. >> good afternoon commissioners, dph staff, members of the public and welcome to the commission commission of october 18, 2022. secretary more will you call the roll. >> sure. commissioner commissioner giraudo. >> present. >> commissioner chow present. >> commissioner green. >> present. >> commissioner bernal. >> present. >> i have a sculpt to read. good afternoon and welcome stot commission. this is meeting is held in hybrid formal at grove street broadcast live on sf govtv available to view via webex and calling the number on

the agenda and the access code is on the agenda. observe we begin i would like to remind individuals in person and present today that all health and safety protocols must be adhered to at all times and we're a mask during the meeting and including when you speak. failure of the rules and requirements may result in the removal of the room. we appreciate your cooperation with the rules in interest of health and safety. please note that a hand sanitizer station is available at the entrance of the room and masks are available if you ask me. we welcome the public's participation during public comment period and general public comment and to comment on each action item on the agenda and limited to three minutes. folks that intend to make public comment you are -- i suggest that you press star three at the beginning of the item to make sure your hand gets up in time.

some of are watching on sf govtv and has a delay and welcomeex shouldn't have a delay and same with the call and encourage to you have the hand up early. public comment is taken in person and from first the people attending in person and then remotely and those are requested to send a comment card to me and those instructions can be on page four of the agenda. please note that policies and local law prohibit discriminatory conduct and will not be tolerated and public comment is only within the matters of the health commission. thank you for joining us. >> thank you secretary morewitz. now i would like to recognize commissioner chow to offer the loan lon land acknowledgment.

>> thank you president bernal. the san francisco health commission noles we're on the unceded ancestral homeland of the ramaytush ohlone who have the original inhabitants of the peninsula and -- [inaudible] nor forgotten their responsibilities as the caretakers of this place sweeled for all people 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 at the ramaytush ohlone community and by affirming their sovereign rights as first peoples. thank you. >> . >> thank you commissioner chow. we will move to the next item 2 and

reminders of the members of the public we're taking the agenda in a different are today due to the importance of the topic of laguna honda hospital and medicare recertification so our next item will be the london breed and rehabilitation center closure plan and cms recertification update followed by a closed session on the same topic. to present we have roland pickens and acting ceo of laguna honda hospital. good afternoon. >> good afternoon commission. how are you? all right. good afternoon commissioners. thank you for this opportunity to give you a update on the status of laguna honda hospital. >> can you please pull up the slides? >> give me a moment.

>> okay. >> my apologize. what item is this under? i only have six and seven? >> it's the london breed presentation that we spoke about last week. member noe emailed it to you. >> let me go ahead and pull it up. >> okay. thanks for

your patience commissioners and mr. pickens. i just reforwarded kenya. do you see it? >> not yet. give me

a moment. . >> okay. i will pull it up. just give me a second. okay commissioners. give me 30 seconds. i just opened it

up. i just got it get it on my screen. okay. okay. again sorry for the wait everyone. let's go. . >> thank you mark. >> so again good afternoon commissioners and again thank you for this opportunity to provide you this update on laguna honda hospital. i am here in person on grove and i am joined remotely by members of the executive team at laguna honda who can help with this presentation. next slide. so as you know laguna honda is the largest publically run skilled nursing facility in the country. more

than 150 years laguna honda has been a pillar of san francisco's health care system providing health care services to approximately 700 residents when we're at our maximum. the hospital cares with people with the effects of complex or chronic conditions such as stroke, traumatic brain injury or degenerative disease such as melt pull sclerosis and the programs include comprehensive rehabilitation services physical, occupational therapy and speech and language therapy and audiology. some of the specialized care arounds mono lingual care in spanish and chinese, a palliative care unit. the only positive hiv care unit in the bay area and the memory care unit. next slide. you will recall that in

april 2022 laguna honda was deemed decertified by the centers for medicare and medicaid services. this came as a result of a 2021 summer of 2021 report that laguna self reported to the state of california cases were there were two non fatal overdoses of laguna honda patients who had been out on pass and came back to the hospital. thankfully those staff were prepared and were able to reverse those over doses and the patients survived. however, as a result of several investigations cms, the centers for medicare and medicaid services found that the hospital was out of substantial compliance with their rules, regulations and standards. thus in april 2022 cms terminated laguna participation in the medicaid and

medicare provider programs, a very significant event because the majority of the funding from care comes from those two sources. approximately $550 a day or more than $200 million annually. next slide. since that decertification occurred in april our number one priority has been moving the hospital back towards the path with recertification with cms. everyday the staff works hard to meet regulatory reg requirements and all requirements to prepare for recertification and includes long-term operational institutional and cultural changes that are needed to achieve recertification and ensure the long-term success of the hospital. our

certification efforts include a comprehensive assessment of the organization with a recognition of gap in compliance and plan for improvement to come into compliance and rehiring on two expert consultant group for the assessments. one is the health service advisory group and researched to as h sag and health management associates as hma. we are confident we have the best team possible in place to help ensure our success and path towards a successful recertification. next slide. so it's important to update particularly members of the public who may not be aware but as you're aware commissioners we're very excited to learn about a settlement agreement between the city that they reach with cms and the

california department of public health on behalf of laguna honda. this settlement agreement extends payment and the closure plan that he will talk about in the next slides. it's important to note that the agreement needs final approval by the board of supervisors and the mayor and that process to achieve those approvals is in process. part of this agreement is good, much -- it's all good news. cms agreed to pay for resident care at laguna until november 13, 2023 almost a year from now. this extension adds a year of federal payments beyond the current agreement with cms that is set to expire in number of this year. in addition to the extended payments cms has agreed to

continue the current pause in involuntary discharges and transfers of residents from laguna until february 2, 2023. however cms will have the option to further extend the pause depending laguna's progress towards recertification. during this pause resident initiated transfers and discharges will still occur which is the right that our residents have and are entitled to if they choose to relocate to another facility. however, overall we're very pleased we could reach this agreement with cms and dph and appreciative of the time for laguna to prepare for recertification. next slide. in addition the agreement requires that laguna will continue to have the presence of a

cms facilitator. that individual has been on campus for the last three months and part of the settlement agreement will continue in that role. in addition there will be surveys conducted every 90 days by cms and/or their subcontractor here in california, the california department of public health and this is going to be important because they will be on site every 90 days to assess our compliance with the cms conditions of participation and we expect their first survey to be no later than the end of january in 2023. we are very confident that the work we've done over the last several months will put us in good stead for their first and all of their visits so that we can actually show the great progress laguna made over the last several months towards process improvement and regulatory compliance. laguna will continue to work with our

expert consultants on our path towards recertification and in fact part of this settlement agreement requires the designation of what cms referred to as a quality improvement expert. cms has designated the hsag group we're currently working with to be that expert. they will continue to work with us towards recertification and correcting the deficiencies identified by cms. next slide. so given the settlement agreement and the new requirements and timelines associated with it we've decided to postpone mock survey number two. as you can imagine with all the work that's coming now with the settlement agreement we want to make sure that our staff have the appropriate focus and time to

prepare for the forthcoming surveys that will be coming every 90 days. in addition, this delay of the mock survey number two allows more time to really address the new what are called phase iii set of regulations that cms is implementing effective october 24. the surveyors will be assessing facilities nationwide against these new regulations starting this month, and again this pause in the closure plan and ongoing funding and postponement of mock survey number two will allow laguna to best prepare for implementation of these new phase iii requirements. next slide. so in terms of our ongoing

preparation for recertification again staff are working hard everyday, every shift to make sure we're ready. we're continuing to use the expertise of our consultants as we continue to make refinements in our processes and begin to correct each and every one of those previously identified deficits. next slide. so in order to make we're on track with making the required improvements we're tracting and sustaining our improvement through the identification of key performance indicators also called kpis. to that extend we have a dashboard that really combines the most critical elements of our recertification work into one visual tracking source. this source is shared with all staff throughout the

institution and we meeting regularly to go over its compliance status. in addition in all of our patient neighborhoods there are dashboards and huddle boards where this information is shared and presented so the staff can see where they are in terms of compliance within the neighborhood and also make suggestions for ways to improve ongoing processes. it's important to note that the kpis that we have established reflect an extensive number of inputs including personal observations that happen 24 hours a day seven days a week throughout the institution. it includes many cases of document review, and they're actually using the same assessment tools that cms is using when they come to visit so again we think with the support of our

consultants that we've set up a process to ensure success making sure that we're training our staff really in the working knowledge and tools that cms will be using when they come to do our visit. next slide. so the next slide give you a high level overview of some of the key performance indicators. this first one represents the readiness of our 13 neighborhood resident units in terms of area of environment of care. environment of care was one of the areas that was cited in the april survey so we paid a lot of attention to it. some of the areas involved in environment care include how quickly our resident call light is responded to. when the resident is in bed and press the button

