>> the san francisco health commission. it is wonderful to see the laguna honda team here in force in person and will you please call the roll. >> yes. commissioner green, present. [roll call] >> commissioner christian will read the land acknowledgment. thank you. >> the san francisco health commission acknowledges that we are on the unceded ancestral homeland of the ramaytush (rah-my-toosh) ohlone (o-lon-ee) who are the original inhabitants of the san francisco peninsula. as the indigenous stewards of this land, and in accordance with their traditions, the ramaytush ohlone have never ceded, lost, nor forgotten their responsibilities as the caretakers of this place, as well as for all peoples who reside in their

traditional territory. as guests, we recognize that we benefit from living and working on their traditional homeland. we wish to pay our respects by acknowledging the ancestors, elders, and relatives of the ramaytush ohlone community and by affirming their sovereign rights as first peoples. >> thank you. secretary morewitz now has an announcement to make. >> hi, everyone. the health commission will be discontinuing remote public comment by members of the public effective at the next full commission meeting scheduled for january 16, 2024. accommodation for remote public comment will continue to be made available to individuals with disabilities so they can participate in our meetings. individuals requesting accommodation for disability will need to submit their request via e-mail or phone noon monday before the health commission meetings. today's meeting will be the last for remote public comment by the general public.

anyone without a disability accommodation wishing to address the commission on items or other matters not callanered need to be present and in person. those unable to attend commission meetings in person may still submit written public comment commissioners will read and review. future agenda and website postings include these changes to remote public comment procedures and clear instructions how to submit request for accommodation for disability. additionally, access to view health commission meeting via webex will continue to be made available. the health commission hearing concerns and input from all community members. >> thank you. we already received written public comment today and do receive and do read them, so we'll try this out and hopefully it will work with anyone and again, anyone with disability is welcome to continue with remote public comment so thank you. i believe the next item agenda

is laguna honda hospital employee recognition awards and commissioner guillermo, who chairs the jcclhh will proceed. >> thank you president and thank you all. i'm so glad to see your faces and wish we could see them more often. i'm pleased to open this recognition. this year we recognize all laguna honda hospital staff for this role in securing the future of the organization. this team was a national model for covid-19 response and saved countless lives during the pandemic. barely a moment to catch a breath, staff was faced with greatest challenge in the 150 year history. a multi-year cms recertification process. for the last several years have been extremely challenging, we know we can count on our laguna

honda staff. all the laguna honda staff continue to make rapid improvements and elevating to be a top performing skilled nursing facility. most importantly, each staff members day in and day out for our residents and prioritizing their care and wellbeing. also there for each other. there is no place like laguna honda, no city and county made and sustained the commitment to publicly funded long-term care. as we near thend of our path to recertification, we will always remember all employees have been a vital part of the team that save laguna honda. we want to also acknowledge contributions of the dph leaders who deployed and transferred to assist laguna honda through the recertification process. lifesafers. we are grateful for patience and support through the process. we are thankful for every

individual who contributed towards recertification effort and mission of laguna honda. we hope each staff member can end this year proud of their hard work and their role in san francisco. so, without being overly dramatic, i like to stand and give you all a hand. a standing ovation. [clapping] >> thank you so much and we all are so proud of what you've done. is there public comment on this item? >> is there public comment in the room on this item? folks online, if you like to comment we are on item 2, you can press * 3. i see no hands, commissioners. >> any commissioner comments? >> i said a lot already. i'm just hoping again that 2024

really opens the door to this new vision that we had for laguna honda and more then just being a model for overcoming this process and all the challenges, but really a model for what the future is supposed to look like and really be the kind of facility people aspire to be part of whether a resident or staff or family member or supporter, and that is my christmas wish and whatever part of the new year's resolution we can be part of, i'm happy to be there with you. thank you. >> i just want to join and congratulating you on theered hawork hard work and thank you for the hard work and tireless aspect of it. recognizing that fact and knowing how difficult it was on all levels, because how much you care as well as that you

are human and only have so much capacity for pain and no sleep. thank you. please know that we definitely have seen your work and understand as much as we can prom a distance, some of us closer distance then myself, but thank you on behalf of the families and the city and all the people who will come through the doors of laguna honda in the future as a result of your good work and your dedication, so thank you. >> commissioner chow. i think you are on mute. >> fellow commissioners, to all at laguna honda. i think this was very appropriate to not single out individuals, because every individual was so important. fallowed laguna honda for all

the years i have been on the commission. in fact, was involved in laguna honda prior to the commission. my first introduction to city [indiscernible] and that was the blue ribbon committee and the committee that many years ago said [indiscernible] that laguna was a important part of san francisco and we made a number of recommendations at that time. to watch laguna go through this last crisis and change so significantly so that [indiscernible] so today we are on the brink of being at the apex of a world class organization and delivery of care. that turn-about from thinking we were in an appendage to an

acute care system to now work on behalf of the residents as a world class skilled nursing long-term care facility is another tribute to the city's dedication seeing that those in greatest need will have an opportunity to have the finest care we can deliver. again, i would just echo what everybody has said. the staff is the answer. all those who have worked hard and they were tireless in leading the charge and asking the staff to actually [indiscernible] new standards,ering we can probably say the staff has done that, so thank you very much and i look forward to the continue [indiscernible] service to the city.

>> i of course want to associate myself with all the comments. as i thought about it as a member of the jcc, i think what has been most remarkable to me is the way you are able to maintain your morale. some requests in human or impossible to achieve and you never acted resentful. i think one reason the families have done so well and the residents is the way you have come through this with your spirit and with your commitment and your dignity and that is so unusual in medicine today where so many people feel it is a job and not profession and you to my mind elevated this profession beyond imagining and it is wonderful to see the team.

i see dr. lam in the audience and welcome and it is just a wonderful to see you all together and to be able to recognize the super human work you have done over these past way too many months so very encouraged about the future and we are so confident that you'll continue to shine in every way, so thank you so very much. i know director colfax wants to say a few words as well. >> thank you. thank you president green and really appreciate the comments from the other commissioners and just to extend on behalf of myself and the rest of the department how grateful and proud we are of laguna honda and what everybody has done. we are the city of saint francis and the quote attributed to saint francis particularly apt to what you have all done in the last year and a half which is, first do

what is necessary, then do what is possible and see you are doing the impossible and i think that is apt for the incredible work that you've done and the leadership you have shown in terms of shifting a culture of the institution in so many ways through a very challenging bureaucratic system. one thing that never changed and think your north star was inshoring the health and welfare of the residents and their families were central so grateful for everything you have done and everything you will continue to do. >> thank you so much and thank you for being such wonderful care-takers of god's hotel. so, do we have any--okay. >> next item. >> next we go to the report, right? >> the recertification update. >> okay. the next item on the agenda is the recertification update and director pickens will present

to us. >> good afternoon commissioners. roland pickens. my pleasure to be here in person with you today and joined by sandra simon, our new ceo nursing home administrator along with other members of the laguna honda executive staff and members of the cms incident command are also present and joining us virtually. i stand here today on behalf of all of them to present you with the very brief but hopefully comprehensive update on the cms recertification journey of laguna honda. as you imagine, staff work tirelessly towards cms

recertifyation. we welcome surveys for the cms medicare certification survey. that survey consisted of two components. the first was a health inspection portion, which took place between november 27 and december 1 and the second portion, the fire, life safety and emergency preparedness portion which took place december 4 through december 7. you will recall after the successful medicaid recertification back in august, we achieved our goal of becoming recertified in the medicaid program. as you know, more then 95 percent of laguna honda residents rely upon medicaid as primary funding source for their care. this most recent survey is for the recertification to the

medicare program. you will hear more about that throughout today's presentation, but wanted to share with you in addition to the medicare survey we just completed, when state and cms surveyors were here, they also did a very rigorous job with all most 30 surveyors on site to review the last remaining open cases that had been on the books for laguna for the last several years. there were 39 unopened unresolved cases, 7 unresolved complaints and 32 self-reported. the surveyors were able to resolve 34 of the 39 cases with preliminary resolutions showing 0 deficiencies so hats off to the staff at laguna for doing all the work that resulted in

there being no negative findings thus far from those cases. next slide. so, there is and has been much to celebrate. it is important to note when surveyors were at laguna over the past few weeks, they noted that they saw great improvement and it is clear laguna honda isn't the same organization decertified back in april of 2022. while we are excited and grateful for these words of encouragement and recognition from the surveyors, we know our journey is still not complete. we are still awaiting to receive what's called the official 2567 statement of deficiency with findings from that survey. as always, we do expect findings, especially for facility the size of laguna

honda, and our goal is insure the findings are as miner and isolated as possible. staff since the ending of the survey in the exit conference have been hard at work preparing for the 2567 statement of deficiencies and working along with our quality improvement expert, the health service advisory group. we again want to thank each and every laguna honda staff person as we know surveys are very stressful and it is hard to imagine a series of surveys more high stake and more scrutiny then the most recent one for the medicare recertification. the next step in the medicare recertification process is to receive that 2567 statement of deficiencies, which we expect to receive any day now, and then we'll have a usual 10 day turn-around period in order to

