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February 15, 2023

An Insider's Story — Part II

LHH's “Leadership” Boondoggle

A Twindemic Involving Restorative Care and “Leaders”

by Patrick Monette-Shaw

In its 157-year history, Laguna Honda Hospital (LHH) came dangerously close to being renamed a “social rehabilitation” facility in 2005 under the San Francisco Health Department’s then leadership.

In order to consider recertifying Laguna Honda Hospital, the Centers for Medicare and Medicaid Services (CMS) seems to believe LHH must be forced to join the California Association of Health Facilities (CAHF) and LHH staff must enroll to attend CAHF’s so-called “Leadership Academy” in the hopes it will help “install permanent leadership with appropriate experience in nursing home administration.”

To recertify the hospital, CMS also wants patients’ “restorative care” services at LHH fixed — again — after it had been an issue with the U.S. Department of Justice’s Civil Rights Division in 1998.

It was strange CMS zeroed in on requiring LHH to affiliate with CAHF, rather than, say, affiliate with the National Association of Directors of Nursing Administration of Long-Term Care [NADONA], which is a more traditional Skilled Nursing Facility (SNF) professional association. 

LHH’s recent past history of its clinical staff going through so-called “leadership” training hasn’t panned out particularly well.  Like any good boondoggle, LHH’s foray into leadership programs gave the appearance of having value.  In actuality it had little, or no, value.

Take for instance LHH’s clinical staff who chose independently (not as a facility or regulatory requirement) to attend a “Leadership Program” offered though the California Health Care Foundation (CHCF).

This article focuses on Mivic Hirose, who started her career with the San Francisco Department of Public Health working as a medical/surgical registered nurse at SFGH and rose through SFGH’s management ranks before she transferred to LHH, and eventually became LHH’s co-Director of Nursing before becoming LHH’s CEO; Lisa Pascual, MD, LHH’s then and still current Chief of Rehabilitation Services; and Paul Carlisle, a senior physical therapist in LHH’s Physical Therapy Department managed by Pascual.

The three amigo’s each attended the CHCF “leadership” training program.  Toss in Jennifer Carton-Wade, for good measure.

This is a story about the management training of LHH employees, and is expressly not a discussion about anyone’s clinical skills, experience, or qualifications.  It’s also about four public employees engaged in developing public policies in, and for, a public hospital.

LHH’s Restorative Care Program

Carlisle, who reported to Dr. Pascual, had been hired along with a highly-qualified Senior Occupational Therapist widely-respected by patients, and a Speech/Language Pathologist to develop a functional maintenance program in response to the U.S. DOJ Civil Rights Division’s 1998 concern LHH was providing substandard and inadequate care to its residents by not providing rehabilitation therapy services to prevent premature functional decline of patients on LHH’s long-term care wards.

His team developed a successful centralized “Functional Maintenance Program” (FMP) in LHH’s Rehab Services Department with a goal of preventing functional declines in patients’ health.  The program began as a proposal in December 1999 and was signed off on and approved in May 2022 by Pascual; LHH’s Chief of Staff, Dr. Paul Isakson; LHH’s Medical Director, Dr. Terry Hill; the Hospital’s Policy and Procedure Committee; Larry Funk, LHH’s CEO; and the then-Director of Public Health, Mitch Katz.

For unclear reasons, Dr. Katz demanded the FMP be rebranded and renamed as the “Restorative Care Level I” program with a companion ward-based Nursing Restorative Level II care auxiliary program in the patients’ residential units on nights and weekends to provide therapeutic modalities supervised by nurses.  The Level I and Level II Restorative Care programs were implemented in 2009 (contrary to dates listed in the two respective policies).

The two restorative care components initially implemented satisfied the DOJ, which closed its Civil Rights investigation.
The Level I program successfully acquired City budget approval to hire four additional therapy aides for the Level I restorative program.  Carlisle and his team won great respect within the hospital for the program’s accomplishments.  The Restorative Care Level I program was expanded over the years and currently has seven Rehabilitation Therapy Aides.

But sadly, the Nursing Restorative Care Level II program never really got off the ground, and was never really implemented or sustained long term. 