do staff respond in a timely manner? are trash and linen bins clean and orderly and in the right place? are medication carts locked and secured in compliance? and you will see that we are very much for the last five weeks have exceeded the 90% threshold goal and are are actually in the 97, 98% when it comes to environment care readiness of the units at laguna. next slide. the other area you recall that was a deficit in that april survey was hand hygiene and again we are exceeding the 90% threshold and for the last four weeks have been at 99, 98, and 100% compliance for hand hygiene among the resident neighborhoods at laguna and finally the next slide, and this

shows the areas of infection prevention and control. so for example is there appropriate personal protective equipment available on the neighborhoods? are staff appropriately donning and docking their ppe? is there prompt disposal of open food items and no out dated with respects in the fridge? so again we're happy to report we're exceeding the 90% goal and this last report shows that we're at 92%. next slide. you will recall that in july we had our mock survey number one. that mock survey again utilized the same tools that cms is using to do our visit. in that mock

survey our consultants identified 101 -- what are called tags. each federal regulation has a number to it like a f tag or a k tag but there were 101 identified by the consultants as being gaps and we didn't meet the standard for cms but that's a good thing. remember we asked for this mock survey. we see it as a best practice among health care organizations to do internal assessment as they player for survey readiness. happy to report that 100% of the 101 tags have plans of corrections that have been implemented. 79 are what we call the monitoring stage for compliance. that means 78 of the --% and the others have moved correspond

the compliance and validded extensively and they're corrected and sustained and our goal is to be at 100% on all of these and we're well on the way and i anticipate being there by the end of november if want earlier. next slide. so again in addition to doing the work to correct these deficiencies there's some positive improvements that occurring at the institution as a result so here's just a list of some of the examples, so from some of the deficits we've updated the policy on herbal supplements to assure they're meeting current guidelines. wife added additional weekend cashier hours. this is an important requirement from cms that residents have access to their cash seven days a week so we're

made sure we're in compliance with that standard now. we've also instituted learning bulletins for all of the staff after a resident is injured for example after a fall so everyone is aware of the most current events at the institution and as i previously mentioned we've instituted what are called huddle boards in all of our neighborhoods and the huddle board is a central place where staff come together and what the current data regarding compliance with standards regarding patient care, and it's also an opportunity for staff to celebrate any successes and also make recommendations for continued improvement. in addition as a result of some of the mock survey findings and observations that we find every week when we go into the units we've instituted some of our lean

practice tools by doing what is called a 5s process in our neighborhoods in order to get front line and management staff's input on were is the appropriate place to store the many different pieces of medical equipment that you will see when you go into the hospital? part of the requirements is that we maintain an orderly environment for our patients and so we're utilizing this lean process to help us figure out what's the best place for pieces of equipment that allow us to meet that regulatory requirement for an orderly and clean environment of care? next slide. also just want to update you on the issue of the what we're calling triplet beds. you recall that when laguna honda became decertified we

were informed by cms and california's department of of public health whenever we submit for recertification they're expecting we will meet the current cms guidelines which call for only no more than two patients sharing one bathroom. the current fig -- configuration has more than sharing and there are approximately 120 beds sharing that criteria. it's important to note because of several of the transfers and discharges that happen before the pause and the closure plan and the fact we can't do new admissions we were able to comply with the standard because of a smaller patient population at laguna so currently laguna is meeting that standard of no more than two residents per bathroom. however, it's

important to note that we are still believe strongly that it's important that laguna have its full complement of beds whenever it reenters the cms program, so we're not submitting to delicense those third beds. instead we'll continue to provide for them on our license and we will be working with cms to encourage them to consider certification of those beds when they do come out for our recertification survey. next slide. also i want to update you on the kitchen floor project. we shared several months ago we did a comprehensive assessment of the capital facilities issues that might pose a problem for

recertification and a kitchen floor replacement bubble to the top of that. at the time we originally thought that the kitchen floor would need to be completely replaced and renovated prior to the cms recertification survey. however, we've worked closely with the california department of public health and they have consulted at laguna and determined that complete -- completion of that comprehensive renovation is not required to be successful in recertification. they however instead given guidance there are some interim mitigation steps that we can take that will allow us to be successful in meeting the requirements, and not pose a risk towards recertification, so those interim mitigation steps are currently in process, and we feel confident that

when the recertification visit occurs we will have those done. however, we are still in the active planning stage for the full kitchen renovation, and we will move forward with that as soon as we have all the appropriate approvals and contracts in place. next slide. so as you can imagine the last six months have been just tumultuous time for residents and staff at laguna so we're putting a lot of effort and focus into care experience and change management. care experience in terms of making sure we're taking care of our staff and our residents and families knowing that this is a unsettling time for them and make sure we have check in

surveys and then doing different opportunities to get feedback and also celebrate successes. the picture you see here actually is dr. colfax who came to laguna who actually comes every week and comes to the neighborhoods and presents certificates for those meeting their compliance standards and the patient experience goals. the other thing we're actively reinstituting our leadership rounding and that involves members of the executive staff going out to the hospital to actually touch base with staff not to monitor for compliance but more of personal touch base. how are you doing? what are your successes? what are your challenges? what are your barriers? so we can only be a better organization as we listen to our staff and partner with them to address their needs and make sure they have the tools

to be most successful. next slide. so here are pictures of examples of some of the change management care experience activities. you recall in august we put over 1200 laguna staff through a comprehensive training and education on cms requirements, and so had a graduation celebration last week. you see these are pictures from the celebration out on the pavilion. we had games, food, just an opportunity to celebrate staff for going through that education process which was like a little one week -- well, four sessions over a month period of college courses, so you know we got great feedback from the staff that they enjoyed the education process and we look forward to

bake it into the annual process at laguna and do a big annual education every year. we also have instituted what is called a pulse survey. our goal is have at least 10% of staff complete this every week and just a quick little simple survey where staff are asked how are you feeling about the recertification effort? yes it's going well, not going well, again just to give us so we have the information to help inform how we continue to do work with our staff as we move forward, and through our communications colleagues we have banners throughout the institution that deliver the message "at this time we can" . together we can recertify. together we can make sure that laguna honda continues to be successful and operate for another 150 years in the future. next slide. and so again

pictures of our staff who are the people who are doing the work in terms of taking care of our residents and also doing that transformative change in management getting us ready for cms recertification so a lot of work going on at laguna but it's to ensure that the institution can continue to be a resource for san franciscans in the future so i am happy to answer any questions you may have. >> thank you director pickens. before we go to commissioner comments or questions secretary morewitz do we have anyone on the comment line? >> yes we do. i will read a statement. for each agenda item members of the public will have the opportunity to make comment up to three minutes. the public comment process is designed to invite input and feedback from individuals in the community however the process doesn't allow questions to be answered in the meeting or members of the public to engage in back and forth conversation with the commissioners.

the commissioners do consider comments from members of the public when discussing an item and requesting for dph and each individual may speak one and not return to read statements from others that can't attend the meeting much written comment can be sent to the commission at the address on the website. if you wish to spell the name for the record you can do without the allotted time. as i mentioned everyone gets three minutes. please press star three and i will start with the first person i see. caller you're unmuted. >> i am. >> please go ahead. >> yes closure and recertification presentation mentioned the path to recertification. the tentative recertification timeline presented to the board of

supervisors on june 14 indicated forms for cms enrollment and recertification was planned for a mid-august submission in the final cms recertification and inspection survey by the end of december this year. this presentation also mentioned the sudden settlement agreement may push recertification to november 2023. why does laguna honda need another full year to become recertified? city attorney chiu's august 3 northern district of california lawsuit stated "laguna honda should not need to be recertified at

all" . and had he not dropped the lawsuit and appeals and prevailed in the appeal to lawsuit certification would have been automatically restored preventing permanently eliminating 120 beds in laguna honda because you wouldn't have fallen into the category of applying from the ground up for certification and it would have allowed new admissions to laguna honda during this time no mess, no fuss with another year of applyings for recertification. this is smokey back room political deal dropping the lawsuit and appeals in exchange is a grave costly mistake. thank you.

