Among unaddressed conditions that were cited by the Centers for Medicaid and Medicare Services of the LBJ Hospital in its follow up survey of last year is that LBJ did not ensure that the medical director responsibilities included quality assessment and performance improvement.
The medical director is Dr. Iotamo Saleapaga
LBJ CEO Taufetee John Faumuina Jr,. was informed in an April 27th letter that based on a second revisit survey of the hospital’s end stage renal disease facility, on December 4, 2015, CMS has determined the LBJ facilities no longer meet requirements for participation as an ESRP facility in the Medicare Program established under the Social Security Act.
LBJ has had to submit a correction plan to CMS to address outstanding deficiencies, dating back to their 2013 visit.
The federal agency says if this plan of action is not submitted timely or is not to its satisfaction it will initiate a process which may result in termination of LBJ’s Medicare approval for coverage of Endstage Renal Disease Facility at midnight on October 31st, 2016.
CMS certifies hospital and health care facilities in order to participate in the Medicare program which pays for medical treatment and services for eligible Social Security clients.
According to the CMS report, the Medical Director did not participate in the development or review of patient care policies and procedures regarding unstable patients, and did not ensure that all policies and procedures relative to patient care infection control, and safety were all adhered to by individuals treating patients in the facility.
CMS said the cumulative effect of these systemic practices resulted in the failure of the facility to provide care and services in accordance with regulatory requirements under responsibilities of the medical director.
According to the CMS report out last month, during an interview on December 4, last year the medical director stated he participated in quality assessment and performance improvement program when he was on island which was every other month.
When on island, he conducted meetings and reviewed information from his visits.
But said CMS, a review of patient clinical outcomes from May to October 2015 revealed lack of documentation of any meeting minutes outlining the agenda, list of participants and any discussions made.
Also there was a lack of indication to show participation by the medical director in any review conducted regarding the quality indications, the monitoring of stats on a continual basis, development of action plans and assessment of the effectiveness of action plans.
The federal agency also points out that there’s no indication of close communication between the medical director and governing body of LBJ.
It says there was lack of documentation that the governing body through the medical director was being apprised about the status of quality assessment and performance improvement activities, prioritization of indicators selected for monitoring and of any performance improvement to address, for example, staff shortages against an increasing patient census which had increased by 33% in 2010.
CMS also documents that the medical director did not participate in developing, and periodically reviewing and approving a patient care policies and procedures manual for LBJ.
It said the hospital did not develop a list of unstable patients ,including patients with extended or frequent hospitalization, marked deterioration in health status or unmanaged and inadequate dialysis.
Also the medical director did not ensure all policies and procedures relative to patient care , infection control and safety were all adhered to by individuals treating patients.
The report lists examples of questionable treatment regimes for dialysis patients.
LBJ submitted its correction plan on time last Thursday and is now awaiting a response from the CMS.
