Laguna Honda interim CEO outlines 460‑milestone plan to win CMS recertification; CMS pauses involuntary transfers

Roland Pickens, interim CEO of Laguna Honda Hospital, told the San Francisco Health Commission that the hospital and a CMS‑approved Quality Improvement Expert (Health Services Advisory Group) have put in place about 460 corrective milestones intended to address deficiencies identified during surveys that led to decertification.

"All 126 milestones for the month of January were met," Pickens said, and he added the hospital expects roughly 130 milestones due in February as part of the settlement agreement’s timetable. He said Laguna Honda submitted an action plan on Jan. 6, revised that plan after CMS feedback and the first 90‑day monitoring survey, and re‑submitted a revised action plan on Jan. 31 and an updated closure plan on Feb. 2; both remain under CMS review.

Pickens told commissioners the 460 milestones are distinct from CMS regulatory "tags" assigned to findings. He said the first 90‑day monitoring survey cited 66 tags with an aggregate risk score of 796; the hospital’s goal is to drive that score toward zero by May 13 by documenting fixes to each cited tag.

Pickens also described efforts to rebuild Laguna Honda’s leadership team. DPH human resources and CFO Greg Wagner are pursuing an executive search firm from the city’s approved vendor list, with a target to have a firm secured by March 15, begin a nationwide search March–April and interview candidates starting May 1. Five top leadership positions (nursing home administrator, two assistant administrators, director of nursing and medical director) are posted on the city recruitment site and applicants will be referred to the search firm.

Pickens said interim leaders are being supported by external consultants and DPH clinical teams — for example, a wound‑care leadership team from Zuckerberg San Francisco General Hospital — while permanent hires are pursued. He emphasized that the hospital is continuing work on its action plan internally “as if” documents will be accepted, because time is of the essence.

Public commenters raised concerns about persistent safety and quality issues. A caller identified as Patrick said Laguna Honda had numerous scope‑and‑severity findings across surveys and urged expedited hiring of an experienced skilled‑nursing administrator. Dr. Teresa Palmer asked the Commission to produce the legal citation referenced at a prior Board of Supervisors briefing that, she said, would allow Laguna Honda to "grandfather" rooms and avoid a 120‑bed reduction; Pickens’ presentation noted the city had sought related clarifications from CMS.

The Commission’s discussion centered on how milestones map to CMS tags and the relative weight of different regulatory citations. Pickens reiterated that milestones are the operational tasks to address themes identified in the root‑cause analysis while the CMS tags and their point scores are the regulatory measures used in the 90‑day monitoring surveys.

The presentation included no formal vote; commissioners thanked staff for the update and requested continued reporting and documentation of CMS responses and recruitment progress. The Commission also noted the Feb. 1 CMS agreement to pause involuntary discharges from Laguna Honda, which Pickens said allows staff to concentrate on remediation rather than transfers.