The Center For Medicare & Medicaid Services (CMS) survey report, in its summary statement of more than ten violations of federal regulations at LBJ Medical Center, points to a ‘condition’ that must be met by the provider of Medicare & Medicaid services — which is that “the hospital must have an effective Governing Body that is legally responsible for the conduct of the hospital as an institution.”

According to the CMS report, “if a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.”

Samoa News should point out that the CMS report uses the term “Governing Body” and does not identify it as the LBJ Board of Directors. However, Samoa News notes the LBJ Board has conducted itself as a ‘governing board’ by being responsible for personnel hires and terminations, which includes medical doctors and the hospital’s CEO and CFO, as well as financial issues.

The report is the result of a surprise survey conducted by a CMS team from the San Francisco Regional Office in June this year of the LBJ Medical Center’s Dialysis Clinic and a full Medicare certification survey of the hospital.

According to the CMS Medicare report of LBJ, the CONDITION (their capitalization) — that a hospital must have an “effective Governing Body that is legally responsible for the conduct of the hospital as an institution” was not met, based on interviews and record reviews the CMS team conducted in June this year.

The survey lists 12 areas in which the governing body is deemed deficient, and notes it failed to do the following:

1.            “…to ensure that the categories of the eligible medical staff practitioners/ candidates were appointed to the medical staff”.

2.            “…to ensure that the medical staff was accountable” to the Board for the quality of care provided to the hospital’s patients.

3.            “…to ensure that the criteria for selection of medical staff membership included individual character, competence, training, experience, and judgment.”

4.            “…to ensure that the hospital had an overall institutional plan that provides for capital expenditures for at least a 3-year period.”

5.            “…to ensure that it promoted and protected the rights of the each patient receiving care and services.”

6.            “…to ensure the development, implementation, and maintenance of an effective quality assessment and performance improvement program.”

7.            “…to have an organized medical staff that operated under by-laws approved by the Governing Body and was responsible for the quality of medical care provided to patients in the hospital.”

8.            “…to have a Nursing Service that met the needs of the patients in accordance with acceptable standards of care and practice.”

9.            “…to ensure that the hospital was arranged and maintained in a manner to ensure the safety of the patient, and also provide facilities and equipment maintained in a manner to provide for the diagnosis and treatment of patients receiving services.”

10.            “…to ensure development of an active hospital-wide infection control program for the prevention, investigation and control of infections and communicable diseases of patients and personnel.”

11.            “…to have a discharge planning program that applied to all patients.”

12.            “…to ensure the safe and effective delivery of Respiratory Services” to LBJ’s patients.

BACKGROUND

Of interest is that the CMS revealed in its cover letters of its survey results that these violations of the Medicare program were first identified in 2010 but were never addressed.

According to two CMS letters — both dated Aug. 13 — addressed to then LBJ acting CEO, Taufete’e John Faumuina, the CMS is requiring LBJ to correct the violations, or face the loss of its CMS re-certification.

(Samoa News notes with the return of Mase Iakapo, chairman of the LBJ Board from an off-island trip, Mase is now the acting CEO of LBJ, as well as chairman of the Board.)

The cover letters about the surprise surveys indicate the seriousness of the problems that LBJ faces in that Steven D. Chickering, the Associate Regional Administrator for Western Division of Survey & Certification, writes that “mere plans of correction at some future date” or evidence of progress toward correction are not sufficient. And this applies to both the ESRD facility and full Medicare coverage.

Failure to meet corrective actions will result in termination of the LBJ Medicare provider agreement and ESRD coverage, the letters say.