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Safeguards Must Be Strengthened To Protect Medicare Hospice Beneficiaries From Harm


This report describes specific instances of harm to hospice beneficiaries and identifies vulnerabilities in CMS's efforts to prevent and address harm. In past work, the Office of Inspector General (OIG) raised a number of concerns about the care provided to Medicare beneficiaries. As part of a recent portfolio, OIG found that hospices did not always provide needed services to beneficiaries and sometimes provided poor quality care. Hospice care can provide great comfort to beneficiaries, their families, and caregivers at the end of a beneficiary's life. Medicare hospice beneficiaries have the right to be free from abuse, neglect, and other harm. When hospices cause harm or fail to take action when harm is caused by others, beneficiaries are deprived of these basic rights. This report is the second in a two-part series addressing hospice quality of care. The companion report identifies risks posed to Medicare beneficiaries from hospice deficiencies.


We based this report primarily on 12 cases of beneficiary harm from a review of the survey reports for a purposive sample of 50 serious deficiencies in 2016. We reviewed the survey reports and the associated plans of correction to describe the 12 cases of harm and to gain an understanding of CMS's efforts to prevent and address beneficiary harm. We purposively selected these 12 cases for review because of the severity of harm to the beneficiary. 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.


Some instances of harm resulted from hospices providing poor care to beneficiaries and some resulted from abuse by caregivers or others and the hospice failing to take action. These cases reveal vulnerabilities in CMS's efforts to prevent and address harm. These vulnerabilities include insufficient reporting requirements for hospices, limited reporting requirements for surveyors, and barriers that beneficiaries and caregivers face in making complaints. Also, these hospices did not face serious consequences for the harm described in this report. Specifically, surveyors did not always cite immediate jeopardy in cases of significant beneficiary harm and hospices' plans of correction are not designed to address underlying issues. In addition, CMS cannot impose penalties, other than termination, to hold hospices accountable for harming beneficiaries.


These cases reveal vulnerabilities in beneficiary protections that CMS must address. The findings of this report provide further support for an existing OIG recommendation that CMS should seek statutory authority to establish additional, intermediate remedies for poor hospice performance. To effectively protect beneficiaries from harm, CMS must have enforcement tools. In addition, we make several new recommendations to strengthen safeguards to protect Medicare hospice beneficiaries from harm. CMS should (1) strengthen requirements for hospices to report abuse, neglect, and other harm; (2) ensure that hospices are educating their staff to recognize signs of abuse, neglect, and other harm; (3) strengthen guidance for surveyors to report crimes to local law enforcement; (4) monitor surveyors' use of immediate jeopardy; and (5) improve and make user-friendly the process for beneficiaries and caregivers to make complaints. CMS concurred with the first four of these recommendations and partially concurred with the fifth.