Admissions to Laguna Honda Won’t Happen Soon

Although LHH Was Just Medicare Recertified, Don’t Set Hopes High

Still Unresolved:

Is Patient “Cohorting” Still on the Table, Reducing SNF Beds?

When Will the 120-Bed Waiver Request Be Submitted to CMS?

Has the “Consistent Bedside Care” Initiative Been Abandoned?

News: Laguna Honda Hospital (LHH) has regained full recertification. It should be taken with a grain of salt. If ever there was a time for warning “Not So Fast,” it’s now.

San Franciscans shouldn’t get their hopes up about how soon Laguna Honda Hospital and Rehabilitation Center (LHH) will resume admitting patients halted since mid-April 2022.

by Patrick Monette-Shaw

• • • • • • • • • • June 25, 2024 • • • • • • • • • •

The recent news only means that LHH has been awarded a new Medicare Provider ID number. Period. Not that admissions are imminently forthcoming.

After all, LHH was recently fined on December 5, 2023, an additional $248,000 for violations dating back to February 2016 and January and June 2020, for three violations by the California Department of Public Health (CDPH) involving the illegal release of protected patient medical information under HIPAA not previously reported, and five other violations by CMS. We have no idea (yet) how much more the facility may have been fined in the first six months into 2024 or how much more in LHH fines and penalties from previous years are due to backlogs in facility inspections conducted by the CDPH. Costs to rescue LHH continue to spiral.

Some good news — as you may have heard in the past week — Laguna Honda Hospital received its Medicare recertification from the Centers for Medicare and Medicaid Services (CMS) on June 19 or June 20.

That good news started to leak to San Francisco’s Department of Public Health (SFDPH). It appeared to have advance notice prior to the Health Commission’s meeting on June 18 that LHH was about to receive its long-awaited full recertification in the Medicare provider program.

The news leak came internally — from Health Commissioner Guillermo herself — during the June 18 meeting (at 2:16:17 on videotape) “Really waiting and eagerly for the letter [from CMS] that says we are [have been awarded] recertified. We understand that [letter] goes to [the] Billing [Department] first, where any official wording goes, so you get a [CMS] provider number, I guess. That’s how the bureaucracy works. So, we’re waiting [to receive that official notice].”

Mainstream Media Cheerleaders Weighed In

The San Francisco Examiner reported on June 20 that LHH “will now resume admissions for patients on Medicare or Medicaid.” Not so fast.

That’s misleading precisely because the only thing that has happened is that Laguna Honda is, once again, “eligible” to receive Medicare and Medi-Cal reimbursement from the Centers for Medicare and Medicaid Services (CMS) — not that admissions to LHH are imminent.

For its part, the San Francisco Chronicle also reported on June 20 that “Laguna Honda leaders were informed Wednesday that they regained Medicare certification, which means they can begin admitting new residents again and bring back the dozens of residents who had been transferred to other facilities in 2022 as part of the federally mandated recertification process.”

Unfortunately, the Chronicle didn’t include any details of when admissions might resume. It’s as if the Chronicle is unaware that San Francisco’s Health Commission—LHH’s inept “governing body”—had recently been saying during its twice-monthly meeting that admissions will essentially resume incrementally, and slowly.

And Newsweek chimed in on Friday, June 21, reporting, in part, that one observer had commented: “… being recertified is a huge step in the right direction for Laguna Honda, and will likely help to repair the reputation of the hospital after the reported safety issues.”

Admittedly, this is a huge step in the right direction. However, these mainstream media print publications didn’t wade into how soon admissions might resume for patients who have been denied admission for the past 26 months following LHH’s decertification on April 14, 2022. That’s because LHH’s population of residents has plummeted by 287 residents, from 710 on October 14, 2021, after “troubles” when its patient sexual abuse scandal surfaced in 2019, to just 423 residents as of May 22, 2024 — representing a 40.4% percent change decrease in residents following LHH’s decertification in April 2022.

The mainstream news outlets barely scratched the surface of the remaining problems at LHH that will delay the resumption of actual patient admissions, let alone more robust oversight going forward.

Unresolved Problems

To her credit, the Chronicle’s health care reporter, Katherine Ho, reached out for comment to our associate, geriatrician Dr. Teresa Palmer, a frequent and intrepid contributor to the Westside Observer. Ms. Ho thoughtfully included Palmer’s concerns, saying, “Some of the same practices that got Laguna Honda in trouble in the first place will continue because of political and economic pressure.”