provide our plan of correction and submit that back to california department of public health and cms for their review and hopefully follow approval. it is important to note that the plan of correction does not have with it a reasonable insurance period. we talked about this in theest pa. for the medicare recertification process there was initial certification in august when we received our medicaid recertification and the most recent second survey had a period in there of about 180 days so we met the requirement for the reasonable assurance period and so when we submit the 2567 there will be no further delay in terms of period of reasonable assurance. so, we are-we are not quite

there, we are nearing the finish line for recertification. we have much more to do and we will continue to share our status and updates with you as time goes by. as we look to surveys for 2024, we anticipate the acute care license survey for the 11 acute care beds at laguna honda. that part of the organization has not been surveyed post covid-19, so we expect that survey to come at any time and we are prepared and ready to hopefully do well on that survey. and finally, we know the status of readmission to laguna is top of mind for everyone. as we said currently we are laser focus ed on recertification, but we do look forward coming back to the joint conference committee at laguna and health commission to share with you both our plans

for ongoing sustainability of improvements made and to share with you our path towards returning to more normal operations at laguna honda and of course, admissions is part of the update we'll be bringing to you. so, it is my pleasure and you will more from sandra simon later on to introduce to you the newest member of the laguna honda executive staff and that is medical director and chief medical officer dr. albert lam and invite him to come up to say a few words. >> good evening everybody. very excited to join this team and i have been impressed with i met people in the janitorial and environmental service staff

all the way up and very impressed with the people i have had a chance to meet with. everyone seems dead dicated providing the mission of care and excited to help us get that nudge we can be at the top. i look forward to getting to know all the commissioners here in the future and hopefully we'll be able to celebrate a lot of our success. thank you. >> thank you. we are very very happy to have you and welcome. >> dr. lam is very modest. he didn't go into his lengthy cv, but we were able to recruit him after more then one year long search process. there were over 400 inquiries in terms of potential applicants for this job and dr. lam is the person that rose to the top and was very clear he was head and shoulders above

the rest. just a little bit about him. dr. lam lead one of northern california's top performing post acute care departments at the sutter health palo alto medical foundation and served as the chair geratric department and senior post acute care consultant. dr. lam will be taken over the helm for dr. [indiscernible] who is served in that position on interim basis for all most a year now, and we want to extend our thanks to her for all her work and effort and she will continue to be like many on site to continue with the transition to this new leadership team. next slide. that concludes my recertification update and as you know, there is a much more in depth annual report that will come subsequent in the

days, but i'm happy to take any questions at the appropriate time. >> thank you. is there any public comment on this particular item, which is recertification update? >> yes. i seen one hand and maybe in the audience. i'll read a statement. for each item, members of the public have a opportunity to make comment for up to three minutes. the public comment process is designed to invite input and feed 37 back, however does not allow questions to be answered or members to engage in back and forth conversation with the commissioners. a commissioners consider comments from members of the public discussing a item and making request to dph. each individual is allowed one opportunity to speak per item. individuals may not return more then once to read statements from other individuals. written public comment may be sent to the health commission, health.commission.dph@sfdph.org. city policy along with federal,

state and local law prohibit harassing conduct against city employees and others and will not be tolerated. we'll take public comment from those in person and then remote public comment from individuals who receive accommodation for disability. i have given one person accommodation for the meeting. i have given each individual a code to speak to prevent others speaking during this time. finally, we'll hear from others who are remote. there will be a time limit of 20 minutes of remote public comment from each item who have not received accommodation for disability. anyone in the room who would like to comment on item 3, the laguna honda recertification update? i don't see any hands, so we'll go to the two folks that have hands up for remote public comment. please unmute the first caller. >> it is patrick manet shaw,

code aa. can you hear me okay? >> yes, you are loud and clear. you have three minutes mr. shaw. >> thank you mr. morewitz. please commissioners, stop calling laguna honda "god's hotel". it isn't a hotel. it is a skilled nursing facility. previously [indiscernible] testified to san francisco board of supervisors, [difficulty hearing speaker due to audio quality] 90 day reasonable assurance waiting period between the two

inspections. the medi-cal inspection, mr. pickens just referred to was technically a mandatory "90 day monitoring survey", required by the [indiscernible] that is required under medicare rules. cms approved this change to its standard rules applicable for recertification of all facilities?

anonymous complaints are a concern because laguna honda is still getting a inordinant number of anonymous complaints. [indiscernible] what's the status of the 120 bed waver request you [indiscernible] wave application submitted. thank you. >> thank you. janette, please unmute the next caller. >> hi. this is-can you hear me? >> yes, you have three minutes. >> hi. dr. palmer. i thought we were going to hear what the timeline to the readmissions was and given some

timeframe and i'm a little late, but i did not hear that and would like to hear it, and also, what the timeline for submitting a waver to keep the 120 beds in, i would like reassurance that there is still a full intention to fight to keep those 120 beds. i would also like reassurance that the new laguna honda leaders will be completely supported in turning down inappropriate admissions that laguna honda cannot safely care for from san francisco general hospital. thank you very much. >> that's the last public comment. >> any commissioner questions or comments? commissioner guillermo. >> thank you. i know you can't give assurance of this mrs. pickens, but do

you have any reasonable hope we might get the 2567 before the end of the year? >> yes, i do. last friday would have been the 10 day period that cms by their own rules should have returned this 2567 to us, so they are a few day overdue so why we are expecting it any day now so one would hope they will resolve those issues and get it to us as quickly as possible and we will continue to do our due diligence to contact them and ask them for a update, which we have done already and awaiting for a answer. >> thank you. >> mr. chow. >> yes. thank you mr. pickens for the report. i do wonder if you have some--well, i am curious about understanding more of this 90 day gap and the recertification

process that then you are saying has been fullfuled because we had the medi-cal-we sent the medi-cal survey which can serve as the 90 days. did i understand that correctly, we still are waiting another 90 days? >> thank you dr. chow for the question. you did understand correctly. the reasonable assurance period is a period from 90 up to 120 days, so that august survey, which gave us back certification in medicaid has been deemed by cms to be our first of two medicare recertification surveys, so we have met the requirement for the reasonable assurance period. that is over and done and we are beyond that. >> very good. according to your previous statements, the issue of the

120 beds was going to be pending the recertification completion for medicare, so it would be good to hear that we are still intending to do that. >> very much so. we maintain all along that we know the importance of those 120 beds, not only to laguna, but the entire san francisco bay area, and so we have every intention upon applying for the requisite waver when we feel we will be successful and have that waver received and hopefully approved. that is still our plan and the most appropriate time we will be submitting that forward, but again that is after we achieve medicare recertification. >> great. once again, i want to congratulate you that we have received the medicare survey at this point, and that we'll be

looking forward to the corrective action plan and seeing we receive our [indiscernible] thank you again to your entire staff for the hard work you have done during this survey process. we have been following it day by day as you have been giving us update and it's clear the amount of work. when you have 30 surveyors on site, you all most need people to keep up with them. having been a surveyor before, i know the stress on both sides, so again, our thanks for the very hard work and we are hoping for success. thank you. >> thank you. >> i guess i have one last question. if you do get the 2567 before the end of the year, what kind of flexibility do you guys have

see so you don't have to work the week between christmas and new years when half of san francisco county is enjoying families and holidays? >> as we know, we like to be prepared so we started working immediately after that exit conference on the plan of correction, so we actually have our preliminary plan of correction already done, and as long as we don't anticipate surprises, if there are not any we will be able to populate that right away and turn it around. >> thank you. perfect. alright. thank you so much and we are about to go to our next laguna honda item, which is the annual report and again, mr. pickens will be presenting. >> i am going to turn it over to-- >> wonderful. >> director simon. >> hello. good afternoon. welcome to the laguna honda hospital annual 2022-2023 annual report presentation. my name is sandra simon, serve

as laguna honda nursing home administrator and chief executive officer. as you know, i joined the team june 2023 just as the fiscal year was coming to a end so i'm accompanied by colleagues to help with this presentation. i will say, it has been such a honor to serve alongside the staff of laguna honda during this challenging time and very challenging year and i am so grateful and so proud of this team and the staff for their dedication, their perseverance, their excellence and just really the pride they have in their work. it really was quite a honor during the survey to see the staff and how they interacted and proud of the work they have done and how they have really carried the changes through. it is also been such a honor to

serve the residents not only have i received such a warm warm welcome from them, the patience and support throughout the recertification process has been outstanding and we all know it is their care, their wellbeing, their life that really drives and lifts this work. just after the close of fiscal year, laguna honda earned back the recertification into the medicaid program. that is the funding source that serves and supports about 95 percent of our population. our path to full recertification continues. i do want to acknowledge and just again celebrate as we just heard that it is a major accomplishment. next slide, please. who we are. as we have all said tonight and as we know, there is no place quite like laguna honda

hospital. we are one of the largest skilled nursing facilities in the country [indiscernible] and also adults with disabilities. the uniqueness of [indiscernible] why cms recertification has been top priority for the department and the city. next slide, please. our mission and about laguna honda, provides a welcoming, therapeutic healing environment that promotes and supports individual health and wellbeing. resident centered care. our vision is to build a healthier lives of leader in post acute care and skilled nursing and carry out the mission with resident centered care, values of compassion,

