Failure to make home visits, failure to manage patients’ pain, and maggots infesting a patient’s feeding tube site are just a few of the safety deficiencies cited in a new report from the U.S. Department of Health and Human Services Office of the Inspector General (OIG). About 20% of hospices surveyed by regulators or accreditors between 2012 and 2016 had a deficiency that posed a serious safety risk.

A second OIG report released simultaneously explores the safety deficiencies in-depth.

OIG examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016, focusing on a sample of 50 types of serious deficiencies. Regulators and accreditors surveyed nearly all hospice providers in the nation during those years.

More than 87% of the 4,563 hospices operating in the United States during those years had at least one deficiency, according to OIG. Some hospices had a history of serious deficiencies spanning several years.

About one-third of U.S. hospices serving Medicare beneficiaries had a complaint lodged against them during the study period, OIG reported. 

Though most hospices have deficiencies during surveys, the severity of those issues varies widely, from instances that pose an immediate threat to a patient’s life and safety to relatively low-risk considerations such as clerical errors in patient documentation or a hand hygiene dispenser protruding an extra inch into the hallway of an inpatient facility. 

“There is a really large range of deficiencies and the ones that are highlighted in this report  which represent neglect  really seem like they should be a path towards termination,” Mollie Gurian, chief strategy officer for the National Partnership for Hospice Innovation (NPHI) told Hospice News. “We would ask that CMS educate the people who are doing these surveys to make sure they understand the difference.” 

Poor care planning, mismanagement of aide services, inadequate patient assessments were among the most commonly identified deficiencies. A number of hospices also received citations for improperly vetting staff and inadequate quality control that could pose serious risks to patients. 

Hospice organizations were quick to stress that organizations experiencing the most serious safety issues are not representative of the industry at large.

“The [National Hospice & Palliative Care Organization (NHPCO)] continues to stress that outliers in the field do not adequately reflect the vast majority of hospice care provision in the United States,” NHPCO President Edo Banach told Hospice News.

Banach’s comments will be included in a public statement to be released later today.

The NPHI expressed similar concerns to Hospice News.

“It’s a small proportion of hospices that act this way, so we wouldn’t want to the reputation of the industry to become ‘Hospices let maggots get into patient wounds,’” Gurian said. “That being said, it’s clear that there are hospices that are acting very badly, and we would support the recommendations from OIG to address those bad actors. That’s something that we have been advocating for since the formation of our organization.” 

OIG called for the U.S. Centers for Medicare & Medicaid Services (CMS) to step up enforcement efforts to stem the tide of these violations. OIG made its initial recommendations for improving CMS enforcement in a July 2018 report on vulnerabilities in hospice care. The inspector general also made additional recommendations in the new report. 

OIG called for CMS to expand the deficiency data that accrediting organizations report to CMS and use these data to strengthen its oversight of hospices; take the steps necessary to seek statutory authority to include information from accrediting organizations on Hospice Compare; include on Hospice Compare the survey reports from State agencies; and include on Hospice Compare the survey reports from accrediting organizations, once authority is obtained.

The inspector general also recommended that CMS provide education to hospices about common deficiencies that pose serious risks to patients and to step up oversight of hospices with a history of such safety issues.

CMS concurred or partially concurred with all the recommendations except for the inclusion of state agency reports on hospice compare. CMS responded to OIG that while it supports increased transparency of hospice survey findings, publicly reporting state agency survey reports could present an incomplete view of the industry because the agency is currently prohibited from sharing survey reports from accreditation organizations such as The Joint Commission or Community Health Accreditation Partner (CHAP). 

“We note that the survey reports from state agencies are currently required to be publicly available. We urge CMS to make these reports more readily available and accessible on Hospice Compare. In the interests of transparency and clarity, CMS could post an explanation about why similar information is not available for hospices surveyed by accrediting organizations,” the report said in response to CMS concerns.

Hospice organizations generally expressed support the recommendations, but they cautioned regulators against casting a wide net over the industry rather than focusing on bad actors with a history of serious deficiencies.

“The report outlines some great tactics in terms of going after people who have serious deficiencies,” Gurian told Hospice News. “We would encourage CMS to look at factors that could really penalize these providers that are highlighted in the report, as opposed to the more general targeting that they are using now that scoops up good providers and bad providers into auditing.”

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