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Laguna Honda reports sharp drop in survey findings as city pushes for CMS recertification
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Summary
Laguna Honda Hospital leaders told the San Francisco Health Commission that federal monitoring surveys showed a reduction in deficiencies from roughly 124 to about 23, and city and hospital officials said they are working with CMS, CDPH and the city attorney to preserve beds and secure recertification. Commissioners and public commenters pressed for greater transparency and faster action on waiver requests.
Roland Pickens, acting CEO of Laguna Honda Hospital and Rehabilitation Center, told the San Francisco Health Commission on March 21 that the facility has made measurable progress toward regaining participation in Medicare and Medicaid after an April decertification.
"We continue to work hard to meet all the regulatory requirements, to make rapid improvements, on our path towards recertification," Pickens said, describing a multi‑component settlement and systems improvement agreement reached Nov. 10, 2022, with federal partners.
Pickens said the hospital engaged a CMS‑approved quality improvement expert and developed a corrective action plan with about 460 milestones. He described two recent monitoring surveys and said the second survey yielded roughly 23 preliminary deficiencies compared with about 124 in the first survey, calling that improvement "very significant." He also reported that the HSAG quality‑improvement expert verified completion of a set of monthly milestones, noting, "we successfully completed those 133 milestones."
The presentation reviewed actions taken to comply with a 2016 federal rule that limits skilled‑nursing rooms to two residents: Laguna Honda temporarily decommissioned the third bed in triple rooms, reducing capacity by about 120 licensed beds while leaving those beds on the facility license so they could be reactivated if accommodation is obtained.
Pickens said the hospital has submitted a revised closure plan to CMS and CDPH (resubmitted Feb. 2) and is awaiting a response. While the revised closure plan remains under review, he said transfers and discharges remain paused, and the hospital is pursuing every avenue through the city attorney and federal partners to restore the beds.
Public commenters pressed for faster action. Patrick Monet Shaw told commissioners the city attorney should immediately file a written waiver request under applicable federal rules to preserve triple‑occupancy rooms and avoid displacing residents. Another caller, identifying as Dr. Palmer, urged greater transparency and public release of the second survey’s findings so community members can help advocate for any needed CMS extensions.
Commissioners sought clarity on timing and protections for residents. Commissioner Chow noted the risk of last‑minute determinations and urged the department to develop contingency plans well before mid‑May, the window during which Pickens said additional monitoring and funding extensions have been discussed. Director Grant Colfax and Pickens said the city is actively advocating with federal partners and that monitoring surveys will continue on a roughly 90‑day cycle.
The commission’s Joint Conference Committee earlier recommended several Laguna Honda policies that were later approved on the consent calendar. Pickens said the facility has increased on‑the‑ground quality‑improvement activity and that progress has been measurable, but he cautioned that work continues and the bar for the next monitoring visit will be higher.
What’s next: Laguna Honda expects another 90‑day monitoring survey within approximately three months of the most recent visit, and the commission said staff will continue to press federal and state partners for timely responses on the closure plan and any waivers involving triple rooms.