>> thank you for your comments. caller you're unmuted. please let us know that you're there. >> hi. can you hear me? >> yes, please begin. you have three minutes. >> yeah. this is dr. theresa palmer. i'm a [inaudible] and doctor at laguna honda and pediatrician and aging resident of san francisco, and the city attorney told me himself yesterday that settlement is based on closure and the settlement is silent on the laws of 120 bed and the city attorney says this is the best we can do given the position of cms. i don't know what goes on at the table. all i know is there's no universe where closure of laguna honda or force discharges of patients that need nursing home care should ever occur

and we need to continue to fight this. in addition patients who have been inappropriately discharged from laguna honda when they need nursing home care should have the right to return to laguna honda when admissions are reestablished. the ones that are still alive because we know a lot died. we need to not repeat the 10 years plus of neglect that by the department of public health that lead to this mess at laguna honda. i am extremely grateful it's being fixed and the city is finally doing the fix but let's not start over with the neglect as soon as it's off the front burner. this has been a painful and horrible experience for the staff, for the patients and for people who might day need a bed

there, and it's been a testimony to bad management on all levels of government, yet with the appropriate find appropriate housing and treatment for people whose primary diagnosis is unstable mental illness and substance abuse and don't use laguna honda as a satellite of san francisco general and a depository of patients they don't know what too do with. make a place but don't sacrifice laguna honda to this in the future. please fight to save laguna honda and all the beds. with the shortage of medi-cal beds in the resources there's no way any bed should be cut. this is not right and further litigation should be pursued if there's any attempt to do this. also

cdph should help with bridge funding needed given the bad advice and absence they have practiced in regards to laguna honda until the big mess when they said they told laguna honda to tell cms to close. >> your time is up dr. palmer. >> that should have never occurred. thank you. >> thank you. all right. caller you're unmuted. please let us know that you're there. >> yeah. this is michael and also of gray panthers. we're glad to hear of the postponement of the [inaudible] continued funding for a year, but the 120 beds absolutely must be preserved. there's a five year wait to be able to get into laguna honda as it is, so the loss of beds would make that even worse. i am very worried about what is going to

be happening between now and february 2 when if the thought situation now is closure than the deadly discharges could resume on february 2. now we're hearing that if things are going along well that be extended, but what does that mean? we have no idea what is going on between dph and cms. the whole situation of cms requiring the closure earlier is [inaudible]. we want some transparency about how this process is proceeding particularly we want to make sure that there's not a whiff of

the flow project single laguna must be able to determine its own admissions policy. also displaced residents must be able to get back into laguna honda as soon it starts [inaudible] and dph must provide beds at lower level care with people with mental illness and substance abuse and i suggest starting with the behavioral health center using that it was intended to be used, not as a navigation center, and dph must pressure and work with the supervisors to provide more medi-cal beds for frail seniors of san francisco. thank you. >> thank you so much for your community. that's all the comments commission of public comment. >> thank you to members of the public who called in and

shared their concerns. i know we're going to commissioner comments and questions and now i cannot see raised hands [inaudible] but i will start with a few questions of my own. welcome back director pickens. so two questions i have the first one if you go to the six slide and surveys by cms and dph will occur every once every 90 days. how do those surveys interact with or differ from the actual recertification survey that cms is going to conduct? and for example if that survey is conducted in the first quarter of 2023 for cms recertification and recertification is achieved will those 90 day surveys continue or will that be the end of the process?

>> sure. so i will start with the second question. >> okay. >> so if certification visits were to be achieved and we were to be successful then that will stop the every 90 day survey process. we would be deemed recertified back into the program thus the settlement agreement would cease to exist. in terms of the 90 day questions we asked cms what should we expect? the response we got you expect the surveys to look at your compliance with the condition was participation which means all 200 plus tags that cms has related to skilled nursing facilities so they're looking at everything but having said that one of the things in the settlement agreements they focus on the elements of deficiency that were cited in previous surveys over the last

couple of years so it gives an idea of particular areas of focus but they also left it open it to say everything but also the smaller subset, so as we have been for the past months we are going to be preparing for full compliance with every cms standard. >> great. great. thank you for that clarification. very helpful. and my second question concerns slide 13 resulting mock survey findings. what's the process or validation process to determine that there is sustained correction? >> yes great question >> and how is sustained correction defined? >> sure. sure. like i said we have 100% of the f tags with plans of correction. of those 79 are in what is called the monitoring phase and monitoring phase means the plan of

correction was approved. again we're modeling the way that cms and dph do it so the internal experts approve the plan of correction. the departments where the deficiencies occurred implemented those corrective plans and required to monton them over a two week period to see if they actually fixed the problem. once they have an initial two weeks of monitoring that shows that the fix has been sustained then we have a separate team that is a validation team that comes in and says okay i'm going to review that information from the last two weeks and do another assessment and independently validate yes you've had at least two weeks or more of ongoing compliance and thus you're validated, so there's a separate validation team of surveyors that actually goes and looks at each of the 101 tag

deficiencies. >> thank you director. very helpful. let me back up by saying it's great to see these green bars grow and grow and grow by the week and see that you know we're meeting that laguna honda and its ded indicated team and staff worked so hard to get to where we are and meet and exceed the 90% goal and thank you to you and the team at laguna honda for the hard work and the results that came from that work, and secretary morewitz can you tell me what other commissioners? >> yes, we have commissioner commissioner guillermo and commissioner chow chow. >> okay. commissioner guillermo. >> thank you president bernal and for the report and i am glad there's progress and a serious deep dive as we prepare for the

continuation of progress towards recertification. i had a question about the phase iii regulation. maybe as well as the question about the surveying around sort of previous facility related events, and whether there is any linkage between the new phase iii regulations that have yet to be assessed or implemented in full and the fact that we've got a backlog. there have been investigations around almost two years of facility reported incidents and i am just wondering whether there has been

any discussion how those new regulations and the old existing investigations might impact the recertification process? and that might be too complicated to answer now but it's a concern. >> sure. i can try to answer so thank you for the question, and there definitely is a link between some of the past survey deficiencies and the first phase iii requirements particularly in the area of patient rights. patient rights related to search and autonomy. you recall that some of the previous plan correction related to illicit substances and contraband required that we institute searches of patients when they come back to

laguna when they have been out on pass. much of the new phase iii requirements deal with the issues of appropriate both patient searches and care planning are related to contraband and items so to that extent so we've asked for clarification and we have plans in place that they have approved that appear to be contradictory with the phase iii requirements and we've asked for guidance how do we deal with when the phase iii requirements go into effect on the 24th? what they have shared with with us any new promulgated rules like phase iii

will take precedence over previous rules however we're still requesting more specifics well then do we need to have you modify what you approved in the plan of correction or do we just change our plan of correction based upon the new rules? so we're still seeking that clarification and hope to have it shortly, and commissioner guillermo your question really brings to mind this issue particularly related to contraband and illicitted substances. much has to do with the small segment of the laguna population that suffers from behavioral health issues, either mental health issues or substance use disorder issues and i think it's important for everyone to know that you know laguna has been responsive to their

changing demographics in san francisco for the past 15, 20 years so in order for any patient to be admitted to laguna hospital there's an admissions committee. that committee consists of three physicians and two nurses. part of the admission criteria for laguna says that it will consider individuals who have behavioral health issues, mental health and substance use issues; however they can't be in active cries so the example i can use for example is laguna cannot take them in an active skate attic services and not set up for services but if someone has a history of that diagnosises that shouldn't exclude them from coming into laguna if they have needs and assure the public and the commission we hear the

concerns about patients being dumped at laguna and that is not the case. that admissions committee makes a decision on each patient. san francisco general or any other hospitals in the city can dictate who gets into laguna honda hospital and i wanted to share that. >> i appreciate that and thank you for addressing that because as i understand and as you explained the new phase iii regulations do address behavioral health to a greater degree than in the past so given the demographics of san francisco and the region as well as laguna honda are reflecting that it will be really important for us to make sure that we don't get caught up in a rock and a hard place around the phase iii regulations and we get as much clarification as we can possibly can, and make that very

transparent to the public as well as within the facilities themselves. thank you. >> thank you commissioner guillermo. commissioner chow. >> yes thank you and thank you mr. pickens for this encouraging update. >> commissioner chow could you speak up please or get close to the microphone. you're a little bit faint. >> okay. thank you. i was just thanking mr. pickens for this very encouraging update. i think it shows that the task force that you have put together and the people that have now come to laguna to try to reorient laguna in the manner in which many of us unaware and look at this as a long-term care facility rather than following the two tier role and is paying off and the change and the staff has changed its own

approach and culture, and i don't think you could have accomplished this without the staff agreeing that this is really important so i think this is wonderful news, and looks like you're really on track to achieve a recertification path to which the feds have given you up to a year so i am assuming if we're prepared prior to the year that you're actually going to apply for recertification? is that not correct prior to a year and that -- then what would be the trigger to make those applications and apply to it in your mind? do you have to wait for a second pilot? are you waiting for the experts to say we're ready? just to give an idea about that. i appreciate that the commissioner asked you about phase iii and i think it's becoming clear that phase iii

does take into account those patients we had been informed earlier that you had noted phase iii would be addressing, and so i think it would be good for us to get a better understanding of what the phase iii [inaudible] is and therefore what skilled nursing facilities are expected to do. i think as laguna is part of a delivery system of the city it's not isolated and it needs to of course carry its obligations to take care of the public as to your explanation we have a committee already at laguna to make sure that laguna is appropriate for those hospital transfers is reassuring, but it would be just as important i think the public as said we ought to continue to find those beds. i

