OIG Issues Two Reports Identifying Medicare Hospice Beneficiaries at Risk of Harm from Hospice Deficiencies

On July 9, 2019, the US Department of Health and Human Services, Office of Inspector General (OIG) released two reports addressing hospice deficiencies and the risks, potential harm, and actual harm those deficiencies posed to hospice beneficiarie. 

The OIG found that from 2012 through 2016, more than 80% of hospices were cited with at least one deficiency in quality of care; 20% of hospices were cited with one or more serious deficiencies; one-third of hospices had complaints lodged against them, with nearly half of those complaints considered to be severe complaints; and over 300 hospices were designated as poor performers. The most commonly cited deficiencies involved poor care planning, mismanagement of aide services, and inadequate assessments. The OIG reviewed 12 cases where serious deficiencies were cited and resulted in actual patient harm, including a patient whose lack of care led to an amputation, patients with severe unaddressed pain, wounds that increased in severity, and one patient who was found to have maggots around a feeding tube.

The OIG Notes Limitations in Reporting Requirements, Information Availability, and Enforcement Options

The OIG identified deficiencies with respect to reporting harm to hospice beneficiaries. The OIG identified that a hospice is only required to report signs of abuse, neglect, and other harm when it involves an individual providing services on behalf of the hospice and the hospice verifies the allegation, with additional obligations imposed on the hospice if the patient is in a long term care facility. Additionally, recent changes to the Centers for Medicare and Medicaid Services (CMS) guidance for surveyors no longer require surveyors to report immediate jeopardy situations to law enforcement.

The OIG also identified issues with the survey system. Most hospices undergo a standard survey at least every three years. Some hospices, depending on the history of cited deficiencies, may be surveyed more often. Hospices also can be surveyed when certain complaints are made. When CMS identifies noncompliance with the Medicare Hospice Conditions of Participation (COPs), CMS cites the hospice and the hospice is required to implement an acceptable plan of correction. If a surveyor identifies a situation where a hospice’s lack of compliance with one or more COPs places the health and safety of beneficiaries at risk for serious injury, harm, impairment or death, the surveyor is supposed to cite the hospice with an “immediate jeopardy” citation. The OIG found that surveyors did not always cite hospices when an immediate jeopardy citation was warranted.

Additionally, the OIG found that relevant information about hospice quality was not consistently available to the public. Individuals who would like to compare hospices in their area can obtain information regarding specific hospice quality measures on Hospice Compare, a publicly available Medicare website. However, information from accrediting agencies, as well as survey results and complaints against hospices, are not included in the information that is available to the public. The OIG noted that the lack of complete information does not permit beneficiaries to make informed choices and to hold hospices accountable.

Another issue the OIG flagged was the lack of available interim penalties. Unlike penalties that CMS has the ability to impose on other types of providers, the only remedy for a hospice’s failure to comply with the COPs is to remove the hospice from participation in the Medicare program, a step that is not taken by CMS very often. CMS does not have the ability to impose a civil monetary penalty or other interim penalties against a hospice that is cited with deficiencies.

The OIG Sets Forth Several Recommendations for CMS

In both reports, the OIG reiterated a prior recommendation that CMS should seek statutory authority to impose intermediate sanctions for poor performance. In addition to reiterating prior recommendations, the OIG recommended that CMS take the following actions:

  1. Expand the deficiency data that the accrediting organizations report to CMS and use the data to strengthen the oversight of hospices
  2. Take the steps necessary to seek statutory authority to include information from accrediting organizations on Hospice Compare
  3. Include on Hospice Compare the survey reports from State agencies
  4. Include on Hospice Compare the survey reports from accrediting organizations once authority is obtained
  5. Educate hospices about common deficiencies and those that pose particular risks to beneficiaries
  6. Increase oversight of hospices with a history of serious deficiencies
  7. Ensure that hospices are educating their staff to recognize signs of abuse, neglect, and other harm
  8. Strengthen guidance to surveyors to report crimes to local law enforcement
  9. Monitor surveyors’ use of immediate jeopardy citations
  10. Improve and make user-friendly the process for beneficiaries and caregivers to make complaints

CMS concurred or partially concurred with all of the OIG’s recommendations, except the recommendation to include on Hospice Compare the survey reports from State agencies.

It is evident that the OIG and CMS have been focused on, and will continue to focus on, factors that impact the health and safety of Medicare beneficiaries, especially those who are most vulnerable. Hospices should ensure that they are providing all required services in accordance with all the COPs and, if deficiencies are identified, initiate a thorough review of the reason for the deficiency as well as meaningful corrective action. Hospices also should train staff to identify and report signs of abuse, neglect, and other harm.

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