professionalism, competency, teamwork, collaboration integrity and communication. next slide. who do we serve? we have a diverse population and here's a few photos. we serve residents with complex medical needs. we are often low and very low income and we serve a broad community in terms of both care needs and demographics and really proud of the fact laguna honda does serve residents that may not be able to be served well in other nursing homes, so we are very proud of that fact also. next slide, please. you can see the demographics here. one of the thingz that makez laguna honda special is diversity of the resident population. as we said, we are public

funded and nearly all the resident care comes from medi-cal and medicare program. home to residents with very complex medical needs and really just would not have other places where they could find care. racially ethnically diverse with many languages spoken and the facility and also have two specialty units, dedicated spanish language unit and chinese language unit. next slide, please. just a couple highlights. especially in this really new year. we did serve even with reduction, we were able to serve 849 people over [indiscernible] these two numbers really represent our remarkable facility wide effort

not only supporting our residents through all the changes and provided resident centered care through the changes and just to talk about the financial, i want to invite lily up now, the cfo from laguna honda. >> thank you. hello commissioners. lily, cfo. i'll be reviewing our financial report. if you can go to the next slide, please. great. so, i'll start with revenue. year over year we saw revenue growth despite having lower overall census. this was primarily due to increase in the distinct partner reimbursement rates and prior year settlement of $8 million. increase to the reimburse ment rates with the primarily driver to off-set the lower census and

that result in a surplus in total operating revenue for the year of $5.4 million. on the expenditure side, total expenditures increase year over year due to recertification and registry cost primarily. recertify cost include consulting service with health service advisory group, health management associates and [indiscernible] in addition to consulting companies we had increase security and communication service costs for the year. on the registry side, the increase to registry cost was due to recertification specific registry, covid continued need for covid registry services and to cover just general increase need of registry for vacancies and [indiscernible] we saw over the year at laguna. increase to non personnel cost covered by labor savings and material supply savings within

the laguna honda operating budget and also a $24 million fund transfer from general dph network wide savings. this reallocation of funds contributed to higher year over year general fund subsidy you can see on the slide there. next slide, please. this slide goes over our payer sources for the year, and we continue to rely primarily on medicare as payer source and historically we don't see much of the shift year over year in our payer mix. we did see a slight shift over the last year from outpatient visit from medi-cal to medicare due to increased outpatient clinic volume and primary covered by medicare part b.

payer sources remained largely consistent year over year and we expect to see a similar payer mix for fiscal 24. we'll wait to do questions until the end. >> thank you lily. so, our path towards recertification could not have happened without the support of the laguna honda recertification incident command structure and i want to acknowledge our coincident commanders in the audience, troy williams and baljet. they really helped to drive much of improvement work we have done. also want to acknowledge dr. [indiscernible] who as transitions out of being interim cmo will be the interim chief medical officer for san francisco health network and continue to support laguna honda recertification in that

position and also maggie--joined remotely who is part of incident command supporting overall hospital administration and [indiscernible] who has been the executive sponsor for nursing leadership and has been the chief nursing officer over the last several months. so, incident command, it is one of the beauties of being part of the department of public health that focuses on all hands approach, particularly to emergencies and critical incidents, so we are truly utilized the hospital incident command structure to take on this overwhelming task of recertification and it served us well and again thank you to all parts of dph that supplied staff to help support incident command structure, because that

structure was really beneficial to support the staff at laguna as we work towards recertification. as we shared, we've met all of the many different milestones and metrics put forward towards us for recertification, and again cht to say thank you to incident command structure for supporting that and making it happen. next slide. i'll turn it over to naz. >> good afternoon commissioners. naz, quality officer for laguna honda hospital. as part of the annual report today i want to share with you the action plan work we all did over the last fiscal year in particular response to first monitoring plan done in december of 2022.

laguna honda partnered with qie to develop our first action plan in response to that survey which consisted of 500 milestones. the facility was able to successfully complete that action plan and submit it with supporting evidence as of may 2023. those milestones covered areas such as medication management, care plans resident rights and more and the facility continues to do more action plans throughout the year to insure we continue this great work towards certification. with that, i'll pass it to jennifer and the next slide, please. >> good afternoon. my name is jennifer, [indiscernible] and you imagine with all the milestones comes a great need for education. over the past year we were very successful in having two major facility wide education fairs is what we called ed them.

we were able to educate over 1200 people including [indiscernible] reaching up to 97 and 98 percent compliance each time. this was a really exciting event for us to be able to put in the sense that it was really important to support our recertification efforts, and we will continue to participate as we move forward. have to see what the future brings. next slide. another thing we have done this past year was we increased our executive rounding. we go to the different units, all the executives have assigned units and we review not only the environment of care, but talk with residents, talk with families, talk with staff. we make sure that people's questions are answered and the higher visibility really has

garnered a different relationship quite frankly with staff, which i think is appreciated as we have been going through these very challenging times. next slide. i'll pass it off to dr.-- >> hi. interim chief medical officer. i'm going to come in about the restraint free journey. this is a huge success of the recertification effort and moving the organization towards the reduction in elimination of the use of restraints, which are not only about safety, but also about resident dignity and dependence and took partnership across multiple disciplines, nursing, rehab, everyone helping to make sure we approach this in a resident centered trauma informed way and at this point we are well within the goals we set for ourselves in this line of

standards across the country. next slide. turn it back over. >> thank you doctor. as i shared with you before, one of the key initiatives we undertook this year was the consistent care at the bedside initiative. professionally known as ccbm initiative. you recall back in june and july of this year, we were little over a year into recertification journey and we saw that despite tremendous progress there were still areas that needed more detailed and higher level of expertise. in essence, the ccbm initiative was born out of that need, where we worked with our quality improvement expert to bring on-board senior nurse leaders who had served previously as directors of

nursing at skilled nursing facilities and assign one to each of our 13 units in order to again, bring more direct supervision and coaching and expertise to the nursing unit level. so far that program has been very successful and i think by virtue of the most recent surveys, we feel that this program was very significant, particularly in allowing us to proactively identify areas of challenge and barriers and correct those before they were being found by surveyors. the ccbm initiative was key to that and we are planning to continue to operationalize that at least through our first year recertification as part of our

sustainability program. next slide. let's go one more slide and then come back to this one. you recall back in february, mayor breed hosted u.s. secretary of health and human service javier [indiscernible] it was a great opportunity for the secretary himself to all the work at laguna honda and it was a great visit for him to really put names and faces with what he had only seen in writing and heard through verbal reports. you recall i previously reported at the conclusion of that visit the secretary said that he was so glad he was able to come out and it grave him a different perfective of laguna honda and i see that as part of a turning point in this whole recertification effort, so again, that's why we wanted to

highlight that visit as part of this report. let's go back to the previous slide, . at this point, i want to reintroduce our new nursing home administrator and chief executive officer and give her the opportunity to further introduce the new members of the laguna honda leadership team. >> hi. extremely honored to introduce this team. every day i am so inspired by this team and coming together to really help lead the path to the new laguna honda and these professionals and passionate long-term care professionals and guides and leaders, it is just really a thrill so i want to introduce you to them and maybe you can stand up. jennifer--you probably know her already. assistant nursing home administrator for south tower.

right? and [indiscernible] or the assistant nursing home administrator and he is over the north tower and they all still have their respective areas of expertise and support services all under [indiscernible] greg is not able to be here today. don't know if he is online, but greg chase is executive director of facilities. engineering, fire life safety and capital projects. michael collins is here, one of our directors of urs nursing and over the clinic and nursing operation and oversee the south tower. and then tracey brown, who is ill today. she is not able to be with us, she-tracey and michael joined on the same day, started together and she oversees the north tower and some other initiatives, care initiatives

and dr. albert lam comes to us here as chief medical officer week two. third week already. anyway, just such an amazing team and to-we never get a chance to all-very unique opportunity for executives to come together at the same time with a goal in mind and to just mesh and do this work together, so really exciting opportunity. with that, i think jen has a few--[indiscernible] >> next slide. maybe not. so, as you imagine with all the work we are doing we like to give back to staff as much as we can, so we are able to have a food truck event which was fun and exciting. our staff love food trucks so

try to get them as frequently as possible. who doesn't like a food truck? we did part with the union at the event which was really special and i think that the partnership we have developed with them throughout the past year i would like to see that grow and continue to help benefit our continued staff experience. next slide, please. this next event i want to say i had the good fortune of attending the opening just across the street for the art with elders summer exhibition that featured some of the laguna honda residents. it was very special. it was one of our first outings, official outings post pandemic and it was a real lovely celebration of life. when you live in a facility,

sometimes humanity isn't seen anymore, because you live in a facility. partnership with art with elders for the past 30 years they have done the best by showcasing and showing that humanity and that beauty that comes and might change and morph throughout the different stages someone might have at laguna honda, so really beautiful. i hope you got a chance to see it. if not we have a bunch of art featured at laguna honda. special too because the mayor was able to join us and spend time with the residents, so it was really beautiful. thank you. next slide. so, as we talk about numbers, compliance, work, operations, we never want to lose sight of why we are here. our mission is to support our residents through this time of

their life. here for our residents and so before we close, i want to highlight two of our residents and share a few stories with you and both of these residents participated in our art with elders program and their work is displayed i believe still at city hall. the program that jen spoke about. felipe comes from a small town and you can see that his 1977 father bought a ice cream factly and his family made ice cream, sandwiches and all the products they sold here and that inspired him to embark upon a path of business school and started working in coca cola at the accounting department and then in 1998 he became a american resident and that is how he came here. he used to live in la and worked at various facilities and in 2003 moved to san

