Initiative to address the needs of the highest utilizers of Public Health services. On the fifth of november a broad update. We are concerned about the health and wellbeing of those in San Francisco. We take our role seriously and we will continue to use our meetings as a public forum to discuss important Public Health issues. Members of the public are always invited to attend and provide input. I am mark. Health commission secretary. If you have Public Comment, please hand a slip to me. If you would consider today, there are a lot of people who feel passionately about what you are here for. As others speak, they may have different opinions than you, try to be respectful. Be silent in your show of your opinion by either doing Something Like this or this. If you like what is being said. If you dont like being said do this. Vocalizes is not respectful to the person at the podium. Please consider that. Item 2. Approval of august 20 and september 17 meetings. In front of you is slightly revised Meeting Minutes for the 17th. I was to add it was adjourned 4 29 p. M. Due to disruption of the meeting. Please consider that version for your approval. The minutes are in the hands of the commission. If you have comments about the first set of minutes on september 17, please do so now. We will follow with the minutes from august 20th. I move approval of the minutes. Second. Those in favor signify by saying aye. Is that both sets . I move september 17th. Second. A. Item three directors report. Good afternoon, commissioners, grant colfax director of health. We have a full agenda this afternoon. I will highlight the key items in the directors report in front of you. One thing that is exciting, the first item. Yesterday mayor breed and the department of health announced a new Overdose Prevention program for the hotels to be carried out. This program is in response to the rising number of Overdose Deaths in San Francisco, approximately which 30 occur in single room occupancy hotels. This program is based on the successful tenant Overdose Response program from vancouver. We will work with the sr operators to develop the prevention programs. It will expand the Overdose Prevention further and support installation of naloxone boxes. That will begin later this year. The Health Department supports Harm ReductionCoalition DrugOverdose Prevention project which provides 15,000 doses of naloxone to thousands of those witnessing overdose in 2018 alone. The drug Overdose Prevention product reported 1658 overdose reversals that year and is on track to double that in 2019. We are concerned about overdose death in San Francisco. We are doing everything we can to minimize that terrible situation, and this project is a major step forward to help people most at risk for overdose. I want to emphasize that on september 24th, the mayor and the director of Mental Health reform announced plans to launch an online inventory of dph Substance Abuse and Mental Health treatment beds, we want to be sure there is increased transparency in terms of bed availability in the city within the system. We expect this public web page will improve the timely access to treatment and Health Providers make the best use of beds in the programs. The first space in november will have withdrawal management and 90 day programs. In the second phase the short term beds will be added. In addition to transparency this will help data driven decisions where we need to target new investments and bottle mecks in the bottlenecks in the healthcare. We are going to spend time on the Behavioral Health system today. The department has chosen to pause changes while the mayor and board of supervisorses have a conversation how to have expanded access to services. You will be hearing about that today directly from the dph in terms of history and Public Comment. I look forward to that part of the agenda. Just to emphasize with regard to vaping, the California Department of Public Health urges everyone to refrain from vaping given the current status of vaping risk. Since june of 2019 the California Department has received reports of 90 people in california who were hospitalized for severe breathing problems and lung damage. San francisco does not have any suspect cases we will be diligent in that regard. Nationally the epidemic associated with pulmonary injury grew 52 compared to the prior week. There are 805 from 46 states with 12 deaths reported. We continue to be vigilant on both the regulatory and the policy fronts. With regard to the recent heat wave on september 24 and 25, the National Weather service issued a heat advisory in San Francisco with temperatures in the 80s and 90s. They worked together with the department of Emergency Management and joint Information Center for city agencies to coordinate efforts and share messages to stay cool, hydrated and connected. City officials remind the people about the importance of window, water and pet safety. I think as we see the effects of Climate Change continuing, dph will ensure that we are resilient in the city with regard to our adaptation to Climate Change, including potential health risk for residents. That is a final note. I am excited to announce tomorrow the mayor celebrates the groundbreaking for the maxine hall remodel. She will celebrate the remodel, to improve safety during an earthquake. Locate primary Care Services and for the construction maxine hall will move to a temporary clinic on golden gate avenue. We want the community to be informed of that. As a provider i recently visited. The staff is committed and clients are receiving great care. It is time for refresh. I am excited that is happening tomorrow. Thank you very much. I