D EPARTMENT OF HEALTH A1~'D HUNIAN SERVICES 
OFFICE OF INSPECTOR GENERAL 
WASHINGTON, DC  2020 l 
AUG  2 9 2013 
TO:  Marilyn Tavenner 
Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Recommendation Followup Memorandum Report:  Frequency of 
Medicare Recertification Surveys for Hospices Is Unimproved, 
OEI-06-13-00130 
This memorandum report follows up on an unimplemented recommendation regarding the 
frequency of hospice recertification surveys conducted by State survey agencies to ensure 
compliance with Medicare conditions ofparticipation (CoPs).  To assess hospice 
compliance, the Centers for Medicare & Medicaid Services (CMS) contracts with State 
survey agencies to conduct onsite surveys of hospices.  In the 2007 Office of Inspector 
General (OIG) report Medicare Hospices:  Certification and Centers for Medicare & 
Medicaid Services Oversight, we found that the most recent recertification survey for 
14 percent of State-surveyed hospices had occurred more than 6 years before our index 
date ofJuly 5, 2005, with the length of time between the most recent survey and the index 
date averaging 9 years.'  Further, when surveys did occur, 46 percent ofthe surveyed 
hospices received citations for health care deficiencies, with the most frequently cited 
deficiencies related to care planning and quality issues. 
We recommended that CMS seek statutory or regulatory timeframes for the frequency of 
hospice recertification surveys by State survey agencies and suggested a timeframe of 
3 years.  CMS did not concur with the recommendation, indicating that conducting more 
frequent surveys would require congressional action to allocate additional resources. 
CMS policy sets targets for the frequency of hospice recertification surveys by State 
survey agencies.  These targets vary over time based on available resources and priorities. 
To determine whether the frequency of hospice recertification surveys had changed since 
our prior report, we compared current survey frequencies to our prior findings. 
1 Office of Inspector General (OIG), Medicare Hospices:  Certification and Centers for Medicare 
& Medicaid Services (CMS) Oversight (OEI-06-05-00260), April2007 .  Page 2  Marilyn Tavenner 
SUMMARY 
 
We found that the frequency of recertification surveys had not improved since 2005.  As 
of the index date of February 28, 2013, 17 percent of State-surveyed hospices had not 
been recertified within the preceding 6 years, with some hospices experiencing longer 
intervals since their most recent survey.  This finding confirms that the frequency for 
recertification surveys has not improved since 2005, when 14 percent of hospices had not 
been surveyed in 6 years.  We also found that in 12 States, more than 25 percent of 
hospices had not been recertified within the last 6 years.  These findings (1) suggest that 
CMSs use of fluctuating annual targets does not ensure timely recertification surveys of 
all hospices and (2) raise concerns about whether CMS and contracted State survey 
agencies can ensure that hospices comply with Medicare CoPs and quality-of-care 
requirements for hospices.  Therefore, we reiterate the recommendation that CMS set 
specific timeframes for the frequency of hospice recertification surveys.   
 
BACKGROUND 
 
The goals of hospice care are to help terminally ill patients live comfortably with minimal 
disruption and to support patients families and other caregivers throughout the dying 
process.2  Generally, hospices provide services to patients and their families in their 
homes; in a hospital, skilled nursing facility, or other nursing facility; or in a freestanding 
inpatient hospice facility. In 2011, Medicare paid for 84 percent of all hospice services 
provided nationally.3    
 
Recent Growth of Hospice 
Between 2005 and 2011, Medicare payments to hospices increased from $8.2 billion to 
approximately $13.8 billion.4 The number of hospices certified for Medicare increased by 
43 percent, from 2,537 in 2005 to 3,632 in 2011.5  In the same period, the number of 
Medicare beneficiaries receiving hospice services increased from 871,249 to over 
1.2 million.6, 7  
 
CMS Oversight of Hospice  
Medicare Certification. State survey agencies, contracted by CMS and following CMSs 
survey protocol and guidelines, conduct surveys of hospices at the time of initial 
certification, for recertification, and in response to complaints.  As an alternative to initial 
certification or recertification surveys by State survey agencies, hospice providers may 
seek to have these surveys conducted by an accrediting organization with CMS-granted 
deeming authority.8, 9   Accrediting organizations use their own survey protocols and 
                                                 
2 CMS, Brief Summaries of Medicare & Medicaid, Title XVIII and Title XIX of the Social Security Act, p.  9, 
 
November 2, 2011. 
  