francisco. then in 2006 he had a stroke and became handicapped and moved to laguna honda and he has been there 15 years and has wanted to share that he has enjoyed and participated in art with elders for the last 5 years . ida was born in san francisco in 1940 and had a stroke that paralized her right side when she was only 2 years old, but ida will declare she doesn't feel-inspite of the stroke, never missed out on anything. her parents were immigrants from northern italy and she grew up in north beach and she just cherished memories of her with her family and children and telegraph hill and strolls at fisherman's wharf and union squared and always loved art and enjoyed coloring throughout her life and you see

her in the studio doing artwork and she can do it all day long. she always wanted to do it for extended periods of time. never had the chance and now has the chance through the art with elder program. i hope you enjoy hearing about ida and felipe. next slide, please. so, we look to the new year and you hear how optimistic this team is and excited and we look forward to the path to recertification as this comes to a close and we are looking forward to new beginning and what beginning of a new chapter and what i like to call the new laguna honda hospital. this new organization that is as we talked about providing leaders and exemplary care in the skilled nursing field and being a model for other said. on behalf of the laguna honda leadership team, again, i just want to take a moment to thank

the dedicated staff. so proud of them. their dedication and they met this challenge with such grace and such strength and fortitude. thank you staff of laguna honda. we would not be here today if not for your work. finally, a big thank you to the san francisco health commission for your guidance, support through this process and happy holidays to everyone. >> thank you. public comment on this item? >> anyone in the room who would like to comment on this issue? this item? don't see any hands. anyone on line who would like to comment on this item? we are on item 4, the laguna honda annual report. i see no hands, commissioners. >> any commissioner comments or questions? commissioner guillermo. >> thank you. and thank you for the report. i really enjoy always every year hearing about really what

is going on at laguna honda and aside from all the going's on on recertification and covid prior to that and the other things that occurred prior to that, it really is about the residents and the staff and this report really does bring that home and i just appreciate even though only couple stories about the residents, those two stories give a flavor of the kind of quality care and the comprehensiveness i are think of services and care that comes to the residents at laguna honda. felipe who has been there 15 years, for him to feel as a resident that he can enjoy art and he can really be a vibrant human being in a institutionalized setting means he doesn't feel

institutionalized, right? so, i think that is really really important for us and the public to understand and hear it is not all about rules and regulations and policies and facility report incidents. those things are obviously important, but to the end, it is about the people and i always enjoy getting the report, particularly since we don't-especially with covid, we didn't get a chance to be in the facility and be witness that energy and the vibe that goes on at laguna honda, so i thank you for putting the time and effort into putting the report together and to giving us a glimpse into laguna honda. i did have a question about when the readmission occur, i don't know how much a sense of

who will be coming back and might be coming in, but do you have a sense that is going to change significantly the demographic or diversity mix in the population or we strive to keep that stratifyed in terms of both age, gender, identify and all the things that show up here as soon as we are able to reinvite folks to come in? >> thank you for the question. i'll start and then i'll ask doctor who has been coleading the group looking at preparing for readmissions. in essence, we remain committed to our charge to serve all of san francisco meaning all san francisco in terms of the diversity in every reexpect. respect. with a focus on under served, those who cannot get care

anywhere else and so that remained constant in all our planning. overseen the work with medical staff in terms of reviewing admission criteria. we have a very robust process that we are started about a month and a half ago and continue over the next few months to look at every aspect of what's needed to begin to safely resume admissions and make sure we have all the resources, the staffing and programs in place to care for residents. >> thank you. i think i would just say that i think we are all very excited to begin the process of opening the doors again and i think also very committed to making sure the quality of care improvement work we have done translates to the new admissions so i thank the health commission for feedback and help getting the admission policy we feel comfortable with

and everybody is committed to the core principals and criteria you helped us develop and as part of the process this week had great conversations with folks at the san francisco health plan and the san francisco consortium clinics across primary care so i think everyone wants to make sure as we do this we are transparent about all the work we have done and we can carry that through to the process of the readmissions and again, san francisco is diverse community with a lot of needs and you [indiscernible] i think we-there are a lot of folks who i think will be perfect fits to come into laguna honda hospital from san francisco and so i think that will still represent the diversity of san francisco as part of this process and i think bringing that trauma informed equity lens to the process will be crucial as we do this as well. any particular questions on that that i can address? >> no, that was--just good to

hear that the robustness i guess of the process for readmission and really making sure that the population of laguna honda continues to be as diverse and reflective of the diversity in san francisco as we have seen. >> i think it is tribute to the leadership of the organization, both the folks who have been there and the new folks who have come in. i think we can meld that experience from the past with the standardization and quality that our leadership have brought and saying how can we do this all better and continue the mission of the organization, so very confident we can do that and again, one of the best parts you all know is we are part of brouder san francisco helt network so everyone has a place to receive care that is right for them and a lot is figuring where is that place to find a right fit that meets needs where they are.

>> great. i did have one other question around, i think for lily around the financial's. given that we anticipate these readmissions and recertification there is hopefully increased revenue associated with that from medicaid and medicare, so will we be needing the general fund subsidy to the extent that we have had in the past given the budget cuts required in this year and the future so how might that effect the operational and economic health of laguna honda if you take the budget cuts along with the potential increase in revenue is going to be? >> yeah, i think in the upcoming fiscal year, i don't know that our admissions will be ramped up enough to make a significant increase to revenue to off-set the budget cuts, but those are things we are

modeling right now to see based what we know and what we think may happen in the next year we can anticipate additional revenue, but we wouldn't be back to our pre-recertification process revenue levels when we had a higher census. probably second year out we might have that higher revenue picture again. >> so, we should anticipate there will be a [indiscernible] >> i think it is just a ramped up increase that wouldn't be going from here to here and in a short period of time. >> just concerned we are able to continue to fund the stability and sustainability efforts that have come to date so something that we will be watchful for and very concerned about. >> yeah, and i think we benefited this year and i think we would continue to benefit from the higher reimbursement rates we experienced last year

and that would continue into this year, so the revenue picture isn't as dire as it would be had we not seen that change that allowed that to increase. >> great. thank you. commissioner chow. >> yes, thank you. i think this is a exciting annual report. it was when we first heard the decertification a downer and it is hard now looking back over the two years that so much has been done and then i think this year in particular in the annual report reflects, we are moving out of just a stabilization, first of all, bailing out the order from a ship having trouble. that word now actually pivoting to a brand new day for laguna, like sandra said. a new laguna honda and i think

it shows in this document. new ways of doing things, resident centered, looking for the best that we can do under these new regs that cms has been promulgating in order to see that residents are properly cared for and respected, so i want to again congratulate everybody with--it looks like to me we turned a corner, we have a new way of doing things, we have a brand new team that looks very exciting and [indiscernible] i think in a different ball park here. thank you all for this very hard year and i think the work is showing and you're really turning not just turning the corner er, but moving forward getting that world class care that roland had talked about

earlier. thank you. >> commissioner christian. >> thank you. as commissioner chow said, this is really exciting report and the thing that i think probably always probably not unique in this way, but really impacts me is what we learned about the people who are working in the space and the people who are being served in the space, and thank you for the two resident stories. look forward hearing more about the residents going forward. fe ipe and ida because it helps everyone and someone like myself who is new to learning about laguna honda as somebody when i came on to the health commission and still learning a great deal about it, and

knowing that we have sister citizens there, but really not having a sense of who they are as individuals and so thank you for this and the importance of the work is--lies in seeing the faces and stories and hearing the stories of the people and thank you for caring for them. and, on the same note, i wanted to tell you that i am impressed and thank you for the idea of this increased executive rounding that you are bringing to us today. i know someone who works in a organization and not at the top of the food chain, it is always incredibly useful and inspiring and helpful for the people who are making the decisions at the executive level to interact with the people who are doing the day to day work and it will

definitely insure a greater positivity and have a huge impact on the staff. believe me, i know from personal experience one way or another so very impressive and glad to hear you intend doing that more regularly going forward. and, in the same vain of finally i think i will say, when the recertification initiative moving to restraint free--it has been impressive to see the level of performance and care has been lifted in the last year, and one thing i like to hear more about is, how you will be incorporating bringing this critical eye to not only meeting the federal and state regulations, but continuing to exceed them and to be continuing to step into a leadership space going forward

in the country around providing care for people and what is right and what is healthy. i don't know if you can tell me how that will look going forward once the doors are fully open again and people are coming in and what will it look like next year? >> thank you for the question. i'll start and most people on the team can help answer this. so, i mention briefly in the presentation that we will be coming to the jcc and health commission with what our best thinking in terms of a long-term sustainability and stabilization plan that will lay out what were the things that we put in place doing recertification that need to stay and also how do those day to day operations so we can build forward and towards our goal of becoming the premier

exemplary skilled nursing facility in the country. we brought in best practices that have been incorporated into daily operations. when she came on board introduced the idea of [indiscernible] she meets with the leaders from all the nursing units. that is best practice that had not previously existed so that will continue. we'll continue to have key performance indicators that we publish so there is transparency to all in terms of operations and we are incorporating ongoing external skilled nursing quality improvement expertise over the long-haul, so as commissioner guillermo was saying we don't lose track of the progress, we