will take any further questions on the directors report. Commissioners. I thank you for the report in regards to especially the coordination during the heat advisory, and because we were in chinatown just several months ago. I am wondering what type of coordination actually occurred in chinatown for that because it would be a very good example of what we are trying to do down there. I believe that doctor aragon has an update with regard to the specifics there. Thank you. Good afternoon. I am sorry i dont have an update. Doctor baba does. Thank you, doctor chou. There are a couple places impacted with heat. We checked in with the chinatown community. Chinatown has a library with airconditioning, which is great. The messages really went to the community. As with all of these incidents we debrief to see what we can improve in our communication. We will keep our eye on how we are able to respond to that community during these heat advisories. We did the same thing with bayview because that has a lot of heat as well. Thank you. Other questions . Thank you, doctor. No Public Comment for that request. Item 5 report back from the finance and Planning Committee from today. Thank you. I am sure commissioner chung would have been pleased today in our reports on the monthly contracts we were able to get some outcomes. The outcomes were quite satisfactory. On the block of the monthly contracts that included the Fountain Institute that is actually a Diversion Program and then several programs that actually were looking at improving employment from the university of california and the positive Resource Center. We spoke somewhat at the positive Resource Center if that information was getting back to primary providers in a way that they may find it useful to understand how their clients were assisted beyond the medical illness. We heard request for a retroactive contract with the San FranciscoCommunity Health authority, San Francisco health plan, administering the San Francisco covered mri program. It is a contract that goes back four years. Because of the changes of funding in which the Services Rendered by the San Francisco health plan on behalf of the mra program and changes in the mra program, there have been some delay, therefore, being able to actually pay for all of the services which the San Francisco plan continued to render. The retro activity will include also an additional two or three months to the end of 2019, at which time all the San Francisco health plan tpa type contracts for the covered mra and other tpas would be brought fort to the finance and the commission. At that time we will be able to understand better the allocation of the types of services being rendered for those people in the various programs. Barring that, then we also have one more contract which relates to an outside vendor to perform mixtures of different compounds and types of medications that we know longer do, and it is a certified contractor from the fda and will giv give us a Super Service at the general for those types of medications. At the consent calendar we will ask for consent on all of these contracts. Questions from the commissioner . I apologize. I made a mistake as we went forward i skipped general Public Comment. Hold any questions on the report back and go to item 4, general Public Comment. I apologize. It wasnt intentional. I hold an egg timer. Everyone gets two minutes. When the buzzer buzzes, finish your sentence so the next person can come forward. For general Public Comment, mike hill, crystal duran and heather roninger. I am one of the nurses in the er. Our concerns are about General HospitalEmergency Department staffing issues, transparency, lack of, promises made to us at the joint commission that were supposed to be built into our contract. For instance, the ratio change in the er. We havent had any information funneled down to us how that will be accomplished. We assume they will hire temporary staff for the changes. That is not the safest way to care for our patients. If that is the plan, but we dont know the plan. There has been multiple issues. Care start is another implementation that didnt respond to any of the input from the nurses that have to work the care start program. It is not safe to our patients. There are so many different issues the other nurses with me will speak about. I wanted to introduce those problems in the er. Would you identify yourself for the record . Mike hill, nurse in the er. Thank you. Good afternoon, commissioners. I am actually going to read a letter on behalf of one of my colleagues. One of my colleagues felt fear in speaking out because of retaliation. I will read this. I am crystal. I am a nurse in the Emergency Department at San Francisco general. For nearly half my life i worked as a nurse in the Emergency Department at San Francisco general and for the department of Public Health. Our department is pushed to unsustainable point. The ed is a disaster scene almost daily. As safety net of the city we reflect the picture of the community. The department of Public Health and city are not well. Our population is more complicated and desperate. Imagine unhoused with cancer, diabetes. It is cruel and heart beating. We are a special group. We are drawn like special forces to this department. We have the knowledge and the skills to bring back people from the dead, literally or care for an 85yearold fractured hip fall patient, 7yearold hit by a car. Kisdisaster is taking a toll. One colleague tried to decrease antidepressants and cried and had to go on it. A group of p103s are on a six month leave of absent for stress and Mental Health reasons. We have contract rns making 30 of total staff. I