By Dietrich Knauth
A new report surveyed worst-case scenarios, such as an Alzheimer’s patient who had to have a leg partially amputated after going untreated for ulcers in both heels.
The HHS Office of Inspector General (OIG) detailed 12 examples of serious harm suffered by patients in the Medicare hospice program in a new report and recommended better tools for cracking down on hospice failures and reporting violations to law enforcement. The OIG found that patients were sometimes harmed by poor care received from hospices, and sometimes as a result of hospices’ failure to respond to abuse by caregivers or others. The report revealed several vulnerabilities in CMS’ efforts to prevent and address harm, including insufficient enforcement mechanisms, inadequate reporting requirements for hospices, limited reporting requirements for surveyors, an ineffective system for making complaints (OIG Report, OEI-02-17-00021, July 3, 2019).
Background. Hospice is a growing benefit for Medicare, which pays for four levels of end-of-life care for terminally ill beneficiaries. The number of hospice beneficiaries has grown every year in the past decade, and Medicare spending on hospice care rose from $9.2 billion in 2006 to $17.8 billion in 2017, according to OIG. Hospice beneficiaries are especially vulnerable, as they are often bed-bound, cognitively impaired, and reliant on caregivers, according to the report. OIG has previously reported on deficiencies in hospice care, as well as fraud and abuse within the program, including hospices that have enrolled beneficiaries who were not terminally ill, altered patient records, falsified documentation, and billed for services not provided. The current report is the second in a two-part series, with a companion report that focused more broadly on the quality of care provided to hospice beneficiaries and the deficiencies found by surveyors who conduct onsite reviews (see Patient safety impacted by hospice deficiencies, July 10, 2019).
Findings. A key weakness of CMS oversight is its inability to impose penalties on hospice providers, short of cutting them off from Medicare completely, according to OIG. CMS did not take that drastic step in any of the 12 scenarios OIG reviewed, and as a result, none of the hospices suffered serious consequences for their failures, according to the report.
Surveyors who inspected hospices on behalf of CMS also did not properly report that the deficiencies resulted in "immediate jeopardy" to beneficiaries, even when beneficiaries were clearly harmed, according to the report. Only five of the cases reviewed by OIG resulting in findings of "immediate jeopardy," and the ones that avoided that designation included serious patient risk, like failing to help a patient who reported vomited blood while at home, and not following up until a scheduled visit days later. Hospices’ response to reported deficiencies rarely went deep enough to address root causes of the failure, and individual staff members were rarely disciplined for harming beneficiaries – only twice in the 12 cases reviewed by OIG, according to the report.
Three of the cases revealed poor care, such as an Alzheimer’s patient who was untreated for ulcers and developed gangrene, eventually needing a partial leg amputation. Other cases involved a patient that developed maggots around a feeding tube while in home hospice care, and a beneficiary who did not receive needed respiratory therapy and eventually elected to discontinue hospice due to poor service.
Other cases involved failure to report abuse, a problem exacerbated by poor guidance from CMS, according to OIG. Three of the cases reviewed by OIG involved abuse or neglect, including a possible sexual assault at an assisted living facility, a son who abused his ill father, and reports of a neighbor stealing medication from a hospice beneficiary. In the case of the possible sexual assault, the hospice not only failed to recognize warning signs, it also pushed back against its citation for failing to investigate the abuse, claiming that had no obligation to investigate unless a sexual assault accusation had been leveled at a hospice employee, according to OIG.
OIG based its report on 12 examples of beneficiary harm taken from a review 50 serious deficiencies reported by state agencies and accrediting organizations in 2016.
Recommendations and response: OIG made five recommendations 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 recommendations, although it only partially concurred with the fifth, saying that it would explore improvements to the complaint-making process within regulatory constraints and with available resources.
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