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 auditors 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. Ill 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 citys 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 were representing in the comprehensive Financial Report is accurate. So what we have here today is the external auditors reporting to you on their audit work for last fiscal year, the 17 18 plan, and the cafer for the close that were working through now. Ill say briefly as a bit of backgroun back background fo, a bit of a challenge because it was the first time we were closing the books in decades. People cut over were cutting off the famous citys 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 were now closing the book for the second time, and finding it a much simpler process. We would expect to have this years 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 ill 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 righthand side of the slide youll 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 dont 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 isnt 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 youll see in the pact packet the full management response, but we are working actively with the control managements office for improving the 18 19 close. With that, ill 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 couldnt 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 dont 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 si will take that, iy questions that you have. Chairman i have no questions. Were 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 impact or implications for 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 preaudit results available in february, mentor tha meant thatt first Building Block wasnt 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 citys 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 im so anxious to not have it occur again in the future, and im confident it wont, given the fact that we now have experience with the new system. And for the new system thats in place uhhuh. You expect the timeframe for the subsequent years financial back to our former timing. For the fiscal year that closed on june 30th, were well along in the process, months shaved of aheadf where we were last year, and im confident we will have our cafer released and on a december timeline. Im 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 citys single audit, which had no single audit findings this year. Way to go, mr. Controller. And the team behind me and throughout the Controllers Office and the citys Financial System is what makes it work. My thanks to joshlin and carmen and the broader family of professionals in the Controllers 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 dont 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, were 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 president ial 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 dont we take a 15minute recess. Do you have another item . If i could go grab him chairman is he here . I dont 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 wellbeing are safeguarded from any potential abuse. Chairman and were going to take a brief 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 lagua 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 hearings 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 wellbeing of every single patient. And if there is ever a hint of violation of any patients 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, retainin 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 im 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 im 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 patients 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 hospitals 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 muchneeded hearing. Okay. Then i understand that we have, first, today to present is maggie ro ryecowski. I am maggie, and im the acting chief executive officer at laguna honda hospital, and im 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 were 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. Well talk to you about the leadership, quality and safety, and what were 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 were 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 coulkofax 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 youve 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 publics faith in the ability of laguna honda high quality, safe, and abusefree care to the next generations of san franciscans. Next im 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, rathe incarcerated, rather than the president of the board to my left. This is norman, and this is le leland, f. Y. I. Hopefully you can correct that. Apologies for that. Good morning, my name is troy williams, and im 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 theyre 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 im 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 breeds and director kofaxs press conference, there are additional situations weve 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 midaugust. 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. , weve had a very good openness and theyre many pressed with the improvements that we put forward, and feel like were 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 dont anticipate one thing that is also important, that forensic analysis is complete and we dont 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 FranciscoPolice Department yesterday and are developing a plan to help facilitate interviews with residents. So that is along those along those lines, too, weve been in contact with all of the licensing and certification boards for those individuals, and they are also investigating. We dont 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 thats why were 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 . Im not sure. I dont 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, im 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 weve 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 were 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 doesnt look right, do you report it . There are surveys that do this, and weve taken one that were 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 longterm c. E. O. S at the hospital . Um. At that laguna chairman if thats the best practice done at the general, that that would be the best practice that would be done at laguna honda . Yeah. I dont know the answer as to why that hadnt been done in the past. I know that is something weve been doing since 2012, measuring, and its super helpful for us. One of the things were really focused on, which were really bringing into laguna honda, including frontline staff into the decisionmaking. 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 hondas 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 werent 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 youll see in the plan of correction, really getting laguna honda to the best place regarding Medication Administration. Chairman can you elaborate when you say youre 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. Weve increased the amount of medication past audits that were doing with frontline staff. Dwriewl havyoull have a managea charge nurse that will be there during med pass times, and theyre observing, are they pulling one medication out at a time . Are they doing all of the steps that theyre 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 weve developed a Medication Diversion Prevention Committee that will be very datadriven 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. Theyve met a handful of times and are really starting to dig down down into the data. And theyre 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 theyre not always need the. Needed. Theyve been on them and it has been years so really being mindful of what medications they need. And discontinue meds that arent needed anymore. Part of my concern is that not so much that well, it wasnt about whether theyre 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 . Thats 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 ive been privy to, its 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 weve done in terms of a tangible action around that is weve put together a protocol and this is something that c. D. P. H. Was very impressed with, that triggers a urine tox. If it wasnt for the fact that patients were decompensateing and being transferred to another hospital, we may not have known. Thats where the urine tox was obtained. Now, based on altered mental status, change in behavior, it will trigger a utox, 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 . Thats what i was hoping i would hear because the followup question would have been if theyre bringing it in from outside, then what observations can one have to Say Something is wrong here . Yeah. Yeah. Ive been involved in this now since april, and its 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 theyve told us and my colleagues, adrian smith, who has been working with me over there we 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. Im not saying that is a perfect program, but i think we have a very wellfunctioning, wellrun 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 im 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, whats on your mind . Whats your next safety event . Lets talk about it. Lets 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 weve been in contact every time there was an image or a photo or a video weve been in contact with the residents and or their decisionmaker. Weve 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 witcompliance with stated federal regulations, which is a very important step, but we have a lot of work to do. I know that weve said were in compliance, and thats a great, great thing, and its 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 dont come for quite a while. But im 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 havent heard that. Thats a really good question, and i can bring that back to the City Attorneys 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 weve 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 youre talking about, that we brought to the Health Commission. This happened, i think, five years ago, six years ago, and thats the only one that i know about. Chairman thats 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 dont want to dwell on this, but everybody is probably coming together to try and improve it and get it back on track, but im 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 . Its one thing to say weve 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 didnt do anything . Im 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 function 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, im not trying to pick on any individuals here, but im concerned about what kind of systems we have. For instance, if it didnt work, maybe the Health Commissioners didnt 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 subcommittee 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 were doing as a part of plan of correction has to go through theyre going to be monitoring everything that were doing as a part of the plan of correction. But ongoing, its a good point. Making sure that theyre 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 theyre privy to. Basically what weve talked to you, theyve heard. I think they understand how serious this is and are going to have some big expectations for us how were presenting them information and data. These things that happened, you know, previously i dont 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. Theyre 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 longterm care facility. Were one of the largest in the country. So we really want to get our reputation back. Weve been partnering with consultants and experts in longterm care and we are in the process of pursuing an r. F. P. With some longterm care experts who can also give us some consultation and guidance. Were going to continue reviewing and implementing all recommendations and just making sure that were on the right track. You know, in the past several months weve been meeting and listening to staff. Weve been meeting weve 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. Im 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 youre 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. Its one of these things when you look at any bylaw or organization, if its a long enough organization, you know what issues theyve went through those theyll change the bylaws every so often and say this happened and we need to deal with that. Well, weve 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 thats supposed to be providing quality care for elderly and disabled patients. Thank you so much for the presentation. Its 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 dont 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. Im just wondering if theres 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. Im 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 lifethreatening 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 hondas medical director in february 2008 and was told that an internal investigation was underway. Apparently that internal review wasnt 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 didnt 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. Didnt 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. Ive 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 im 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. Hes at an obligatory meeting up in sacramento. But im sure he would agree with me that there probably is a very Important Role that on me