Historic Reversal

In April 2022, The Centers for Medicare & Medicaid Services removed federal beneficiaries from Laguna Honda Hospital & Rehabilitation Center. The historic San Francisco facility has 769 licensed beds across 13 nursing units spread across unkept and neglected buildings. The facility repeatedly failed to meet the standards after four substandard surveys that raised questions regarding staff training and competency, infection control prevention, and neglect.

CMS issued a move-out order. The public was outraged over the deaths that resulted from the eviction. The agency then decided to pause involuntary discharges and transfers. Barb Averyt, senior executive director for Health Services Advisory Group, said, “They weren’t paying attention to the signs and the cues and the rules to guide them to safety,” during a discussion on the facility’s recovery.

Averyt stated that the biggest obstacle during this was that the staff was not resident-centered in their approach during their care. Many used an acute-care
mentality in their jobs while serving long-term care residents. The high population at Laguna required high levels of care that went above basic nursing home care.

Currently, the facility is a city-operated home for people with substance use disorder or complex medical and behavioral health needs. Admissions have remained halted because of the lack of Medicare coverage.  Getting the facility back on its feet and the right path meant bringing in additional workers and ones whose leadership will allow the facility to thrive.

The Health Services Advisory Group worked with the San Francisco Health Network to complete unit rounding and interviews with staff and residents. After the interviews, it was clear that the facility needed to realign its management. In addition to bringing in extra leadership, the team created a mentor program. This mentor program offers weekly training on issues like wounds and other recurring patient concerns. This program will also help find ways to get middle managers engaged with the frontline staff.

A San Francisco Health Network chief quality officer, Troy S. Williams, outlined a plan to “hardwire” a transformation that began earlier with the Consistent Care at the Bedside Monitor program. This transformation brought in DON consultants who worked with each unit’s care managers to coach them while reporting patient safety concerns to the chain of command. This transformation supported recertification initiatives, including survey readiness, improving direct care staff observations, the delivery of action plan milestones, and education on fire and life safety.

Last year, Laguna Honda was recertified by Medi-Cal. Shortly after this recertification, city leaders authorized the spending of up to $28.4 million on emergency renovations, which officials said were still needed for Medicare compliance, while the Medicare recertification remains under review. At the last survey in December, the facility had 15 findings, none significant or rose to Immediate Jeopardy. The article says:

 “Laguna Honda is part of the fabric of San Francisco. We could not fail.

There was no use in doing it if we’re not going to continue to sustain it.”