good morning. the meeting will come to order. welcome to the thursday, march 24th, 2022, meeting of the public safety and neighborhood services committee. i'm supervisor gordon mar and i'm joined by kathryn stefanie and supervisor haney shortly. i'd also like to thank sfgov tv for staffing this meeting. madam clerk, do you have any announcements? >> clerk: yes, i do, mr. chair. the board while still providing remote access and public

comment via telephone. the board recognizes that equitable access is essential and will be taking public comment as follows. public comment will be taken on each item on this agenda. we'll take those waiting on the telephone line. for those watching, either channel 76, 88, or 99 depending on your provider. and sfgov.org, the public comment number is streaming across the screen. (415) 655-0001. then enter 24929495822 then pound and pound again. when connected, you will hear the meeting discussions which you will be muted and in listening mode only. when your item of interest comes up press star three to be added to the speaker line. please remember to turn down your tv or any listening

devices you can also e-mail your public comment to me at alisasomera@sfgov.org. you may also submit your written comment via u.s. postal service to our office at city hall. 1 dr. carlton b. goodlett place. finally, items acted upon today are expected to appear on the board of supervisors agenda unless otherwise stated. mr. chair. >> chairman: thank you, madam clerk. can you please call item number one. >> clerk: yes. item number one is a hearing. on sale beer and wine, public premises liquor license located at 950 mason street inside the fairmont hotel and will serve

the public convenience or necessity of the city and county of san francisco. please call in to the public comment call-in number now enter the meeting id 24929 a system prompt will indicate you have raised your hand. please wait until we take for public comment on this item. that will begin your queue to begin your comments. mr. chair. >> chairman: thank you, madam clerk. first off, we're going to hear from the sfpd liaison unit. >> good morning. i'm here. >> chairman: good morning. >> okay. so bin 415 has applied for a

license to operate. considered high crime. >> chairman: thank you, officer sellmanson. is the applicant here? >> yes, i am. >> chairman: would you like to speak to your application? >> yes. somalia guided local wines and napa valley cinema inside the fairmont hotel. so much more of an educational

setting and service rather than a bar setting. our intention is to educate for the region, for people that are out of town visiting san francisco. >> chairman: great thank you. thank you for that and sounds pretty good to me. colleagues, do you have any questions? great. why don't we go to public comment on this item, madam clerk. >> clerk: thank you, members of the public who wish to provide public comment should line up to speak now alongside of the windows, your right, my left and for those joining us remotely call (41) 565-5001. enter 24929495822 then press pound and pound again. once connected, press star three to enter the speaker line. and that will be your cue to

begin your comments. all speakers will have two minutes to speak. since it does not appear we have anybody in person, d.t. is checking to see if we have any remote attendees. if you are not on the phone please press star three to line up to speak. do we have any commentors. if you can put the first caller through. hello, caller. hello, caller. that person seems to have dropped out of the line and it does not appear we have anymore callers in the queue. mr. chair. >> chairman: thank you, public comment is now closed. colleagues, i understand that supervisor peskin is supportive of this license transfer.

given that, i will make a motion directing the clerk to prepare a resolution determining that this license will serve the public convenience in necessity and that we send the resolution forward with a positive recommendation. madam clerk, please call roll. >> clerk: yes. on item number one, [roll call] there are two ayes. >> chairman: thank you. thank you officer sellmanson. colleagues i'm going to call out of order. can you please call item four, madam clerk. >> clerk: yes, item number four is an ordinance amending the health code to require general acute care hospitals in

the city to report annually to the department of public health the number of and certain demographic information regarding the patients transferred to health facility outside of the city to receive sub acute skilled nursing care and patients who qualify for sub acute skilled nursing care but are not transferred to a health facility outside the city. once connected to the meeting press star three to enter the speaking line. a system prompt will indicate you have raised your hand. please wait until we call for public comment on this item. that will begin your queue to begin your comments. mr. chair. >> chairman: thank you, madam clerk. i just want to start by saying thank you, supervisor safai. it really comes out of five

years of work in the city and in the community to address a problem that's really urgent. and i first got involved in these issues as a community advocate around when cpmc was moving to close the sub acute unit at st. luke's hospital which is the last remaining hospital based sub acute care in the city. i really want to thank supervisor safai and supervisor ronen for all your so thank you supervisor safai. the floor is yours.

