develop multiple long-term, systemic, and chronic conditions that threaten their survival.

Kerr and Rivero’s February Westside Observer article explored five of the first eight problem areas in the first RCA report exploring the causal root factors leading to LHH’s decertification, including:

  • Quality Assurance & Performance Improvement (QAPI),
  • Infection Prevention and Control,
  • Behavioral Health and Substance Abuse,
  • Comprehensive Care Plans and Quality of Care, NS
  • Competent Staff, Training, and Quality of Care

But following the Fire Life Safety inspection resulting in four “Immediate Jeopardy” citations over a fire alarm debacle during the first 90-Day Monitoring Survey CMS and the California Department of Public Health (CDPH) conducted at LHH in December, the list of eight problem areas grew to 11, including the last three:

  • Medication Management and Administration
  • Resident Rights and Freedom from Harm
  • Emergency Preparedness Program
  • Fire and Life Safety
  • Resident Quality of Care
  • Food and Nutrition Services

The additional three problem categories outline significant problems State inspectors uncovered between December 1 and December 16 after the first 90-Day Monitoring survey wrapped up.

The final two categories, Resident Quality of Care and Food and Nutrition Services were among the most damning, which will be reviewed in detail in an upcoming article.

Back in May 2015, Drs. Kerr and Rivero’s Westside Observer article, “Laguna Honda’s Falling Star,” documented LHH’s CMS five-star rating plummeted to just two stars. Four years following their 2015 article, LHH’s patient sexual abuse scandal surfaced in June 2019. That was when CMS slapped LHH with its then-new red stop-hand warning icon for consumers. Since then, LHH sank to its current pathetic one-star CMS rating. The warning icon remains next to LHH's name to this day on CMS’ Nursing Home Compare website.

The 261 Citations

In the three years and four months, since news reports surfaced reporting LHH's sexual abuse scandal, the hospital racked up 261 citations across 12 State survey inspections.

  • LHH received only ten citations in the July 2019 inspection survey of LHH’s sexual abuse scandal, including four separate “Immediate Jeopardy” citations.
  • Then LHH received 17 more citations four months later, in November 2019.
  • The near-fatal patient fentanyl overdoes in July 2021, triggered a succession of eight separate State survey inspections beginning on October 14, 2021, and running through April 13, 2022, during which LHH ignored successive CMS and CDPH warnings that it faced potential decertification for worsening violations. Across those eight consecutive surveys, LHH racked up 22 citations, including another citation alleging a pattern of “Immediate Jeopardy” violations, until CMS finally resorted to decertifying LHH on April 13, 2022. It is thought CMS had the option of placing LHH in receivership, but didn’t.
  • Fast forward to LHH’s first 90-Day Monitoring Survey that began on November 28, seven months after being decertified. At that point, LHH received a whopping 56 patient-care-related citation violations, plus 20 “physical plant” (facility) violations, for a total of 76 violations — representing a combined 28.8% of the 261 total citations across the actual official survey inspections and the unofficialMock Survey” citations.
  • [Note: The 261 citations excludes an additional 23 (if not higher) deficiencies LHH just received following its second “90-Day Monitoring Survey” that just concluded, described below.]
  • The jump from 22 citations in the eight survey inspections between October 2021 and April 2022 to receiving 76 citations during the first “90-Day Monitoring Survey” in December — more than three times higher than the 22 that led to LHH’s decertification in April 2022 — is particularly disturbing, since LHH’s three external consultants were brought on board in May 2022 to fix LHH and stop receiving further citations.
  • Assuming the 23 new deficiencies identified in the second “90-Day Monitoring Survey" that just concluded all involve patient care, not facility "F-Tag" violations, they will represent a reduction of just under half of the 56 patient care violations received during the first "90-Day Monitoring Survey" in November and December. While that represents some progress, it remains worrisome. Nine months after DPH hired three consultant groups to fix the substandard care , LHH continues to rack up citations.

LHH racked up 118 patient care citations in those intervening three years and four months. Chart 1 shows LHH also amassed 20 citations related to "physical plant” deficiencies uncovered during the first 90-Day Monitoring Survey for a total of 138 citations across the 12 formal State survey inspections.