know that our [inaudible] has and continue to point out how rapidly we're try address that and get the bed and we have to remember that laguna is part of our system and we need to get it to where it is meeting the compliance requirements that the fed and the state so it can remain a vital part of the system and i want to thank you for the several months you and your team and of course the entire staff at laguna have had to come up in unison. it shows here that we can so thank you very much. >> thank you commissioner chow and i would like to remind commissioner chow and commissioners the number of issues will be addressed during the closed session, so i think that a number of the (

dropped) and the

number of observations every week that this entail and i thought it would be helpful for the commission to understand the size and scale and the staff at panhandling are doing in being held accountable for so can you share with the commission on a daily or weekly basis how many observations are happening in terms of the quality oversight here. >> absolutely. thank you. we try to make our report as concise as possible but the recertification kpis that you see are based on over 6,000 data points and they're data points that are ascertained through direct observation of the clinical rounders on the unit 24 hours a day seven days a week. in addition there's medical record review that occurs and so the results and that you see on those 6kpis

and 6,000 data points to give us the data that we report back to you on a weekly basis. >> thank you. >> all right. i would like to go to vice president green. >> i do as well. first i wanted to commend everyone at laguna with the speed that you responded to this complex and intrick at problem you developed. i have two questions. one is we talked about phase iii. i'm wondering whether that is one reason why it would make sense perhaps to delay the recertification visit? in part because if i understand correctly they can come out and look at laguna on the points raised but they can find anything else at the same time and in turn create further (s (problems

and if i am wondering if you're comfortable you have the information and they do the recertification survey and look at the modified elements and that could create a lot of problems? the second things i am wondering if you could reassure us about is whether you're confident in terms of being able to keep our leadership stable? in other words i know we have wonderful people but we borrowed from other areas of dph and if things go longer you are able to stay in the passions and have other areas adequately covered? because obviously you did such a great job so far and would love to see that continuity condition. >> thank you very much for the questions. >> i want to remind commissioners we're going into closed session and a number of details of

the proposed settlement will be discussed as well. >> so in terms of the staff leadership i can assure you that myself and the rest of us who have been deployed to laguna we're in this for the long haul. you know we have incorporated ourselves into the laguna fabric, have been welcomed by the staff and are very much vested in ensuring the long-term success of the organization, so while as we await some of the recommendations coming from the consultants in terms of what is the best long-term organizational structure for laguna? what positions are best needed to ensure that long-term success? all of those are coming in those reports from the consultants so i think it's then that will be presented to dph leadership for consideration along with the commission and then

decisions can be made about you know what would be the long-term leadership at laguna? but until then i'm -- myself and my team will be there, and even when new people come on board we will still be there because i am not letting go until i know it's in safe hands so we're in this for the long haul. >> great. thank you. >> thank you director pickens for the stated commitment and we certainly appreciate your leadership at laguna honda. we're wrappings up this item and as stated in the agenda we will now go into a closed session. also stated in the agenda that closed session will last for precisely 60 minutes which takes us to 6:08 p.m. so as we move into the next item do we have a motion to go into closed session?

>> so moved. >> second. >> all right. and there's a couple hands up commissioners so we will take public comment on this item. >> thank you secretary morewitz >> and as someone you're going to speak as well? >> i want to speak on public comment. >> this is the closed session. public comment on the closed session. >> i understand that. >> so public comment on closed session. >> okay. before i get started where is the timer? >> right here. >> all right. i will set my timer. >> you have three minutes and this is about the closed session. >> let me have one moment. hang on and i will set my timer. >> [off mic]. >> so again public comment on the closed session. >> i will set my timer. three minutes. hi. i am michael and i came here at 5:00 o'clock

expecting that you would have already respected the public and gone into your closed session for one hour. this is really disrespectful that you did not say in your advance agenda that the public should come at 6:00 p.m. for the rest of the agenda including general public comment so now you're going to go into closed session in the middle of your meeting, and i have to question why? why didn't you wait until the very end of your meeting to go into closed session? you really need to address this question if you want to convince me you're respecting

the public today. i understand what you say on your agenda will be only for 60 minutes. well, i would like to remind you that the security guard downstairs was not going to let me use the restroom because they close the restrooms at 5:00 p.m.. he's now left. if i'm going to wait around for another 60 minutes and i need to relieve myself you will not be able to accommodate me and open the restroom. now i understand you're under no legal obligation to respond to me, but regardless of no legal requirement for you to respond to the public i would like

one of you, two of you to show some respect and explain why you did not tell the public that you would go into closed session for at least an hour and that if we wanted to make public comment in person we would have to get here a little bit after 6:00 o'clock. it is really disrespectful and it is not healthy to my mental well being to leave here angry because you have not respected the public and my final 10 seconds i want to call on the president dan bernal to resign because he submitted a letter to the mayor. there's no way we can trust you that you dated that undated

resignation letter. that's the three minutes. please respond. >> thank you for the comment. >> i want to note there's two votes to do, usually it's one. one is a vote to hold closed session and one is to cold closed session for attorney client privilege. i wanted to be sure that we're clear. >> thank you. so we have a motion on the floor to -- >> i'm sorry. there's two public commenters online. i apologize. okay. folk on the line i'm going to unmute you. all right. you're unmuted. please let us know that you're there. >> i am. excuse me. it's patrick shaw. >> go ahead. you have three minutes. >> thank you. [inaudible] known and appeared to agree during the october 11 closed session that it would issue a

joint statement announced by cdph press release the very next day on october 12 regarding the at any timetive agreement in principle with cms, dddph and the office related to laguna honda a proposed settlement agreement about u.s. dh hs administrative proceedings in federal court litigation regarding laguna honda. the joint statement indicated laguna honda will continue receiving cms reimbursement for the current patients through november 13, 2023. the press release and media coverage suggests there are additional key issues still

unaddressed in the agreement including lhh 120 bed cut and not resuming new admises to laguna honda until november 2023 because the proposed settlement is silent on both key issues. as you discuss the proposed settlement in today's closed session the commission must add the 120 bed restoration and the start of new admissions now before approving this agreement. in addition one of the key positions that mr. pick epidemics is dragging his feet on billing. >> . >> is part of the ongoing key leadership is the nursing home administrator and assistant nursing

administrator positions that he announced back in june. those should be the people who are the actual ceos of laguna honda. after all nursing home administrators are required by licensure to be well versed in cms regulations governing skilled nursing facilities. you need to start recruiting for both of those positions now and the health commission should direct mr. pickens to start that recruitment process now. thank you. >> thank you for your comment. we have one more commissioners. hi. you're unmuted please let us know you're there. >> my name is anxious leashia and in a primary care clinic -- >> i'm sorry. this is about the closed

session for laguna honda. >> okay. >> so the comment -- if you can do that it's fine but if has to be about the closed session. >> okay. i called in a month ago and that we're aware of the massive damage of the safety net of cms to eliminate funding for laguna honda and evident from on sieve -- >> i'm sorry. i'm not hearing anything about the closed session. >> okay. >> this is public comment about the closed session. >> i'm sorry. i had a general public comment about laguna honda but i can submitted in another forum like email if that is appropriate. >> okay. that's the end of the public comment. >> thank you to the folks that expressed the views. we will go into a vote whether or not to go into closed session.

>> i'm sorry. i forgot there were motions (calling roll). >> great. and the second vote on holding a closed session in relation to item 3e which regarding pending littation and the attorney client privilege with that discussion. >> do we have a motion? >> so moved. >> second. >> roll call vote. >> commissioner green. >> yes. >> commissioner guillermo. >> yes. >> commissioner chow. >> yes. >> commissioner chung. >> yes. >> commissioner giraudo. >> yes. >> commissioner bernal. >> yes. >> all right. thank you. so we're going to take the settlement first and i have been advised by the city attorney the only people that can be in the room at this time are mr. wagner and mr. pickens along with the commissioners so everyone else i'm

going to move you to the attendee list and we can if you're coming back in for the other portion i can move you over. give me a few seconds to . >> we have two votes to consider now that we reconvened. ed the first is to vote whether to disclose any portion of the closed discussion. do we have a motion to disclose or want to disclose commissioners? . >> i'm sorry commissioner. >> oh -- >> give me a minute. i apologize. >> that's all right. >> it was so eloquent. >> all right commissioners i will repeat what i just said. we're back in

open session so we have two motions to consider. the first is a notion whether to elect whether to disclose any portion of the closed session discussion. do we have a motion to disclose or not to disclose? >> i move to not to disclose. >> i second. >> i will do a vote. commissioner guillermo. >> yes. >> commissioner chung. >> yes. >> commissioner giraudo. >> yes. >> commissioner chow. >> yes. >> and commissioner green. >> yes and commissioner bernal. >> yes. >> thank you. >> okay. the second motion that we will consider the motion whether or not to report on action taken in closed session. do we have a motion whether or not to report on action taken during the closed session? >> [off mic]. >> commissioners?