3  Ibid., p. 10. 

4 Medicare Payment Advisory Commission (MedPAC),  Report to the Congress: Medicare Payment Policy,  

p. 261, March 2013.  Accessed  at http://www.medpac.gov/chapters/mar13_ch12.pdf on June 17, 2013.  
 
5 CMS, CMS Financial  Report Fiscal Year 2012, Pub. No. 954940, p. 147, November 15, 2012. 

6 CMS, Medicare Hospice Data.  Accessed at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/Hospice/Medicare_Hospice_Data.html on  August 20, 20133.   

7 MedPAC, loc. cit.   

8 Social Security  Act,  1865(a)(1); 42 U.S.C. 1395bb(a)(1). 
 
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 3  Marilyn Tavenner 
include standards that ensure compliance with Medicares CoPs.  According to staff of 
the three accreditation organizations, their policies require that they conduct accreditation 
surveys every 3 years for accredited hospices, which are subsequently deemed by CMS 
as meeting Medicare requirements.   
 
CMS does not have a legislative or regulatory standard for the frequency of hospice 
recertification surveys.  Instead, CMS policy establishes annual targets for survey 
frequency based on available resources that year.10  For example, in 2005 CMS directed 
State survey agencies to conduct onsite surveys of individual hospices at least every  
6 years, which changed to 8 years in 2006; in 2013, the target is 6.5 years.11   Additionally, 
for 2013, CMS directed State survey agencies to achieve a Statewide average of 
conducting surveys at least once every 6 years across all State-surveyed hospices.  In 
comparison, the recertification intervals for certain other types of Medicare providers are 
set by Federal statute or regulation. For example, nursing homes and home health 
agencies are required to be recertified every 15 months and every 36 months, 
respectively.12    
 
Additional Quality Oversight.  The Patient Protection and Affordable Care Act (ACA) 
authorized CMS to collect additional data in an effort to ensure the quality of care 
provided by hospices to beneficiaries and to address potential concerns.13 Beginning in 
2012, CMS required hospices to submit data on two quality measures:  a structural 
measure and a pain measure.14 For FY 2014 and each subsequent year, the ACA 
mandates a reduction in payments for hospices that do not comply with the reporting 
requirements.15    
 
The reporting requirements from 2012 will soon be replaced by new ones.  On August 7, 
2013, CMS issued a final rule that further enhanced its quality oversight in two ways.  
First, the final rule changes the requirements for the hospice quality-reporting program by 
discontinuing the currently reported measures andbeginning July 1, 2014 
implementing a Hospice Item Set with seven measures endorsed by the National Quality 
                                                                                                                                                 
9 CMS has deemed three accrediting organizationthe  Accreditation Commission for Health Care, Inc.;  

the Community Health  Accreditation Program; and The Joint Commissionas having standards that meet
  
or exceed Medicare hospice survey certification requirements.   

10 These fluctuating targets are identified in CMSs annual  Mission and Priority Document.  CMS, Survey 
 
and Certification Group, Center for Clinical Standards and Quality, Quality Assurance for the Medicare    

& Medicaid Programs, FY [Fiscal Year]  2013 MPD, Survey and Certification, November 21, 2012.   

11 CMS, Survey and Certification Group, Center for Clinical Standards and Quality, Prudent Action for the 

FY 2012 Medicare Survey & Certification (S&C) Budget, S&C 12-12-ALL, December 9, 2011.  

12 Social Security Act,  1919(g)(2)(A)(iii)(I), 42 U.S.C.  1396r(g)(2)(A)(iii)(I), Requirements for Nursing 

Facilities, and 42 CFR  488.308(a), Survey Frequency, Basic Period; Social Security Act,  1891(c)(2)(A), 

42 U.S.C.  1395bbb(c)(2)(A), CoPs for Home Health  Agencies, and 42 CFR 488.730(a),  Survey 

Frequency, Basic Period. 