Palmer added, “They [LHH and SFDPH] say they’re going to be minding the ship again but if there’s immense pressure to take behaviorally disordered people who aren’t stabilized and treated, and active substance users and seekers from San Francisco General, the regulatory problems will recur.”

Palmer is right to worry so. That’s because of outstanding problems none of the mainstream media addressed in their rush to praise Mayor Breed, U.S. House of Representatives Speaker Emerita, Nancy Pelosi, and Director of Public Health Grant Colfax, who are collectively tooting their own horn prematurely.

Palmer’s concerns, also just published in the Westside Observer, include:

1. How can a system of oversight for LHH be created so that admissions resume and repeated profound mismanagement of LHH doesn’t persist or recur?
2. Whether San Francisco’s Board of Supervisors will closely monitor the submission of a waiver to prevent the permanent loss of 120 beds at Laguna Honda.
3. A required annual report from SFDPH on out-of-county patient discharges to skilled nursing facilities for all San Francisco hospitals for 2023 was due were due to SFDPH by January 31, 2024, but DPH is MIA on the data showing how many more San Franciscans have been exiled to out-of-county facilities.

That report is now promised in July.

There are other concerns.

LHH’s “Sustainability Plan” Faux Pas

Although it was frequently mentioned to be “forthcoming” for months, the San Francisco Health Commission delayed presenting an “LHH sustainability plan” that would shape how LHH would be managed in the future following its Medicare recertification.

The sustainability plan is a significant step.

Unfortunately, the faux pas — French for “false step” — was that when it first surfaced, it wasn’t presented to the Health Commission for prior approval. The faux pas was essentially a “process” issue San Franciscans deserve to have had better managed.

Well-founded concerns arose as early as May about the “sustainability plan” premiere at a national conference on April 10 — without prior review and approval by the Health Commission.

Why hasn’t a “sustainability plan” been presented in an open public meeting so the public can see what it involves? Why was the LHH “sustainability plan” presented to CMS’ national conference but not to the Commission? For that matter, why wasn’t “the sustainability plan” submitted for this Commission’s review BEFORE CMS’ Conference?

A Non-Denial Denial

Roland Pickens, from the San Francisco Health Network (SFHN) introduced as the “Executive Sponsor of LHH” during the Health Commission’s June 18 meeting, rushed to suppress legitimate criticism about the Commission’s stonewalling of the LHH long-awaited “sustainability plan.” Pickens prefaced his presentation on June 18 by saying:

“I’d like to try and clarify some misinformation that continues to permeate, and that is the inaccurate impression that Laguna Honda presented a “sustainability plan” at the CMS Quality Conference a few months ago. That is, emphatically, not true. Nothing at that Conference was presented without having first come to the Laguna Honda JCC or this Health Commission. Perhaps those who have that opinion are mistaking the fact that the presentation referenced that there would be a forthcoming “sustainability” plan that would be presented to the Health Commission. So, that may be the source of the misunderstanding, but I wanted to clarify that and assure you that we would not present anything on a “national stage that did not come first to this group.”

In fact, there was a slide presented during the April 10 CMS Conference describing LHH’s planned sustainability plan, which had not previously been presented to the Health Commission before it was presented on a national stage at the CMS Conference. Not that the slide had “referenced” a sustainability plan would be forthcoming. The slide appeared to be clear to conference attendees that it was the sustainability plan envisioned.

On April 10, after Health Service Advisory Group (HSAG) had been awarded $26.9 million in contracts since May 2022 to help rescue Laguna Honda (as a CMS-approved Quality Improvement Expert contractor to CMS), HSAG’s Executive Director, Keith Chartier, and Barb Averyt, a Senior Executive Director at HSAG, presented at the CMS Quality Conference, along with a co-author and co-presenter from SFDPH, Troy Williams, SFDPH’s Chief Quality Officer of the San Francisco Health Network (SFHN and one of the two “Co-Incident Commanders” SFDPH dispatched from SFHN’s management group to help right LHH’s sinking ship.

The CMS Quality Conference presentation was titled “The Quality Improvement Journey: Recertification of Laguna Honda Hospital and Rehabilitation Center (LHH).”