Toss in another 123 rated and un-rated citations uncovered during an unofficial “Mock Survey” conducted by LHH’s consultant Health Management Associates (HMA), which has been paid $5.8 million to date to assist LHH in CMS recertification. That brings total citations for various known LHH deficiencies to 261 — clearly a symptom of mismanagement of the hospital in this LHH pre-mortem.

A full-page version of Chart 1 is available online.

Spoiler Alert

Unfortunately, just before publication of this secondary analysis article, news surfaced that the numbers presented here may be under-reported.

On March 21, LHH’s acting CEO, Roland Pickens, announced during a Health Commission meeting that LHH’s second CMS/CDPH “90-Day Monitoring Survey” had concluded, apparently on Friday, March 17. He gushed that LHH had only been slapped with an additional 23 new deficiencies that he didn’t describe or summarize, and which haven’t been released to the public yet.

Another records request has been placed to obtain CDPH’s new Form 2567 report rapidly, rather than having to wait for HSAG to write a third “Root Cause Analysis” report and another follow-up supplementary “Action Plan” for CMS.

The potential 23 new citations will push LHH's total citations since July 2019 to a new record of 284 citations, up from 261. Hopefully, LHH hasn't received another "Immediate Jeopardy," which CMS had warned against.

During the March 21 Commission meeting, Pickens claimed LHH had received 124 deficiencies during its first “90-Day Monitoring Survey.” He appears to have been confused, or he misspoke, because the second “Root Cause Analysis” report documented 76 citations (50 related to patient care plus 20 “facility" citations). Pickens may have been trying to compare and contrast the new 23 deficiencies to the 76 deficiencies (but wrongly claimed 124) in an effort to claim LHH has been making progress on implementing reforms and reducing the number of citations.

If LHH received 23 additional patient-care-related deficiencies, that would still be more than the 22 citations that led to LHH's decertification across the eight separate inspection forms. While a reduction from 76 to 23 between two surveys indicates progress, 23 more citations suggest LHH is still not ready to pass an actual recertification survey!

How many additional "milestone” corrective actions will be needed in another “Action Plan" to fix the 23 new citations? We still need to determine if the new corrective milestones will have to be corrected by May 13, along with the other 454 milestones. This portends that LHH must undergo a third “90-Day Monitoring Survey,” which probably won’t start until mid-June.

Attaining actual CMS recertification looks farther and farther away, to the detriment of LHH's current residents. And San Franciscans needing admission to LHH will be denied, given the continuing ban on new admissions.

By the time LHH received the new 23 deficiencies on March 21, LHH had not updated the Health Commission about whether, between November 18 and December 16 (or after), all 123 deficiencies identified in the "Mock Survey" conducted in June had been cured. Only 63 were fully resolved, with the remaining 38 unresolved by November 18. Following LHH’s dashboard report for the week ending November 18, LHH stopped publicly presenting its weekly dashboard reports in December, so it’s unclear whether those 38 remaining deficiencies were ever fully resolved.

A reasonable person would assume management would have resolved the 38 outstanding deficiencies in the five months between June and November. The status of their resolution vanished into thin air before LHH was hit with the 23 new citations.

Scope of the Citations

Across the 12 surveys between June 2019 and April 2022, another perspective is the sheer numbers within each "scope" category. An alternative Chart 2 available online is helpful for visualizing the 261 citations:

Chart 2 summarizes the citations by severity and scope, showing:

  • Twenty-two — a significant 8.4% — of the 261 citations involved the Level 4 “Immediate Jeopardy” severity, including 13 “L” citations, representing the number of patients who had faced immediate jeopardy.
  • Seventeen of the citations involved “Actual Harm” that had not risen to the level of posing immediate jeopardy to patient’s health and safety, ranging from “Isolated” to “Widespread.”
  • The 22 “Immediate Jeopardy” and 17 “Actual Harm" citations combined, comprise 14.9% of the 261 violations.
  • 162 of the citations involved “No Actual Harm,” but had the potential for more than minimal harm, including 67 during the first “90-Day Monitoring Survey” alone that began at the end of last November.
  • Another 33 citations had “No Actual Harm,” but had the potential for minimal harm.