13 ACA, P.L. 111-148  3004(c)(2) (codified at 42 U.S.C.  1395f(i)(5)). 

14 CMS, Technical Users Guide for Hospice Quality Reporting  Data  Entry and Submission, Version  1.5,  

January 1April 1, 2013.  Accessed at http://www.QTSO.com/hospicetrain.html  on April  30, 2013.  The 

structural measure includes hospice-selected care topics for which the hospice has at least one quality 

indicator in its Quality Assessment and Performance Improvement Program.  The pain measure includes 

the percentage of patients who report being uncomfortable because of pain at the initial assessment [...] 

who report pain  was brought  to a comfortable level within  48 hours. 

15  ACA,  3004(c)(2)  (codified at  42  U.S.C. 1395f(i)(5)) .
  
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 4  Marilyn Tavenner 
Forum.  Second, effective January 1, 2015, CMS will implement the hospice Experience 
of Care Survey to gather feedback from hospice patients and family members regarding 
their experiences and satisfaction with hospice care.16    
 
Related Reports 
In addition to the 2007 hospice study that reported long periods of time between hospice 
recertification surveys, recent OIG and media reports have raised concerns about aspects 
of hospice care. OIG reports have included concerns about hospices that rely heavily on 
beneficiaries who reside in nursing facilities and the high percentage of hospice claims  
for such beneficiaries that did not meet requirements for Medicare hospice coverage.17   
Recent media reports indicate that some hospices may bill Medicare inappropriately for 
services provided to patients who do not meet requirements for hospice coverage.18    
 
METHODOLOGY 
 
To determine survey frequency, we analyzed all hospice survey data maintained in 
CMSs Certification and Survey Provider Enhanced Reporting (CASPER) system as of 
the index date of February 28, 2013, the date OIG received the CASPER data.  We also 
obtained Medicare payment data for each hospice from CMSs National Claims History 
File for 2011, the most recent year for which we had complete claims data at the time of 
analysis. 
 
From CASPER, we identified those hospices that State survey agencies had certified on 
behalf of Medicare, excluding those hospices surveyed by the three accreditation 
associations.  We then used the National Claims History File to identify hospices that 
received Medicare payments for hospice services provided during 2011.  Using these 
criteria, we examined the study population of 2,483 hospices across 54 States and 
Territories, hereafter referred to as State-surveyed hospices.   
 
We determined the certification survey frequency for each State-surveyed hospice by 
calculating the time between the date of the most recent certification survey (either initial 
certification or recertification) and the index date, February 28, 2013.  In keeping with 
the prior report, we used only the dates for certification surveys, not complaint surveys.  
We determined the proportion of hospicesboth nationally and by Statethat had not 
been surveyed within the 6 years preceding the index date and compared those results to 
our prior findings. 
 
                                                 
16 78 Fed. Reg. 4823448281 (August 7, 2013).  Accessed at https://federalregister.gov/a/2013-18838 on 
    
August 7, 2013.   

17 Recent hospice reports by OIG include  Medicare Hospice Care for Beneficiaries in Nursing Facilities:  

Compliance With Medicare Coverage Requirements (OEI-02-06-00221), Medicare Hospices that Focus on 

Nursing Facility Residents (OEI-02-10-00070), and Medicare Hospice:  Use of General Inpatient  Care  

(OEI-02-10-00490). 

18 Kaiser Health  News, Slowly dying patients, an  audit and a hospices undoing, January 16, 2013.  

Accessed at http://www.kaiserhealthnews.org/stories/2013/january/16/san-diego-hospice.aspx on  June 10, 

2013.   

Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 5  Marilyn Tavenner 
Limitations  
As stated, we used 2011 Medicare claims data to identify the hospices for analysis.  As a 
result, it is possible that our analysis included some hospices that left the Medicare 
program after 2011.  We believe that these limitations have minimal effect on the reports 
main objectiveto assess whether survey frequency has improved since 2005chiefly 
because the prior study and findings had similar limitations based on data availability at 
the time of each set of analyses.     
 
As in the prior report, we did not verify with State survey agencies the dates maintained 
in CASPER.    
 
