When Hospices Mistreat The Dying, They Almost Never Get Punished

Key Findings Federal regulators punished just 16 hospices over the past decade for violating health and safety standards, HuffPost found. While many hospices have clean records, others were cited for dozens of problems that posed a direct threat to patient health. The only enforcement action available to federal regulators is revoking a license, the ultimate penalty. Top-violating hospices were cited for the types of problems that would lead to fines or penalties if detected at nursing homes. Regulators consider hospice a lower priority for oversight than other health systems. More dying Americans than ever now spend their last days in the care of a hospice, a service that offers a gentle alternative to a hospital setting. Hospice providers give comfort to the terminally ill, often in their homes. The promise is of a dignified death, surrounded by loved ones. But when a hospice fails in this mission – for one, by putting patients in physical danger – it almost always escapes sanctions. The federal government rarely punishes hospices that violate its health and safety rules, an examination by The Huffington Post reveals. In June, HuffPost found that hundreds of hospices had gone six years or more without a government agent conducting an inspection to make sure they were following Medicare’s rules. Now, the new analysis shows that when inspections do occur and problems are identified, government inspectors are almost always satisfied with hospice promises that they’ll reform. Medicare’s federal regulator has punished a hospice just 16 times in the last decade, despite carrying out 15,000 inspections and identifying more than 31,000 violations. In each instance, the regulator terminated the hospice’s license, the only sanction available under federal law. Because Medicare provides about 90 percent of funding for hospices, losing a license essentially forces a hospice to close down. Not all hospice violations of Medicare rules are cause for alarm. Some are minor: A dead battery in a smoke detector or a single mistake in a patient chart can trigger a violation, known as a deficiency. Other offenses are major, such as administering the wrong dose of medicine in error and killing a patient as a result. Because violations are not ranked by severity, it is not possible to say when a hospice should have been punished, but was not. But it is clear that hospices are punished far less often than other health providers that get money from Medicare. At nursing homes, which also rely on Medicare funding, regulators rank infractions and routinely assess fines and other sanctions. In just the past three years, the U.S. government has suspended payments to more than 800 nursing homes and fined them nearly $100 million.

50 Hospices With The Most Violations To qualify for Medicare payments, hospice agencies must undergo inspections to prove they are following rules set by the federal regulator that oversees the massive insurance program. This map shows the 50 active and inactive hospices that accumulated the most violations identified by government inspectors since 2004. The Huffington Post reached out to all the top-violating hospices that are still active. Read their responses here. Source: The Centers for Medicare and Medicaid Services For hospices certified by third parties, violation counts are a minimum.