Carlisle left LHH employment in January 2012.  After he left, Jennifer Carton-Wade, a different Senior Occupational Therapist at LHH, became an “acting” leader as LHH’s Interim Director of Rehabilitation Services for just three years through July 2015.  Her LinkedIn bio shows she then resumed being a Senior Occupational Therapist for another year.  [The “senior” job classification title refers to therapists having certification in advanced treatment modalities, not employment longevity ranking.]

As the Westside Observer reported in July 2014, everything suddenly changed when under the watch of Carton-Wade the Restorative Level I Therapy Aides were transferred on July 1, 2014 from the centralized Rehab Services Department to the Nursing Department to be re-assigned on wards (“neighborhood” units), instead.  By then, Carton-Wade was thought to be a direct report to Dr. Pascual.

It wasn’t clear whether the Aides would continue providing Level I restorative rehab treatments as a ward-based program under the supervision of licensed Physical Therapy clinicians as they were hired for, or whether Nursing staff would provide the supervision, possibly in violation of State law.  It also wasn’t clear whether Level I rehab treatment modalities would be eliminated, potentially angering the DOJ’s Civil Rights Division and bringing on a new investigation of LHH.

During my tenure supporting the Rehab Department, the antipathy of some Occupational Therapy staff to provide patient care on LHH’s long-term care wards was painfully obvious, since therapists wanted to focus primarily on 60-day short-stay rehab patients, and not have to supervise restorative Therapy Aides’ treatments of long-term care patients. 

Occupational Therapy clinicians, in particular, were very annoyed that a weekly wheelchair repair clinic for LHH’s residents was being done near their O.T. gym.  According to documents submitted last December to CMS for LHH’s recertification, the wheelchair repair clinic has been reduced to monthly and only for facility-owned wheelchairs, contributing to LHH receiving State inspection citations involving residents becoming bed-bound for extended periods of time.

Why Pascual allowed the transfer of the Therapy Aides to LHH’s Nursing Department supervision in 2014 isn’t known.

Carton-Wade aggressively sought promotions and is currently an Administrative Director reporting to LHH’s interim (and currently vacant) Chief Operating Officer, some observers think way beyond her league.  She doesn’t hold a Master’s degree in Public Health (MPH) or in Public Administration (MPA).

By report, she’s thought to be now enrolled in a preceptor-supervised Administrator-in-Training program to qualify to take the Nursing Home Administrator (NHA) license exam, hoping to move even higher in LHH’s management echelon, where she would be poised to become a NHA or a CEO.

Five years after Carton-Wade transferred the program to Nursing, by 2019 the Level II Restorative Nursing program had unfortunately fallen by the wayside and essentially stopped functioning, with the Therapy Aides very frustrated by the demise of their programming.  It’s now been nine years since the program became ineffective in assisting LHH’s residents.

On February 8, 2023 the first “Root Cause Analysis” (RCA) report LHH submitted to CMS on December 1, 2022 (which CMS accepted on December 12) was released to the public.  The report had been written to identify the root causes of factors that had led to LHH being decertified in April 2022.  One of the factors in the “Resident Rights and Freedom From Harm” category of root causes was a “lack of formalized Restorative Nursing Program.”

The first RCA report noted [emphasis added]:

“LHH does not have a formalized restorative nursing program that was designed to improve or maintain the functional ability of residents.  This appears to be the result of ineffective communication between [Rehab Services Department] therapy and nursing, and restorative nursing program coordination.

During the height of the [COVID] pandemic, the [centralized] wellness gym [near the Rehab Services Department] was closed.  As guidance from CDC has been modified, the gym still has not been opened [as of December 2022], and no alternatives were identified.

LHH has a poorly defined reporting structure for the restorative nursing program, resulting in no ownership or responsibility to develop and maintain the program.

LHH does not consistently and regularly screen for declines in range of motion, balance, and activities of daily living.  LHH does not have appropriate follow-up actions for those identified in need of restorative nursing services.”

What a damning indictment that the Rehab Department formerly led by Carton-Wade and the Nursing Department feel no shared responsibility to maintain the restorative program!

In fact, as late as six months to 48 months (four years!) before LHH was decertified in April 2022, the Nursing Department was still quibbling about its “ownership” of the Restorative Nursing program.  In a November 2021 PowerPoint presentation first created on March 6, 2018 titled “Dedicated Restorative Nursing Program at LHH” the Nursing Department stooped to sniping about the Restorative Care Level I program and its predecessor Finctional Maintenance Program that the Rehab Services Department had implemented 20 years earlier in 2002, alleging that the two Restorative programs weren’t working in tandem, and that the two programs were a duplication of services with both programs working on the same goal. 