In a section of the presentation titled “Hardwiring Systemwide Improvement: Sustainability, Success, and Certification,” slide # 23 titled “LHH Strategy to Stabilize and Sustain Improvement” presented a nine-step outline of LHH’s planned strategy to sustain improvements that have cost taxpayers approximately $177.5 million (and counting) so far since LHH was decertified in April 2022.

While Pickens’ may want to nitpick over whether the “sustainability” slide #23 presented on a national stage at the CMS conference was merely “misinformation,” it is nonetheless clear that Chartier, Averyt, and Williams had not presented the HSAG-authored work product first to the Health Commission or to the LHH-JCC, but had presented it there, first.

The “properties” of the PowerPoint presentation PDF file showed the author of the presentation had been HSAG — not LHH or Mr. Williams. Perhaps HSAG felt that after it had been awarded $26.9 million in contracts, it didn’t need to obtain Health Commission approval to show its LHH accomplishments at a national conference, absent the Health Commission’s pre-approval.

“Sustainability Plan” Radical Changes

The version of LHH’s potential nine-point “sustainability plan” presented at the CMS conference on April 10 was notable.

HSAG asserted on April 10—while still under contract with San Francisco’s City Attorney’s Office, the Department of Public Health, and Laguna Honda Hospital—along with Troy Williams that the second “step” in the sustainability plan would be to continue the “Consistent Care at the Bedside Monitor” initiative (CCBI) into the future.

HSAG recommended the adoption of the CCBI initiative as part of the eventual 1,000 “milestone” and corrective actions in the “Action Plan” developed to fix problems at LHH. The CCBI was rolled out in May 2023, a year into HSAG’s multiple contracts with LHH after HSAG had reported in one of its nine “Root Cause Analysis” reports that some LHH staff — particularly on LHH’s Nursing units — were jeopardizing progress towards LHH’s recertification because of inconsistent bedside care and adherence to common healthcare standards that are basic in every nursing home (such as washing hands, and changing gowns).

In fact, Roland Pickens promoted the CCBI initiative in his May 14, 2023 letter to CMS and the Secretary of Health and Human Services (DHHS) responding to an “Immediate Jeopardy” citation LHH received on May 8, 2023. Pickens claimed the CCBI initiative would cost $1 million a month to observe, monitor, and provide advice “to frontline staff and management on every floor, in every unit, for each shift.” Pickens assured CMS and DHHS that “LHH will take appropriate disciplinary action against LHH personnel as warranted by the results of [the] investigation [into the circumstances leading to the ‘Immediate Jeopardy’ citation].”

Over time, LHH bedside Nurses appear to have grown extremely tired of the constant monitoring of Nursing staff, and during heated contract renewal negotiations, threatened to go on strike in May 2024. [Note: Of interest, a press release from SEIU Local 1021 dated May 10, 2024, regarding a rally at LHH involving the planned strike vote included a hyperlink to Westside Observer articles noting costs to rescue LHH had grown at that time to $125 million, but have grown to $177.5 million since then!]

Later, HSAG’s contract was abruptly curtailed before May 21. Was the close proximity in time between the Nurses threatening to strike and the sudden announcement that HSAG was being terminated a coincidence? On May 21, testimony to the Health Commission questioned whether HSAG’s contract was cut short in response to the SEIU Nurses threatening to strike:

“HSAG is curtailing its consulting contract scheduled to run through 8/31/2024. HSAG prematurely leaving in May before LHH obtains full recertification is exceptionally worrisome! LHH’s “Consistent Care at the Bedside Initiative” (CCBI), supervised by HSAG, was to ensure ‘That LHH remains recertification survey ready,’ because HSAG had asserted that LHH’s staff continued demonstrating practices that could jeopardize its recertification. The CCBI involved HSAG staff observing bedside Nursing care to correct deficient Nursing bedside practices. HSAG’s Barb Everyt indicated during the 4/10/2024 CMS Quality Conference continuation of the CCBI program is a key component of LHH’s nine-step ‘sustainability’ plan for ensuring compliance with CMS regulations. Without HSAG around, what happens to sustaining the CCBI program SEIU Nurses complained about so bitterly?”

It should be noted that Health Commissioners Laurie Green, Dr. Edward Chow, and Tessie Guillermo had been closely monitoring the CCBI initiative since Pickens had announced it in May 2023, and the three Commissioners had been very supportive of it.