In recent months, Congress has passed new legislation to try to close the inspection gap and make sure hospices are reviewed at least every three years. Health experts said it may not be enough to weed out the worst providers and persuade violators to reform. “If a compliance system doesn’t have any teeth it will be ignored,” said Josh Perry, an Indiana University professor who has written extensively about the hospice industry. When an inspector finds that a hospice has violated Medicare rules, hospice administrators are typically given multiple chances to submit written plans that explain how they will prevent such offenses in the future. The most serious offenses put a hospice on the termination track – an outcome that can be avoided if the hospice makes changes verified by inspectors in a follow-up visit. In the time between the violation and the follow-up visit, which can span several months, the hospice can continue to care for patients. And despite the promises of reform, some hospices are cited months or years later for the same violations. Part of the problem is that the industry has grown more quickly than regulators can keep up with. Over the last decade, the hospice industry has quadrupled in size. There are now more than 4,000 hospices in the U.S., serving more than 1 million patients a year. A majority of hospices are now operated as for-profit entities, a departure from hospice’s beginning as a niche service offered by charitable concerns. Even the best providers are sometimes cited for violating Medicare rules, though usually not very often. Ninety percent of all providers were cited for fewer than 20 violations over the past 10 years, HuffPost found. HuffPost’s investigation focused on the outliers – the 16 hospices terminated for health and safety violations, and the 50 active hospices cited for the most violations over the last decade that were not punished. Problems that turned up on those inspections included failing to offer core services, such as counseling, and not intervening to stop domestic abuse. That only 16 hospices were sanctioned over the last decade is “shocking,” said Brian Lee, a former long-term care ombudsman for the Florida Department of Elder Affairs who reviewed the results of HuffPost’s analysis. The fact that end-of-life services are almost never booted from the Medicare program undermines the argument that the current inspection system is a sufficient check on bad behavior, he said. While hardly perfect, a more sophisticated system that includes sanctions short of termination, such as fines and payment suspensions, would give regulators far more flexibility in handling hospices with serious abuses, Lee said. “Nobody should experience negligence in their dying days,” he said in reaction to accounts described in this article. “That is the whole point of hospice – to give patients the most dignity possible.” At Accent Hospice Care in 2013, a small for-profit in Meridian, Idaho, inspectors found that medical staff failed to intervene to protect a 78-year-old patient who said her husband was trying to kill her. The woman told the nurse that he was prone to fits of “uncontrollable rage, ” yet the hospice failed to call law enforcement or adult protective services, as required by law, even after the nurse made a chilling discovery – someone had tied a knot in the woman’s oxygen tubes, cutting off the air flow. In almost all instances, whether problems were minor or major, the outcome was the same: Hospices avoided sanctions, as Accent did in the 2013 case. A BETTER WAY TO DIE The modern hospice movement emerged as a reaction to the over-medicalization of death. Until the 1960s, the attitude of most health providers was that death was something to be fought, to the bitter end, no matter how painful the treatment or disheartening the experience. The hospice philosophy, as it is often described, is meant to be “holistic” care – tending to the emotional and spiritual needs of patients and their families. Instead of treatments, hospice practitioners seek to make patients as comfortable as possible. Morphine and other pain drugs are commonly used. The approach resonated with a new generation of patients and caregivers who were increasingly skeptical about the benefits of putting dying people in the hospital. Medicare patients receive hospice care for free, provided that a doctor certifies them as appropriate, meaning that they likely have six months or less to live. Until recently, hospice was a nonprofit service mostly catering to cancer patients. Hospice care usually happens at home, where a nurse or caretaker visits a dying patient and comforts him or her. Occasionally it happens in an institutional setting, such as a nursing home. A few hospices also have inpatient facilities. Business Is Booming Since 2000, the hospice industry has ballooned in size, adding providers and caring for more patients, who are living longer. Because Medicare pays most hospice claims, the cost to taxpayers has increased substantially. Here is a look at the expansion of Medicare-funded hospice. Beneficiaries Expenditures Providers Average Length of Stay Source: The Medicare Payment Advisory Commission As HuffPost detailed in June, hospice has transformed from a small niche service into a booming industry dominated by for-profit entities. Medicare largely bankrolls the hospice industry, providing $15 billion out of $17 billion in revenue in 2012. Since 2000, for-profit companies that have aggressively courted new types of patients for hospice, including people suffering from degenerative diseases like Alzheimer’s and Parkinson’s, have come to dominate the field. Because these patients live longer, the average stay on hospice is much longer at the typical for-profit. Federal prosecutors have sued most of the largest hospice companies in recent years for Medicare fraud – enrolling patients who were not close enough to death to qualify for the service and boosting them to extra-expensive levels of care they didn’t need. The average bill sent to Medicare for each patient is also higher at for-profits, a factor critics say is because of the increased use of services like crisis care, which is supposed to be for people whose pain is out of control. HuffPost’s previous investigation focused closely on Vitas Healthcare, the largest hospice company in the country, which federal prosecutors sued last year for alleged billing fraud. One of the charges in that case is that Vitas boosted billings by overusing crisis care. There is now a rift in the industry. Many nonprofit hospices blame the for-profits for sullying hospice’s good reputation. The for-profits respond that families of patients overwhelmingly say they were pleased with the care they received, and that the for-profit revolution has swept across all health services, not just hospice. “I think the majority of us are trying to meet the needs of our patients and families and trying to do a good job,” said Carolynn Peterson, a nurse who manages a small nonprofit hospice near Sacramento and is the board president of the California Hospice and Palliative Care Association, a trade group. ESCAPING PUNISHMENT Regulators are in a tough spot when it comes to figuring out what to do about a hospice with serious problems, said a former official in the Medicare inspector general’s office, who spoke on condition of anonymity because he still has professional business dealings with the agency. “They have very little sanctioning authority aside from the nuclear option,” he said. “It would be very helpful if they had the ability to impose monetary sanctions, which would make a lot of sense in hospice.” Shutting down a hospice can pose political and practical challenges, the former official said. For example, finding a new provider for current patients can be a huge logistical challenge – and traumatic for the patients themselves. “There are some terrible hospices and you can find some awful stories,” he said. “There aren’t easy answers but are certainly times when the balance is in favor of terminating, and it doesn’t happen.” When it comes to sanctions, lawmakers and regulators have largely deferred to state agencies to determine when a license should be revoked. There is no bright-line termination standard, so it is difficult to say with certainty that a hospice deserved harsher treatment than it received in any instance.

Breaking The Same Rules The 50 active hospices with the most violations since 2004, and those that were kicked off the Medicare program, were cited for many of the same violations, The Huffington Post found. The chart below shows how the most common violations accumulated by both groups compared with the hospice industry at large. Terminated Hospices Top Violators All Hospices Source: The Centers for Medicare and Medicaid Services For hospices certified by third parties, violation counts are a minimum.