It was beyond the resources of this article to tally the number of individual residents identified anonymously across the 12 survey inspection reports that had earned the 261 citations. But given LHH's typical resident census was 710 people, and the scope ranged from isolated to widespread incidents, it’s reasonable to imagine that the aggregate number of patients affected may have neared or exceeded the 710 residents.

For instance, just one inspection — on July 12, 2019, involving the sexual abuse allegations that had earned four “Immediate Jeopardy” scope ratings of “pattern” or “widespread” — had found 21 residents had been harmed by physical, mental, verbal, and sexual abuse, and chemical and physical restraints. And it found that five residents endured life-threatening complications due to purloined medications from LHH staff that their physicians had not prescribed.

About the F-Tags

Want to get into the weeds? Table 1, available online, lists the titles of each of the 78 separate “F-Tag” (patient care) violations. CMS is thought to have 211 separate "F-Tag" criteria all skilled nursing facilities nationwide are required to comply with; 48 of the 211 — 22.7% — involve sub-standard care, by definition.

So, the 78 F-Tags LHH violated — accounting for 118 actual survey patient care citations and an additional’ 57 “Mock Survey” patient care F-Tags findings in the 261 citations — represents 37% of all 211 F-Tags.That suggests LHH’s widespread and potentially willful disregard of the “F-Tag” CMS standards.

This bears repeating: The sheer volume of citations during the three years was mismanaged — as if it were an acute care hospital, not a skilled nursing facility (SNF) — is a symptom of, and a result of, LHH managers having no experience in running SNF's.

Add in 38 “K-Tag” (physical plant) violations across LHH’s actual inspection report citations plus the “Mock Survey” findings, out of an unknown number of total “K-Tags.” Again, that suggests LHH’s willful neglect to keep its “physical plant” in safe operating condition to house its vulnerable residents.

About the Federal Regulatory Groups

As for “Federal Regulatory Group” categories, Table 2, also available online, illustrates that the 118 citations LHH received for “F-Tag” patient care violations across the 12 inspections spanned 17 of 21 Regulatory Groups.

  • Three of the 17 groups shown in Table 2 exclusively involve sub-standard patient care (Freedom From Abuse and Harm, Quality of Care, and Quality of Life). They accounted for 37 — 31.3% — of the 118 citations.
  • Two other Regulatory Groups that don’t exclusively involve sub-standard patient care — “Comprehensive Resident-Centered Care Plans” and “Resident Rights” — also racked up 37 (31.3%) of the 118 citations involving patient care.

The “Regulatory Groups” are analogous to organs and parts of the body, such as the brain (Hospital Administration), heart (Nursing Department), liver (Quality Management Department), lungs (Medical Services Department), stomach, kidneys, and skin (encompassing the “physical plant"), and eyes, arms and legs, etc. The scope and severity of LHH's diseased citations necessitated this pre-mortem, if you will. LHH's prognosis? Poor.

Suppose you agree to the sheer quantitative numbers in this preliminary analysis of root causes leading to LHH’s decertification and its subsequent inspections are scary. In that case, the qualitative narrative in a planned next installment is even scarier.

About the Causal Root Factors

The consultants hired to root out the causal factors that led to LHH’s decertification did yeoman’s work, but stopped short of holding anybody accountable. Had LHH corrected its “culture of silence” — which the consultants themselves admitted they uncovered — back in 2019 when LHH had claimed it would develop a "culture of [patient] safety” with a “60-Day Reform Plan” it would roll out (discussed further, below), perhaps CMS wouldn’t have decertified LHH in April 2022.

The need for LHH to implement a "culture of managers" qualified to run SNF's was never mentioned.

Table 3 is a detailed list of the 63 underlying root causes grouped by each of the 11 major problem categories across the first two RCA reports exploring the causal root factors leading to LHH’s decertification. A sampling of some of the more shocking root causes includes:

  • Quality Assurance and Performance Improvement (QAPI) program not aligned to skilled nursing facility (SNF) setting
  • Lack of nursing involvement [in infection prevention and control
  • Inadequate electronic healthcare record [system] (EHR)
  • Insufficient hand hygiene and personal protective equipment (PPE) audits
  • Non-compliance with safe medication management practices
  • Lack of proactive interventions to prevent [resident] abuse
  • Lack of formalized restorative [care] nursing program
  • Ineffective [patient] care planning by interdisciplinary [care] team
  • Lack of leadership with SNF [skilled nursing facility] experience, regulatory knowledge
  • Lack of fire and life safety awareness
  • Use of outdated clinical nutrition standards of practice

There are other equally alarming root causes contained in Table 3 online.

