City and County of San Francisco Wednesday, October 23, 2019
testing for S.F. Gov.
>> Chairman: good morning, everyone, the meeting will come to order.
Welcome to the thursday, October 23rd is special meeting of the government audit and oversight committee. I'm supervisor gard
gordon mar,
and I'm joined by
supervisor peskin. Thank you to this
committee's clerk, john carroll, and I would like
to thank corwin and calana
at S.F. Gov. Tv for staffing the meeting as
well. >> please ensure you have silented your cell phone and other electronic devices, and your documents should be
submitted to the court. Agenda item number one is
a hearing to review external auditor's financial report and single management letters
for the fiscal year ending June 30th, 2018, and the
audit plans for fiscal year 2018/2019.
>> Chairman: I would
like to welcome controller ben rosenfeld. >> good morning. I'll briefly introduce it
and hand the floor over to our external auditor.
As you know, the city has two key financial documents that we prepare each year. The first, at the
beginning of the year, the adopted budget, which is the plan on how the city
is going to spend funds in the year ahead. At the close of the year, we close the books and produce financial statements that disclose
the city's actual financial condition at the end of the fiscal year. To ensure that those documents are full, complete, and tested, the
board of supervisors
retains an external financial auditor that reviews them and other things and then reports to
you on their findings. The goal is to ensure that there is a reasonable assurance that what we're
representing in the comprehensive financial report is accurate.
So what we have here today
is the external auditor's reporting to you on their
audit work for last fiscal
year, the '17/'18 plan, and the cafer for the close that we're working through now.
I'll say briefly as a bit of background
back
background for '17/'18, a bit of a challenge because it was the first
time we were closing the books in decades.
People cut over -- we're
cutting off the famous city's former system which
was installed initially in 1980. So the first time in any
close in a new system is a
challenging one it.
It meant that the cafer is so late. And we're now closing the book for the second time,
and finding it a much simpler process. We would expect to have
this year's cafer in early December. With that, I will turn over the floor to annie
louie, and she can provide the report from the auditors.
>> no material weaknesses.
>> good morning, I
represent the audit firm. You all have in front of the presentation. First all go over the audit reports from fiscal
year '17/'18, and then
I'll go into the audit
plan for '18/'19.
There are two audits as well as compliance audits. On the left side are the ones that we are responsible for, and then
on the right-hand side of the slide you'll see all
of the ones that kpmg performs the audits for.
In terms of the audit
results, we seek unmodified opinions for all of the audits, as well
as the compliance audit.
And then the report to the G.A.O. Is our direct communication on information that you don't necessarily see in the financial statements, butt we need to communicate to
you as the governing body.
These are the required communications, and you have the details of this in your package.
There isn't anything atypical in terms of the required communications. I want to highlight in terms of the qualitative aspect of the audit, the
city implemented new
accounting expenditures,
and that put a fuge a huge financial situation. It is a large number that
is different from the previous year.
In terms of the
significant deficiency alluded to before, we reported a finding in the financial close process and the current process, mainly because of the newly implemented system that the controller had alluded to just now.
And you'll see in the pact
packet the full management response, but we are working actively with the control management's
office for improving the '18/'19 close.
With that, I'll go into
the audit plans for the
fiscal year '18/'19, and
this is a joint
presentation with K.G.M. K.G.M.B., and they
couldn't make it here. There are no changes in
terms of the audit scope
from fiscal '18 to fiscal year '19.
We have two lead partners
at the top and separate
audit teams for each of the main departments and the city, over all.
And this is the audit team
for K.G.M.B. Our auditor responsibilities, the highlight I want to make
is we are here to provide
an opinion on the fairness of the financial statements.
It provides reasonable assurance as opposed to absolute assurance.
If we have any findings over internal controls, whether over compliance or financial reporting, we would report that to the G.O. At the end of the audit process.
In terms of management responsibilities, I want to highlight financial statements are prepared by management, and they are responsible for the fairness in presentation, as well as the compliance
with the applicable
compliance requirements.