have never been in such a hostile stressful environment not only from the management but from the patients with complicated desperate needs. They are promised by leadership, dont worry, we will take care of everybody. Do you think the zuckerberg building with hundreds of millions on lobbies, balconies and hallways is providing effective quality Public Healthcare . Really . What percentage of our patients would agree with you . We see the multitudes it is failing. The sad suicidal teenager doubles up in a room with a person in a severe combattic episode or the 90yearold with dementia next to the psychperson who cant get in the group hope. They are on the street. Finish up, please. Thank you. It is time for the painful honesty, the abuse scandal, people jumping out of the windows and the admitted patients in the ed getting bills for care impossible to provide. Please finish. The hundreds of care patients are waiting in the triage area and getting a full ed visit. The goal of numbers and ignoring front line staff has costs which may include juror death or detriment of patient as is and staff we want to care for mom, dad, sisters and brothers. Please help us. Ladies and gentlemen, please respect the people be anhind you. There are a number of people to speak. We are giving you two minutes. Please respect those folks and give them the opportunity to speak. We want to hear from all of you. Thank you. I am krista durand, er nurse. Contract bargains is over. Now there is no reason to think we are asking for raises. We are here because we said we would return. The leadership style at San Francisco general has a culture of intimidation is so severe we fear interaction with management. Our rn director pushed 50 of the best leaders out in less than four months. Why wasnt this a red flag to the administration . This is having detrimental effects of the Mental Health of the staff and distracting them from providing staffing care. Adding an additional layer of leadership not transparent to maintain control is having direct effect on patient outcomes. Front line staff are being dictated to risk licenses. They are aware of it and has done nothing about the administration poor implementation of programs. I became a nurse to provide compassionate and competent care. It is my duty to advocate for the patients. The petition we sent to you guys shows a lot of violations. If you turn a blind eye now you are going to be part of the problem. We sent multiple letter goes with the same outcome. You let Administration Lie with numbers and charts. Now we have submitted the explanation of the crisis. What are you going to do . Are you going to do something what people diane Staff Members are injured or commit suicide . I am heather a nurse in the er12 years. I have been here before. I thought about how to convey the severity of the situation to you. We tried emotional pleas that havent worked. San francisco general is about compassion, not quality care, data. These are data points to consider. 25 to 30 of the emergency beds are housed with admitted patients every day. We get zero nurses to help support their care. 50 of our most trusted respected and experienced leadership staff are forced out of positions in the last four month. 50 . Our department houses from eight to 12 behavioral 12 Health Patients in acute psychiatric bases in space designed for four. Resuscitation area exceeds level of 15 to 17 patients. It is designed for six. We discharge 700 patients each month out of the waiting room. That is where they receive all of their care, in our uncomfortable perfectly public waiting room. 63, that is the number of nurses who have signed the petition sitting in front of you today asking for your help. Asking you to engage. You dont need lean workshops and Software Programs to understand what is going on with our patients. You need to talk to the staff. You need to listen to what they have to say. Thank you for your time. Thank you. Those are all the slips i had for public testimony. Does anyone else want to speak on general Public Comment . Call the next item. Thank you everyone who chose to make Public Comment. The petitions are in your packet for item 7. It is altogether. I want you to know it is there. Item 5. We have gone through with commissioner chow, review of the finance and Planning Committee meeting. I would like to know before the concept calendar the dph staff asked to change the amount on the second contract. They had incorrectly figured out the contingency. 4,431,259. As you vote i want you to have the right amount. That is for the San FranciscoCommunity Health authority contract. That is correct, thank you, mark. That reduction was with a recalculation of the approximate 12 for the 2019 fiscal year. Since the other years had closed. The new amount is actually in the San Francisco health plan contract. The commission would like to move those items on to the consent for your approval on the consent calendar. There is one other item on the calendar which i assume ultaup separately. It is the resolution on alice chen. I will defer to you on alice chen. Why dont we do this first then. Thank you. All those in favor of accepting the finance committee report. Opposed. Hearing none it is adopted. Now we go to consent calendar. The resolution for alice chen. Correct. The consent calendar for resolution 1913, honoring doctor alice chen requested by the Health Commission and a draft had been presented to doctor chen at a reception at the San Francisco general for her. I would like to move that consent. All those in favor signify by saying aye. Aye. Next item. No Public Comment for 6. Item 7 the San FranciscoBehavioral Health adult residential