The Centers for Medicare and Medicaid has determined that the dialysis facility at the LBJ Hospital no longer meets the requirements of the Medicare Program.
The agency also found that the local hospital remains out of compliance with eight conditions for Medicare coverage:
- Patients Assessment,
- Patient Plan of Care,
- Quality assessment and
- Performance Improvement,
- Personnel qualification,
- Responsibilities of the Medical Director,
- Medical Records and
- Governance.
LBJ CEO Taufetee John Faumuina Jr,. was informed by the CMS in an April 27th letter that based on a second revisit survey of the hospital’s end stage renal disease facility, aka the Dialysis Unit, on December 4, 2015, CMS has determined the facilities continues to no longer meet requirements for participation as an ESRP facility in the Medicare Program established under the Social Security Act.
CMS certifies hospitals and health care facilities in order to participate in the Medicare program which pays for medical treatment and services for eligible Social Security clients.
CMS Manager Western Division of Survey, Certification and Enforcement Branch listed gave the history of CMS surveys of the Dialysis Unit from 2010 up to 2014.
In 2010 there were 7 non compliance conditions. A June 2014 revisit survey by CMS documented 6 non compliance conditions.
According to CMS, one deficiency found in the June 2014 revisit posed an immediate and serious threat to the health and safety of dialysis patients.
To LBJ’s credit, immediate jeopardy was abated on July 9, 2014.
But a December 4, 2015 revisit survey demonstrated that LBJ remains out of compliance with 8 conditions for coverage.
CMS said these deficiencies either individually or combined substantially limit the Dialysis Unit’s capacity to render adequate care or adversely affect patient health and safety .
The federal agency gave notice it was initiating 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.
But this could be avoided or postponed if within ten days of receipt of the April 27 letter, the LBJ submits a Plan of Correction documenting and demonstration correction of each deficiency.
LBJ was able to provide this plan on time yesterday.
CMS said upon receipt of this correction plan it will postpone the termination date to allow time to verify the corrections and further consult with the hospital as warranted,
The CEO was told that if an acceptable plan of correction is not received timely,CMS will notify him it will proceed with termination and issue public notice, payment limitation, the readmission process and appeal rights.
CMS spelled out that the plan must cite how each deficiency identified will be corrected, how the same deficiency would be prevented from reoccurring, procedures for implementing the plan, a timeline for the correction, monitoring and tracking procedures, and the name of the person responsible for implementing the correction plan.
The deficiencies and findings of non compliance cover 98 pages which are laid out in a graph like format with lots of white space on each page.
KHJ News requested a copy of the CMS report from the federal agency but Lt Venus Uttchin of the US Public Health Service, Division of Survey and Certification said yesterday the report is not yet releasable.
We were able to get a copy from other sources and will feature the findings in future bulletins.
In response to our questions about the report, LBJ CEO Taufetee John Faumuina said LBJ has reassured CMS of its commitment to providing the best healthcare for the people of American Samoa.
He noted this was the first time ever that LBJ submitted its corrective action report on time without asking CMS for an extension,
Asked if there any parts of the CMS report that LBJ disagrees wit, the CEO said “nothing at all.”