On the timing, we actually
start the audit process in early March/april. We come out usually in
May, the June timeframe,
where if there are any changes that have occurred in the fiscal year, and we the financial close is in September, through January, for the various departments and the city
cafer audit, as well as
the compliance piece, the
single audit. Starting around November, all the way through January, which is usually for the compliance piece
of it. There are two new
standards that are new for
fiscal year '19, and one is for retirement obligations, and the other
one we listed at this point don't expect any significant changes in
terms of the accounting of such transactions, but you
will see additional
closures related to the transactions that the city has.
With that s-I will take that, I will take any questions that you have.
>> Chairman: I have no questions.
We're also going to hear
from somebody from kpmg?
>> unfortunately, the kpmg
could not make it this
morning, so Ms. Louie has presented their portion of the presentation here. >> I did have a question,
just given the one main
finding from the audit in
around -- relating to the
sort of late -- how late it was to finalize the financial report and then the audit this year. I just wanted to ask if that had any sort of impact or implications for
our city and terms of the
budget process? >> the timing? >> yes.
>> it certainly made
everything is little harder. Where we end one fiscal financial year is preparing the budget for the year ahead. So to have it occur -- to have us kind of complete the process this year in
March with pre-audit results available in February, mentor that
meant that that
first building block wasn't known until a little later in the budget process. So it created some challenges. There are a lot of different parties that have an interest in the city's financial
statements, investors and others.
One of the key constituencies that really
uses the cafer are our
organized departments. It did create some challenges in them have timing access to information in the process. So, yes, there were certainly challenges with timing. It is one of the reasons
I'm so anxious to not have it occur again in the future, and I'm confident it won't, given the fact that we now have experience with the new
system.
>> and for the new system
that's in place --
>> uh-huh. >> -- you expect the
timeframe for the
subsequent year's financial --
>> back to our former timing. For the fiscal year that
closed on June 30th, we're well along in the
process, months shaved of ahead of where we were last year, and I'm confident we will have our cafer released and on a December timeline.
>> I'm always happy when I see no material weaknesses, and I have been on this panel when we did.
>> and I have been controller when we did, so I am pleased by it as well. Obviously, we take a deficiency seriously and we are working to remedy it.
In the city's single
audit, which had no single audit findings this year.
>> way to go, Mr. Controller.
>> and the team behind me and throughout the controller's office and the city's financial
system is what makes it work.
My thanks to joshlin and
carmen and the broader family of professionals in the controller's office and throughout the city
that makes this good work happen. >> of all of the things we have to worry about, your shop is not one of them. >> thank you. >> why don't we go to public comment. Are there any members of the public that wish to
speak on this item? Seeing none, public
comment is closed.
And I would make a motion
to file this hearing. Is there anything we need to move to the board?
>> not for this item, no.
>> so without objection. So I think for item number two, we're going to
need -- it would be best if President Yee is here for that.
Maybe we can take a brief recess. >> I do have a committee -- I have a presidential action memo
that would appoint him as
a member of this committee starting at 10:30, which
is in about 15 minutes.
>> I could change it to 10:15, if he could make it
here in one minute.
Why don't we take a 15-minute recess.
Do you have another item?
>> if I could go grab him --
>> Chairman: is he here? >> I don't know. >> should I call the item.
>> Chairman: Mr. Clerk, please call item number two.
>> number two sa hearing regarding the status of
the laguna hospital patient abuse.
That safety and well-being
are safeguarded from any potential abuse.
>> Chairman: and we're
going to take a brief recess until President Yee is here.
>> I'll go grab him.
[Recess taken]
Caf fer
mar
lin islamabad
>> Chairman: the board is back in session.
Mr. Clerk, can you please read item number two.
>> agenda item number two is the hearing regarding
the status of the lag gene laguna hospital, measures to make sure that the patients are safe gardened from any potential future abuse.
>> Chairman: President Yee, the floor is yours. >> thank you for your support for calling for a public hearing into the
current status of the
laguna honda hospital. After allegations of abuse at the hospital were made public in July of this year.
Let me be clear that this
hearing's focus is on the turnaround plan for the hospital. The public needs to know exactly what the hospital has done to turn itself
around and to ensure that
patients are receiving the highest quality of care
without any risks of
exploitation or abuse.
To summarize briefly the situation that triggers
the need for this hearing, a city attorney investigation originally initiated by the human resources complaint
uncovered evidence that 23 patients were subjected to privacy violations and
abuse by staff between
2016 and early 2019.