As Kerr and Rivero rightly noted in their February 23 article that although HSAG bravely exposed many of the underlying root causes that led to LHH's decertification, HSAG omitted to mention that the disastrous “Flow Project" of SFGH patients routed to LHH beginning in 2004 was the start of LHH's decline. Kerr and Rivero noted:

The Root Cause Analysis [reports] omits [that] foundational history, but covers its grim outcome” and also observed the report "exposes the ignorance and mismanagement that befell the hospital.”

Sadly, none of the managers who allowed these root causes to germinate and then flourish, have been held accountable. None have been terminated to date, except LHH's recent CEO, Michael Phillips, who served for just two years, long before the problems had begun. Nobody else has been held accountable.

Defrocking the “Minimizers

I’m reminded of comedian and former U.S. Senator Al Franken’s 2003 book, “Lies … and the Lying Liars Who Tell Them.” Franken asserted God had suggested he title his book, “Bearers of False Witness and the False Witness That They Bear." It was great that Franken worked with God's suggestion, updating it to modern vernacular. His book put me on alert 20 years ago for liars.

I became a columnist for the Westside Observer because the truth matters, since too many people lie to attain power and abuse people. Locally, lying to us undermines our trust in DPH. Public figure or private, lies impose real harm.

Me? I have to keep doing my part to give voice to LHH's voiceless.

For those who have continued to minimize LHH’s problems, deception has been the point all along: Theatrical propaganda from unreliable narrators. I wonder if God will defrock them for bearing False Witness, as Pappas was defrocked.

The minimizers need to stop their deliberate misinformation.

Sadly, LHH, as we have known it, may not survive its pre-mortem, if lies continue leading to its post-mortem.

- - - - - - - - - - - - - - - - -

The full version of this article posted on the author's website includes additional information about LHH’s planned “60-Day Reform Plan” published in August 2019 it claimed would be implemented following its patient sexual abuse scandal. Had that Reform Plan worked, LHH might have avoided decertification in 2022. There's also additional information on the methodology LHH's consultants used in their recent reports, and a section on three politicians attempting to minimize the severity and scope of LHH’s citations.

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

April 10, 2023


More articles by Patrick Monette-Shaw...

Click to find more investigative articles by Monette-Shaw.

More Trending Articles

West Portal Station

Nightmare Plan from Melgar, Breed, and Tumlin

Showdown on West Portal

by George Wooding

SFMTA still has no quantifiable road safety data other than right turns are bad, left turns are bad, fast-moving cars are dangerous, slow-moving cars are dangerous, cars are bad, and bikes are good.

Read More

Laguna Honda Costs graphic

So What’s the Damage?

Counting the Costs of the Laguna Honda Debacle

by Patrick Monette-Shaw

Sadly, LHH has not been recertified, patient admissions have not restarted. So patients needing skilled nursing care are displaced out-of-county.

Check it out

West Portal graphic

Addressing the West Portal Tragedy

Planning for a Safe Intersection

by Supervisor Myrna Melgar

The winning projects will be most closely align to the criteria and can be successfully completed with the funding allocated as a one-time grant.

Read More ...

Removing density controls in western and central SF?


Mayor’s Upzoning Plan Endangers Our Neighborhoods

by Dennis Antenore

Demolitions, speculations, and displacement are in store if the city moves forward with Breed’s approach.

Check it out

Homeless seek respite at Ocean Beach

homeless at Ocean Beach

Life at the end of the safety net

by David Romano

If you do get into a shelter — they’ll take away your belongings, you can’t have a pet, you can’t have visitors and after a few days or a week, you’ll likely be turned out on the street again with nothing.

Check it out

Pill popping

Overdose Deaths Bewilder DPH

Battling lethal drug combinations

by Dr. Derek Kerr

The devastating effect of drug addiction is evident from the human wreckage ...Yes, it’s a nationwide plague. But SF overdose rates are twice the national average.

Check it out

© 2023 Westside San Francisco Media. No portion of the articles or artwork may be republished without expressed consent. Legal disclaimer.