>> move to disclose. >> no. >> to report. >> this is motion commissioners i will say it for you. >> okay. >> so that you all in closed session approve the recommendation of the city attorney for the board board to approve the laguna honda settlement so you're voting yes i mean you're voting whether to disclose or not to disclose that. >> okay. that motion i move. >> i second. >> all right. i will make sure it's in the minutes correctly. commissioner guillermo. >> yes. >> commissioner chung. >> yes. >> commissioner green. >> yes. >> commissioner chow. >> yes. >> commissioner giraudo. >> yes. >> and commissioner bernal. >> yes. >> all right. thank you. closed session business is done. >> all right. >> we can move on to item four. >> all right. item four is approval of the minutes of the health commission of october 4, 2022. commissioners you have the minutes before you. if there's

no amendments do we have a motion to approve? . >> so moved. >> second. >> let's see. i will take public comment. folks on the line i see a hand but if you want to make comment on item four the approval of the commission minutes for october 4 please press star three now. person on the line i will unmute you. please let you know that you're there. >> yes, it's patrick shaw. i agree that you should approve the minutes of the october 14 meeting, but as robert's rules of order point of privilege when you make a motion like you just considered you should be taking public comment on the motion before you vote, so i think i would

like to make public comment on the motion that you just took to approve the settlement of the lawsuit. >> that is not on the agenda today. i understand your concern. the city attorney provided this language so i can't comment on the legality and the appropriateness of this but for today there's no public comment for that item. >> well then you should revisit and the city attorney should revisit roberts rules of order on taking public comment on a motion before you vote. >> i understand. thank you. >> you need to revisit that issue and this is totally not transparent. >> anything else? you have another minute and 30 seconds. okay. thank

you. commissioners i'm sorry i forgotten if there's a motion already. i apologize. i'm a little hazy. motion to approve the minutes? >> yes. >> i will do the roll call. commissioner green. >> yes. >> commissioner chow. >> yes. >> commissioner giraudo. >> yes. >> commissioner chung. >> yes. >> commissioner guillermo. >> yes. >> and commissioner bernal. >> yes. >> thank you. the minutes are approved and we will definitely check with the city attorney on that commissioners because we always want to be appropriate. thank you. >> thank you. our next item is the director's report and we have grant colfax director of health. >> hi. good afternoon commissioners. thank you president bernal and grant colfax director of public health and i will highlight a few key issues in the report, so one is that our annual department of public health shows

decline in drug overdoses in 2021. we recently released this report and the decline in three years. with the encouraging decline the report of people dying remains at crisis levels. in 2021 unfortunately 625 people died in drug over doses methamphetamine or heroin or cocaine and above pre-pandemic levels. the pandemic contributed to the high number of deaths in 2020. fentanyl is the remain driver of deaths in the city and 75% using this powerful opioid and the profound inequalities with black african-americans in san francisco experience a death rate that is five times higher than the city-wide total. the health department

released over dose date are preventable and a plan a 4.strategic road map to reduce the number of death and eliminate disparities with deaths in san francisco and measurable goals to reduce deaths and increase treatment with people with high risk. in 2021dph worked including with our community partners to save lives and improve wellness. an example of this with community partners san francisco substantially expanded the distribution of naloxone and had many reversals in 2021 and doubling the number of reversals in 2020, so really we encourage the commissioners to review the substance use trends in san francisco through 2021

which reports on these over dose trends and also ensuring that the commission understands that dph is taking this crisis extraordinarily seriously with our over dose deaths are preventable strategy prevention plan and the 4.plan as i described. i also want to now go to a welcome news that we are excited to welcome the newest member institution of the san francisco health network family dph new clinic, the maria x martinez center that opened on the 19th and the person of whole person care clinic formerly on ivy street and administration and the department of homelessness and supportive housing homeless outreach team sf hot so this is integrating and coalesces services for people that need them.

services at this center are focused on searching people experiencing homelessness and unconnected to charles where in the system andure gent care and primary, dental and podiatry and she worked for 23 years and director of whole person care when she died in 20 went and proud to open this center and name in her honor and exemplifies the values she holds dear and passed to us in the department and we encourage the commissioners to visit the center when you go and then i'm sad to announce the recent passing of garza a bridge of the hiv team for years and the bridge team is an hiv prevention unit part of the

population health division. garza joined the program in 2005 and quickly learning about the hiv preventioned its we conduct and was hired a recruiter and so much more and i can say that and meant a lot to the communities and created ties with multiple organizations in the community and serving clients and used the talents to raise funds for the organizations and died recently and leaved a legacy of compassion and deep community ties and embodied the heart and soul of what we are at dph and who we inspire to be and share that sad these and celebrate her life. the next item is highlighting national lead prevention week. the

children's environmental promotion program of the health branch is participating in a number of activities particularly around education and getting the message out that lead poisoning and lead contamination remains a series issue and working with communities most affected and at risk for lead in raising awareness this week, so really important that the commission hears the work that the environmental branch continues to do in this very important issue. we know how serious lead contamination can be particularly in early childhood development and with that i will move on to our covid and m pox updates. slides please. say them a couple of times. >> yes. kenya is having trouble with the computer and give her 20 seconds. >> okay. i want to give the commission a verbal update on what is taking place

with regard to baker place. i think you've heard i know you're aware that baker place is transitioning its services because they are no longer able to fiscally sustain the behavioral health services in serving some of our most high risk clients. our top priority at dph is maintaining services for these clients and preserving treatment beds that are currently under the baker place auspices. as you know in late september we learned that the financial situation at baker place was deteriorating and considering shutting down programs in the short and long-term and this is despite efforts of the health department to be solvent including additional funding that was voted on by the board of supervisors. we're actively working with baker place for short term solution that will allow

a six month transition of services. as you know the tighter the timeline the more complications we have with regard to ensure a smooth transition and we believe dph it's in the best interest of clients and the public and prc -- sorry baker prc and the city to find alternate care providers we work them and the board to transfer services and also recognizing the importance of maintaining qualified behavioral health staff. we're looking to potentially assist in the transfer of baker place behavioral health staff to other partners in order to sustain the services as well. our goal is to avoid any gaps in service for clients and we will continue to keep the commission updated on this situation. right now again we're focused on making sure that

the transition is as smooth as possible support baker place to provide time for the transition to occur and make sure that services are maintained so that is my verbal report on the director's report. make i will pause before the next update because i went through quite a bit and if there's questions or should i continue with covid and m pox. >> we can continue. >> with regard to that update i have slides to present to the commission. next slide please. so as you can see here we are in a relatively low cases of covid 19 per 100,000 residents in the city again with the caveat this doesn't include home tests so it's not necessarily at all a representative of all the diagnoses in the city but the

trend is downward on the cases that we do count through our testing system. we're now at 9.3 and you can that is similar to the level where we were before the summer swell. next slide. in terms of hospitalizations we had 46 people hospitalidessed with covid-19 as of october 13 which included nine in the intensive care unit and remember they're all people admitted to the hospital regardless whether they're admitted for covid-19 specifically or not and this also includes out of county transfer. you can see on the insert there that the icu care unit and bed capacity remains robust. next slide. in terms of vaccine administration you can see from this slide all residents 86% have completed their vaccination and booster rate at is 75%. sorry

this slide is obscured from where -- yeah, 75%, and you can see among the zero to four year olds and the last row here that 33% received at least one dose and 19 completed the series. i know we're encouraging everyone to get the flu shot and the other vaccine as quickly as possible. we currently gave 116,000 boosters in the city valuant and we're encouraged about that and more rapid uptick than other jurisdictions but again we're getting that message out. i believe the commission is aware that the fda just approved the boosters for people ages five and up so that's another positive development and we expect that the data systems from the state that we depend on report to the

public on that will mature soon and have that rate up in our public data systems within the next several weeks. again we're waiting for the state to ensure that system is robust and functioning, so that's my -- >> [off mic]. >> covid update and i will now go to the one brief m pox slide to show some promising data here in regard to the seven day rolling average of cases per day. you can see cases plummeted since august and now we're down to 0.3 and you can see that our cumulative cases over time leveled off dramatically. we continue now to have robust vaccine supply which is good news and the focus is again on reaching populations that are still at risk for

m pox and may not have access our vaccine sites early on and ensuring that people understand it's important to get that second vaccine. m pox to ensure thatom malperfection is obtained and that's my update and i am ready for questions. >> before questions or comments do we have public comment on this item? >> folks if you would like to make comment on this item please press star three. no. no hands. >> commissioners any comments or questions for the director? . >> well, had wanted to know where the new center was for [inaudible]. >> commissioner chow could you speak up? >> i just wanted to know where the new center was for the maria [inaudible].

is it still on ivy street? >> i believe it's ivy street. >> no, it's at mission and stevenson. >> the exact address is on the director's report. >> it's in soma at mission and stevenson streets. >> thank you. >> great thank you. >> thank you. >> commissioner green has her hand up. >> commissioner green. >> thank you for your reports. i wonder where the public can get information about intervals between vaccines? because we're getting many questions and a lot of confusion. i don't know if it's from websites or where and a lot of people think for example if they had a prior vac even have to wait six months to get the [inaudible] and i believe in previous meetings it's two months after the last vaccine and do it concurrently with flu. it's three months after you had covid but people are quite

confuse body that information of. some are delaying that vaccine because of that and it can be given in pregnancy in addition to five and up. where can people get the true information on this? >> they can go to our dph website that is continually updated with the most recent information information. we align with the state and cdc as well and people should get the bihave ant vaccine as soon as possible and just as you're saying commissioner green you can get the flu vaccine and that at the same time and that's important and again at our dph website or talk to their direct provider. we're working with kaiser and other systems that cover people and we're consistent with our messaging around this. >> great thank you.