On June 28th, Dr. Cofax, the director of the department of public health, stated that the department would be taking immediate action to develop a turnaround plan for the hospital, and
would be able to report
back within the next 60 days, which brought us into September. the hospital first presented this turnaround plan to the health commission, and now they are presenting it to us at the board of supervisors, with a progress report since the execution of the
plan itself.
There is no excuse for what transpired.
Families like my own
depend on laguna honda for care. They should be able to trust it is going to be the highest quality. I think it is critical to hear from the hospital regarding the protocols that they have in place to ensure that abuse like this never happens again. We cannot ask our residents to entrust the care of our loved ones to any entity that cannot
prove that they have an
effective system that guarantees the safety and well-being of every single patient. And if there is ever a
hint of violation of any patient's rights, that there is a system in place
to immediately identify
any possible violation. Steps taken so far by the city have included conducting patient
wellness checks, retaining
retaining -- retraining of staff, reporting of violations, contacting all
state and local regulatory and law enforcement agencies and more.
My office has been contacted multiple times by concerned families and individuals, and I'm sure that other offices May also be dealing with those concerned about the situations. My office has been in
touch wit department of public health and has shared with you exactly what I'm looking for as
far as information today.
So let me just note now, for the record, that the
two main issues that I would like representatives of the department of public health to respond
to are: details of the
turnaround plan, including the oversight that you have in place to ensure that any possible violation of any patient's rights are immediately identified and addressed.
Number two, the status of any investigations by
state regulatory agencies,
as well as local law enforcement. And I would like the
department to have -- to share with us just the
status of those investigations, if they are still active. If they are closed, then please share any findings that are relevant to the hospital's operations and subject matter for this hearing. Now, would any of my colleagues like to make
any comments before we begin? >> no. But I thank you, Mr. President, for
bringing this much-needed hearing. >> okay.
Then I understand that we have, first, today to
present is maggie ro --
>> ryecowski.
>> I am maggie, and I'm
the acting chief executive
officer at laguna honda hospital, and I'm here with my colleague, troy williams, the chief
quality officer for zuckerberg san francisco
hospital and trauma centre
and laguna honda hospital. We are here to talk to you about our reform plan and things that we have had in
place so we can get laguna honda back on the right track. Okay.
And so we're going to just
very briefly go over -- not briefly, but troy will be going over the regulatory compliance of where we are in the investigation, and where we are today. We'll talk to you about
the leadership, quality and safety, and what we're going to do to prepare for
the future.
So this slide is a
snapshot of the timeline
of the incidents at laguna
honda in February of 2019, is when leadership was
made aware of the incidents -- was made aware of the incidents.
At that time, all of the appropriate regulatory agencies and appropriate individuals were notified. A lot of work has been
done between February and now, and I can tell you that we're very proud that
on October 15th, laguna honda was found to be in regulatory compliance with
the state.
Laguna honda, for over a hundred years, has taken
care of generations of san san franciscans with dignity
and respect. This is the last several
months of investigation of problem solving by
numerous and other staff and state agencies and
regulatory bodies. As supervisor yee mentioned, on June 28th
of this year, mayor london
breed, our President Of the board of supervisors,
norman yee, and grant could
kofax reported to the community about the
reported abuse of patients
at laguna honda hospital. A reform plan would be developed and presented within 60 days.
On September 3rd, the plan was presented to the health commission and to the mayor.
In the reform plan
document, that you've been provided, you can see an
overview of the findings
of deficiencies and corresponding items and
plans for improvement. Many deal with gaps in patient care and quality and safety. While our california department of public health plan of correction and this reform plan outlines the work that continues at laguna honda, we plan to make good on
our promise to restore the public's faith in the ability of laguna honda
high quality, safe, and abuse-free care to the
next generations of san franciscans. Next I'm going to turn it over to troy williams, who will talk about
compliance.
>> Chairman: I will pointer out the reform plan dated September 3rd refers to a former member
of this body, subsequently
in cars rapisted, rather incarcerated, rather than the President Of the board to my left.
