CMS Proposes to Revamp Hospice Enforcement in Home Health Rule

The U.S. Centers for Medicare & Medicaid Services (CMS) has proposed the creation of a Special Focus Program (SFP) with the power to impose enforcement remedies against hospices with poor performance on regulatory or accreditation surveys. The agency also has plans to implement a hospice program complaint hotline through which the public can report issues to CMS. 

Hospices flagged by the proposed Special Focus Program would be surveyed every six months rather than the current three-year cycle. The SFP would have the authority to impose fines, suspend reimbursement, appoint temporary management to bring the hospice into compliance, or revoke a provider’s Medicare certification altogether.

CMS inserted these provisions within the proposed rule for Fiscal Year 2022 payments to home health agencies. If made final, the new regulations would require multidisciplinary survey teams, prohibit surveyor conflicts of interest and update the surveyor training process. The agency expects that implementation of these proposals would cost an estimated $5.5 million annually.


“In this proposed rule, we are proposing a comprehensive strategy to enhance the hospice program survey process, increase accountability for hospice programs, and provide increased transparency to the public,” CMS indicated. “Our goals include: maintaining the public trust through addressing conflicts of interest and improving survey transparency; addressing inconsistency within the survey process through training and survey team composition and use of common hospice program deficiency reporting mechanisms; and ensuring hospice programs are held accountable for addressing identified health and safety issues.”

The proposed language would also require accreditation organizations with deeming authority to use the same forms to report deficiencies as CMS state agencies. Three accreditors currently have this authority: the Accreditation Commission for Health Care (ACHC), Community Health Accreditation Partner (CHAP), and The Joint Commission. These agencies have deemed close to 50% of Medicare-certified hospices, according to CMS. The proposed rule would also make accreditation survey reports publicly available. Historically these have been kept confidential.

Accreditors would also have to require their surveyors to undergo the same training programs as those affiliated with Medicare state agencies, which would be updated if this rule were made final. The new training program would emphasize quality of care, according to CMS.


“CMS continues to review and revise our health and safety requirements and survey processes to ensure that they are effective in driving quality of care for hospice programs,” the agency said in the rule language. “The basic training online courses provide surveyors with the key knowledge and skills needed to survey the respective provider or supplier type for compliance with the Medicare conditions and assure an adequately trained, effective surveyor workforce.”

CMS is taking these actions pursuant to the Consolidated Appropriations Act of 2021. Congress included these provisions in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS). Industry stakeholders have voiced a number of concerns about the law, arguing that remedies should be focused on organizations that have a history of serious deficiencies rather than the hospice community as a whole.