While it may be true the two programs were both designed to provide complimentary restorative services, what Nursing confounded was that each program was working on different restorative modalities, and were not duplicating therapeutic services.  The Nursing restorative modalities should be working on such things as urinary or bowel toileting training, passive and active range of motion daily exercises, splint or brace assistance, bed mobility and walking training, transfer training, and dressing, grooming, and/or eating and swallowing training provided by Nursing staff, not skilled Rehab clinicians.

The PowerPoint presentation created in March 2018 appeared to be a pitch for support for funding and additional staffing by Nurses or Certified Nursing Assistants.  Three years later, in November 2021 that funding apparently hadn’t been provided.  In response to a public records request for the name of the presentation’s author and the target audience for the presentation, SFDPH declined to answer, saying it isn’t required to respond to “interrogatories.”  The question wasn’t in relation to a lawsuit and didn’t require an answer under oath.  It wasn’t an interrogatory.  It was a simple media inquiry.  So much for LHH’s transparency with the public.

Matters worsened between March 2018 and December 2022 when the RCA was submitted to CMS, since no support had materialized, which is why LHH’s draft “Action Plan” based on the RCA also released on February 8 identified eight corrective actions that need to be taken to repair the Restorative Nursing Program and update its policies; review current restorative program job positions and descriptions to clarify staff responsibilities; screen residents to identify their restorative nursing needs; initiate training for restorative nursing staff on program components, job functions, and documentation requirements; and other remedial corrections.  The eight actions are part of the much larger 454 “milestones” listed in the full Action Plan.

None of this would have been necessary, had the initial Restorative Level I program not been abandoned and not mistakenly transferred out of the Rehab Services Department under Carton-Wade’s presumed and interim (clearly inexperienced) “leadership.”

Now, in order for LHH to regain its certification as a Medicare provider through CMS, one of the 454 “milestones” (corrective actions) it must meet is fixing the Nursing Restorative Care program that had gone severely missing in action in 2019 — around the same time that Hirose was stripped of being LHH’s CEO — or much, much earlier, say in 2014.

A Field Trip to “Leadership School”

I had supported Carlisle’s team in developing the Restorative Care Level I program’s documentation when I served as a secretary for a decade in LHH’s Rehabilitation Services Department between 1999 and 2009.  In addition to helping design and develop the Rehab Services Department’s Microsoft Access database, part of my duties was to proofread documents for clinical staff who were trained to be clinicians, not necessarily trained in writing or proofreading.

I also proofread the applications and edited the curriculum vitae of three LHH employees who had applied to the CHCF “Leadership Program” that purportedly offers clinically-trained health care professionals experience and skills necessary for effective leadership in health care systems.  CHCF is a separate lobbying and trade organization in California from CAHF.  The first three LHH employees who attended CHCF’s Leadership Program were Pascual (Cohort Class 1), Hirose (Cohort Class 2), and Carlisle (Cohort Class 5). 

Sadly — but predictably — Carton-Wade also attended CHCF’s “Leadership” in Cohort 11 between October 2011 and September 2013.  Nine months later, she facilitated transferring the Restorative Care Therapy Aides from Rehab Services to Nursing in 2014.  She’s also a transplant to LHH, having begun her City employment as an Occupational Therapist at SFGH between 2002 and 2010.

I distinctly remember helping Dr. Pascual develop a PowerPoint presentation she had to present to her Fellowship Cohort class members to graduate from the program.  As the theme of her presentation, she chose the Wizard of Oz with audio snippets of Wizard of Oz songs sprinkled in.

I wasn’t impressed with the “leadership” skills Pascual had learned.  What does “There’s no place like home” have to do with healthcare facilities?  “Could patients just stay at home for their healthcare?,” I kept wondering.

The Wizard of Oz was a terrible metaphor to have adopted.  The inherent irony seemed lost on her.