This is norman, and this is lee
leland, F.Y.I. >> hopefully you can correct that. >> apologies for that. >> good morning, my name
is troy williams, and I'm
the chief quality officer
for zuckerberg san francisco general hospital, and I was asked
to come to laguna honda for investigation and improvement in their quality program. It is important to note that upon discovery of patient abuse in February
of this year, it became evident there was assistance needed at
laguna honda, additional resources specifically in quality patient safety and regulatory compliance. To that end, the health network deployed staff
from areas like myself, and other team members to
go to laguna honda and assist with the
investigation.
As was previously shared
with the health commission
back in September, the california department of public health did issue a
plan of correction.
You May hear the term 2567, or statement of deficiencies, and they're
all the same thing. Outlining specific areas where laguna honda was found to be out of compliance with state and federal regulations. Prior to the receipt of the statement of deficiencies, the plan of correction, as President
Yee had pointed out, there were a number of things put in place even before that time, and included a lot of staff education and training, wellness checks for the residents, and also the removal of the employees that were responsible for these
heinous acts.
But overall, so the reform plan and the summary of the plan of correction that you have as a part of
your packet, has more details around the specifics of the plan of correction, but there were some overall themes we
found as part of the D.P.H. Investigation and
the C.P. H. Investigation, and I'm going to go more in detail on those in a little bit. First I wanted to give to your point, President Yee, a little bit of an update on the investigation and where we stand. So the investigation has
been an interim process.
Since mayor breed's and
director kofax's press conference, there are additional situations we've had to report. Based on the forensic analysis of the cell phones taken from the
staff members that were
involved. Very unfortunate. We reported additional photos and videos to C.P.
H. On a rolling basis up
until mid-August. So as a result, there will
be more C.P.H. Compliance
the laguna honda.
But it disappear from our
conversations with C.D.P.
C.D.P.H., we've had a very
good openness and they're many pressed with the improvements that we put forward, and feel like we're getting to the root
cause of what led to these events. But there will be more activity. Important to note that as
a result of this forensic analysis and the additional photos and
images, no new employees have been identified, having involvement with the use of chemical
restraints or images or text messages. It is all the same employees who have been removed. A little bit of update on the numbers. Frustrate original 23residents that were involved, and that is the current plan of correction
you have in front of you, 19were substantiated at privacy breaches, seven as
abuse, in the form of physical abuse, sexual abuse, and psychological abuse.
I want to say really quickly about the sexual abuse, we have no evidence that there was sexual
assault or touching. Sexual abuse is still awful, but it was in the form of a picture being taken of nudity. I want to be clear, when we say sexual abuse, what
that means.
And five as abuse in the
form of the use of
chemical restraints. As a result of the new
reports, there are approximately 130
residents involved. Additional recordings also
include some physical, sexual, and psychological abuse. But the majority of the additional images have been reported as privacy breaches. So there was no recording
of residents, only P.H.I. Residents, or residents being seen in the background of a photo. But there were some photos that did depict some of
the images from the previous. we don't anticipate -- one thing that is also important, that forensic analysis is complete and we don't anticipate any
further images. We feel at this point
there will be no more images, text messages, videos, or anything coming forward after that forensic analysis was
complete.
So as I talked about before, the themes that
were identified during the
D.P.H. And C.P.H., investigations, they
approved and came out and validated it. They were with us for a week and made sure we did everything we said we were
going to do with a monitor in plan, and it was very rigorous, and the staff
there at laguna honda did a great job.
So you have a copy of that.
But I wanted to go through kind of themes to give you an overview of what they found and what we found
and how that really plays --
>> before we do that, just
real quickly, in regards to probably the dismissed staff, the staff that did
the abuse, are there going to be criminal charges?
>> yeah, so there is an ongoing criminal investigation. In fact, we met with the san francisco police department yesterday and
are developing a plan to help facilitate interviews with residents.
So that is along those -- along those lines, too, we've been in contact with
all of the licensing and certification boards for those individuals, and they are also investigating. We don't feel like those folks should ever work
ever again in any health care setting.
>> and they should be in jail. >> and they should be in jail.
So that's why we're really pushing that part of it as well. >> certainly the terms of their separation include the fact they can no longer access pensions -- is that true? >> I'm not sure. I don't know. But I can certainly find out.
