Medicaid non-compliance issues at LBJ surface during House hearing

Pago Pago, AMERICAN SAMOA — Based on a careful review of the findings of a full Federal recertification survey completed on September 23, 2019 by the Centers for Medicare and Medicaid Services (CMS), it has been concluded that the LBJ Tropical Medical Center is still not in compliance with the applicable Conditions of Participation under 42 code of Federal Regulation (C.F.R) Part 482 for a provider of hospital services in the Medicare program established by Title XVIII of the Social Security Act.

This was part of a Nov. 5, 2019 letter from the CMS to the LBJ former CEO, Faumuina Taufetee Faumuina. The letter was signed by Paula Perse, Manager for Certification and Enforcement for CMS.

The letter surfaced at the House Health committee hearing this past Monday and several lawmakers voiced their concern about the letter that cited LBJ was still not in compliance with CMS standards and rules, which can affect the Medicare program for many people in the territory.

It would seem that none of the LBJ members of the board of directors at the hearing knew if the non compliance issues had been corrected, as they left the hearing assuring faipule that they would look into this matter and inform them (faipule) if they have any findings.

Vice Speaker of the House, Hon. Fetu Fetui Jr told the LBJ board during Monday’s hearing that the issue of LBJ non-compliance with CMS requirement is not a new issue, and it appears that the 2019 letter had just surfaced when the new acting CEO and board of directors chair came onboard.

“I don’t want our LBJ hospital to face the same problem we faced many years ago where these federal programs were frozen due to the non-compliance. These federal programs benefit our people and we want our hospital to continue to have these federal programs,” Fetu told members of the LBJ board of directors.

Due to the fact that this letter was almost three years old, lawmakers wanted to know whether there was an attempt by LBJ to fix the problem of non-compliance, and is it now in compliance.

THE LETTER

According to the letter, the recertification survey of LBJ Tropical Medical Center completed on July 30, 2010 and August 3, 2010 — documented non-compliance with nine (9) CMS standards.

CMS notified Faumuina of these findings by a letter dated Sept. 22, 2010, followed by a full survey, which was completed on June 20, 2014. This was the survey that documented the 9 non-compliance Conditions of Participation (CoPs)

A Medicare revisit survey was conducted on Dec. 11, 2015, which documented there was still non-compliance with the nine CoP.  A second revisit survey was conducted Jan. 27 ,2017 and documented non-compliance with six (6) CoPs. A third revisit survey conducted on Mar. 29, 2018 documented non-compliance with five (5) CoPs

“In a letter dated May 18, 2018 you were informed that based on the findings of a Sept. 23, 2010 full recertification survey and the continuing non compliance with the requirements LBJ Tropical Medical Center’s Medicare provider agreement could be terminated if the facility did not come into compliance with the Medicare CoPs,” the letter said.

This survey demonstrated that LBJ remains out of compliance with the following CoPs:

Governing Body, Patient Rights, Quality Assessment and Performance Improvement (QAPI), Nursing Services, Medical Record Services, Food and Dietetic Services, Physical Environment Infection Control and Surgical Services.

The findings of the full recertification survey are set forth in three Statements of Deficiencies including;

Full Health, Life Safety Code and Emergency Preparedness.

To participate in the Medicare program, a hospital must be in compliance with each of the applicable regulatory CoPs for hospital.

Because LBJ is not in compliance with all CoPs, it could result in termination of the LBJ provider agreement on May 31, 2020 to provide LBJ more time to achieve and maintain compliance.