For his part, when Carlisle returned from his CHCF Fellowship spewing management nonsense when not gobbledygook left and right, staff in Rehab Services openly mocked him behind his back.  Before he was selected to the CHCF’s “Leadership Program,” he had already implemented Quality Improvement and Performance Improvement (QAPI) programs in all three divisions of the Rehab Services Department.  He had advanced Plan-Do-Study-Act (PDSA) as an iterative, four-stage problem-solving model used to improve processes to carry out changes throughout the Rehab Department and was seeing results.

Carlisle hadn’t needed CHCF’s Fellowship to teach him about QAPI methods or create the FMP/Restorative Care programs, although professional networking opportunities later materialized for him.

Apparently, Pascual, Carlisle, and most importantly, Carton-Wade didn’t learn in Leadership School to take ownership of the Restorative Care program that had initially been developed in their own Rehab Department.

For her part, Hirose was eventually ousted from LHH’s management team she had ladder-climbed to become LHH’s CEO, despite having become LHH’s second CHCF “Leadership Fellow.”   She was forced out in 2019 following the patient sexual abuse scandal at LHH after she had wailed about the lack of a “culture of safety” under her watch.  LHH’s sexual abuse scandal helped expose the “culture of silence” Hirose had fostered in lieu of a culture of safety. 

Her leadership style was a heavy-handed mix of intimidation of subordinates, expectations of maintaining silence, and retaliation against employees.  I endured an icy, haughty, closed-door intimidating interrogation from Hirose over something inconsequential and was well aware she had wrongly terminated Dr. Derek Kerr, which wound up costing the City over a million dollars between Kerr’s settlement agreement and the City Attorney’s time and expenses fighting Kerr’s wrongful termination lawsuit.

I barely escaped that interrogation without frostbite and my First Amendment rights intact.  I counted myself lucky I hadn’t become Hirose’s next wrongful termination victim.

Hirose, too, benefited immensely from her professional networking CHCF contacts.

History of LHH’s Social Rehab Grant

As CHCF leadership program graduates, Pascual and Hirose went on to submit an application to snag a “Leveraging Leadership” grant from CHCF only available to Fellows who had successfully graduated from CHCF’s Leadership Program.  I’m almost ashamed to admit I also had proofread, edited, and polished their grant application in 2004 to make it look more like a medical research project as I had been trained to do when I worked at the University of Illinois, which the grant wasn’t.  I remember chalking it up as putting lipstick on a pig.

The grant application in 2004 had a mouthful of a title befitting academic research projects, and was titled “Social Rehabilitation:  Changing the Culture to Close the Gaps in the Long-Term Care Continuum.”  It’s title belied its true intent:  To curry favor with the then-Director of Public Health, Mitchell Katz, MD.  Indeed, Pascual and Hirose had to have been aware of Katz’s focus on social rehabilitation, which explains why the term was incorporated into the title of the application, and helped their advancement in Katz’s orbit.

The grant application was accompanied by a letter of support from Katz himself, claiming it was vital for SFDPH to shift LHH’s skilled nursing care delivery model to a culture of social rehabilitation and community re-integration.

Of note, then Health Commissioner Jim Illig had helped found the California Association of Social Rehabilitation Agencies (CASRA).  Illig had said ever since Gavin Newsom had been elected San Francisco’s mayor that the role and mission of Laguna Honda Hospital was going to change, so it was no coincidence social rehabilitation programming was fast tracked for implementation and operationalization at LHH.  And it was no mere “political’ coincidence that the social rehab grant application Hirose and Pascual submitted to CHCF listed Illig’s colleague, Health Commissioner Roma Guy, as an advisory board member for the LHH social rehab pilot project.  Guy held a Master’s degree in Social Work and also served on the Health Commission during the period of Hirose’s grant.  Carlisle was appointed the unofficial, assistant grant coordinator role within LHH.

This is precisely what the LHH social rehab grant submitted to CHCF claims it was designed to do:  To teach people “self-care” activities.

Unfortunately, as I reported in 2007 before I ended employment at LHH, in 2005 a ruckus ensued over implementing a “psycho-social rehabilitation” model of care that had been exported to LHH by Mozietta Henley, RN, PhD who was shunted from the former Mental Health Rehabilitation Facility (MHRF) on the grounds of SFGH to LHH, toting along with her, her “BioPsychoSocialSpirtual” (BPSS) model of care proposal that was never tested — and never implemented — at the MHRF.  As such, it was an untested, unproven approach.  And it was never really implemented at LHH, either.