>> great. any other questions or comments? >> i see no other other hands commissioners. >> seeing none we will take the agenda out of order and move from the director's report to general public comment. i understand we have people in both the chambers here and the also people online who maybe interested in general public comment so secretary morewitz. >> yes, i have a statement to read before we begin the process. at this time members of the public may address the items that are subject matter of the commission but not on the agenda and again this is really important. this is the time to talk about topics not on the agenda today. the brown act forbids the commission from taking action or discussing any item not on the posted agenda including those during public comment. each note each individual is allowed one time and not allowed to read statements from others that can't attend. comments can

be sent to our sfdph.org and if you wish to spell the name in the minute you can do during the comments. everyone get three minutes and we'll start with the folks in the room. if you feel comfortable giving a name but it's not required and whether the buzzer goes off your time is off. >> my name is bruce wright. i have sleep apnea for 18 years and i say that in the tense and developed an exercise that reverses the conditions known as sleep apflee a i have been working with men mostly large guys outside doors that keep you safe at night, right, or whenever you're out. i just talked to an acquaintance. i met this guy on september 13. he works for one of the organizations that keeps an arms distance between tourists and somebody having a mania episode and after three weeks he was just

feeling tremendously better. he's on a cpap now. at the time i met him he was taking three hour naps everyday. he hasn't taken a nap for weeks. there is notice intervention needed, nothing swallowed, no device. this is an exercise to work out and reduces it in weeks. i understand that of the 2,000 drivers for the city appropriately so someone probably on this commission asked them to have a sleep apnea test because they're transporting my children around. if i want go from market street to fisherman's wharf and get their safely and the equipment operator and if they drop something it's a lot of money for the city. this is according to someone i talked to and i don't know the numbers and 50 percent of the drivers were

diagnosed with sleep apnea yeah. a meaningful percentage diagnosed can't tolerate the nodes blowing air into the nose and the other half are under the diagnoses threshold and they get no help from the cpap. this can be implemented by anyone who can understand very simple breathing instructions and within weeks i start to see cpap -- you know they will give me -- friends of mine will let me see the data card and lead it into the program and see the apnea events going down but the graph isn't as meaningful as they feel. within three to four weeks. there's about a 1500 year per employee recurring cost related to fatigue. absenteeism is 20% and presentism is 40% and meaning they show up and mess up. it's

cheaper to have someone not show up and the other 40% and the cpap and other inward related health costs. the number one reason why the older population is in cardiac clinics is degradeed sloop. number one reason people end up in ers they lose alertness. i would appreciate if you consider this. >> thank you. other person in the room i'm sorry. okay. >> [off mic]. >> so there's another hand. person on the line i have unmuted you. please let us know you're there. >> i am. it's patrick again. >> yes, you have three minutes. >> thank you mr. morewitz. i would like to know what the health commission has been doing and what efforts it has made to fund additional -- to fund opening of additional skilled nursing facilities in san

francisco? what is the health commission's efforts been to open 60 to 90 sub-acute beds in san francisco so that those patients who need that level of care are not discharged out of county? what has been the health commission's efforts to fund and open a separate skilled nursing facility for behavioral health patients so that you're not mixing them with the frail elderly patients who have dementias or need hospice and palliative care at laguna honda hospital? what is

the commission been doing about all of this, and trying to stop out of county discharges? i have submitted a public records request that i am now being delayed by 10 days for the board of supervisors ordinance requiring that all acute care hospitals, laguna honda. sfgh and the jewish home report annually the number of patients each of the facilities discharge to out of county sub-acute snf facilities and out of county regular snf units? that data was due from the acute

care hospitals by october for the first reporting period, and i think staff member pael in the office of planning should have received that by now and frankly the health commission needs to schedule an agenda item to review that data that the board of supervisors' ordinance required that report facilities to report to the department of public health. the out of county discharges should be a keen interest -- >> you're time is up. thank you. >> all right. thank you to those that offered public comment. we will now move back to our regularly scheduled agenda items starting with the annual compliance training.

this is for the health commissioners to fulfill their annual requirement. >> we have the slides in early. she wasn't scheduled until november 1 and thank you for staying later and agreeing to come on afternoon earlier date. >> yes thank you very much. >> my pleasure. well good evening commissioners. i am pleased to present our annual compliance training and that will be followed by the office of compliance and privacy affairs annual report. on the training i'm going to go through these slides rather quickly because this is all a refresher for you. you have had this training in the a. this is meeting our annual requirement. next slide please. and this is the overview which i will touch on today. next slide please. okay. so the overview of our dph

compliance program and the key is we want to ensure integrity in our business and clinical operations. we want to assure that we promote and understanding of and compliance with all law and regulation and do this through education and working with our staff and providers integrating compliance into the daily operations at dph. next slide please. so the d dph compliance and it's a form of the health care organizations of the proactive efforts to detect and respond and report violations of law government violations and ethical rules much our program does follow the office of the inspector general and has seven recommended elements of the compliance

program which we follow. next slide please. these are the seven elements and it is the oig's position that health care organizations can reduce fraud, waste and liability through these compliance programs. next slide. i will briefly touch on each of the elements. number one is compliance officer and having a compliance committee. i am the compliance office for dbi as in my role as integrity office and monitoring the compliance program and we have a compliance committee which includes members of key functions within dph that support the compliance officer. next slide. we we procedures that promote the commitment to compliance and address risk. next

slide. employees must feel comfortable reporting internally and organization should have multiple reporting avenues such as reporting directly to the compliance officer or a anonymous hot line so we have open lines of communication and have a confidential hot line and anyone can report a concern or issue and they can remain anonymous if they desire. we have a dph email and we get compliance issues and concerns directly. i receive them and so does our deputy director. next slide please. education and training. all employees must receive on fraud and laws and the compliance program and we provide annual training through online training modules. we do

targeted training as needed if we have an area that has anne issue and we can do target training for groups and distribute newsletters throughout the year on education on topics of interest on compliance. next slide. auditing. we do a lot of auditing. this involves ongoing process of evaluation and assessment to look at the behavior and effectiveness of and corrective action. we have risk assessments of the practices and develop work plans and audit schedule and monitoring that we use throughout the year and as i present the annual report i can go over our work plans for the last fiscal year and then we proactively identify issues and we do give feedback to providers becausey what we want to do when we identify issues we want to make

sure that providers have the tools and the knowledge necessary for and act accordingly. next slide please. [inaudible] response to offenses failure to report action can create additional exposure to dph so weest every issue and concern that is brought to our attention. we willest it thoroughly and if it is substantiated we will develop a corrective action plan and do monitoring. if it's not substantiated then we will close that out. everything is reviewed thoroughly. next slide. and enforcement and discipline. standards of conduct out lying dph's rules,

responsibilities of proper practice and expectation of all employees and one thing we work closely with hr, human resources, on disciplinary standards and standards are imposed fairly and uniformly regardless of status within dph. okay. next slide. okay. those are the seven elements. i just want to touch on fraud, waste and abuse of federal and state government monitors this to protect tax paying dollars and patient care and services and dph -- this is anyone who is either dph employee, contract or facility, anyone who does work on behalf of dph they must carefully document the services provided, bill correctly and follow all regulations. next slide please. so we have just a few health care regulations that you should be aware of. the false

claims act. this is a federal statute that sets up civil and penalties for falsely billing the government and why we do robust auditing. next slide please and then the deficit reduction act. this is similar to the false claims act but it relates to medi-cal. next slide. and then we have fraud enforcement and recovery act and this has increased funding for federal agents to combat fraud and enforce provisions of the act. next slide please. okay. so our code of conduct. this describes the commitment to conduct business practice and compliance with all applicable laws and standards. next slide. and these are the elements of a code of conduct. it's a pretty robust document. it's 20 plus pages that