But I know that they can no longer have employment with the city and county of san francisco.
But in terms of the H.R. Details around that, I'm not sure, but we can certainly find out. >> I would think that would be appropriate, if I might say. So I wanted to go a little bit through the themes and how it relates to the plan of correction that you have in front of.
You know, the culture of safety, if I May, on the
first one -- D.P.H. Is pursuing new policies and procedures to really emphasize and strengthen its culture to ensure employees understand their responsibilities, meet all
safety allegations, and promptly report any allegations of safety concerns. I think this is a very important piece to this. One of the things we learned as a part of our investigation is that there was a culture of silence. These things were able to go on undetected for
years. And, you know, what we've learned is that people
were afraid to report. Retaliations -- specifically we heard a
lot about these specific individuals involved, that there was some fear of them and retaliation from them. Overall, we heard that -- since my time being there
at laguna honda -- I think that is something that is really important because leadership creates and really sets the tone for the culture. And we have to do a better job, which I believe we're really on the right track
of doing, of letting staff
know we want to hear from
you. Illicit their feedback, include them in our improvement work.
Measure the culture of safety.
Something that laguna
honda had never done, measure it. how many reports do you -- when you see something that doesn't look right, do you report it? There are surveys that do this, and we've taken one that we're currently going through and doing the analysis of the answers,
but we are now going to do
it like we dot a do at
zuckerberg, every 18 to 24 months.
>> Chairman: is that a function of their not
being long-term C.E.O.S
at the hospital?
>> um...At that laguna --
>> Chairman: if that's the best practice done at the general, that that would be the best practice that would be done at laguna honda? >> yeah. I don't know the answer as to why that hadn't been done in the past. I know that is something
we've been doing since
2012, measuring, and it's super helpful for us. One of the things we're really focused on, which
we're really bringing into
laguna honda, including
frontline staff into the decision-making.
The frontline staff are
doing the work every day, they know what the challenges are the barriers are, and we need to be working with them in a different way to improve.
Moving forward, it would
be measured every 18 to 24 months. Medication management,
very important as well.
Changes to laguna honda's
medicine management program, administration of medications is the most innovative thing we do. Medications.
And there are patients, a part of this investigation, that received medications that weren't prescribed to
them, as a way of chemical restraint. We really needed to tighten up our medication oversight, medication administration audits, diversion prevention committees, that you'll
see in the plan of correction, really getting
laguna honda to the best
place regarding medication administration.
>> Chairman: can you elaborate when you say you're tightening up the administration or oversight on this? It is one thing to just say it -- >> yeah -- no. Thank you for that. A number of very tangible things. We've increased the amount of medication past audits that we're doing with frontline staff. Dwriewl have
you'll have a manager or a
charge nurse that will be there during med pass times, and they're observing, are they pulling one medication out at a time? Are they doing all of the steps that they're supposed to be doing with medication administration?
A couple of other things: the management of controlled substances is
really important. And, you know, when you
think about opiates and those types of things, it is very important that we have a good sense we have control of that. And we've developed a medication diversion prevention committee that will be very data-driven
to look, are there trends
in the different units? Are certain nurses taking
out an overabundance more of certain medications than others?
This is going to be an oversight committee that will be looking at these things. They've met a handful of times and are really starting to dig down down into the data. And they're looking at
medication simplification program. You can imagine that residents who have been there for many years have a lot of medications that are ordered. And maybe they're not
always need the. Needed. They've been on them and
it has been years -- so
really being mindful of what medications they need. And discontinue meds that aren't needed anymore.
>> part of my concern is
that -- not so much that -- well, it wasn't
about whether they're taking usual medication.
It was more like that they were giving additional medication to restrain them.
And the question I have
is: where did the staff members get this medication in the first place? How do you tighten that piece up?
>> that's a really good question. I think there is evidence to support the possibility of those staff members bringing medications from the outside. You know, there is some evidence to support that maybe they could have diverted it from laguna honda, but a lot of the
things I've been privy to,
it's quite honestly probably medications that they brought from the
outside and were medicating patients with medications that were not prescribed. And one of the things that
we've done in terms of a
tangible action around that is we've put together
a protocol -- and this is
something that C.D.P.H.
