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Audit (A-05-12-00086)

CMS's Reliance on Ohio Licensure Requirements Did Not Always Ensure the Quality of Care Provided to Medicaid Hospice Beneficiaries

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CMS's reliance on Ohio licensure requirements did not always ensure quality of care and that adequate protection was provided to Medicaid hospice beneficiaries. We determined that hospices did not always meet State hospice licensure requirements related to hospice workers. Of the 100 claims that we sampled, 15 involved direct care provided by unqualified hospice workers. On the basis of these sample results, we estimated that 15,550 of the 103,668 claims covered by our review were associated with unqualified hospice workers.

For the 15 claims that involved direct care provided by unqualified hospice workers (3 of which had more than 1 type of deficiency), the following licensure requirements were not met: background check requirement not met (11 claims), tuberculosis test requirement not met (4 claims), training requirements not met (2 claims), performance evaluation requirement not met (1 claim), and written job description requirement not met (1 claim).

For Medicaid, only hospice care services payments associated with unqualified hospice workers are affected, not room and board payments. Because all 15 claims were room and board payments, we did not estimate the effect on Medicaid payments during the audit period.

To improve protection provided to Medicaid hospice beneficiaries, we recommend that CMS (1) work with the Department of Job and Family Services (State agency) and the Ohio Department of Health to ensure that hospices meet the State licensure requirements for hospice workers and (2) consider working with the State agency to modify the State agency's hospice payment conditions by implementing provisions similar to the State licensure requirements for hospice workers. The State agency agreed with our recommendations. CMS generally agreed with our first recommendation and concurred with our second recommendation.

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