>> supervisor safai: thank you, chair mar. my first year in office, we found out that we would have been the only county in california that had no sub acute hospital base. we called for an emergency

hearing. and ultimately forced cpmc sutter to keep the day beds. right now, that's the only city and county. we were pushing really hard. we've been working to and work with our remaining hospital facilities to provide that. this today is about ensuring a reporting system tracking how people are getting care. many of the families come from very low income backgrounds. don't have the ability to travel to see their family members that need care and

they're being transferred out of county. we wanted to be able to track that. we wanted to hold the accountable. so today this ordinance is a critical piece of transparency for individual care for individuals who need that skilled nursing. since the last hearing, we've talked about this before. we have a series of amendments to expanded scope of the legislation so we get a better look at the system overall. i want to talked the amendments. generally, we're going to expand the facilities from hospitals and include skilled nursing programs. we'll also expand the facilities that we transfer out to to include skilled nursing facilities and at the request of dph, we're moving the reporting date back to october 21st, 2022. some of this work has already been happening.

a lot of the data has started to be collected and we feel like it's important to give a little additional time to get the right data. finally, we intend to have the report heard at the public health commission rather than just being a written report transmitted back to this body. i'd like to thank thank supervisor mar for working collaboratively with our office and it's noted this is simply a first step. i look forward to working with all of you on this issue. because until we have more sub acute care in hospital and sub acute reporting, we're not going to stop and we're not going to have a full fledged and proper health care delivery system. i also want to acknowledge san francisco hospital who reached out and asked for some additional time. we're happy to hear what concerns they have and it was

mainly about reporting, the reporting systems and ensuring they have the right mechanisms to report. since these amendments are substantive today, i think i'm correct an automatic continuance will be required. i look forward to this very important topic and then i'd ask chair mar if you would move the amendments that we have introduced here today is she available to say a few words? is she online? >> yes, supervisor safai, i am online. sorry i didn't make it over thank you. special programs with the department of public health.

we want to thank the supervisors for responding to this request. we are supportive in trying to get the data sets and working with the hospitals to and hopefully we'll have time to and so part of our changes are being adjusted. if there's any other questions, i'm available the real issue is

what we're doing at the city to create the sub acute care capacity right in our city. so i just wanted to see if you could share a quick update on the work that dph has been doing with health care facilities to add sub acute care beds and facilities in our city. i know supervisor safai's been involved and he mentioned the chinese hospital example. can you just give an update on that, the work you've been doing? >> certainly. we in partnership with the controller's office we obtained consulting report from consulting and they are helping us reach out to the hospitals to gather data and based on the environmental landscape that was completed prior to covid

times, we were able to do an environmental landscape to see if there were any partners in the community that are working on sub acute and we did finance the hospital that has a unit. they've been working as getting certified and they are open to actually having that unit be used for subacute. so we've been working closely with them to get through license certification for skilled nursing and then to do medicare certification for billing and then they'll be working to get certified for subacute. that work is active and ongoing. we also found out there's a private skilled nursing facility that has been looking to convert some of the beds in their facility to subacute. and so we've been trying to partner with them as well. they've had some challenges in terms of getting staffing in place to help them move through

occupational safety and health certifications. so we've been collaborating with them as well. so those are the two facilities that are most actively moving forward on having the sub acute beds come online and we've been working with the different hospital systems to talk about partnerships as we move forward to have those subacute units go live. we've had active interest from dignity and we also have active conversations with ucsf and preliminary interest from kaiser. so we are actively engaging conversations with those partners at this time. >> chairman: thank you. thanks for those updates on this really important work. why don't we go to public comment on this item, madam clerk. >> clerk: yes, and for those

joining us remotely, please call (415) 655-0001. enter the meeting i.d. 2492 to enter the speaking line. for those on hold, please continue to wait until the system indicates you have been unmuted. do we have any commentors here in person. it does not appear we have anyone. so if mr. baltazar could check, do we have callers on the line? and it does appear we have eight listening and four in the queue. if you can put the first caller through, all speakers will have two minutes to speak. >> good morning supervisors, thank you for your time today. this is raquel rivera who's sister sandra is one of the

