CMS's Reliance on New Jersey Licensure Requirements Could Not Ensure the Quality of Care Provided to Medicaid Hospice Beneficiaries

CMS could not rely on New Jersey's licensing requirements to ensure quality of care and that adequate protection was provided to Medicaid hospice beneficiaries. Specifically, we found that most hospices did not meet certain State requirements for employee health examinations. Of the 150 beneficiary-months in our sample, hospices could not document that 300 hospice workers met State requirements related to hospice worker health examinations during 118 beneficiary-months.

On the basis of our sample results, we estimated that hospice workers did not meet health examination requirements for 16,022 of the 20,367 beneficiary-months covered by our review and that the Federal Government reimbursed New Jersey more than $16 million for these services during our audit period.

To improve protection provided to Medicaid hospice beneficiaries, we recommended that CMS (1) work with the Department of Human Services (State agency) and the Department of Health to ensure that hospices meet State health examination 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. State agency officials stated that they were not in a position to comment on the validity of the facts presented in the report because records from the audit period were relatively inaccessible. CMS concurred with our first recommendation but did not indicate concurrence or nonconcurrence with our second recommendation