are building ongoing external review and validation to make sure that we are sustaining the [indiscernible] and moving forward. >> i was asking the question, can we do better and how can we do that? >> absolutely. >> thank you for this report and for your incredible work and i'm really looking forward to seeing the future. >> yes are, this report is so beautiful and we hear so much about the regulatory and bureaucratic aspects of laguna which is mandatory but this is the human istic part of laguna and as the other commissioner says, so wonderful to hear about the residents. the few i interacted with are such incredible people and overcome major disabilities with such strength and character, many i know there are a lot of individuals that have other struggles, but this is so uplifting to read and we are really grateful and i think speak on behalf of all the

commissioners that we are very grateful to those who deployed to lu laguna and want to acknowledge [indiscernible] she was critical supporting your team. she was often a liaison to commission leadership helping really help us understand a lot of complexities of the step by step you were going through, so very appreciative of the role you played and delighted with the new team. it seems each of you has such amazing unique skills you are bringing to the organization. i cannot imagine there is another skilled nursing facility in the galaxy that has a team like this one so we look forward to 2024 and thank you for all you have done and this beautiful report. director colfax. >> thank you president green and the commission for your comments and i want to acknowledge the incredible work

that has been done by this team and across laguna honda and reinforce the connection of the report with humanity of laguna honda and also the fact i think with the transformational year the team has proven and culture changed. having a resident centered human istic approach intertwined with also continually improving your work. those are now intertwined at laguna honda and you can walk down the laguna honda hallways and pass by the art studio, which is incredibly inspiring, the beauty parler, people getting care there and go to the neighborhoods, you see the environment now when people receive meals, table cloths and flowers and go into the nursing rooms and you actually see the quality improvement indicators.

you see celebration about staff and what they have done and also see post it notes staff put up about suggestions for improvement. all this is transformational and changed and it is under a very focused environment how we continue to improve and just an example i don't think has been spoken today. there are 6 thousand observations a day at laguna honda for quality improvement. 6 thousand a day. to your point about the galaxy, i think across the country there isn't another nursing home that continues to drive that and thank roland pickens for his leader ship and insure the top leaders for laguna honda were selected and also thank the commission for your support and leadership through a really challenging time both for supporting the team and making sure that they felt like they were getting what they needed and also for supporting the department and the

considerable amount of financial resources that it took and will continue to take to make sure laguna honda continues in the right direction and just to assure the commission, laguna honda remains a priority for the department going forward. thank you. >> thank you. approval of the minutes of the health commission meeting of december 5, 2023. >> do you mind-can we do one more round of applause for all the laguna honda folks? as a coworker and colleague, you don't have to stay beyond your items. feel free to do whatever is comfortable for you. sorry-- >> you dont want to hear about the minutes? >> they have so much work to do. >> alright. thank you. having commissioners seen the minutes, any additions or corrections to the minutes? hearing none, is there a motion to approve the minutes? >> so moved. >> second. >> is there any public comment

on the item? >> any public comment in the room on the minutes? how about folks online? i don't see hands, but that is item 5. no hands, commissioners. >> alright. then we'll take a vote. >> commissioner chow, yes. everyoneen the room, how do you vote? >> yes. >> thank you so much. the minutes are approved. >> now go to general public comment. >> folks, read a statement and then look at the room and online. at this time members may address the commission on items of interest to the public within the subject matter jurisdiction of the commission but not on this meeting agenda. each member of the public may address the commission up to three minutes. the brown act forbids the commission taking action or discussing item not appearing on the agenda, including those raised during public comment. please note each individual is allowed one opportunity to speak per item. may not return more then once to read statements from other

individuals. written public comment sent to the health commission at health .commission.dph@sfdph.org and everybody else i read in the previous staement. any folks in the room who like to make general public comment? if you would i guess get in line and each will have three minutes. note when i say time is up, please finish your statement like the sentence because your time is literally up. thank you. by the way, the microphone, just speak and it will pick up your voice. >> my name is [indiscernible] license clinical social worker in intensive care units at san francisco general hospital. i'm a social worker in the icu at the level one trauma center because i know first hand what the effect of genocide displacement and generational trauma look like and work every day to mitigate the effect on

my patients. i'm lebanese armenian. each generation of my family the last 4 generations were refugees. my personal and profession experience brought me today to discuss the [indiscernible] genocide is a public health issue. in gaza not only do we see the murder of innocent civilians by way of bombing, we see disease and setting of 2 million displayed and fleeing individuals with little to no shelter or medication, lack of hospital and clinics, lack of supplies like ventilators and lack of food, water and electricity all due to bombing and blockade. the [indiscernible] the death toll surged over to 19 thousand people. over 40 percent killed are children. saturday a tank ran over 20 sick and injured people. this was deliberate assault of

those seeking care in northern gaza. we all watched the premature babies die because bombed [indiscernible] cut off electricity and killed the healthcare workers. sunday israel bombed the muturnty ward. these are well documented human rights violations and only a mere snow flake on avalanche of human rights violation we have seen in palestine since october 7. these attacks on hospital and healthcare workers murders of entire generations of families, blake odd of aid in gaza are preventable and stand in stark contrast with entire ethical framework of public health. genocide isn't acceptable and leaders in public health and hope you feel the same. your silence with regard to the crisis in gaza is deafening. leaders and representatives of dph your [indiscernible] not only in san francisco but

globally. there is no situation no political landscape that justifies genocide of the people of palestine. call for cease fire is call for [indiscernible] including in san francisco. i implore you the san francisco dph health commission to declare genocide what it is, human right crisis and public health crisis. i urge you to call for immediate permanent cease fire in palestine to see end to killing, occupation and displacement of the palestinian people. i call to recommend the board of supervisors past dean preston cease fire resolution as soon as possible as gaza cannot wait. thank you for your time and consideration. >> next. thank you. >> hi. my name is elizabeth a therapist at primary care

clinic for queer and tran youth here today because i'm devastated by the occupation and genocide of palestinians and the rapidly escalating health crisis in gaza. i appreciate dr. colfax called for protection of healthcare workers and patients november 20, i'm alarmed by department has not done more to speak out against the atrocities we witness every day in gaza. i'm proud to work for a department declared antiblack racism a public health crisis and denounce violence against the api community. i can't understand why we are not decrying the massive loss of life, injuries and wide spread disease and hungers impacted palestinians now. the violence of the israeli occupation isn't new. when i visited palestine in 2014 i went to the refugee camp in west bank established 70

years ago after [indiscernible] near entrance of the camp is a large statue made from crap of ambulances blown up in 2002 during the [indiscernible] over 2 decades ago healthcare infrastructure targeted just as it has been the last two months in gaza. the occupation has been a public health crisis for decades and it is time for this department to name as such. the occupation and genocide of palestinians is within the jurisdiction of the health commission as it is directly impacting the people of san francisco. palestinian patients and colleagues have lost loved ones and grieving the assault on their people. our muslim patience and colleagues experience heightened islamophobeia and fear of retaliation. one of my clients has been reeling from watching the genocide unfold reminded of another that impacted their home country. all of us effected by this are aware of the silence of our department.

silence is not a neutral position. silence perperchwits the idea occupation and genocide are permissible. this harm to health of san franciscans which is the opposite of the mission of dph. many of my clients, all young people told the ways they take action in their community to raise awareness and stand in solidarity with the people of palestine. how is it a 17 year old has more courage then one of the largest and most progressive public health departments in the state or the nation? i urge the health commission to declare that occupation and genocide of palestinians is a public health crisis and human rights crisis. i ask you use your privilege and your voice to support the cease fire resolution supervisor preston introduced to the board of supervisors. thank you for your time. >> is there anyone else in the room who would like to make comment?

>> good evening san francisco health commissioners. dr. [indiscernible] occupational health service clinic based at san francisco general hospital. in response to the humanitarian crisis in, mid-november we circulated a letter among dph employees to issue a statement in support of cease fire. we have all most 200 sig torry. we took to various leaders and to date have not received acknowledgment of this request. despite national and international calls for cease fire including from the american public health association and the world health organization our leaders

remain silent. i like to share a poem by june jordan, she wrote the poem after 40 years ago after learning of a [indiscernible] in lebanon. her words are as urgent now as then. moving towards home. i do not wish to speak about the bulldozer and red dirt not covering all the arms and legs. nor do i wish to speak about the night long screams that reach the observation post where soldiers lounged about. nor do i wish to speak about the woman when shoved her baby in the stranger hands as lead away. nor the army that [indiscernible] so others see the backs of their victims lined against the wall. nor do i wish to speak about the piled up bodies and stinch that will not float. i do not wish to speak about the bulldozer and not covering all the arms and legs because i do not wish to speak about

unspeakable events that follow from those who dare to perify a people those who dare to exterminate a people and [indiscernible] dare to mop up to tighten the nuse and step up the military pressure to ring around civilian streets with tanks. those are the ones we must redeem the words of our beginning because i need to speak about home i need to speak about living room where land is not bullied and beaten into a [indiscernible] take place in my language. i need to speak about living room where my children grow without horror. i need to speak about living room where the men of my family between the age of 6 and 65 are not marched into a round up that leads to the grav. i need to speak about living room where i sit without grief and wailing allowed for loved one. where is [indiscernible] because he will be there besides me. i need to talk about living room because i need to talk

about home. i was born a black woman and now become a palestinian. there is less and less living room and where are my loved ones? it is time to make our way home. thank you. >> thank you. anyone else in the room who would like to speak? >> good evening. thank you commissioners for the opportunity to speak. [indiscernible] working at maria martinez urgent care. here to ask each and every one of you commissioner and dr. colfax to uphold the mission to preserve, momoat promote and protect the lives of all san franciscans. i read your bioes and see you have histories serving marginalized communities.