really outline in detail of expected conduct of our employees. next slide. just want touch on conflict of interest and this is very important to be aware of this. conflict is interest involves any circumstance in the city, office or employee with a financial interest that may improperly influence their duties at dph and [inaudible] include for personal benefit, inappropriately accepting gifts, have unauthorized outside employment because i think as employees we have annually employees with outside employment and must have that outside employment authorized. next slide please. and the statement of [inaudible] activities. this is actually city-wide since 2008 and every city department has to have their own

sia so our -- these are activities that are considered to be incompatible as a city employee. the type of activities covered by this include activities that conflict with official duties, use of city resources, use of [inaudible] office for personal gain and use of city work product for personal gain. next slide. so health commissioners -- the health commission responsibilities. the federal government believes that the governing body is ultimately responsible to comply with the rules and regulation and laws. next slide please. and so we're -- i really believe that the commission you're very aware of our operations. you have very good oversight of dph. you have report. you have these commission meetings. jcc

annual reports and other committee meetings as a health commission you really do follow the responsibilities of oversight for compliance. and then just you know one of the things that we really want to ensure that our employees comply with laws and regulation, code of conduct and other policies that apply and avoid actions that may present as a conflict of interest and which is so important to actively participate in compliance activities such as our annual compliance training which is mandatory. next slide please. and then on everyone that works does have a duty to report, and so this is dph officers employees [inaudible] anyone that does work on

behalf of dph they have a duty and responsibility to report misconduct including potential violations of laws, regulations procedures or dph standards code of conduct so we really encourage individuals if you see something say something. we will investigate. next slide please. and this is our poster throughout dph and has our toll free hot line. we also have email and guidelines what should be reported and some reporting options that they have. okay. and next slide please and then consequences. there are potential compliance violations that will be thorough investigated by and once the investigation is completed appropriate action is taken. if substantiated we have a corrective action plan and if not we will closed out the

case. next slide. and these are some other consequences of compliance violations. next slide. that's concludes the annual compliance training. i am happy to take any questions if anyone has any. >> thank you and certainly i appreciate your taking the time to come to the commission. we know this is a very important responsibility for all commissioners and city staff, and we embrace that responsibility and our grateful for your time in leading us through it. before commissioners have any questions or comments do we have any public comment? >> folks on line if you would like to comment on item 6 please please press star three or let me know in the room, star three. no hands commissioners. >> all right. commissioners any questions or comments? >> let's see if anyone has a hand up. no hands. >> no hands? all right. well thank

you again for leading us through our annual compliance training and we will move on to the second portion of your presentation or the next item on the agenda that is always you so please take it away annual report. >> okay. so this is the office of compliance and privacy affairs annual report. okay. you can go to the next slide please. okay. so we're responsible the area that we're responsible for our privacy compliance data sharing and whistleblower investigations. next slide please. so this is just an executive summary, some of the highlights of fiscal year '21-22. we were glad we returned to normal operations following the covid-19 public health emergency. we began to increase the number of

behavioral health audit and we're filled several key positions and responded to external compliance audits as government audits began to resume. during covid a lot of # government audits were put on pause. we lead the revisions to the privacy and conduct research policy and we worked with key stakeholders throughout dph to improve the research protocol process -- approval process for research and so we were really did a lot of work on that so we're glad that was finalized and we also worked closely with the maddy team to revise the guidelines for public health and data to meet the needs of dph as we publish health statistics for the community. next slide please. this is dph chart we fall

under the operations under the greg wagner chief operating officer and then this is -- next slide please. and this is an organizational chart just so you can see our staffing. okay. so next slide. okay. now on to compliance. i did touch on this in the previous presentation and the program ensures dph and the work force conduct operations and activities ethically with the highest level of integrity and compliance with regulatory requirements. one thing that we do is auditing and we want to make sure that we have appropriate billing and when we find that our billing does not either was -- we don't have documentation that supports the billing, appropriate

billing or billed incorrectly and we call that a disallowance or setback so in the past fiscal year dph returned 2.8 million in disallowed claims as a result of internal and external audits. now [inaudible] they do auditing for hospital program and during the covid health emergency those were suspended so there were no audits so they started again and that's why you kind of see this uptick in number. of the 2.8 million 2.2 million were sfgh related and for non qualifying stays and $377,000 for laguna honda and that was returned to medicare due to -- theres was an external review of one patient we have facility patient

and this was when laguna honda was transitioning to epic and there were technical issues with getting the documents into epic which caused note to be signed after admission and there's a requirement they're signed prior to admission so the external auditor denied the claim and we choose not to appeal, and so but and the issue has been corrected, so that is the -- but we didn't receive any compliance fines or penalties to regulators during the fiscal year. okay. next slide please. okay. and this is just a year to year comparison. we worked really hard to get our disallowances down. you can see it was high in 2017-18 so we put a lot of systems in place, a lot of auditing, corrective plans and training and able to get it

down and with the public hospital audits it ticked up again but we're continuing to work on this because we would like to see the disallowances go down. okay. next slide please. so these are the risk years. as i -- areas. we do risk assessment every year and identify risk areas and have a plan what we're going to monitor for fiscal year '21-22 for sfgh we had services and monitoring to ensure the tele-health requirements were met for billing and looked at the two midnight rule for in patient admissions generally to acute hospital under medicare part a if the admitting

practitioner requires a hospital stay that crosses two midnights and the medical report supports the reasonable expectation so we monitor to make sure we have documentation for that two midnight claim and observation so this -- that's typically assigned to patients who present to the emergency department and these visits must be immediateally necessary and a notice provided to the patient who receives the services for more than 24 hours, and these services are highly reviewed by medicare and external auditors so usually you will see our observation on our risk areas that we're looking at and then for laguna honda we had our rehab notes and that was looking to ensure that we had timely accurate documentation, and then we had our mds and [inaudible] accuracy. that's the minimum data set and that's

comprehensive assessment that provides the foundation for the residents, individual care plan. this is a federally mandated process for clinical assessment for resident was skilled nursing facilities, and then the [inaudible] is patient driven payment model and that assigned every resident a care mix classification that drives the daily reimbursement rate for that individual so we monitor that to ensure that's it done timely and accurately, and then for population health division we're looking at coding accuracy and the evaluation and management, documentation and there was some code -- we want to make sure that the accuracy of coding for this program that went into place in 2021. okay. next slide please. okay. this is just a snapshot of what we're

looking at currently for this current fiscal year, and annual report next year you will be hearing how we did on those. okay. next slide please. okay. behavioral health -- so on behavioral health you know our compliance program is ensuring the mental health plan integrity by the contract by the providers. we providing for effective dater audits that may meet plan requirements related to documentation and claims and shows which are not absolutelied to be pay and dph recruitment from the providers and so we really look at the error rate and what you see here and we've have outlined when we have an error rate that exceeds 5% we will require a

corrective action plan and a monitoring plan to addressed deficiency and those are very closely monitored. next slide. and this is just a year of comparison of the number -- we're actually our error rates are going down. if you can see for fiscal year '21-22 we were able to do more audits but we still had our error rate was similar to 2021 when did less audits so we're making improvements. next slide please. okay. so now on to the privacy program. our privacy program ensures the confidentiality integrity and availability of all protected health information which is not [inaudible] dph creates and maintains or transmits and during fiscal year '21-22 we didn't receive any financial penalty related to privacy breaches. okay. next slide

please. and so these are for the privacy incidents for the 21-22 so we have a privacy incident and then if the incident meets reporting criteria then we report. for these it's reported to the california department of public health. for behavioral health and one of the health clinics then that's reported to [inaudible] department of health care services. all reportable breaches on an annual basis are reported to the office of civil rights. next slide please. and this is just a comparison of the fiscal year comparison of our privacy breaches. you know we have seen an increase in the number of total privacy incidents reported, and i'm not -- it's hard to determine if we

have actually have more privacy incidents or now people are reporting because i think people are -- you know we really work hard to let people know if you see something even if you're not sure report it we will look into it. next slide please. so do we have some mitigation efforts. this is one of the posters that we have the privacy policy and we do this around every two months, and i see them posted over. i think people really like them. they take them and content and huddles and staff meeting so we do that. we also have conduct targeted training so we will go if there's an area having -- notice a privacy issue. for example after visit summary report to the wrong person we will go and actually work with that area

to find out what was the issue? what can we do so we can mitigate these privacy incidents? next slide okay. then our compliance and privacy training. we do annual dph privacy training and requirement of all employees and ucsf that work and the training platform managed by the controller's office and we did have a couple updates and staff [inaudible] not have access to the training. the training in addition to the module they also read and sign the code of conduct and read and sign a confidentiality statement. and then for our community based organizations our cbos those not on the platform we