facility. Mr. Pickens do you need help pulling up the presentation . Good afternoon, commissioners, roland pickens, director of San Francisco health network. I will be joined by my colleague Kelly Hiramoto former director of transitions for the San Francisco health network. I am here today to share with you some of the background and circumstances pertaining to the adult residential facility located at 88 88 7 00 p. M. At 8 7 00 p. M. Atrero. I hope it informs you about the current set of circumstances. So in todays presentation i will start with Background Information on the bhc which is the building in which it is located. Next i will provide an overview of the program. Then i will present the facts and circumstances that led to the current plan and, finally, i will review where things stand now in the proposed next steps. Currently, the Behavioral HealthCenter Provides both locked, subacute and patient treatment and unlocked delayed egress Residential Care for adults and seniors who have Behavioral Health needs. However, the bhc didnt start that way. It has a long history that has evolved over time to meet the changing circumstances based by those in need of Behavioral Health services. A brief review of the history includes that the facility first opened in 1996 as the Mental Health rehabilitation facility called the merf. It was then a 147 bed psychiatric Skilled Nursing facility. Then in the early 2000s as the environment in San Francisco began to shift toward the need for more lower level residential beds, in 2003 the mayor of San Francisco established a Blue Ribbon Committee for a new design for the services provided. That process resulted in 2004, thmerf moving to a three program mixed use facility consisting of a 47 bed secure and locked Mental HealthRehabilitation Center on the third floor. A 59 bed psychiatric on the second. 41 bed residential facility. In 2005 the adult residential facility was licensed by the state Community Care licensing and began receiving first admissions. That leads us to what we have today, which is again on the third floor a 47 bed merk also called institute for mental disease, locked subacute Mental Health unit. On the second floor a 59 bed Residential Care facility for the elderly, also considered a board and care facility. On the first floor a 41 bed residential facility. In 2017, we added an Additional Program to the first floor of the Behavioral Health center. That is a hummingbird psychiatric respite center. To familiarize ourselves, the merk is locked subacute of care to elderly houses individuals 60 years of age and over. Again, hummingbird which is a psychiatric respite on the first floor. What you dont see is the arf. I am going to devote the next severals to talk more about its program. The operation of the arf. It is 24 hours each day, nonmedical care but supervised facility for adults 18 to 59 with severe Mental Illness that are stable but still need care, assistance and supervision. Some of the services to the residents are housekeeping of their rooms. Some require assistance with personal care and as they administer medications prescribed by their providers. Where do patients come from who wind up on the arf . They receive referrals from acute care hospitals, locked subacute units like the america and other board and care facilities. It is a licensed residential facility licensed by state Community Care licensing, which is part of the department of social services. I am going to slow down a little more because there is a lot of information that we want to share to make sure you understand. It is important to step back and revisit the circumstances that bring us here today. For many years from 2005 up until 2013, operations a at arf were proceeding. In may of 2014 we submitted a request to the state to expand the number of licensed beds from 41 to 55. However, in december of that year, just 7 months after getting approval to expand to 55 beds we received citations for medication issues that required development of corrective action plan. This was approved by the state and implemented in december of 2014. The plan of correction involved numerous staff straining and education sessions about Resident Safety, Workplace Safety and medication assistance oversight. Some staff to make these errors in the same areas from this they received the retraining. Some of the results of this process was that it led to disciplinary process for some staff which included employee termination. During that time we also saw the unfortunate circumstance of staff beginning to file complaints against one another and reporting each other to regulatory agencies. During december 2014 through september 2018 despite implementing the performance improve meant plan. They were unable to go more than five months without incident or Community Care licensing coming on site to investigate the facility. In september 2018 we were notified the arf was being placed in noncompliance and mandated to attend the conference. We were advised by state Community Care licensing that it was their expectation a facility would need to go one to two years without any additional citations to be removed from noncompliant status. Furthermore it could have resulted in us going to add enough review to result in the loss of the facility license to operate. On december 2018, two months after the nomcompliance concerts we received two level a citations. They are the most serious types of violation. These were in the areas of medication use and the same types of citations which put us into noncompliance. At that time they informed us because these were repeat we were at prior risk of going to the possibility of using losing