you clearly value health safety and wellbeing for all. in our community and beyond, so i'm asking you to take a stand against a genocide committed upon the palestinian people in gaza. the clinic i work is only a few blocks away. at one point located in this building. as a new social worker i would bring clients here for tb [indiscernible] the wait was long clients were treated kindly with dignity and respect. it is a place people can feel safe and cared for, seen no matter how ciotic the world outside may be. which is why it is cut wrenching to see places of refuge bombed relentless [indiscernible] first respondsers shot at. patients and healthcare workers [indiscernible] murdered in healthcare facilities. imagine that in your place of work? imagine your place of work and yourself targeted doing what you love doing?

as a mental health clinician i had the honor working with members of the palestinian in san francisco. our health system serves members of the palestinian community and our health system is incredibly [indiscernible] our silence towards the trauma colleagues and patients faced and actively surviving trauma informed care. how can we tell any patients or colleagues they are safe here if we cannot say we do not condone the genocide and want the violence and killing and brew utality to stop immediately and permanently. this especially so when the [indiscernible] funded by our money, our tax dollars. as our city our healthcare system [indiscernible] budget cuts and program cuts. we are at the same time watchs hospitals in gaza bombed with weapons we are paying for. why is there no funding to solve our healthcare crisis when there is always money for

weapon snz you as the health commission have the power to make a difference to say enough is enough to save lives. i'm asking you to use your power and voice to pass cease fire resolution put forth by supervisor preston without amendment. asking you as a commission to declare occupation and genocide a human rights and public health crisis and call for cease fire as a first step to alleviate the crisis. in your- >> your time. >> thank you. >> thank you. anyone else in the room that would like to make comment? alright. there is one remote public comment person. janette please unmute the person. >> my name is jude, a registered nurse at san francisco general hospital. i have been a nurse 22 years. 15 of these years at san francisco general hospital. calling to lend my voice to my

colleagues who work in different disciplines but connected by the work as are all you on this board. you have so much power as health commissioners which is different i think then the board of supervisors or local officials because you are specific to health and helt care, specifically crisis and umhooen rights abuses and if we just think to the beginning of the meeting i did read the land acknowledgment that often happens in the world these days speaking to indigenous population genocide said in our country and don't know how we can say those words and have land acknowledgment without lending the voices to the genocide happening before us. we are implicateed and need to speak up and speak out. as healthcare workers we are met with ihave lns by all leaders which is just don't know if i have a word for it. why we are compelled to be with

you today. so much of the [indiscernible] if we look at the healthcare infrastructure as someone on a med surge floor turned into covid unit where the crisis was hitting deeply especially in the mission, i think back how days went by and didn't have enough ppe to enter the rooms who had no idea what risks we are taking. these workers risk their lives day in and out working 72 hour shifts. these are kin and colleagues. we are connected all of us and shared work and the work you all do as well. we need your support and helping pass the cease fire resolution supervise r preston put forward. your voices have power and we need them to be spoken loudly right now and join with the chorus we are all saying healthcare workers--300 signed the petition that are falling on deaf ears with senator padilla and [indiscernible] elected officials around the

country in similar ways and i think your power is needed and we hope you support us in speaking loudly and clearly and calling for a cease fire in gaza. thank you. >> thank you. that is the last public comment commissioners. >> thank you all for being here and really giving such eloquent voice to your concern. we really appreciate that you come to us. the next item would be the 4th quarter financial report from jen louie. >> good evening. jen louie, chief financial officer from department of public health. can i have the first slide,

please? i'm pleased to bring forward the year-end 4th quarter financial report to the commission and pleased to report that after what was a long year, we are ending the year positively with overall balance of $70.1 million. there are adjustments that i'll talk about as there is [indiscernible] part of the budget, but overall once we net those out it is $50 million above budget revenues and $20 million of expenditure surplus not spent. year end for total of $70.1 million. this enables us to make additional deposit to the reserve and final balance that would be returned to the city, $63.7 million. next slide, please. in terms of the major highlights, the $50 million

revenue includes news we received towards between the third and 4th quarter report and about $20.1 million of expenditure savings. of the $20.1 million, $15 million related to personnel savings. we had in fiscal year 22-23 we did add significant number of new positions, all most 400 and think we had aggressive assumption in terms ow many we can fill and in terms of workforce retention. one thing we are seeing, we were filling them in the front door, there were people leaving on the back door so in terms of the projections and year end we didn't end up with one time savings. noting, as we prepare first quarter financials for current fiscal year we are moving the needle on permanent vacancies. it is still a bit of challenge, but there is improvement compared to what we have seen in the prior year and something we'll continue to watch closely

over the course of the current fiscal year. as mentioned before, we are [indiscernible] assumed as part of the last year's budget process and so, the first one is $21.2 million one time revenue we thought would come in after july 1, but it came in just before june 30 and so as a matter of practice we had to recognize that surplus when the revenue where we received it, but if we did then we would-create a hole in the current year, so therefore we are netting it out with taking a momentary ride in the management reserve from 4th quarter to the first quarter where we release to really recognize the revenue where we originally expected it to avoid short-fall weez might have. in addition there is $10.8 million of expenditure savings primarily to our april proposal to leverage interest income related to healthcare ordinance

drawing interest income and offset administration fees. the savings was expected and mechanics was to project fund balance year end so we don't want to count that fund balance assumptions used to balance the upcoming budget for the similar reasons in terms of the gmu revenue so those two are netted out which is why it brings down the surplus and expected to do so. and then i also note our actuals following year end by the controller office, we did have to make $33.5 million transfers to [indiscernible] inflationary cost and increased registry cost and census at the hospital and $24.1 million to support the recertification efforts and registry efforts you have seen presented earlier this evening. next slide, please. our report overall just talks about budget versus actuals. i

want to comment on comparison of third to 4th quarter, which is bit unusual. we had significant amount of improvement primarily in the form of revenue, $68 million increase. some changes in information we received that allowed us to recognize this revenue. i will refer to notes to make sure i get this right. $20.2 million zuckerberg san francisco general. 4.7 related to the [indiscernible] revenues related to transition of a portion of the health network patients for fee for service. $6.7 million in improvement in the quality improvement program as the state provided additional reporting options that enabled to meet 100 percent of the thresholds.

rate range settlement of $7.2 million as we-they favorly adjudicated a lawsuit related to unsatisfactory immigration status and we are able to recognize patients we did not expect to be previously eligible for rate range and about $9.6 million sprinkled in other areas of the deerment partment. laguna honda improved by $27.8 million. 21-22 cost report was settled may this year. it enabled us to recognize additional one time rechb new related to 21-22 and also enabled us to create an assumption around there 22-23 per diem rates we have, which bumped up some portion of the current year rates we had for net improvement of 27.8.

and then behavioral health also achieved $14.8 million of additional prior year close-outs, one time that we were able to recognize. as i mentioned earlier, about $9 million in expenditure savings we did not anticipate. i note while these are improvements compared to third quarter, in some areas we remained negative and such as gpp so it is sort of less negative in some areas and some areas more positive so just wanted to make that clarification moving forward as we shift back to looking at budget versus actuals. next slide, please. and so getting into it san francisco general revenues ended $55 million favorable chblt net patient was about 90.5 related to primary fee for service conversion that we

implemented mid-year and after the budget developed, so there was above budget revenue there. the medi-cal waver we were short on both the glaibl payment program, about $30 million and made assumption about $38 million prior year settlement we were expecting to get and budget and did not achieve. we just got word one will be coming in and we were able to recognize that as part of our mid-year savings to meet some of the mayor's mid-year instructions that we have and there is potential for that remaining $60 million to come in by the end of this current fiscal year. we received $7 million additional managed care supplemental revenue as well as additional revenue related to the gme program as well as

increased matching rate for the public health emergency. we also had all most $10 million related to rate increase for capitation we assume in the current year budget and 340b specialized pharmacy program short $8.3 million. overall with transfers made there is $1.9 million of savings overall primarily in areas of salary and fringe as well as miner savings in non personnel and servicess of other departments. you see the service of other departments savings a lot as we have work orders and year end they close out their balances as well and you see this as a theme throughout all the divisions. next slide, please. for laguna honda hospital, again there is-5.4 million favorable after the $27 million improvement and we went over

expenditures but salary and fringe assumptions materials and supplies and work orders savings as we have seen for san francisco general. next slide, please. in terms of behavioral health, we received while we were expecting to be short we had improvement related to prior year one time dollars, so [indiscernible] had a shortfall and one area we are looking to correct but there was improvement in the medi-cal program we had. miner short fall in behavioral health quality improvement. we didn't meet all mile stones and $16 million of realignment and 6.6 in prior savings and again, the salaries and benefits savings due to salary savings due to vacant positions as well as $1.4 million of

contractual services as well as materials and supplies. next slide, please. primary care, we are showing $4.6 million short fall in patient revenue made up of a few things but 1.2 of this is really more recognition of cal aim revenues we are recognizing under the health network under the whole person integrated care program. it was originally budgeted here because we were not sure how the revenues would hit but want to allocate the revenues where they were accrued so it shows as negative but there will be a positive down the road to offset it. in addition, there is 1.9 as we completed an audit. some know, the federal-for our fqhc, the healthcare system we are on prospective payment and so we get interim payments that we recognize based on a

perspective expectation of what they think they may receive, but then they just compare that with a audit year end. we win some, we lose some, in this case we lost some, but the variances are somewhat routine. and then small uptick in capitation revenue similar to the [indiscernible] and again similar salary savings we are seeing in other areas of the department. next slide, please. jail health, $.2 million surplus overall. miner variance and salary and fringe and personnel. supplies. next slide. within the health network itself, overall the revenues ended up being pretty much on budget but there is a lot going on so there is positive and minusment we improved of

patient revenues, we were short on billing activities related to medicare administrative avativities. had a shortfall in healthy san francisco [indiscernible] capitation for health at home and shortfalls on [indiscernible] this is where we recognized interest income savings the budget initiative from prior year, so it shows as balance and we net that out of the total, but it is recognized in this here. next slide, please. and then with pop ulation health, revenues $3.2 million unfavorable. we have seen a consistent shift with lower billing and a change in adult and travel

