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Hospice Update: Surveyors Called to Identify Quality of Care Concerns and Potential Fraud Referrals

Posted on January 29, 2025 in Health Law News, Long-Term Care, Home Health & Hospice

Published by: Hall Render

The Centers for Medicare & Medicaid Services (“CMS”) is reinforcing its emphasis on hospice quality of care and identifying fraud. On November 13, 2024, CMS issued a QSO Memo, “Ensuring Consistency in the Hospice Survey Process to Identify Quality of Care Concerns and Potential Fraud Referrals” (the “CMS Memo”), addressing the importance of consistency in the hospice survey process to identify quality-of-care concerns and instances of potential fraud.

CMS reminds surveyors to identify when a hospice provider’s non-compliance with the Medicare Conditions of Participation (“CoPs”) puts the health and well-being of patients at risk and could indicate the need for a fraud referral to CMS.

CMS oversees the quality of care provided by hospices through health and safety surveys performed by state survey agencies and Accrediting Organizations. These organizations ensure hospices meet all CoPs. Hospice surveys are performed before their initial certification for Medicare participation. After the initial certification, recertification surveys occur every three years. Patients and caregivers may file complaints against hospice providers at any time, which can lead to additional surveys to address health, safety or quality of care concerns.

The CMS Memo underscores the critical role of state survey agencies and accrediting organizations in maintaining patient safety and the integrity of Medicare funding.

CMS’s Focus on Surveys and Fraud Identification

The CMS Memo highlights the dual purpose of hospice surveys:

  1. Ensuring Compliance: Evaluating whether hospice providers meet CoPs.
  2. Identifying Fraud: Detecting practices that jeopardize patient safety or Medicare program integrity.

CMS stresses that surveyors must adhere to consistent practices and employ a range of tools, such as direct observations, interviews and record reviews, to uncover potential fraud or deficiencies.

Key Elements of the Hospice Survey Process

The CMS Memo also outlines specific survey protocols:

  • Surveyor Training and Competency: CMS mandates basic and annual training for surveyors to enhance accuracy and consistency. Surveyors need to complete Hospice Basic Surveyor Training, supervised field experience and participate in annual skills reviews to address areas needing improvement.
  • Observations and Home Visits: Surveyors assess patient environments, care quality and adherence to individualized care plans. Surveyors should observe patient surroundings and interactions with hospice staff and caregivers to identify potential lack of care and support and determine the degree of patient inclusion in decisions about their care. Surveyors should decide if the patient chose to receive hospice services, whether care is based on patient preferences and needs, whether the unit of care is the patient and family and whether that care incorporates the multidisciplinary plan of care.
  • Interdisciplinary Group (“IDG”) Meetings: Participation in or review of IDG meetings ensures that comprehensive care plans reflect both patient and family needs. Inclusion of the multidisciplinary team ensures that hospice care involves all aspects of the patient’s and family’s experience so as not to miss opportunities to ensure that all needs and preferences are addressed thoroughly and to ensure that the comprehensive care plan is established and adhered to according to the patient’s expressed preferences.
  • Multiple Locations: Surveyors must ensure that all locations are equipped to provide comprehensive services as completely as the hospice’s main location. Services should not be curtailed due to staffing shortages, lack of supplies or inability to provide any service the hospice presents as part of its program.
  • Record Reviews: Detailed reviews of complaint logs, care timeliness and election statements validate the hospice’s compliance with CoPs.
  • Administrative Oversight: Surveyors examine the governing body’s role, Quality Assessment and Performance Improvement (“QAPI”) programs and adherence to Medicare forms and requirements. Surveyors are called to look at the Medical Director’s role and responsibilities. Specifically, the CMS Memo states that they should confirm that there is a single individual identified as the medical director and document the medical director’s full involvement (oversight of IDG, certification and re-certification of terminal illness, etc.). This role is pivotal in overall hospice operations and the delivery of high-quality and safe care. Surveyors should also review other professional staff credentials, such as registered nurse licensure and the use of master’s prepared social workers.

Additionally, CMS has introduced enforcement remedies for non-compliance, including civil monetary penalties, suspension of new admissions and temporary management.

State-Specific Measures to Address Fraud

CMS highlights state-led initiatives to prevent fraud, such as licensure bans, mandatory in-person meetings before enrollment and Certificate of Need requirements. Hospice providers must stay informed about their state’s regulations and ensure compliance.

Practical Takeaways

The CMS Memo reinforces the need for hospice providers to prioritize patient safety and program integrity. Hospice providers can protect their patients and safeguard their businesses against enforcement actions and fraud allegations by focusing on compliance, enhancing documentation and maintaining survey readiness. Actions hospice providers can take now include:

  1. Strengthen Compliance Programs. Hospice providers should regularly review and update their compliance programs to align with CMS requirements.
  2. Improve Documentation and Record-Keeping. Accurate and complete documentation is critical for demonstrating compliance and defending against potential fraud allegations.
  3. Proactively Address Survey Readiness. Preparing for surveys is essential to identify and correct deficiencies before they escalate.

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Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.