Was very impressed with,
that triggers a urine tox. If it wasn't for the fact that patients were decompensateing and being transferred to another hospital, we May not have known. That's where the urine tox
was obtained.
now, based on altered
mental status, change in
behavior, it will trigger
a u-tox, that we can get at laguna honda, that we can get on board, and that triggers an immediate investigation. I think that is something that has been a really big improvement to this. Does that answer your
question on the medication? >> that's what I was hoping I would hear because the followup question would have been: if they're bringing it in from outside, then what
observations can one have to say something is wrong here?
>> yeah.
Yeah. I've been involved in this
now since April, and it's maddening, quite frankly,
how they were able to do this.
Very, very unfortunate.
>>> the third is quality
management. D.P.H. Has a quality management process.
I think that the quality
management staff at laguna honda -- they've told us and my colleagues, adrian smith, who has been working with me over there -- we want to make
sure that the quality management staff have the kills that are needed to perform their jobs. I think that there was a
level of expertise there
that was lacking in their ability to be able to investigate things like this as they came up.
And so really standardizing the tools
and the program that we put in place at zuckerberg san francisco general. I'm not saying that is a perfect program, but I
think we have a very well-functioning, well-run management department
there to standardize the processes between the two hospitals. Going to conferences,
getting training, getting certifications for this quality management, so that they really feel able to do their role.
Maggie is the going to
talk a little more about leadership in the coming
slides, but it is really important, and I talked about this, culture starts with leadership. The leadership must be engaged.
And what I'm seeing there is a very, very high level of leadership engagement. And these are still the beginning stages. But -- and she is going to talk more about this, but getting out in the units and talking to staff, what's on your mind? What's your next safety event? Let's talk about it. Let's really engage in those conversations.
And finally, human resources -- assessing the human resources at laguna honda to ensure best
practices in hiring
practices, employee training, and administrative investigations and such, and that is something that D.P.H. Will be addressing.
I do want to say as a part of our process -- this is
a really important part --
we've been in contact every time there was an
image or a photo or a video -- we've been in
contact with the residents and/or their decision-maker. We've met with many of
them to share the video and photo with them and provided them a copy of
it, if they so desired.
We have really done our best to support the residents who have been affected by this. And some of those conversations have been hard.
>> Chairman: I would imagine. And have they, in turn, made claims against the city yet? >> I no there are two pending claims against the
city right now. >>> a couple other quick
things: we are now in cliens with
compliance with state and federal regulations, which is a very important step, but we have a lot of work to do. I know that we've said we're in compliance, and that's a great, great
thing, and it's a great deal, but we have a lot more to do, and I want to
make sure you hear our commitment to making sure
we continue to improve. We did receive, as a result. Deficiencies in our original correction,
we received a $780,000 fine, which we paid.
That was two weeks ago when we paid that. And there May be further fines that come forward as a result of the additional recordings, and more specifically, the privacy breaches, which carry a pretty heavy fine.
Those are often years off. Privacy breaches, in my experience, those fines don't come for quite a while. But I'm confident we will have more fines coming forward.
>> Chairman: and do we
have any plans to sue the individuals civilly to
recoup any of those dollars? >> I haven't heard that. That's a really good question, and I can bring that back to the city attorney's office. Good question.
>> Chairman: without disclosing anything from a closed session, we had to settle another laguna honda matter last week.
>> that just raises a question I had.
Have there been other incidents of patient abuse
and fines that we've had
to pay in recent, like,
say in the past decade or in the past?
>> I know of a class "a" citation, May be the one you're talking about, that we brought to the health commission. This happened, I think,
five years ago, six years ago, and that's the only
one that I know about.
>> Chairman: that's the one that we settled. It will go to the full
board next week.
[Please stand by]
>> that we can have all of the employees feel comfortable that
if they see something, they will say something.
They can feel comfortable that there will be no retaliation.
But I think our executive team
right now that is in place has
worked very, very hard to make
sure that we can get laguna back
on track and get in the right direction. >> I don't want to dwell on
this, but everybody is probably coming together to try and
improve it and get it back on
track, but I'm also concerned about the future.
It seems like everybody is ton track.
You fall into depending on the
leadership, to keep things at a
high level.