our license for the arf facility putting our clients at risk at having to be moved out of the Behavioral Health center. It is important to note in the midses of these changes we were never able to an receive the 55 at the arf. What did management staff do about what was going on at the arf . Since the initiation of the corrective action plan, additional plans have been developed and approved by state regulators. Some of the letter corrective action plans im movement im poos improvements different. In terms of staff complaints we partnered with the department of Public Health to provide assistance with disciplinary actions. In addition to addressing Staff Shortages and vacancies we meet weekly with Human Resources to focus on filling vacancies in the arb. We were three staff away frommenning mullly someplace. We had workplace and regulatory citations. Consequently, our ability to maintain care and not put our license in jeopardy was a real concern for us. It is important for me to note and sum up the situation of citation. Sept 2015 and 18. They received 10 citations, the highless level that can be offered by Community Care licensing. In terms of the decision to suspend beds there is much confusion and misinformation why we chose to temporarily suspend to license to operate some of the beds at the arf. I will share some of the facts. Due to the ongoing unresolved regulatory staff behavior and staff hiring issues at the arf, we determined since there were vacant unstaffed beds on the facility upstairs, Residential Care for the elderly, it made sense to move some of the arf residents upstairs, particularly those 60 years of age. They had 22 empty beds at that time. In addition to moving the residents up tears we were moving staff upstairs. We felt this was appropriate for three reasons. First, to allow all 59 beds on the Residential Care facility for the elderly to be fully staffed and occupied, second it allows those reassigned from the arf. It was an environment not experiencing the high level of complaints and citations so they could experience firsthand what it is like to work in a higher functioning board and care facilities. It would permit the bed on the first floor the opportunity to focus on getting to the corrective actions they needed to improve its operation. Is the status of the arf beds license temporary suspension in may of this year we requested the state and they approved to put 27 of those arf beds in suspension. This is not getting rid of the license but putting it in suspense for another year. This resulted in 41 of the 55 licensed beds being insistent. 14 of the beds would continue and are continuing to be operated on the first police officer. The plan was to have the residents upstairs to the care facility for elderly or other placements if they so chose. Now, i will talk about the circumstances at the arf affecting residents and staff. As a result of our plan, we thought long and hard to make sure we would do something to help our residents and also make sure we were honoring our staff. In this proposed plan no residents would be evicted. No staff would lose employment to ascertain the leading causes of organizational beds. We could move forward to operate all 55 of the arf beds. In addition to these factors, the redevelopment of empty unused beds in the arf could be repurposed to provide additional beds for homeless clients in need of Behavioral Services by expanding the humming bird psychiatric respite program. I would like to talk about hummingbird and why its expansion is important. A background. Hummingbird first opened in 2017 with 15 beds, which as i said before were always full. Then it expanded by 14 beds in february over 2019. Those beds were the result of the beds we asked to go to suspension to use the beds for hummingbird h bird. To date it serves 500 clients. It is a primary discharge for those discharged from zucker bird San Francisco. 30 are from the psychiatric services. This is a safe place to be other than is on the streets where they are the opportunity to engage with staff and be offered services and hopefully willing to accept the services at some point. Next i will review the communication about the arf plan. On july 22 of this year the union with affected staff by this change was neverred and offered the ability to meet with management to discuss the plan. That meeting to discuss occurred this morning at 11 00 a. M. After months of trying to schedule the meeting. Staff and the arf were informed by myself, kelly and linda, the manager of the health center, when we went to the 7 00 a. M. And 3 00 p. M. Shifts to explain to staff what the plan was for keeps 14 bedses on the first floor and relocating 18 residents upstairs. Despite the amount of controversy on this issue. We did not do a sufficient job in communicating the issues involving the arof and proposed change. Going forward we will do better. Where are we now . As the director stated in his report, changes are on hold while the mayor and board of supervisors talk about how to proceed in a way that accomplishes our shared goals. In addition, as always, residents have a choice where they choose to be. If any of the current residents prefer to move upstairs to qualify for of 0 years of age and older. We will accommodate their request to move if they solution. No staff are losing their jobs and that we are committed we will take no further action until the city leaders deliberate this issue and come back with more directive. We are recognizing there needs to be changing in the operation of the arf and other presumes. We are developing a corrective action plan for the arf and we will present that to director colfax. In