Continuous Care at the Bedside Vanishes

But just as suddenly as HSAG vanished or abandoned its post prior to LHH being awarded its Medicare recertification, the CCBM program also appears to have taken a cut, all but disappearing. (Note: CCMI and CCBM are inconsistently used.)

On June 18 — just two days before CMS awarded LHH full recertification — Pickens presented an LHH version of its “Sustainability Plan” that was presented to the Health Commission.

Pickens’ 24-page presentation on June 18 included an eight-point “strategy for sustainability,” which was noticeably different from the nine-point “sustainability plan” HSAG and Troy Williams presented at the CMS Quality Conference on April 10.

First, no mention of the “Continue CCBM [Consistent Care at the Bedside]” program in all nursing units was made. Why was that suddenly removed from the nine-point plan HSAG had authored and presented at the CMS Quality Conference on April 10? Is that because HSAG’s contract was prematurely ended in May, and now that they’re out of the picture, the CCBI was dropped from the nine-point sustainability plan to appease LHH’s Nursing staff?

Pickens’ replacement PowerPoint presentation — authored by Martyn Andres Bonaventura, a Civics Edge Consulting employee — was apparently created on Monday, June 17, less than 72 hours before the start of the Health Commission meeting the next day. [Note: Civics Edge Consulting has a social media contract with SFDPH, approved by the Health Commission.] On Friday, June 14, Health Commission Executive Secretary Mark Morewitz had initially posted Pickens planned five- to six-page PowerPoint presentation and announced it via an e-mail at 2:43 p.m. But then on Monday, in violation of the Sunshine Ordinances’ 72-hour in-advance of meeting rules, Morewitz uploaded the replacement presentation less than 24 hours before the Health Commission meeting started on Tuesday.

Long Arm of SFHN “Embedded” at LHH

The second noticeable change, Step #4 in the “sustainability plan” HSAG and Troy Williams presented on April 10 at the CMS Conference, indicated merely that San Francisco Health Network (SFHN) “oversight” would involve routine performance indicator update reports.

But Pickens’ 24-page replacement presentation grew SFHN’s role. Pickens is the CEO of SFHN and may be seeking to expand SFHN’s sphere of influence (and its budget). Indeed, Health Commissioner Laurie Green refers to Pickens as “LLH’s Executive Sponsor.”

Pickens’ presentation Slide #11 states that LHH’s “Recertification Hospital Incident Command Structure” has apparently ended. We’ll see if the two co-incident Commanders from SFHN—Baljeet Sangha and Troy Williams—continue engaging in LHH’s operations.

HSAG’s “Solidify SFHN Network Collaboration” step #4 has been drastically increased. Pickens now asserts SFHN leadership will be (or has been) “embedded onsite at LHH.” The word “embedding” had not been mentioned previously. SFHN leadership will participate in key LHH meetings to “keep the pulse of LHH’s daily operations.”

SFHN’s inept leadership is what got LHH into trouble in the first place and led to LHH’s decertification. Westside Observer reporter, Dr. Derek Kerr, covered the mismanagement of LHH by SFDPH and SFHN employees who lacked any experience in running skilled nursing facilities in his February 2024 article. Kerr covered the expert witness testimony of Christopher Cherney in a declaration filed in a Superior Court lawsuit seeking class action status in a long-simmering case against LHH. Cherney also documented gross failures of the Health Commission in its oversight role as LHHs “governing body.”

When the San Francisco Health Network was first created in 2013, it was set up to manage and pull together SFDPH’s various primary care and neighborhood health centers … not to oversee LHH or SFGH.

Unfortunately, the SFHN managers were the root cause of deforming LHH, which led to LHH’s decertification.

Nursing Home Administrator Sandra Simon and her team need to operate LHH according to CMS skilled nursing regulations as they were hired to do.

Notably, during the past two years, community members have urged the Board of Supervisors to find and strengthen an independent oversight mechanism to protect Laguna Honda. But what we are now getting is more internal oversight from SFHN. This is not independent oversight.

To summarize, SFDPH and its Billing Department may have received a heads-up notice on Monday, June 17 that LHH’s recertification from CMS was en route to the hospital, news Commissioner Guillermo leaked the next day during the Health Commission meeting. By 4:57 p.m. on Monday, June 17, Morewitz had swapped out Pickens’ planned five-page or so presentation with the expanded 24-page version, including extensive new and revised details of the long-awaited, long-delayed “LHH Sustainability Plan.”