So my concern is where is the check and balance of that leader? Who is going to ask questions of
that leader, the C.E.O.
What is the systems in place
where this leader, the C.E.O.,
or the team, executive team,
will continue to provide a
culture of safety?
It's one thing to say we've got
to get the right person, but beyond that there is
something -- is there a role,
for instance, for the health
commissioners to ask these
questions on a regular basis and
to go in and say to the
executive team, what are your sort of activities around this
to keep it safe?
>> well, we do report monthly to the joint conference committee to the commission.
We do have commissioners
assigned to laguna and they are keeping close tabs on our activities. >> did that exist before? >> yes.
>> so it didn't do anything?
I'm sorry -- they had a committee that was supposed to
be asking these questions and
there was abuse for a long period of time. I would say it was not
functional functional. So then the question becomes: what are we going with the health commissioners?
>> I think there is a heightened
awareness.
Laguna honda and zuckerberg general are part of the san francisco network.
Those two report to the director
of the network, they are part of
the network, and the network
director reports up to Dr.
Dr. Colfax.
So I think they are very engaged and closely monitoring what is
going on at laguna honda.
I know the health commissioners are very interested and concerned and they want to make
sure that things are going well at laguna.
I believe as we move forward,
they will continue to do that.
>> again, I'm not trying to pick
on any individuals here, but I'm concerned about what kind of systems we have.
For instance, if it didn't work,
maybe the health commissioners
didn't ask the right questions. They might be aware of it now. The new health commissioners that come down the pipe might
not be aware of it.
Is there a systematic way where,
for instance, there is this
sub-committee of health
commissioners looking at these
issues, is there a set of questions that they should be
asking all the time, rather
than, how are you doing?
>> as a part of the plan of correction, for sure. All of the improvement
activities that we're doing as a part of plan of correction has to go through -- they're going
to be monitoring everything that
we're doing as a part of the plan of correction. But ongoing, it's a good point. Making sure that they're asking
us the right questions in helping them with that.
I think that this plan of correction with its focus on
culture and all of the things
that they're privy to. Basically what we've talked to you, they've heard. I think they understand how
serious this is and are going to have some big expectations for
us how we're presenting them information and data.
These things that happened, you
know, previously -- I don't know
how they would know about it,
unless laguna honda leadership
knew about it and it would come forward.
I think moving forward with this, it was an event. They're going to definitely have
big expectations for us and they
told us that.
>> just for the future, you
know, we are totally committed
to getting laguna honda back on
track, making sure it goes in the right direction.
We have been -- we really want to be the best long-term care facility. We're one of the largest in the country.
So we really want to get our reputation back. We've been partnering with
consultants and experts in
long-term care and we are in the
process of pursuing an R.F.P. With some long-term care experts
who can also give us some consultation and guidance.
We're going to continue
reviewing and implementing all recommendations and just making
sure that we're on the right track.
You know, in the past several months we've been meeting and listening to staff. We've been meeting -- we've really been talking to our patients or residents.
Going forward, we want to pledge
to rededicate ourselves to hold
each other accountable for
creating a new ethos set at laguna honda. That is our goal. >> okay. I'm sorry.
I used to run an organization.
Is there anyone from H.R. Here? No.
If the C.E.O. Is supposed to develop this culture and
continue to support that
culture, is there an evaluation
question for when you're doing
evaluations, annual evaluations?
Is there a question built in so
that you ask that question of
what are you doing to support
sort of a culture of safety?
It should be rated or something.
It's one of these things when
you look at any bylaw or organization, if it's a long enough organization, you know
what issues they've went through
those they'll change the bylaws every so often and say this happened and we need to deal with that.
Well, we've been faced with this
and I think we should put in
everything we can to emphasize it.
So can you go back to the H.R.
And ask them that? >> absolutely, yes.
This is for a selection of the
permanent chief executive officer?
>> [Overlapping speakers] --
>> no, the evaluation. >> I see.
>> ask that question why would
they focus on it.
>> absolutely.
>> thank you so much, President
Yee, for calling this hearing
and your focus on these
important issues. Unfortunately, elder abuse in
care facilities is not an un
common occurrence.
