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 of participation (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 

CMS’s 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 CMS’s 

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-ServicePayment/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).
 

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include standards that ensure compliance with Medicare’s 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 and—beginning July 1, 2014— 

implementing a Hospice Item Set with seven measures endorsed by the National Quality 

9

 CMS has deemed three accrediting organization—the Accreditation Commission for Health Care, Inc.;
 

the Community Health Accreditation Program; and The Joint Commission—as having standards that meet
 

or exceed Medicare hospice survey certification requirements. 

10 These fluctuating targets are identified in CMS’s 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 User’s Guide for Hospice Quality Reporting Data Entry and Submission, Version 1.5,
 

January 1–April 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)) .
 

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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 

CMS’s 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 CMS’s 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 hospices—both nationally and by State—that had not 

been surveyed within the 6 years preceding the index date and compared those results to 

our prior findings. 

16 78 Fed. Reg. 48234–48281 (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 hospice’s undoing, January 16, 2013. 

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

2013. 

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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 report’s 

main objective—to assess whether survey frequency has improved since 2005—chiefly 

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.) 

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Figure 1: Hospice Recertification Survey Intervals, 2013 

0–3.0 yrs 

(49%) 

3.1–6.0 yrs 

(34%) 

6.1–9.0 yrs (13%) 

9.1–12.0 yrs (3%) 

12.1+ yrs (1%) 

6.1+ yrs 

(17%) 

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* 

State Number of 

hospices in State 

Number of hospices in State that 

did not receive a survey in the 

preceding 6 years 

Percentage of hospices in State 

that did not receive a survey in 

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) 
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CONCLUSION 

These findings illustrate that CMS’s 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 frequency—even for an interval of more than 3 years—could 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. 

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APPENDIX A 

States’ Hospice Certification Survey Frequencies 

State 

Number of 

hospices 

in State 

Number of hospices 

in State that did not 

receive a survey in 

the preceding 6 years 

Average survey frequency 

of hospices in State that 

did not receive a survey in 

the preceding 6 years 

Percentage of 

hospices in State that 

did not receive a 

survey in the 

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)