Standards 
This study was  conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS  
 
The frequency of hospice recertification surveys has not improved since 2005, with 
17 percent of State-surveyed hospices not having been recertified within the last 
6 years 
We found that 17 percent of State-surveyed hospices (416 of 2,483) had not received a 
recertification survey within the 6 years preceding the index date of February 28, 2013.  
These results are similar to our prior findings, where 14 percent of hospices had not been 
recertified within 6 years.  Among the 416 hospices not recertified within the preceding 
6 years, the length of time between the most recent survey and the index date averaged  
8.4 years and ranged as high as 22 years.  These 416 hospices provided services to 
121,868 Medicare beneficiaries in 2011 and received almost $1.4 billion in Medicare 
payments.  
 
The remaining 83 percent of State-surveyed hospices (2,067 of 2,483) had been 
recertified within the preceding 6 years.  Of these, 49 percent (1,212 of 2,483) had been 
recertified within the preceding 3 years, which is the survey frequency standard set by 
accrediting organizations for hospices.  The remaining 34 percent (855 of 2,483) had 
been recertified between 3 and 6 years before the index date.  (See Figure 1.) 
   
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 6  Marilyn Tavenner 
 
 Figure 1: Hospice Recertification Survey  Intervals, 2013 
12.1+ yrs (1%) 
3.16.0 yrs 
9.112.0 yrs (3%) 
(34%) 
6.1+ yrs 
(17%) 
6.19.0 yrs (13%) 
03.0 yrs 
(49%) 
 
Source:  OIG analysis of CMS-provided data on  survey frequency, February 28, 2013. 
 
In 12 States, more than one-quarter of State-surveyed hospices had not been recertified 
within the preceding 6 years  
More than 25 percent of the State-surveyed hospices in 12 States did not receive a 
recertification survey within the 6 years preceding the index date.19 (See Table 1.) 
Among these hospices, the average length of time between the most recent survey and the 
index date was 8.8 years. For 3 of these 12 States, the proportion of hospices that had not 
received a recertification survey within the preceding 6 years was over 50 percent.  The 
334 hospices that did not receive recertification surveys within the preceding 6 years in 
these 12 States provided services to nearly 100,000 Medicare beneficiaries and received 
more than $1.1 billion in Medicare payments in 2011.  (See Appendix A for a listing of 
all States and their survey frequencies.)   
 
Table 1: States with More than 25 Percent of Hospices with Survey Cycles of More Than 
6 Years*  
Number of hospices in State that   Percentage of hospices in State  
Number of  
State   did not receive a survey in the  that did not receive a survey  in  
hospices in State 
preceding 6 years  the preceding 6 years  
Oklahoma  109  80  73.4%  
Idaho  29  20  69.0%  
California  123  66  53.7%  
Washington  21  10  47.6%  
Louisiana  112  51  45.5%  
Nevada  11  5  45.5%  
Nebraska  29  13  44.8%  
Iowa  63  26  41.3%  
North Carolina   44  18  40.9%  
Kansas  52  16  30.8%  
New Jersey   33  9  27.3%  
Missouri  76  20  26.3% 
   Total   702  334   
Source:  OIG analysis of CMS-provided data on  survey frequency, February 28, 2013.
 
*This analysis did not include the 9 States and Territories  that each had  fewer than 10 hospices. 

 
                                                 
19  We  did not include in this analysis the 9 States and Territories that each had fewer than  10 hospices. 
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 7  Marilyn Tavenner 
CONCLUSION 
 
These findings illustrate that CMSs use of fluctuating annual targets does not ensure 
timely recertification surveys of all hospices and raises concerns about whether CMS and 
contracted State survey agencies can adequately oversee hospice compliance with 
Medicare CoPs and the quality-of-care requirements for hospices.  Our research also 
indicates that hospices are often out of compliance; the 2007 report found that almost half 
of hospices were cited with deficiencies when surveyed.  Further, more recent OIG 
reports identified quality-of-care concerns regarding hospice care provided in nursing 
homes.   
 