[indiscernible] in addition with environmental health and lab fees with shift to epic we understand we need to reenroll in medicare for billing. i understand that it has been submitted, but we are waiting and it will take approximately 6 months for that to be approved but we are hopeful that will go through. overall the pandemic probably had a really big impact on the public health overall of service and are adult travel and immunization clinic as travel patterns change and businesses change if focus more on staying home and remote work as well. in terms of expenditure savings, $3.2 million in salary fringe benefits. we did make a significant investment in the population health infrastructure so it did receive significant portion of the new positions for fiscal year 22-23 so not unexpected they achieve additional

savings, but again we are seeing movement in terms of closing the gap in the vacancies and miner savings in contracts and as well as interdepartmental services. next slide, please. in terms of public health administration, just miner variances on the revenue, but close to budget. savings in terms of salary and fringe and miner savings in terms of contracts and then we did have a it project close out which was assumed as part of some of the budget savings with the budget frauss process the prior year. next slide. and then how we finished out the covid response budget, the controller's office did make adjustments. this is a city wide project. multiyear city wide project that was stood up initially in 2020 in response to covid

project. after all the balancing with the controller office we recognize $6.9 million of savings. in prior years, 4.4 of that recognizes technical inventory adjustment for ppa purchased prior years and recognize and utilize and in a [indiscernible] in the current year and $2.5 million of additional savings to get to 6.9. sabeings in contracts and testing overall, $11 million closed out and i could be not more pleased to say that hopefully this will be the last time i report on such a project as the controller's office will be closing this out for us and all city departments and balancing and then as you know in the budget for any continuing cost we believe necessary for infrastructure we allocated to our operating budgets and so, we will not be

reporting on this in subsequent fiscal years. and then for the--next slide, please. i'll note to report in the next slide after that--advance one more slide, please. i note that we did not provide the updated slide. this is from the third quarter, but i note that instead of withdraw we expected in shortfall in the third quarter we will make a positive $6.4 million to match our budgeted revenues in the upcoming fiscal year to fully fund our management reserve at $130 million and in addition, we will put that $21.2 million of revenue budgeted in the current year to recognize it for ending balance of $50 million, but

note in q1 that balance will disappear and we just recognize ourselves as on budget for those revenues. that completes my report but happy to answer any questions from commissioners may have. >> thank you for that extensive work. any public comment on this item? >> person on the line, if you like to comment we are on item 7. press star 3 to do so. i don't see a hand. >> then any commissioner questions or comments on the presentation? commissioner guillermo. >> just a lot to take in i guess in terms of some of the movement in each of the different categories. glad to know at least for this year that we are able to meet the budget and in fact have a

contribution to the reserve, so i don't anticipate that's going to probably be the scenario in the years to come. i guess my concern is i guess looking forward because this budget year will be very difficult, so-but i want to complement you on-jenny on managing what is such a difficult budget and in and out that occur that in many ways are not under our control because we get funding from so many different sources and have to distribute that out in just some ways very convoluted ways to use the budget, so just want to again thank you for all of the work and know you will need a lot of support and you ask your staff will need a lot of support coming forward in the months to come as we look at the coming budget and the

implementation. >> commissioner christian. commissioner chow, any questions or comments? alright. wonderful. i guess i just had one and not sure because this is after all q4. do you have a sense-it looks in many categories revenues improve. we heard from laguna as well. can you make projections how that helps with the short fall and the budget cuts and the other question is, can you refresh how and what trigger use of the reserves? >> sure. i'm pleased to see that we ended the year positively. some of the positive revenue we were expecting and we have already budgeted in the current year. we implemented the fee for service conversion and expect to be worth about $55 million growth in the upcoming budget

so some has been captured and there is additional rate changes and improvements we know we have more data points me and finance team will be taking some of that information over and then trying to put that in n to our crystal ball to make projections for the upcoming year and again, we have the management reserve. what is really to buffer against the fluctuations and assumptions we see and as you recall, what we have significant surplus this year, it enabled to make more aggressive assumptions just recognizing that similar to the case of the fqhc audit we win some and lose some. it is matter of course and this is public health finances [indiscernible] sometimes there is a policy--yes. 10 years is--i'm still-that $38 million of prior year we thought for sure we were indicated from california association of public hospital

that would be finally judeicated for fiscal years. 10, 11, 11, 12 and 13, 14. skipped a year, which is--we thought those would be closed just before the end of the fiscal year, but--at the beginning of this fiscal year and possible they may close them out, but it is real ly hard to predict as we have differed revenue so the idea behind the management reserve is project negative revenue because of the uncertainty associated with all the different programs. it isn't just medi-cal. [indiscernible] different milestones, formulas, percentages, state wide county balancing that happens with state and federal revenues that creates a lot of uncertainty for us. who wh we have negative

revenues as we have seen in previous quarters where we project a short fall as a result of the lower census at laguna honda, instead of having to take corrective action to get the budget balanced we make the assumption short fall would be covered by the management reserve and buy additional time to take the corrective action opposed when you look at the q1 book and say we have to drop everything and have a big fire drill to try to get things back into balance. it gives us a lot of buffer and gave us time to see and what payments also might come in and then any updates we have and enable to continue service. even though it is reserve related to revenues, we can't use it. it isn't expenditure authority and can't use for short fall on the expenditure side but it can help us buffer the ebbs and

flows of healthcare in california. >> thank you. i know there is cal aim and so forth, are there any indication about medi-cal fee schedules? i think medicare is cutting clinicians by 3 percent in 2024. is there anything good or bad about medi-cal reimbursement to hospitals or to the clinics that would impact our revenues? >> i think there is nothing i can quite forecast right now. the state has given the health plans their rates and we are working closely with the san francisco health plan. very supportive so i think we need to wait to finalize and see what they end up with. i don't expect it to be negative or adverse in any way and so usually there is adjustments primarily related more towards cpi and inflationary issues opposed to a big bump up and i know there is a lot of advocacy around just considering public hospital safety net hospitals

the role we served and importance and looking at overall rates and again, as you saw with the financial's, the rates come different times of the year depending on the program. some run on calendar year and some the fiscal year so we get information throughout the year on this and as soon as we get that we'll take that and try to use that to project out our budget for the next year. >> thank you. i see a commissioner chow hand. >> yes. this is more a follow-up on what you were just talking about in terms of medi-cal reimbursement. i wonder on a primary care--for the primary care clinics and all, because we have a large number of medi-cal it is san francisco health plan, hopefully san francisco health plan will also be getting the increase of rates that the practitioners are getting for medi-cal this year. i dont know how that translaets into amounts that are then

capitated for the health plans, but i know you're going to be continuing to look at that, but definitely presumably the state has increase medi-cal fee for service reimbursements. >> i don't know how specifically that will translate, but there is more to come as we prepare the first quarter financials for the commission. >> alright. obviously as commissioner guillermo said, this is complicated work and we are grateful for you to be willing to navigate through all of this complexity and the challenges of the year to come, so thank you so much. >> thank you president green. >> next item is director's report. director colfax. >> good evening president green and commissioners. here with director's report. we have a robust director's report here for you to review.

i'll just go over highlights with regard to the budget update, you see our mid-year budget reductions accepted by the mayor and just to emphasize going forward, on december 13, the mayor issued her instructions to departments for the upcoming two fiscal years. the fiscal landscape is challenging. local revenue growth is flat due to number of different factors, including reductions in property taxes. as a result, department requested to submit proposals to meet 10 percent reduction each year of the proposed budget and 5 percent contingency target with savings taken if the situation worsens. for gph that translate to reduction target of 98.3 million and contingency target is $46.9 million.

the instructions also ask the department not add new positions, so our team is working hard on this. we are holding meetings with our cbo stakeholders including one tomorrow and we will return to the commission in january with greater details on instructions in early february with a full budget proposal. next item is dph awards grant to assist reducing overdose death dispirties. awarded 2.2 million dlr grant for homeless children network of commitment to reducing racial disparities in overdose deaths to revention engagement and education. this funding which is $450 thousand per year over 5 years will help expand capacity of the homeless children network, community based organization to prevent harmful outcomes with