It is shocking to hear about what really has happened with patients at laguna honda
hospital and just the fact that
this is our public health
facility here in san francisco that's supposed to be providing
quality care for elderly and disabled patients.
Thank you so much for the presentation.
It's good to hear about the
focus that the now -- much greater focus that the
department and the hospital is
putting on patient care and
ensuring that we don't have
situations like this in the future. So I would also join with
President Yee and just say that
this board is also going to continue to be closely monitoring the situation and look forward to further updates. >> I'm just wondering if there's public comments on this.
Is there any public comments?
>> Clerk: are there any members
of the public that wish to speak on this? Please step forward.
You have two minutes.
>> I'm a whistleblower and former laguna honda physician.
Why were the patient druggings
at laguna honda discovered by chance rather than through standard medical reviews?
According to state records, five
patients were drugged with pillford medications, resulting
in life-threatening overdoses
and transfers to outside hospital.
Laguna honda doctors were aware
these were not caused by illegal
drugs commonly smuggled into the hospital. They were caused by medications that had not been prescribed. Further, doctors at outside hospitals who treated these
patients conveyed their alarm. One doctor notified laguna
honda's medical director in
February 2008 and was told that
an internal investigation was underway. Apparently that internal review wasn't fruitful.
Instead, the abuses were
discovered 18 months later while
human resources investigated an
unrelated employee despite. yet, laguna honda has two medical committees that are
charged are probing such adverse
medical outcomes.
Why didn't the medical quality
improvement committee or the
performance improvement and patient safety committee
diagnose these drugs abuses? Lastly, health commissioners
regularly met with doctors to
review their medical quality
improvement reports.
Didn't the commissioners notice
that something was wrong? Thank you very much. >> thank you.
Next speaker. >> good morning, supervisors. Thank you for this opportunity to speak.
My name is goddel child.
I am a san francisco ombudsman
advocate working at laguna honda
on the palliative care unit
south 3 and the H.I.V. Positive unit on south 2.
I've been in that position now for about three and a half years
and have firsthand experience of
residents, in particular, being
quite concerned about bringing concerns and complaints forward at laguna honda.
So I'm relieved to hear the presentation today and to know
that we have such a high level
concern and focus on patient
safety and resident safety at laguna honda.
I would suggest, too, that --
and unfortunately, the director
of the ombudsman program is not
able to be here today.
He's at an obligatory meeting up
in sacramento. But I'm sure he would agree with
me that there probably is a very
important role that on me --
ombudsmen at laguna honda.
any role that we could play in a
corrective action plan or protecting and advocating for
resident safety I think would be
strongly welcomed by the ombudsman program.
>> can I ask you a question.
You mentioned that the ombudsman program would like to expand its
support to residents or patients
at laguna honda. Is there a specific proposal around that?
>> as you May know, the
ombudsman program is really staffed by volunteers.
For that reason and because of
limited funds, I would guess there would be a lot of constraints around significantly expanding the role of the
ombudsman presence at laguna honda.
That said, we are actually
undertaking that.
So we are right now forming more
of a group presence there so
that the ombudsmen there are
talking to each other more and trying to bring together what we
are experiencing the problems with communication, especially
the reticence of residents to speak out when they have a
concern or a complaint because
they're very dependant, of course, on the medical staff there. Did that answer your question? >> yeah, it did. Thank you so much for all the
work and you and the program does. >> thank you so much.
>> are electric there any other members of the public that wish to testify?
Seeing none, public comment is closed. president yee.
>> I would like to thank our
presenters for presenting today.
I know there's a lot of work to
be done and certainly if I'm a
little intense with the
questions, I care about this
issue.
I hope some of the suggestions I
made we've heard and that could
actually strengthen some of your
efforts, because all of us want
to make sure that our patients
up there are being well taken care of.
I guess I have to go visit the hospital more often.
I only go up there once or twice a year.
It's a great place.
It's really sad that these incident
incidents happened because the physical environment is really a
lovely place compared to what it used to be. Thank you very much for your --
in terms of trying to improve
the efforts.
>> thank you, President Yee, and to everyone for this important hearing.
Can we file this hearing without
objection?
Mr. Clerk, is there any further business?
>> Clerk: there is no further business. >> we are adjourned.