have another training platform for them to take their training. next slide please. so for data sharing our agreements allow for dph to legally share with vendors and partnerships as well as other relative agencies to coordinate care and services. to do this we work closely with the contract with security and the city attorney office to protect the interest and define the scope here. we actually had a quite few inquiries this past fiscal year. we had 90 and it was questions appropriate access related to research, [inaudible] access, review of business associate agreements and the contract in process, and sharing our data with vendors and other agencies. it was after covid. we had a lot of requests for people to see our data because they were impressed with the work that dph had done. next slide

please. and then our whistleblower program and this is we conduct investigations of referrals from the office of the controller as well as complaints we receive directly and we will conduct the investigation and provide a report either substantiate the allegation with corrective action or if it's not substantiated then we close out the report and then this is to let you know the controller's office manages this program and they're very -- they have very tight control of the inform that is released to the public because they want individuals to feel comfortable so that can report anonymously, and so we've seen 68 complaints from dph and this is between april 12021 to march 2022 and

information that the regional water quality control board has put out. they do a report and i building it's quarterly so there will be coming out with another report probably i would say maybe november, december timeframe and it's for the entire city, so they will look at the whistleblower program for all departments and dph receives the most complaints among departments but we're the largest city december and we have the highest number of employees and also we have a work force that is very regulatory driven so they're used to reporting and we keep telling people if you see something please say something so do get a lot of concerns. next slide please. and this is our hot line and we maintain it and individuals can directly

file complaints concerns. if they have something with employee complains, conduct. we do advice and people ask for advice on different issues that we can assist them with so we see there's no one area that is focused on. it's a variety and it's from all over dph and we do get a lot of training questions. next slide. as we're in 22-23 the areas of focus we're really trying to really work with you know to expand and to really strengthen the department. we started yesterday a dedicated compliance officer for [inaudible] and ambulatory care and excited about that and want to get that program a little stronger and because of the number of privacy incidents in [inaudible] we now

have a a dedicated privacy office. we have the compliances and privacy office that was dual and now have a compliance office and a dedicated privacy officer and started yesterday as well and excited to have the positions in place and have a dedicated education coordinator and improving education and communications to dph and be proactive and work with staff so they can really understand their roles and what we can do to assist them. okay. next slide. that concludes my presentation on the annual report. >> thank you. before we go to commissioner comments or questions do we have anyone on the comment line? >> folks on the line if you would like

to comment on item 7 and the report that was just given please please press star three. i see one hand. i have unmuted you caller. please let us know that you're there. >> yes. it's patrick. >> okay. you have three minutes. >> i won't need that long. i'm going to review the audio of this meeting on the presentation. it's kind of shocking to hear there was a $370,000 fine because epic was unable to import or export documents with approvals prior to submission. i'm going to assume that some kind of disallowed claims until i

review that tape, but it sounds to me like with all of the problems with epic starting with health management associates not being able to get in epic when they were hired to provide consultant services for the laguna honda rehab center recertification project in order to check care plans. it sounds like there's lots and lots of holes or gaps or unveil features in epic. i had placed a records request to get a count of the number of physician orders for

restorative care referrals to the pt and ot departments that at laguna honda and epic -- dph is claiming that the number of physician referrals are somehow protected under hipaa which is ridiculous. for years dph has been providing me with the number of out of county discharges and i am assuming that that information is not protected by hipaa anymore than the number of physician orders, not the number of patients who attended, and therefore violating patients' privacy rights under hipaa but physician orders i would assume are no

different than discharge data in that both of them should be transparent and reported to the public. this is ridiculous that you got a $370,000 disallowance because epic was incapable -- >> thank you. your time is up. all right. commissioners that's the only public comment and i do not see hands currently for the commissioners. >> all right. . >> thank you again. >> thank you again for the presentation. >> president bernal -- >> of course. >> i want to thank maggie and her team for the incredible work. i mean compliance and oversight is something that i don't think we can pay -- we need to continue to pay so much attention to, and the pandemic and the work that was done during the pandemic and maintaining the work of the

organization was just so incredibly important and i want to emphasize that she is also working very hard bringing her perspective and deep knowledge of the work to the laguna honda effort and want thank her for that and want to thank her team for also driving the work as she also continues to play a dual role of leading the compliance part as well as supporting mr. pickens in so much of the work at laguna honda so just wanted to have the commission hear that and make sure they understood what a great leader and talent that she brings to this very important work at dph as you know especially in the areas of ongoing

monitoring oversight compliance is such a pivotal role and as you can see has financial implications for the panel. thank you. >> thank thank you very much. >> i also want to support greg's comments because it's -- grant's comments sorry because at compliance often thankless, mostly thankless work and you only get recognized when you find something, wrong; right? and doesn't make people feel good but it's so critical to be the ongoing success of the mission of any enterprise particularly health care enterprise that is in existence to serve the public and to serve the patients, and if we don't have good compliance and privacy standard and don't comply with them and take them seriously

then we can't fulfill our mission so i want to thank you for that and also for what seems to be i think a relatively good report all things considered with regard to what happened over the last year in health care and i would imagine that going forward even more thank you so much thanks to maggie and your team. >> thank you very much. >> thank you commissioner commissioner guillermo. i sure we're associate with the remarks and thank you again. okay. moving on to the next item on the agenda. we've done general public comment and deferring the public community update to a future meeting and include notes in the minutes from the meeting that happened earlier today. our next item is other business. commissioners any other business? >> person on the line if you would like to make a public comment on other business let us know

by pressing please press star three. i see no hands by the commissioners and the public. >> okay. the next is commission reports and other committee reports and hear a brief report for the jcc meeting and hand it over to the lhh jcc, commissioner. >> thank you president bernal. it will be brief and in the case of the last several meetings the majority time was in the executive team report taken up with considerations on the process towards cms recertification and our regular monitoring of the activities and the operations of laguna honda. in this meeting though the annual laguna honda facility assessment report was

presented, and without going into any detail to note that the assessment areas include the resident population served and the care needs based on the physical and cognitive disabilities that those residents show, and just to note that has been some slight change in the demographics as we've sort of alluded to with reflecting the change in the population and issues that are being evident in san francisco wide population larger greater population slightly of men in particular of a particular demographic and changing but don't know if that's a trend but it's a difference from the year past. the other assessment areas including staffing competencies on services provided and risk analysis for systems and resources in both north and

south towers in the hospital buildings which stand over 50,000 -- 500,000 square feet . this is an annual assessment that happens and as you can imagine a lot of that is now sort of interwoven with the work around recertification and both the operational structural changes that are contemplated going forward but overall a satisfactory report, and it is included in your packet. if there's any questions that folks want to ask about that report otherwise please do otherwise that pretty much concluded the open session for laguna honda and we went into closed session and that was the full agenda for

the jcc. >> thank you commissioner guillermo. secretary morewitz do we have any public comment? >> yes there's one hand up. again folks if you would like to make public comment please press star three, star three. all right. you're unmuted. please let us know that you're there. >> this is patrick. >> yes please begin. you have three minutes. >> before that meeting was called to order on october 11 the commissioner was overheard on hot mic saying "dashboard should be discussed in closed session." obviously that wasn't the only thing discussed during that closed session. this full commission had to have known as the three jcc commissioners had to have known that they were going to agree during that closed

session to issue cdph press release the next day on october 12 announcing the tentative agreement in principle joint statement with cms and dph and the the city and county of san francisco on developing related to laguna honda, the proposed settlement agreement dropping the administrative appeals and david chiu's federal court litigation involving laguna honda. between october 21 and sept 22115 patients died at laguna honda including the nine patients who died from transfer trauma post discharge because of the closure of laguna

honda. between october 20 and september 202-1106 patients died. the 120 beds issue should be restored if only because due to the number of patients who died at laguna honda every year. they are greatly -- those beds are greatly needed. as for the commissioner's comment that the demographics and patient population is reflecting an increase in the number of male patients at laguna honda here's the answer she should have known. yes, it's a trend. it's been a trend for over a decade that elderly women are not as large of the

patient population as they once were. commissioner you should know that that it's a trend because of data that is reported to sfdph or have been formerly reported to them about the gender mix -- >> your time is up. thank you very much. all right. that's the only comment commissioner. >> all right. commissioners any questions or comments? >> i see no hands. >> then we'll move to a consideration to adjourn. >> so moved. >> second. >> roll call vote. commissioner guillermo. >> yes. >> commissioner chung. >> yes. >> commissioner green. >> yes. >> commissioner chow. >> yes. >> and commissioner bernal. >> yes. >> all right. thank you all. >> thank you commissioners. have a good night. >> thank you.

requirements for in person meetings. during the virus disease emergency the citizen's oversight committee will convene remote until this committee is authorizationed to meet in person. public comment will be available on each item. each speaker allows 3 minutes to speak. comments or tuts to speak during the public comment period are available via phone call by calling 415-655-0001.