LBJ Medical Center board member, Rep. Faimealelei Anthony Allen yesterday confirmed to Samoa News that hospital CEO Joseph Davis Fleming and chief medical officer Iotamo Saleapaga will be presenting their corrective “action plan” to the hospital board during a meeting tomorrow (Wednesday.)

He explained this action plan followed an unannounced visit more than a week ago by officials from the U.S. Center for Medicaid and Medicare (CMS) San Francisco Region office who were conducting a survey for Medicare re-certification.

Faimealelei said the hospital was cited for a shortage of nurses in certain clinics, including the dialysis unit.

“This is one of the biggest problems— the shortage of nurses— and this is the same issue that the hospital was cited (with) before back in 2012 and yet the previous administration did not address these issues, they just neglected these important citations,” he said.

“We have tried to address these same issues since we (the current hospital board) took over nine months ago, but with limited timing it’s very difficult to work on these issues.”

Faimealelei promised that a copy of the corrective action plan will be provided to Samoa News so the public can be made aware as to what the hospital is doing to address the cited issues—but he couldn’t immediately provide details.

Samoa News understands that the CMS inspection led the hospital board to call an emergency meeting over the weekend, where hospital officials were told to come up with an action plan to address the issues cited by CMS for tomorrow’s board meeting.

Information received by Samoa News last week states the CMS’ Survey and Certification Division conducted the survey and the team issued an "immediate jeopardy" status for LBJ, which means it has to come up with a corrective action plan within a certain time period. 

Davis-Fleming has yet to respond to Samoa News e-mail questions sent last week about the CMS survey and the CMS findings.

Responding to Samoa News questions, CMS regional spokesman Jack Cheevers could only confirm last Wednesday that CMS was—at the time—conducting a survey of LBJ, adding that this is called a re-certification survey, which all Medicare-certified hospitals must undergo periodically in order to maintain their Medicare certification.

“We can’t discuss the survey while it’s underway,” he said via email from San Francisco, but he did explain that once the survey is completed, the CMS surveyors will write their report, and it will be reviewed internally.

When that review is complete, CMS will send the survey report to the hospital and a cover letter outlining the survey findings and any related enforcement actions will accompany the survey report.

“We can’t discuss these documents until they become public. The cover letter becomes public on the date when we confirm that it was delivered to the hospital. The survey report becomes public either 30 days after it was delivered to the hospital, or when CMS receives a plan of correction from the hospital, whichever comes first,” Cheevers said.

NEXT BOARD MEETING

Faimealelei told Samoa News that aside from the ‘action plan’ the hospital board would be conducting a vote regarding a hospital official.

 “Each hospital board member was told to conduct their own evaluation of this certain hospital official and that the hospital board will act on this position on Wednesday,” he said, but didn’t identify the hospital official by name although Samoa News understands it is the CEO Joseph Davis Fleming.

Faimealelei further stated, “Wednesday is the final disposition [of the official], because something has to be done. Otherwise, what’s the use of the board being there when we’re not acting on what we know and learn about the hospital official?”

Click on attachment to download a PDF from CMS on guidelines in determining “immediate jeopardy” status.

Samoa News reporter Fili Sagapolutele contributed to this story.