eight remaining subacute patients. i would just like to reiterate my written testimony regarding the dyer need for hospital based sub acute beds in san francisco and the three resolutions through legislation that we proposed. number one, require a shared responsibility with all hospitals in san francisco for permanent subacute beds. number two, require a higher ratio of nursing staff to patients to support the staff in each hospital subacute unit. and number three, require hospitals to track how many patients are being turned away and/or discharged out of county and the reason. we welcome the opportunity to collaborate on working on these three resolutions together. thank you. >> clerk: thank you for your

comments. >> good morning, supervisors. first of all, thank you for your time today. this is antonio rivera. sibling of sandra and raquel rivera. i just wanted to add these through legislation that we proposed and regards to the shared responsibility with all hospitals for permanent subacute and san francisco. this was basically inspired by sutter health. from my understanding, they didn't want to solely bare the cost of having a sub acute unit. now, they can speak to this and clarify and if they would be in support of a true nursing staff. how can we support legislation

that would ensure we should all support these resolutions through legislation. lastly in regards to the tracking of outbound and discharge patients, how can we ensure that the needs of the community are being met if we are completely in the dark without data that can tell us otherwise. supervisors, please collaborate with us in bringing all three resolutions through legislation to life. thank you. >> clerk: thank you for your comments. can we have the next caller, please. >> caller: hi, can you hear me? >> clerk: yes, we can. two aspects of the day. one on subacute care.

kelly hiramoto updated us. this update has not changed in at least a year. and so it seems that no progress is being made in actually getting subacute beds to keep people in county and i would like to know the hospital council has not been helpful. it's been protecting its members from spending money rather than helping get subacute beds. and nonhospital based subacute beds are likely to be understaffed and dangerous. the nonhospital site that you mentioned has trouble with staffing for regular shift we should track out of county

discharges also to residential facilities as very sick patients are frequently transferred out of county to these facilities to really look at who we are due to the attrition and loss of in county health and residential facilities for people that are too sick to live on their own. what we're doing and we should amend the legislation to get the full picture. thank you. theresa palmer. >> clerk: thank you for your comments. may we have the next caller, please. >> caller: hello. my name is vivian imperielli.

can you hear me? >> caller: i'm board president of the mental health how many people suffer from being out of sight, out of mind. a year ago, my friend was sent to a facility, psychiatric residential facility. instead, he has seen the physical therapist fewer than ten brief times and is dependent on staff to get him out of bed. there's no library, no computer and no end room phone.

close to their providers, friends, and family. just when people need help the most, we abandon them. this is unconscionable. >> clerk: thank you for your comments. do we have any other callers in the queue? >> caller: good morning. this is patrick menacha. i want to thank supervisor mar for his leadership on this legislation. it's misleading to assert that davys is the only subacute hospital base in the city. if it was not accepting any new patients ever since the patients from st. luke's was

transferred to davys and so any new patients needing subacute care have continued for three to four years to be also dumped out of county. i thought supervisor safai had asked for the amendments to be read into the record. that hasn't happened yet. i am disappointed in dph and ms. miramoto in particular that there's no estimated date yet on when beds will be open that chinese hospital or any other facility. the chinese hospital board agreed in january 2020 to open those 23 beds.

what is the two-year delay in moving that forward in my testimony i submitted, i wondered if those beds are being delayed because of the covid overflow bed contract. we really need to hear today what these proposed amendments are and i direct you to my testimony on specific amendments that many community members have been supplying to both supervisor safai and supervisor mar. >> clerk: thank you for your comments. can we have the next caller, please. >> caller: good morning supervisors. my name is carol lynn kennedy. i'm a community leader in san francisco and i was actually attending this hearing to hear some other items, but i decided

to comment because i can empathize with the families that are speaking today and families that are also affected by the lack of subacute beds for family members. i think this issue of shared responsibility is really important and i thank supervisor safai and other supervisors for bringing this forward. it goes to the larger issue of our mental health services in san francisco and how we really rethink them and rebuild them and restaff them to provide quality care. so please continue with this effort and in particular the reporting i think will be very important to be able to evaluate what the quality of care of people are getting regardless of where they're placed. we really need more beds, and those beds are going to be hard to come by for our residents of our city. so thank you very much for shining a light on this, supervisors. >> clerk: thank you for your