Henley’s model of care comically became the impetus for the small CHCF $50,000 grant Hirose was awarded for “Social Rehabilitation” along with my then-boss, Dr. Lisa Pascual, Chief of Rehabilitation Services at both LHH and SFGH — to curry favor with Katz.  Henley became a co-director of the grant along with Hirose.

Part of the problem was that the proposed model of care for the social rehab grant was initially developed — as stated in the response to CHCF reviewers concerns — as a BioPsychoSocialSpiritual (BPSS) model for residents of the MHRF.  LHH has never been licensed as a residential drug treatment facility, a residential mental health facility, or a residential social rehabilitation facility, so the grant’s programming was an inappropriate model of care for San Franciscans needing long-term skilled nursing care at LHH.

The grant essentially had nothing to do with the long-term care continuum, as Hirose and Pascual had claimed.  It was more focused on changing LHH’s culture to follow Katz’s dictum that following closure of the “Mental Health Rehabilitation Facility” (MHRF) on the grounds of San Francisco General Hospital, he wanted LHH to do short-term “social rehabilitation for the urban poor.”  Knowing Katz’s ulterior motives, Pascual and Hirose hitched their wagons to Katz to demonstrate their allegiance to him with their Social Rehab grant application.  [I was there, and saw it all.]

During 2004 and 2005, when the so-called “flow project” to move behavioral health patients from SFGH to LHH got underway due, in part, to the closure of the MHRF, LHH’s mission statement was changed to remove the term “long-term care” from LHH’s mission statement.  Then-Mayor Gavin Newsom had to step in, ordering the changes to LHH’s mission statement and admissions policy Katz had forced through be rescinded.

Katz was determined to re-orient LHH as being able to care for people with mental health issues.  He said at the time, “although it is not feasible today to move all people who need long-term care from the MHRF to LHH, the future larger LHH will offer ... the same kind of services as offered at the MHRF.”  Other documents around the same time showed LHH was intending to implement both a Social Rehabilitation program, and a separate Behavioral Health program at Laguna Honda Hospital; both programs were likely to further differentially displace San Francisco’s frail elderly and disabled in order to provide social rehabilitation and so-called behavioral health programs in their wake at LHH.

When word got out to the community about the Social Rehabilitation grant and changing mission of LHH, it created such an uproar that then District 7 Supervisor Sean Elsbernd was forced to hold what turned out to be a very contentious hearing at the Board of Supervisors City Services Committee under the guise of accepting the $50,000 grant from CHCF.

To be eligible for its “Leveraging Leadership” pot of funding, CHCF required grant applicants to obtain in-kind support contributions, which Hirose and Pascual obtained via San Francisco taxpayers.  Taxpayers wound up on the hook for an additional $88,000 in LHH employee salaries and fringe benefits to staff the grant project.

The grant ultimately proved to be a flop, and should have embarrassed CHCF for having awarded it.  Taxpayers were left in the dark about how their tax dollars were essentially being flushed down the toilet for the project.

Under such “leadership” — primarily by Katz, Illig, Guy, Hirose, and Pascual — taxpayers are probably lucky LHH wasn’t renamed as the “San Francisco Social Rehabilitation Facility” in 2005.

The question now is how soon LHH, the Health Commission, and the now Director of Public Health Grant Colfax will re-instate the Restorative Care Level I program implemented by Carlisle and his team 21 years ago in 2002 (initially named the Functional Maintenance Program), which was all but dismantled between 2014 and 2019 by Nursing, following “Leadership Fellow” Carton-Wade’s climb up LHH’s management ladder.

This is the sort of nonsense that emanates from graduates of “Leadership Academy’s.”  This can’t really be what CMS wants in the way of developing managers at LHH with appropriate long-term care nursing home administration experience.

And it’s certainly not the level of restorative care LHH’s residents deserve from so-called healthcare public health “leaders.”

Monette-Shaw is a columnist for San Francisco’s Westside Observer newspaper, and a retired City employee.  He received a James Madison Freedom of Information Award in the “Advocacy” category from the Society of Professional Journalists–Northern California Chapter in 2012.  He’s a member of the California First Amendment Coalition (FAC) and the ACLU.  Contact him at monette-shaw@westsideobserver.com.

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