that Performance Improvement plan, we will make sure that Resident Safety is our top priority and that we also address the issues in terms of Workplace Culture of the a rf so we can improve the operation for our staff and our clients. That concludes my part of the presentation. I will make myself and kelly available to hopefully answer questions you may have. I would like to recognize and invite supervisor ronan to come speak to us. Thank you for having me. It is a pleasure to be back. It was very important for me to come here today and urge you all to get more involved in this situation. I have to say it has been incredibly disappointing from the getgo, and i am here mostly to support the workers of the adult residential facility. I tabled with you that i feel of the Mental Health crisis that is taking place in our streets every single day. I dont know about you. I travel through the mission right by general every day. Every single day i see people often with half naked with hospital bracelets still on that are muttering, screaming, clearly just out of the hospital that are severely mentality ill. We are losing the facilities at rapid rates and where the citys only public run facility able to take care of the sickest individuals is also expanded. Iit is not acceptable. These problems have been lapping for the past five years. Where has been the leader ship on the part of management . All i have heard is blaming workers for problems. When there are conflicts on my staff, people are not getting along, mistakes are made. I dont blame them. I am the manger. I set up new systems. I correct it so so i can function with my main job of representing the people of San Francisco. Na should have been going on in the arf for the past five years. Instead despite reports showing corrective action plan in place, the decision to close the facility at the aim time the mayors tom priority is to deal with the crisis on the street. It is so glaring i dont understand how this is happening in our city. I am angry. I dont understand where the leadership is to act with the urgency i have. This is not the dbm that runs the lost innovative programs in the country. This is not the one that led on violence prevention. We are failing the workers who take care of them every day. I hope you are reading the press. Reading the excellent journallism especially at the local. The art chemdetailed step by step what happened. One of the most disturbing aspects is that there were 11 conserved individuals. I have been talking to their public defender. They were languishing in jail, some for over nine months waiting for a for the problems of management. They have been languishing in jail. When their public defender got fed up and said this is ridiculous, i cant get answers, i am going to sub the department of Public Health. All eight are in beds out of jail. Some lang winninged for 8 months. This is a scandal of the highest proportion. People are waiting in jail so desperately i ll we cant find a bed for nine months until they come to Court Everything i am angry. This is the most humane i have seen. All i have seenence i called the mayors office. We it is by our plan. We have staffing issues and blame the workers. It is not good enough. We have got to do something to get those beds up and running. We are talking about hiring 12 more workers. In two years the department of Public Health doesnt have that capacity so that mentality i ll people can get the care they need. Is that the department we are running in the city these days . I have brought copiesna i introduced when this was happening. Directs the department of Public Health to open beds. Directs the department of Human Resources to take over management of the arf and provide some professional management and staff hires to get this facility up and running and serving the people dying in jails and on the streets every day. I implore you to act with the urgency the workers have and i somewhere on the board of supervisors that most of my colleagues that is lacking the vision and leadership to take care of the crisis on the street. Join us and act with that level of urgency. It is morality and an issue of life and death. Thank you. applause . Before the Department Responds to the repor. Reporter we will have from the speaker, would you add here to the timer it would be helpful to folks behind you and gives us an opportunity to hear from everybody who wants to speak. I thank you in advance a apologize for anybodys name i ruin. I will start with first five. Patrish an shaallen, patricia, jennifer, doctor palmer, janette cooling, i believe. I cant read the writing. I stay at the arf facility. I dont think they should close it down. That is my place of living. I have been there for five years along with my other clients there. I feel that the arf shouldnt be closed down. Thank you. Thank you, ms. Allen. Good afternoon. I am a Mental Health worker at the facility also known as arf. I want to thank you. Thank you so much. I dont have anything to say because supervisor ronen said everything i will agree with what he is saying. I is agree with her. I came to the arf to the Mental Health and living en independeny in the community. It is in the hopes of enabling them to get back into the community. Some clients are able to move to lesser care. Unfortunately, a majority of clients are in need of Constant Care and attention. The ones that need the most care received eviction on august 19. We have an established program serving the needs of San Francisco adult Mental Health population for the last 14 years. Instead of building on the program and increasing beds, the program has been losing beds. Not because of thee