comments. can we have the next caller, please? >> there are 0 callers remaining in the queue. >> clerk: thank you. mr. chair. >> chairman: public comment is now closed. i did want to thank the public commentors in particular the rivera family for continuing to advocate for your sister but really the community members in our city and their families who need subacute -- this high level of sub acute care in our city and really health and well being would be undermined by the continued out of town transfer for this care. so supervisor safai. >> supervisor safai: thank you, chair mar. yes, i want to echo that. the rivera family has been so loud and outspoken and so firm in their advocacy for not just their own sister, but the

entire universe of people in the city and county of san francisco receiving the proper care that they deserve. i want to thank dr. palmer and others who have been real helpful in this conversation. i know that we might not have made every single amendment they asked for, but we certainly have expanded the universe beyond hospital care providing skilled nursing and subacute out of county and we think that that's an important part of the conversation. i too am frustrated that we don't have a more we need to

put the resources there. we need to get the hospitals and the room to when subacute hospital care will be provided in the city. we think this is a first step and i really appreciate the partnership, supervisor mar working with us and all of the advocates for advocating for themselves and others. but we will get this right and we will continue to work on this. you have both of our commitments and we're not going to let it go until we see that care provided in the city. thank you, chair mar. would you move the amendments that we've introduced today and then we can continue it for one week i guess and then make a

final vote. >> chairman: thank you, supervisor safai. i would move that we accept the amendments as presented and described by supervisor safai and then we continue this item to the next meeting of the public safety and neighborhood services committee. >> clerk: all right. on the amendments first, [roll call] there are two ayes. and then on the motion to continue it as amended to the meeting of april 14th, [roll call] there are two ayes. >> chairman: thank you. >> supervisor safai: thank you, folks. >> chairman: thanks, supervisor safai. thank you to all the advocates for calling in and continuing to work with us on these important issues. madam clerk, i think we're

going to call item two and three together. is that right? >> clerk: agenda item number one is a hearing to discuss the hearing to discuss the implementation of a housing conservetorship and a legislative analyst report on hasn'terman-petris short conservetorships. and the office of the public conservetor to report. members of the public who wish to provide public comment on these hearings may line up to speak. call (415) 655-0001. enter the meeting id 24929495822 then pound and pound again. once connected to the meeting you will press star 3 to enter

the speaking line. >> chairman: thank you. so we have supervisor mandelman for these items. thank you for your leadership in all of your work on these important issues around conservetorship and how we can look at this tool and. >> supervisor mandelman: thank you supervisor mar. i am frustrated i do want to say before i express all of my frustrations that i have a lot of gratitude for the people in

the various departments and city agencies who are trying to make our systems work. but from my perspective, they're not, and i think from the perspective of all of our constituents. thank you for calling envisioning us going forward and hear from the public conserve and then tackle the housing conservatorship. i've spent some time this week talking about our sidewalks as the waiting room for permanent housing. i think there's even greater fally in using our sidewalks and our plazas and our parks

and our freeway. my impression and our lack of progress is due to a lack of appropriate beds and that's a point that's not new here at this board and remains the case in my view. so i did want to have a hearing to have a conversation about the b.l.a. report shortly after taking office, as we were

having a robust conversation about whether san francisco should opt into the sb1045 conservatorship laws that we already had in place and what additional changes we could be making there what would it take to make l.p.s. work better in san francisco. one of the findings that was remarkable i thought about that 2019 report to refresh folks' memory was a decrease in conservatorships in san francisco between 2012 and 2018, 2019 almost a 50% decrease in new conservatorships and that was shocking and striking to me given the lived experience of

san franciscans who see so many folks who seem to be a danger to themselves or others or gravely disabled. that report cited a lack of appropriate beds and specifically locked subacute and skilled nursing beds as a leading reason or perhaps the leading reason for declines in referrals and overall conservatorship case loads even when the number was to anyone paying attention going up. it also said that the wait times recently opening for the san francisco healing center were averaging 20 days and the wait times for other facilities was averaging 51 days. the bottom line of the report was that we needed to significantly scale up the number of beds available that analysis was at least in the

conclusion was reaffirmed in the mental health of the language sf and as you know, this board was appropriated many millions of dollars for mental health beds over these last three years. talk about this and all of these dollars appropriated i would hope and expect we would be in a different position today than we were back in 2019. and unfortunately this b.l.a. update leaves me concerned that we are not. now the decline in conservatorships has stopped and new conservatorships have ticked up over the last couple of years and i think that's probably good news. but the bed not a lot. according to the 2022 available for dph increased by just two, not 2%.