We reiterate the recommendation that CMS set specific timeframes for the frequency of 
hospice recertification surveys.  This should be accomplished by seeking legislation or 
promulgating regulations.  Embedding in regulation a standard for survey frequency 
would elevate State responsibility to meet such a standard, and therefore better ensure 
that hospices are surveyed more timely.  CMS could consider setting this survey 
frequency standard at 3 years, to match the 3-year interval used by accrediting 
organizations (as approved by CMS); however, given resource limitations, setting a 
mandatory frequencyeven for an interval of more than 3 yearscould help to ensure 
improvement in survey frequency and avoid lengthy intervals between surveys for 
individual hospices. Although we understand that the new quality-reporting requirements 
established by CMS have the potential for improving the quality of care for hospice 
patients, we will not know the outcomes of these processes for a few years.  Once the  
requirements are fully implemented, available data should provide CMS with information 
to identify those hospices that appear more problematic and thus should be the focus of 
further review by State agencies.  
 
This report is being issued directly in final form because it contains no new 
recommendations.  If you have comments or questions about this report, please provide 
them within 60 days.  Please refer to report number OEI-06-13-00130 in all 
correspondence.   
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)  Page 8  Marilyn Tavenner 
APPENDIX A  
 
States Hospice Certification Survey Frequencies  
 
Percentage of  
Number of hospices  Average survey frequency   hospices in State that  
Number of   in State that did not  of hospices in State that   did not receive a 
hospices  receive a survey  in   did not receive a survey in   survey in the  
State   in State   the preceding 6 years   the preceding 6 years   preceding 6 years 
Alabama   95  0  0  0.0%  
Alaska  2  0  0  0.0%  
Arizona  43  0  0  0.0%  
Arkansas  50   9  6.3   18.0%  
California  123  66   13.1   53.7%  
Colorado  36   1  6.3   2.8%  
Connecticut   24  1  6.7   4.2%  
Delaware  4  0  0  0.0%  
District of Columbia   3  0  0  0.0%  
Florida  23   5  6.7   21.7%  
Georgia   131  0  0  0.0%  
Guam  2  1  6.1   50.0%  
Hawaii  7  2  6.7   28.6%  
Idaho  29   20   7.5   69.0%  
Illinois   69  0  0  0.0%  
Indiana  64   0  0  0.0%  
Iowa   63  24   7.7   38.1%  
Kansas  52   16   7.0   30.8%  
Kentucky   15  0  0  0.0%  
Louisiana  112   51   7.7   45.5%  
Maine  8  0  0  0.0%  
Maryland  18   1  6.2   5.6%  
Massachusetts   55  3  6.1   5.5%  
Michigan  42   5  6.3   11.9%  
Minnesota   52  11   6.6   21.2%  
Mississippi  91   8  6.2   8.8%  
Missouri   76  20   6.7   26.3%  
Montana  26   0  0  0.0%  
Nebraska   29  13   7.4   44.8%  
Nevada  11   5  7.8   45.5%  
New Hampshire  19  0  0  0.0%  
New Jersey   33   9  6.7   27.3%  
New Mexico   29  5  7.5   17.2%  
New York  38   0  0  0.0%  
North Carolina   44  18   7.4   40.9%  
North Dakota   13   1  6.8   7.7%  
Ohio  70  0  0  0.0%  
Oklahoma  109   80   8.8   73.4%  
Oregon   42  4  6.3   9.5%  
Pennsylvania  147   0  0  0.0%  
Puerto Rico   34  2  6.5   5.9%  
Rhode Island   1  0  0  0.0%  
South Carolina   72  0  0  0.0%  
South Dakota   13   0  0  0.0%  
Tennessee   35  2  6.5   5.7%  
Texas  194   5  6.4   2.6%  
Utah   61  15   6.9   24.6%  
Vermont  5  0  0  0.0%  
Virgin Islands   3  0  0  0.0%  
Virginia  59   1  6.0   1.7%  
Washington  21  9  6.8   42.9%  
West Virginia   18   0  0  0.0%  
Wisconsin   49  0  0  0.0%  
Wyoming  19   0  0  0.0%  
   Totals   2,483   416        
Source:  OIG analysis of CMS-provided data on  survey frequency, February 28, 2013. 
 
Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130)