In fact, it had just been just a week earlier that Pickens had informed the LHH-JCC (Joint Conference Committee) on June 11 that a “Sustainability Plan” would be presented “soon” (sometime in July), followed by a second “Admissions Plan.”

Pickens stated at 41:22 on audiotape:

“So, in terms of scheduling of the presentation on [the] ‘Sustainability Plan,’ we just had that discussion just today with Director [Grant] Colfax and Deputy Director [Novenna] Bobba. So, we’re in the process of developing that, and having dialog with JCC and Health Commission leadership on when to bring those [plans] before you. We’ve done that … pretty much almost ready to come forward. … I think we want to present the ‘Sustainability Plan’ first, but [following] on the heels of that, present the ‘Admissions Plan.’ They are separate, but there is some overlap between them because the Sustainability Plan informs the pace at which, in particular, new admissions can [resume].”

In fact, when Pickens swapped out his presentation to the full Commission, the “Sustainability Plan” he laid out had not been first presented to the LHH-JCC (essentially usurping the JCC’s authority), another “process” violation of protocol in bringing matters affecting Laguna Honda to the JCC first for review and guidance, presenting it as a done deal to the full Commission. And none of the Health Commissioners raised any concerns that the process had been violated.

Presumably, the “Admissions Plan” will be presented soon to the Commission in July, hopefully at the LHH-JCC meeting on July 9 — not just dropped on the laps of the full Health Commission and bypassing the LHH-JCC, again.

How Many Beds Will There Be at the Inn?

Dr. Palmer is right to worry about the still unresolved issue regarding LHH’s 120 beds still at risk of permanent loss after CMS ordered LHH to close its three-person suites under the “LHH Settlement Agreement” adopted in November 2022, even though three-person suites were allowed when the LHH replacement facility was rebuilt in 2008 and it re-opened in June 2010.

That’s because the CMS’ Nursing Home Compare website reports that LHH is licensed for 649 beds, although CDPH’s website reports LHH is licensed for 769 skilled nursing beds (plus 11 medical acute and skilled rehabilitation acute beds, for a total of 780 beds).

All along its inappropriately named decertification “journey,” LHH has claimed it would not submit the simple request for a waiver to keep those 120 beds until after LHH gained full recertification, ostensibly not wanting to anger CMS and risk not becoming fully recertified.

We’ll have to see now whether House Speaker Emerita Nancy Pelosi, San Francisco’s congressional delegation, and the Board of Supervisors advocate that the waiver request be submitted to save those 120 beds, considering that San Francisco has such a dire shortage of skilled nursing beds available in-county.

However, another issue involving how many beds will be available is another long-simmering and long-overdue analysis and report of how LHH’s remaining beds will be used and for which cohort(s) of patients.

As early as the summer of 2022, after LHH had been decertified, Pickens informed the Health Commission that an interdisciplinary workgroup in the bowels of SFDPH was studying how to use LHH’s facilities. Pickens asserted that there was a proposal being considered to use one of LHH’s two patient towers for elderly and disabled San Franciscans needing traditional skilled nursing care, and to use the other patient tower to house “behavioral health” and “mental health” patients, including those with substance use disorders.

Splitting LHH into two different cohorts of patients has long been a terrible idea because the two groups do not interact well. LHH doesn’t have the trained staff to provide the appropriate level of care behavioral health patients need and deserve.

All of LHH’s 769 skilled nursing beds must be preserved for patients who need traditional skilled nursing facility level of care.

To date, the report from this interdisciplinary workgroup has not been presented to the Health Commission, which report may also influence the development and presentation of the proposed “Admissions Plan.” The Health Commission hasn’t raised any questions about this workgroup report.

In all fairness, details of the eventual “Admissions Plan” will have to be monitored, because Pickens has already warned the Health Commission and members of the public it is going to be a long, iterative process, with several “pauses” introduced to ensure LHH’s “Sustainability Plan” will continue to function safely. It may be a long time before LHH’s bed capacity returns to its pre-decertification patient census.

Even though LHH has finally been recertified, San Franciscans will have to remain eternally vigilant on how LHH is managed into the future, to prevent another disastrous decertification “journey.”

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.

June 25, 2024