two beds between 2018, 2019, and 2020, 2021. from 278 and 2018, 2019, up to 287, but back down to 2 now any discussion of anything health related in 2022 has to acknowledge that we've just had a giant global or we are still in a giant global pandemic. and that has impacted all other endeavors and i will, you know, acknowledge and the b.l.a. report shows that d.p.h. intends to increase locked subacute beds up to 311 before the end of this year and we can hear more about their progress on that when they present. i'm concerned.

if this has been one of the leading health problems in san francisco for years now before the pandemic that we haven't made more progress on this bed problem. even assuming the department meets it goal before the end of this fiscal year, we'll still have 58 fewer beds and we have fewer acute patient beds than we did back in 2013. that is not accounting for the elimination of 500 placements. that would be appropriate for them now and my conversations

2015, 2016 the healing and average wait times for other locked acute facilities increased 51 days bad to 103 days terrible. and just to put some, get some flavor for this, i know every supervisor probably has their stories of the people in there districts who neighbors are worried about not withstanding efforts by our offices and

concerned members and sometimes family members can't get the care that 90% of us agree they need. there is a person within two blocks of my home who i know gets visited daily by street crisis response and outreach teams. the person has depending on the day three or four, eight shopping carts worth of stuff. sometimes gets 5150ed. is in terrible shape to most of us this is not a person for taking on affairs. he remains there. seems like a danger to me and others. and, you know, i happy to know them. many san franciscans have stories like this. there's a woman who sometimes takes up residence in the alley

in my home and screams all night. now, her life has to be rough. we don't seem to have any response to get her the care that she needs. as a supervisor, i see folks who are repeatedly breaking windows or committing other crimes in the neighborhoods that i represent they may or may not be spending time in jail. traffic through the neighborhood. police are out. fire department is out. this person may be taken to the

hospital. i have no confidence that he will get the care that he needs to present a similar situation from occurring to prevent being a danger to himself or others. my informed impression after all these hearings and all this talk over these last few years is that we probably need some changes to our laws, but as suggested by the b.l.a. report, the real problem is that we simply don't have the beds that we need to provide the care, and even if we changed our laws to allow for a mental health detention and more cases than we do, we wouldn't have anywhere to put these folks. that's my impression. i would happy to be disabused by our presenters. and so that brings us to our presenters. we're going to hear from rashi

casarambi. i and then we'll also be hearing after that from jill neilson from the office of public conservator and dr. angel from b.m.h. let's start with the b.l.a. unless colleagues have anything else to say. >> chairman: thank you, i just want to acknowledge president walton has joined us. from. you mentioned who actually on the analyst report. and we have a presentation which i think the clerk is going to help us with. but this as supervisor mandelman mentioned, this report that we did is an update to the report that we did in

2019. in 1959. so that was 60 years ago. and it said uniform civil process for involuntary detention provided for temporary permanent conservatorships. next slide, please. so there are three types of mental health conservatorships in san francisco. our report looked at the traditional conservatorship model. it is provides for placements in the residential environment, but there are also two community based service models under the traditional

conservatorship. which allows individuals to live in the community as long as they comply with medication. the other two types of conservator ships in the criminal justice system and we only so the normal pathway is that somebody's detained in an acute care setting or inpatient setting on a 51/50 or psych hold. it allows an outpatient provider to refer somebody for a contemporary conservatorship without going through that psych hold. in our review, there was 16 individuals who were referred in that way. our understanding is that the court does require a higher degree of scrutiny because

these are not people currently detained, but ultimately 14 of the 6 teen were approved for temporary conservatorship. next slide, please. so this is sort of the comparison that was discussed by supervisor mandelman. so the case load ten years ago in 2012 was about i believe 890, more than 800 individuals and we saw a significant increase in the seven years leading up to fiscal year '19-'20 of case load. it started to tick up again in fiscal year '18-'9 tea and so you see in the six years leading up to 2021, there's a 13% increase in case load. it's still below the case load of ten years ago. next slide, please.

so after we finished our report in 2019, the state auditor came in to do evaluation of conservatorship statewide. one of the findings was that the definition of disability was actually sufficient. you know, that the counties interpreted and applied that definition similarly across the counties and they thought there should not be a change in the nature of the definition that it could lead to an increase in involuntary detentions. san francisco -- los angeles and san francisco both disagreed with that finding. san francisco specifically said there's room for improvement to ensure that individuals with significant behavioral health needs are receiving ongoing care and not just crisis care. next slide, please.