[indiscernible] through innovative tailored approaches. next item is san francisco begins wastewater analysis for fentanyl [indiscernible] and high risk substance s. the health department with assistance of the san francisco public utility commission begun wastewater testing for substances, including fentanyl to track trends and inform response activities. san francisco is one of 70 communities across the united states participate in the first of kind initiative by the national institute on drug abuse to gauge and measure the presence of substance associated with adverse health consequence including overdose through wastewater testing. earlier this month requested dph the public utility commission sent wastewater samples from two treatment plants to a company that received federal contract from nida, wastewater surveillance program testing the water.

dph is expected to receive initial results january and every 2 weeks going forward. san francisco participation is no cost to the city. under the current contract program the program is scheduled to end late august 2024. moving to next item, happy to report to the commission that the dph primary care team hosted awards this week. all 500 members were invited. including eligibility worker, medical assistance, [indiscernible] nurses and providers [indiscernible] takes a great deal of great team to provide primary care across our system and just to note recovering from covid, the worst of the covid-19 pandemic, the primary care team logged more then 250 thousand visits

this year up 23 percent since 2020. next item is zuckerbering san francisco general behavioral health emergency response team received equity award. the team received the equity quality leader award from the california association of public hospital and health system. response team is behavioral health rapid response initiative that began in 2018 and pivotal addressing force on patients at zuckerberg san francisco general. [indiscernible] implementation of a trauma informed approach to care insuring safety for staff and patients in the workplace by de-escalating difficult situations before they become violent. also at zuckerbering san francisco it was-the hospital recognized for reducing disparities in cardio vascular disease.

the cardiologist was recognized in american [indiscernible] the team expanded implemented a heart failure care pathway integrated into epic and tailored to patients needs by targeting social determinant of health. this lead to more then 10 percent drop in 30 day readmission rates. reduction in mortality rate and decrease in racial disparity and readmissions. next item is happy to report that the environmental health branches reach out tobacco program applied to the department of justice for tobacco enforcement grant and awarded nearly $2.9 million for enforcing tobacco laws and regulations, and just to note

that along these lines environmental health retail tobacco program surveyed hundreds of onlie tobacco retailers and about 120 online businesses did not block the sale of flavored tobacco in san francisco. the environmental health branch took this information to the city attorney office and based on their work on december 5 the city attorney announced a lawsuits pagainst 3 online retailers for unlawfully selling flavored tobacco products and electronic cigarettes to consumers in san francisco. our health department health officer susan phillip stated "flavored tobacco products from [indiscernible] and youth in communities of color. i want to thank ehp for their hard work in this very important area. covid-19 update, as of 12-14, san francisco 7 day rolling average of test positive is 4.9 percent.

there were total of hospitalized patients across the city. 24 percent of san francisco residents are fully up to date on their covid vaccinations and you have the item there of dph in the news which you can click on and happy to answer any of the commissioners questions with regard to other areas in this report or more details in the items that i reviewed. thank you. >> thank you for the report and thank you for highlighting the well deserved awards for so many teams within the department. this was a particularly impressive one, diverse departments and individuals getting recognition, which is always wonderful. is there any public comment? >> no public comment. no one on the line. >> what about commissioner questions or comments? commissioner christian. >> thank you for the report. good to see you. can you tell me more about the homeless children network and this grant to reduce overdose

death disparities? what age range of person is generally served or targeted by this work? >> i'll loop back with behavioral health team and get you the information. if you have more specific questions, i'm happy to get them and get back to the team. >> thank you. >> commissioner chow. >> yes. dr. colfax, wond ering in the wastewater analysis, how would the department actually use this? is it just to-i understand when we were doing wastewater on covid and all how we would be watching the pandemic, but these are substances which are used in a different fashion. it is [indiscernible] how would we take a fentanyl level and what are we expect to know from

it, since there are no specific, no neighborhoods and so forth? >> i appreciate the question. as part of this pilot project, those are some things we are going to be testing and learning and as part of our behavioral health update or sooner happy to get the information from the behavioral team. it is a area of trying to link what we learned from covid and wastewater testing to see if we can be more specific and targeted in our response to the substance use epidemic and i think that's part of-your specific question is one thing the pilot is going to seek to answer to see whether wastewater testing truly can be an effective tool, but to get you more specifics i can get behavioral team to report back and they can provide an up date on this project in the next update to the commission. >> that would be fine. thank you very much.

>> seeing no other comments or questions, thank you. the next item commissioner christian will give us a community public health update. >> thank you. so, earlier this afternoon commissioner gerardo and i were able to get a update on two matters. first, we reviewed the draft dph annual report for fiscal year 22-23. as you know, the report summarize and highlight dph data and services. we were generally very pleased with the report and the only thing i think primarily we were encouraging them to do was to highlight more of the successes of--and the increase in service providing and through the communities, particularly given what we have been going through

and focusing on in the last year around healthcare provision and also substance use disorders and providing people with treatment and the stark difference between the availability of treatments in this past fiscal year versus previously. i think it's-commissioner gerardo brought this up, it is very important for the department to highlight that information so people can see in the annual report and the media can see in the annual report the good work and change that is happening and also the really excellent work and increase in service providing to the community and our public health sites and so, basically just more pleased about what

the good work has been and the data and the numbers and so we can focus on those accomplishments and celebrate them. so, the final report is scheduled to come to full commission in february. second item was update from the maternal child and adolescent section. it was an amazing report given by arlean armstrong, the director of the division that section. incredibly impressed with the spectrum of work they are doing and the partnerships in the community. both commissioner gerardo and i were interested in additional specific data to follow-up with the narrative contained in the slides. some of the request included information on various system responses when a parent goes into substance use habilitation service, what cascade of things happen when a person gives

birth and perhaps the child is found to be testing positive and then the legal system and other systems come in, but it was very impressive the body of support that comes into play for the person and the child when something like that does a occur. definitely director armstrong is doing incred rbl work and her presentation was very good and we asked for her to come back soon with a little more information. i encourage you to go through the presentation if you have a few minutes again. things like learning about things like using a non invasive bio marker on children to see what level of nutrients

are in the system to measure and see if they are getting enough of the food they need and fruits and vegetables. that is incredible and great. just the breath of the work and the depth of the impact is really impressive and we are looking to be able to support that in all ways we can going forward. i think that's what i got. >> thank you. is there any public comment? >> no public comment. >> any comments or questions from commissioners? thank you so much and we will definitely look at that hand-out. that sounds fantastic. the next item i believe will be the joint conference committee report from zuckerbering er zuckerberg san francisco

general. commissioner chow will present. >> thank you president green. at the december 12 meeting, the committee reviewed and recommended that the full commission approve the environment of care report, which is as you know on today's consent calendar. which report provides important information about the many logistics and operational systems that enable to be such a highly functioning institution. the work that they have been doing. many of which were aspirational goals, but well explained. earlier reports looked at were

regulatory [indiscernible] and the december ceo report. human resources report. in the report of the ceo [indiscernible] our chief medical officer at the hospital was going to be leaving to go to ucsf health, a significantly important position. he had been our ceo at the hospital since 2018 and lead the medical staff and the hospital through the epic update and the response to the pandemic along with continuing to work and we found him very responsive to our questions. dr. [indiscernible] announced

that the [interference in the background] was going to a very high level position at sutter health. once again, it looks like our work here then continues to allow others to benefit from all the-i suppose learning and the experience that they are getting fraul from us so that is wonderful dph continues to inform so many other organizations. we also were informed that the-and accepted dr. [indiscernible] had been recommended and by the administration and staff and ucsf as chief of pediatrics and jcc accepted that

recommendation. furthermore, under the medical report, we then reviewed all of the policies and procedures that you see listed at the other portion of the consent calendar and recommend that the commission approve all of these. in closed session [indiscernible] that ends my report. >> thank you for the report. is there any public comment? >> no one in the room or online. >> questions or comments from commissioners? we should move to consent calendar and is there any public comment on-- >> no public comment. >> then should ask for a motion first to approve the items on consent calendar. >> so moved. >> second. >> i will do roll call.

chow, yes. commissioners in the room, how do you vote? yes. the consent calendar is approved. thank you. >> the next item is other business. any other business? >> no public comment on this item. >> okay. then the next item is motion to move into closed session. >> first we'll take public comment and there is none. one is closed session and one is to attorney client privilege so start with closed session motion. >> motion to go into closed session? >> so moved. >> second. >> commissioner chow, yes. commissioners in the room, how do you vote? yes. thank you. how about motion for to assert attorney client privilege for this discussion? >> so moved. >> second. >> roll call. chow, yes. commissioners in the room how do you vote?

yes. folks who are watching, please give us 30 seconds. you will not-give us about 15 minutes. you will not hear or see while we are in closed session and folks in the room, please give me 30 seconds to take to closed session. sfgovtv i'll >> is there a motion to disclose or not disclose? >> i move we not disclose closed session. >> second. >> chow, yes. commissioners in the room. yes. thank you so much. now is time to consider motion for adjournment. >> so moved. >> second. >> commissioner chow, yes. commissioners in the room, yes. thank you all so much. happy holidays. >> happy new year. [meeting adjourned]

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