Help Save 120 Beds at Laguna Honda Hospital in San Francisco

Petition to:
Dan Bernal, President, San Francisco Health Commission, and
Supervisor Aaron Peskin, President, San Francisco Board of Supervisors

Summary of Petition:

After 13 years of successful operation, San Francisco asserts it was asked to eliminate 120 of its skilled nursing beds.  San Francisco’s Laguna Honda Hospital — a city-owned skilled nursing facility for elderly and disabled medically indigent (poor) San Franciscans relying on Medicaid as their payor source — was rebuilt and opened in 2010 when three-person suites sharing a single bathroom met then-Federal standards.

And when the architects designed LHH’s replacement hospital that opened just 13 years ago in 2010, the three-person suites had been pre-approved by California’s Office of Statewide Hospital Planning and Development (OSHPD, subsequently renamed “HCAI”) as being compliant with California’s building standards codes for hospitals.  The rooms occupancy didn’t become an issue until late Summer, 2022, following LHH’s decertification on April 14, 2022.

The facility houses San Francisco’s most vulnerable patients. 

This petition seeks to save 120 single-person rooms in the three-person suites totaling about 15,000 square feet of space (averaging 125 square feet per bedroom).  The 120 single-person rooms in the three-person suites were allowed to share a single bathroom when the hospital was rebuilt.  But CMS adopted a rule six years later in 2016 saying only two people could share a single bathroom.

Each bedroom in the three-person suites averages 125 sq. ft. (45 sq. ft. larger than the 42 CFR §483.90 regulation of 80 sq. ft.-per-resident minimum for shared rooms, or 25 sq. ft. larger than 100 sq. ft. for single-person rooms), has its own window, and has a sliding door into the shared hallway (not a curtain). 

Each bedroom is both large, and ADA compliant.  Each of the 120 suites have a 79 sq. ft. hallway between the bedrooms and bathroom,

That essentially makes them all private, single-person rooms, not shared bedrooms.  The issue of two-person rooms should essentially be moot, given LHH’s actual physical layout.

The construction standards at Laguna Honda are considered among the best in the industry.

CMS is trying to force Laguna Honda to leave one room in each three-person suite empty — at least 15,000 square feet of space that would go unused — so that there are only two residents per bathroom.    San Francisco would lose 120 beds that have been used uneventfully for over 13 years.  Those rooms and beds are desperately needed for our county’s most vulnerable people given a sever shortage of such beds.  This is a terrible outcome of a potentially well-intentioned regulation.

The 120 rooms can be saved.  All Laguna Honda’s administration needs to do is submit a waiver, which California’s Department of Public Health (CDPH) has signaled it is willing to approve.  This petition demands that waiver request be submitted rapidly.

Additional Details:

San Francisco is facing the loss of 120 skilled nursing facility (SNF) beds at Laguna Honda Hospital by having to convert three-person suites to two-person rooms.  At the time the replacement hospital was designed and opened in 2010, three-person occupancy was allowed in SNF’s by the federal Centers for Medicare and Medicaid (CMS), and had been approved before the rebuild began.

On March 21, 2023, LHH’s acting CEO, Roland Pickens, testified (in part) to the San Francisco Health Commission that:

“[When] the 2016 Federal requirement that was put into place …  required ‘newly-certified’ facilities to have no more than two residents per room in a skilled nursing facility we shared our grave concerns … that Laguna Honda might be subject to complying with that, because to date that’s the best information we’ve been provided that we must comply [and eliminate 120 beds at LHH].  We continue to work with our Federal partners primarily through the City Attorney’s Office to pursue all avenues to make that the reality to be able to restore those 120 beds.  We continue that dialog on a continual basis.”

A public records request for a letter from CMS/CDPH directing LHH to eliminate 120 beds turned up no responsive records, meaning LHH has not been provided with a written order to do so.  Pickens previously claimed legislation was pending in the U.S. Congress to permit “grandfathering” of three-person rooms.  He was referring to proposed CMS rulemaking in 2019, which has since been approved.

Saving LHH’s Bed’s Only Requires a Waiver Request

42 CFR §483.90(e)(3)(ii), as of March 3, 2023 provides that survey agencies — in this case the California Department of Public Health (CDPH) — may permit and grant a variation on its number-of-patients-per-room rule when facilities request in writing an exemption that the variation to 42 CFR §483.90(e)(1)(i) "will not adversely affect residents’ health and safety.”  Some SNF’s in California have obtained waivers allowing for four- to six-patients per “room.”

Given San Francisco’s severe shortage of SNF beds, the Health Commission and Department of Public Health claimed it would do “everything it can” to save LHH’s 120 beds.  But it hasn’t submitted a written waiver request to CDPH yet!  As LHH’s governing body, President Bernal and the Health Commission — and the Board of Supervisors — should take action and direct LHH and Mr. Pickens to submit a written request to CMS/CDPH seeking an exemption to CMS’ two-patients-per-room rule.

This petition asks Health Commission President Bernal and Board of Supervisors President Peskin to do “everything thing they can” to ensure a written waiver request to save the 120 beds at Laguna Honda Hospital is submitted to CMS/CDPH.

Severe Shortage of SNF Beds in San Francisco

Between May 1997 and August 2022, public records show San Francisco lost 1,381 SNF beds in county.  Losing 120 more beds at LHH will push that to 1,501 lost SNF beds, leaving only 2,161 remaining. 

"Prop Q” hearings are required when private-sector hospitals propose reducing or eliminating services they provide to the community.  Between 2002 and 2015, San Francisco lost 926 hospital-based SNF beds.

Those closures have been detrimental, resulting in massive out-of-county discharges for patients needing SNF level of care.

Unfortunately, closure of public-sector facilities — like LHH — aren’t covered by the “Prop Q” Ordinance, and their SNF beds can be closed without holding a public hearing before the Health Commission or the Board of Supervisors.

If LHH loses 120 beds, it will only have 660 remaining, half the 1,200 beds it had before 2010.  If we lose LHH’s 120 beds, more elderly and disabled low-income San Franciscans will be dumped out-of-county.  We can’t afford to lose these beds!  

Massive Out-of-County Discharge History

Between 2006 and 2019, SFDPH public records responses revealed 1,736 out-of-county discharges for SNF placement, based on very limited data from SFGH and LHH for 13 years, plus two private-sector hospitals — but only across two years.

In May 2022, the San Francisco Board of Supervisors passed Ordinance #77-22 requiring private-sector hospitals report out-of-county discharge data for patients discharged for both Sub-Acute SNF level of care, and SNF-level of care.  A new report issued on April 4, 2023 revealed there were 4,186 transfers and discharges of patients to out-of-county SNF’s alone across all San Francisco hospitals in calendar year 2022, and 4,185 such discharges in 2021 to out-of-county SNF’s.

LHH’s census in October 2021 of 710 patients has shrunk to 490 patients as of August 22, 2023.  That 220 patient census loss suggests new patients who could have filled those beds faced out-of-county discharges.

Help Save LHH’s 120 Beds to Prevent Out-of-County Discharges

Sign the Petition:  Urge the Health Commission and Board of Supervisors to Submit a Waiver Request to CDPH!