Laguna Honda staff hailed as recertification nears; facility awaits CMS 2567 findings

San Francisco Health Network director Roland Pickens told the Health Commission that surveyors recently completed a Medicare certification review at Laguna Honda Hospital and resolved the majority of long-open cases, with "preliminary resolution showing 0 deficiencies." Staff expect to receive the official CMS 2567 statement of deficiencies any day and will have the usual 10-day turnaround to file a plan of correction with the California Department of Public Health and CMS.

Pickens described two survey components: a health inspection conducted Nov. 27'Dec. 1 and a fire, life-safety and emergency-preparedness review Dec. 4'7. He said 39 previously open cases were reviewed; surveyors resolved 34 during the on-site review. "So again, hats off to the staff at Laguna for doing all the work," Pickens said.

Laguna Honda's incoming chief executive and nursing-home administrator, Sandra Simon, presented the hospital's 2022'23 annual report, emphasizing the facility's role as one of the country's largest city-run skilled nursing facilities and noting that about 95% of residents are supported by Medi-Cal. She highlighted work to preserve resident-centered services, two large staff education "fairs" that reached more than 1,200 employees, and programs such as Art with Elders that connect residents with the broader San Francisco community.

Commissioners pressed leadership on next steps for resuming admissions and on preserving Laguna Honda's 120-bed waiver. Pickens said the August Medicaid certification survey met the regulatory "reasonable assurance" period and that the department plans to apply for the waiver once Medicare recertification is final: "We've maintained all along that we know the importance of those 120 beds...and so we have every intention, upon applying for the requisite waiver when we feel we'll be successful, to have that waiver received and hopefully approved."

Laguna Honda leaders also described quality-improvement steps taken during the recertification process, including a reduction in restraint use and a "consistent care at the bedside" (CCBM) initiative that assigned senior nurse leaders to each unit to provide frontline coaching. Chief Quality Officer Nasaneen Tlaai noted the facility's 500-milestone action plan submitted in May 2023 covering medication management, care plans and resident rights.

The commission and department leaders repeatedly framed the work as both regulatory and human-centered: commissioners praised resident stories presented in the annual report and emphasized sustaining reforms once admissions resume. The commission approved the related consent calendar items later in the meeting and moved into a closed session before adjourning.

The next procedural step for Laguna Honda is receipt of the formal 2567 statement and submission of a plan of correction; commissioners and DPH staff said they will return with updates to the Joint Conference Committee and the full Health Commission as those items progress.