The Centers for Medicare & Medicaid Services (CMS) needs to strengthen the oversight of its Medicare hospice program to protect beneficiaries, according to a newly released report (PDF) from the Office of Inspector General (OIG).
According to the report, which relied on CMS' survey of the 4,563 hospices in the U.S. between 2012 and 2016, 87% of hospices had at least one deficiency. The report also found 20% of hospices had serious deficiencies—which they defined as a condition-level deficiency in the quality of care—meaning that "the hospice’s capacity to furnish adequate care was substantially limited, or the health and safety of beneficiaries were in jeopardy."
The number of hospices with these deficiencies nearly quadrupled between 2012 and 2015 from 74 to 292, according to the report. It dipped slightly in 2016.
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Among the examples of problems flagged, the OIG pointed to:
Background checks: Some hospices failed to vet their staff through criminal background checks, while others did not update employee credentials, putting the safety of beneficiaries at risk. For example, at one facility, 18 employees were not screened for abuse and neglect prior to working at the hospice and three employees did not have their required professional licensure.
Inadequate responses to patient needs: Some hospices did not always address needs, putting some beneficiaries at risk of suffering unnecessary pain and distress. For example, at one hospice, a beneficiary who was being treated for pain experienced several days in an escalation of that pain before being reassessed. At another hospice, a beneficiary developed a stage IV pressure ulcer—the most severe type—despite having a policy stating that wounds were to be measured weekly at minimum. Hospice staff also did not follow the physician’s orders to treat the wound.
Poor care coordination: Some hospices failed to adequately coordinate care, at some times leaving patients' physicians uninformed. At one hospice, a nurse did not notify the physician of the beneficiary’s escalating pain or his use of a higher amount of pain medication. The patient ended up taking double the dose of fentanyl ordered on the care plan.
The report found one-third of hospices had complaints filed against them, and for almost half of these hospices, the complaints were severe.
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The rates of deficiencies varied greatly by state. For instance, 50% of all hospices surveyed in Maine had a deficiency, while 99% of hospices in Michigan had a deficiency during that same period.
Almost half of the hospices that had a complaint filed against them had multiple complaints over the five-year period. One hospice in Florida had 70 complaints in that five-year time period while another hospice in Texas had 12 complaints filed against it in a single year. Both raise concerns they may have systemic problems.
Nearly a third of the complaints filed against hospices were substantiated, meaning a surveyor found evidence to verify the complainant’s concern.
OIG offered recommendations for CMS, including expanding the deficiency data that accrediting organizations report to CMS in order to improve oversight. For instance, CMS should identify hospices with persistent problems, such as those with high numbers of deficiencies in multiple years, the report said. CMS should also track basic measures and identify—on a national scale—issues and trends that warrant further examination across all hospices.
OIG also recommended CMS seek statutory authority to provide public information from surveys conducted by accrediting organizations to provide on Hospice Compare to inform beneficiaries about hospices that have provided poor care.