another state audit finding was specific to san francisco. there was a lack of coordination with medical facilities to ensure disabilities that they're connected to intensive services. now the state audit was actually really focusing a lot on services funding through the mental health services act and through the full service partnership. [please stand by]

but the definition of disability is not a permanent condition. so when we looked at the caseof , we found 50 percent had been conserved in the previous episodes so there are debates in and out of conservatorship. next slide please.this is the waste timeissue. between the two reports , wait times in seven facilities and these are facilities or one of the most likely place to report individuals. the wait time among these facilities between the two reports doubled and the san

francisco healing center has increased fivefold. some of that may have been due to the restrictions of covid but the wait times have definitely increased and our understanding is the state hospitals no longer accept new patients . next slide please. so as pointed out, one of our conclusions really was the conclusion of the state on it is that there simply need for more beds. san francisco is planning for 108 new beds either purchasing or contracting with facilities. >> those 408 bed stove are primarily not conservatorship. >> those are a wide range of beds.we identified 137 beds we thought would be appropriate for placement but for the most acutely ill you would want

skilled nursing facilities. there were 44 beds so that 11 present of the beds was the most acute patients and 137, some ofthem are ordered and care that could be an appropriate placement for conservatorship . next slide please. so this is the issue of beds. as you see in a 10 year period the number of beds available to san francisco decreased significantly. at the end of 2020, 21 there were only 280 beds which was significantly less in 2012, 2013. there was a plan to increase substitute beds, aplan to increase 31 beds in the current fiscal year . and as of the time of our report 21 city beds hadbeen required . so this is just 137 beds that

we were going to find that could potentially be available to conserved individuals. and the 41 that are skilled nursing and substitutes, the others are enhanced care. next slide please. so in terms of the policy consideration, one of the things we were asked to look at is what's the population in need and it's not a way for us to evaluate that the condition of grave disabilityis not a permanentcondition . people can be disabled at one point, given medication , stabilized but we used as a reference the high users that are being tracked as part of the whole person care project so in fiscal year 2019 20 there were 314 individuals that have multiple site emergency admissions .

and yet that compares to about 135 individuals during that same year referred to lps conservatorship. it doesn't mean these are the same individuals, it was just a way for usto understand whothe most severely disabled population might be . next slide please . and then in terms of the recommendations, obviously the focus was on beds. our recommendation is to report some dpa to the board in the fiscal year so wewere looking at giving an update on the beds that have been acquired . the barriers to acquiring those beds and actions takento address thosebarriers and an update on reports on occupancy and wait times five kinds of bed . next slide please .and then the second recommendation we had is for our report back to the board on state audit

recommendations about the dph connecting individuals who are discharged from an acute , inpatient facility connecting those individuals to services. so that's an update and i think i discussed in dph those two reports would get the same time. it was in the third recommendation we have made a couple of years ago and repeated in this which is for dph public conservator to have an m.o. you on information sharing and we did receive a memo from the public conservator's those negotiations are now underway andi'm sure they could give you an update on that process . that concludes ourpresentation but we are available for questions . >> supervisor stefani.

>> thank you chair mar i'm wondering i was writing that down,i don't have the slide in front of me . if you can go back to that . i just had a questionon that . it'sslide 14, page 14, that's what i saw .>> could you bring back slide 14 please. [inaudible] >> supervisor stefani,was this about the wait times ? >> we need you to speak into the microphone. >> it seemed tosuggest lack of mental health treatment beds impacts referrals to conservatorship , too. >> that's thesuggestion that bla is making which i think is correct . >> that is one of our findings.

the lack of beds. that comes from not just us but the state audit address the issue of the lack of beds date why being a major barrier to referrals and we also had an academic study that had reflected that so it was based onthat information . >> i'm having trouble with the conclusion being drawn because there's no treatment beds that there is no then referral for ability to deal with someone's mental illness when there are so greatly disabled need to be conserved. logically what follows for me is that i mean, mental illness needs to be treated just as if my arm happens to be amputated in a car accident. if there's not a bed at as a general and i need to be flown helicopter to deal with that, you cannot say lack of beds. we just weren't able to refer that person because we didn't