The majority of Medicare-certified hospices providing care in assisted living communities, skilled nursing facilities, homes and other settings had one or more deficiencies in the quality of care they provided to patients from 2012 through 2016, according to two reports released Tuesday by the Department of Health and Human Services Office of Inspector General.

“Some Medicare beneficiaries were seriously harmed when hospices provided poor care or failed to take action in cases of abuse,” the OIG said.

Among other recommendations, the reports call for increased oversight of hospice programs, which two advocacy organizations representing hospice providers said they support.

One OIG report found that more than 80% of hospices were cited with at least one deficiency for failing to meet a requirement for Medicare participation. “The most common types of deficiencies involve poor care planning, mismanagement of aide services, and inadequate assessments of beneficiaries,” the OIG said. “In addition to these, hospices had other deficiencies that also posed risks to beneficiaries. These failings — such as improperly vetting staff and inadequate quality control — can jeopardize beneficiaries’ safety and lead to poor care.”

More than one-third of the hospices had complaints filed against them, and 18% of all hospices surveyed in 2016 were “poor performers,” with at least one serious deficiency or at least one substantiated severe complaint, according to the report.

In addition to implementing the OIG’s previous recommendations to strengthen the survey process, establish additional enforcement remedies, and provide more information to beneficiaries and their caregivers, the OIG said, the Centers for Medicare & Medicaid Services should strengthen its oversight of hospices using expanded deficiency data from accrediting organizations and work to include more information on Hospice Compare, including survey reports from state agencies and accrediting organizations, and educate hospices about common deficiencies.

CMS Administrator Seema Verma said the agency agreed with the recommendations to educate hospices about common deficiencies, strengthen oversight of some hospices, and expand deficiency data collected from accrediting organizations. CMS did not agree with the recommendation to include survey reports from state agencies on Hospice Compare, however. Verma said CMS partially agreed with the report’s other recommendations.

For the other report, the OIG reviewed survey reports and associated plans of correction for 12 cases involving serious deficiencies to gain an understanding of CMS’ efforts to prevent and address beneficiary harm.

“We purposively selected these 12 cases for review because of the severity of harm to the beneficiary,” the OIG said. “These cases do not represent the majority of hospice beneficiaries or hospice providers. They also do not reflect the prevalence of harm to hospice beneficiaries.”

Two of the cases involved assisted living community residents. In one, the OIG said, hospice staff did not recognize signs of a possible sexual assault of a beneficiary, and in the other, hospice staff did not provide essential pain management services yet was not cited for immediate jeopardy (which would have necessitated the hospice taking immediate corrective action to prevent the situation from recurring).

In addition to implementing a previous recommendation to seek statutory authority to establish additional, intermediate remedies for poor hospice performance, the report recommended that CMS strengthen requirements for hospices to report abuse, neglect and other harm; ensure that hospices are educating staff members to recognize signs of abuse, neglect and other harm; strengthen guidance for surveyors to report crimes to local law enforcement; monitor surveyors’ use of immediate jeopardy; and improve and make user-friendly the process for beneficiaries and caregivers to make complaints. 

Verma said CMS partially concurred with the latter recommendation and agreed with the others.

National Hospice and Palliative Care Organization President and CEO Edo Banach said the group “has been and continues to be a champion for accountability and transparency within the hospice community, and we have long supported additional oversight of the hospice program.”

“The bottom line is that all hospices must ensure that every single patient receives care within all regulatory and statutory limits, that quality is never a question, and patient and family safety is never compromised,” Banach said.

Mollie Gurian, chief strategy officer at the National Partnership for Hospice Innovation, said the group concurs with the reports’ recommendations “and we are strongly in favor of increasing oversight on hospice programs that deliver poor-quality care.”

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