CMS Reinforces Hospice Oversight: Focus on Program Integrity and Fraud Prevention

The Centers for Medicare and Medicaid Services (CMS) on November 13, 2024, posted the memo Ref: QSO-25-06-Hospice (Subject: Ensuring Consistency in the Hospice Survey Process to Identify Quality of Care Concerns and Potential Fraud Referrals) which outlines updated guidance to ensure consistency in the hospice survey process.  It emphasizes identifying and addressing quality of care concerns and potential fraud in Medicare-funded hospice programs.  The memo highlights CMS’s dual responsibility: overseeing compliance with Medicare’s Conditions of Participation (CoPs) and protecting program integrity by identifying and mitigating fraud.

Key Points:

1. Survey Processes:
   Hospice surveys, conducted by state survey agencies (SAs) and accrediting organizations (AOs), ensure compliance with Medicare CoPs.  Surveys occur at certification, recertification (every three years), and in response to complaints.  They assess the quality of care, patient safety, and administrative compliance, while potentially uncovering fraudulent practices.
2. Surveyor Training:
   CMS has standardized surveyor training to ensure consistent practices.  Surveyors must complete Hospice Basic Surveyor Training, supervised field experience, and participate in annual skills reviews to address areas needing improvement.
3. Comprehensive Survey Techniques:
   • Observations:  Surveyors observe patient environments, interactions, and care delivery, focusing on patient-centered care and adherence to the interdisciplinary plan of care.
   • Interviews:  Confidential discussions with patients, caregivers, and staff help uncover concerns not evident in records.
   • Record Reviews:  Documentation is reviewed for complaints, individualized care plans, timeliness of care, and informed patient consent.
   • Multiple Locations:  Surveyors ensure consistency of services across all hospice locations and compliance with care level requirements (i.e. inpatient, respite).
4. Administrative Oversight:
   Hospices must maintain an active Quality Assessment and Performance Improvement (QAPI) program, a functioning governing body, and accurate documentation.  Additionally, Medical Directors and professional staff must meet defined roles and credentials.
5. Abbreviated Surveys and Enforcement:
   CMS may conduct focused surveys (i.e. complaints or changes of ownership) to address specific issues.  Enforcement actions for non-compliance include payment suspensions, civil monetary penalties, directed training, and/or temporary management.  CMS may terminate providers failing to meet standards.
6. Fraud Referrals:
   Survey findings suggesting fraud must be referred to CMS for further investigation.  States are encouraged to implement measures like licensure bans, in-person enrollment meetings, and public education on fraud detection.

Conclusion:

This memo reinforces consistent survey practices to protect patients and Medicare funding while addressing non-compliance and potential fraud.  It calls for immediate implementation and communication with appropriate staff within 30 days.

Hospices are encouraged to utilize CMS’s resources, including the “Quality in Focus” video series, to reduce common deficiencies and enhance care quality.

Reference:  www.cms.gov/files/document/qso-25-06-hospice.pdf