Laguna Honda
A 2020 aerial photo shows the sweeping layout of Laguna Honda Hospital & Rehabilitation Center in San Francisco. The skilled nursing facility has been working to regain Medicare certification for two years. Credit: San Francisco Chronicle/Hearst Newspapers via Getty Images/Contributor
Laguna Honda
A 2020 aerial photo shows the sweeping layout of Laguna Honda Hospital & Rehabilitation Center in San Francisco. The skilled nursing facility has been working to regain Medicare certification for two years. Credit: San Francisco Chronicle/Hearst Newspapers via Getty Images/Contributor

BALTIMORE — Two years after federal officials stripped the nation’s second largest nursing home of its Medicare and Medicaid certification, officials have outlined the 960-step plan it took to walk it back from the brink of closure.

The Centers for Medicare & Medicaid Services revoked Laguna Honda Hospital & Rehabilitation Center’s ability to serve federal beneficiaries in April 2022 due to four substandard surveys that raised major questions about staff training and competency, patient-centered care and infection control efforts. 

The facility repeatedly failed to meet requirements of its plans of correction, and CMS issued a move-out order.

But following public outrage over the deaths of several residents soon after eviction, the agency agreed to pause involuntary discharges and transfers. And behind the scenes, long-needed resources started pouring into the historic San Francisco facility whose 769 licensed beds were split across 13 nursing units in multiple, often unkempt buildings. 

“It takes a lot to become decertified. It takes years and years, and at Laguna Honda, maybe a decade,” said Barb Averyt, senior executive director for Health Services Advisory Group, a CMS-backed Quality Improvement Organization that has served as a hired consultant at Laguna Honda since its recertification efforts began.

Averyt led a discussion on the recovery at the CMS Quality Conference on Wednesday, accompanied by her executive director, an executive from the San Francisco Health Network and the acting director of the CMS regional survey office.

“They weren’t paying attention to the signs and the cues and the rules to guide them to safety,” Averyt said, sharing photos of extra beds and equipment crammed into common areas, blocking resident access; contaminated laundry; and latex gloves shoved beneath a sign that said not to put gloves there.

The biggest obstacles, Averyt and others said, were that staff didn’t appear to be resident-centered in their approach, and many took an acute-care mentality to their jobs while caring for long-term care residents. The population at Laguna required tactics that went above and beyond basic nursing home care, too, Averyt added. 

Carrying on its early almshouse legacy, the facility has become a city-operated home for people with substance use disorders or complex medical and behavioral health needs; 40% were under age 65 at the time of decertification. Admissions have remained halted without Medicare acceptance.

Focus on leadership

Getting the facility on the right path again meant bringing in additional workers, and ones who could help return leadership to the floundering buildings. To help identify areas of need, Health Services Advisory Group worked with the San Francisco Health Network to complete routine unit rounding and interviews with staff and residents.

It was clear the facility needed to realign its management, said Keith Chartier, DrPH, of HSAG. Laguna Honda had no nursing home administrators nor did it have a director of nursing.

“They’re really the ones who guide compliance efforts every day,” Chartier said, adding that the building had a poorly functioning quality improvement program that rarely involved frontline clinical staff even after years of struggle.

In addition to bringing in extra leadership resources from the city, the team created a mentor program, offered weekly training on issues such as wounds and other recurrent patient concerns, and other ways to get middle managers engaged with their frontline staff.

Troy S. Williams, chief quality officer with the San Francisco Health Network, outlined an effort to “hardwire” transformation that began with the Consistent Care at the Bedside Monitor program. It brought in DON consultants to work with each unit’s nurse manager, coaching them and also reporting patient safety concerns up the chain of command.

That supported recertification initiatives including survey readiness, improving direct care staff observations, delivering on action plan milestones and educating about  fire and life safety. Among some of the goals achieved: reducing use of restraints from 700-plus devices used due to “lack of expertise” to 20 deemed “necessary” for specific patients; a 33% reduction in pressure ulcers; and improved meal tray accuracy for resident satisfaction and nutrition needs; and replacing the 30% of hand sanitizer dispensers that were broken.

To keep the focus on maintaining such gains, the facility has now hired an administrator, two assistant administrators, two directors of nursings and a new medical director — all of whom are versed in skilled nursing care and regulations.

Hitting milestones

Meanwhile, HSAG was developing the action plan and monitoring steps toward fulfillment of goals daily. They developed nine separate root cause analysis reports that were shared with staff and CMS, each initiated by the survey findings that came before decertification. That gave leaders 13 core areas on which to focus their efforts, and a final action plan went into effect in early 2023.

HSAG routinely held office hours for staff, an element Chartier said was a key to success. So was offering education using adult education techniques such as teach backs (where a patient shows that they understood what was just taught or shown), rather than just depending on digital training.

“If they didn’t buy in, change would never happen,” he said.

Last year, Laguna Honda was recertified by Medi-Cal, the state Medicaid program. Shortly after, city leaders authorized spending up to $28.4 million on emergency renovations that officials said were still needed for Medicare compliance, and Medicare recertification remains under review.

At its last survey in December, the facility had 15 findings and none were significant or rose to Immediate Jeopardy, the CMS official on the panel said. That’s meaningful in itself, given that a survey team of 25 might show up to conduct an inspection of a campus that size.

“Laguna Honda is part of the fabric of San Francisco. We could not fail,” said Williams, who insists a higher level of resources and programming will remain once Medicare coverage returns. “There was no use in doing it if we’re not going to continue to sustain it.”

Editor’s note: This story has been updated to remove an erroneous number of citations.