Health Commission hears Laguna Honda recertification update, approves revised policies amid public outcry

Acting CEO Roland Pickens told the San Francisco Health Commission on Jan. 17 that Laguna Honda Hospital submitted a draft action plan to the Centers for Medicare & Medicaid Services on Jan. 6 and has asked CMS to extend a pause on involuntary resident transfers that was due to end Feb. 2, 2023.

The action plan, Pickens said, grew out of a root cause analysis conducted by the Health Services Advisory Group and contains eight broad categories and hundreds of corrective milestones aimed at recertification. "That action plan represents our new blueprint for how we will accomplish recertification," Pickens said during his presentation.

Pickens reviewed the settlement terms with CMS, noting that CMS is conducting unannounced monitoring surveys every 90 days; the first monitoring survey began in late November 2022 and concluded Dec. 16. He said Laguna Honda had received the survey report (a form 2567) on Jan. 9 and had submitted required corrective plans to CMS and to the California Department of Public Health (CDPH).

The presentation addressed CDPH findings related to post-transfer deaths. Pickens said CDPH issued Class B citations after reviewing 12 former Laguna Honda residents who died after transfer; he emphasized the department "does not agree with all the allegations" and that Laguna Honda had initiated an appeal. "Those CDPH citations did not find that Laguna Honda caused serious harm or was the direct or proximate cause of any resident's death," he said.

Public commenters pressed for greater transparency, repeatedly asking the department to release the root cause analysis, action plan and the revised closure plan submitted Dec. 21. Several callers alleged that transfers were tied to resident deaths and cited varying counts (callers referenced 11–12 deaths) and timing analyses; others demanded that the commission prevent further transfers and provide a list of capital projects tied to recertification. Dr. Teresa Palmer said the public had been "concealed" from seeing key documents and urged their release.

Commissioners asked for clearer, ongoing metrics. Pickens said dashboards and revised key performance indicators are being developed and a draft will be reviewed with Director Colfax imminently. "We will be reviewing our first draft of those revised key performance indicators tomorrow...and begin to reproduce that same report that we previously supplied," he said.

The commission then considered a voluminous package of Laguna Honda policies, many updated to comply with CMS Phase 3 regulations—including expanded definitions of restraints, revised admission and discharge planning language for people with behavioral health and substance use disorders, and training and onboarding processes for staff. Pickens said roughly 44% of the policies were updated to meet Phase 3 requirements.

Commissioner Chao moved to approve the Laguna Honda policies; after a second and roll-call vote the motion carried. Secretary Morwitz announced the item as approved and commissioners publicly thanked staff for the work involved.

What happens next: Laguna Honda officials said they have requested CMS exercise discretion to continue the pause on transfers while the action plan and related materials undergo CMS review. The settlement agreement identifies May 13, 2023, as the date by which action-plan milestones must be completed; Pickens said the department is implementing the plan now regardless of CMS approval. Commissioners asked staff to publish regular progress dashboards and to return with updates.

Authorities and clarifications: The presentation and discussion repeatedly referenced the settlement agreement with CMS, CMS monitoring surveys and CDPH citations and appeals. When commenters or staff cited counts of deaths, fines or citations, the commission record reflected differing claims in public comment and the department's response that it disputes some citation findings and has filed appeals.

Ending: Following the vote approving the Laguna Honda policies, commissioners moved on to other business. The commission left open the question of whether CMS will extend the transfer pause; staff said they will keep the commission and public informed of CMS's response.