Support Mounts for Increased Hospice Accreditor Oversight

Calls are growing louder in support of increased accreditation organization oversight that could help curb fraudulent activity in the hospice space.

In a proposed rule released in February the U.S. Centers for Medicare & Medicaid Services (CMS) introduced a number of provisions aimed at addressing conflicts of interest and establishing more consistent standards, processes and definitions among accreditation entities.

The proposed increased oversight would be an important step forward in addressing instances of fraud, waste and abuse in hospice, according to members of the California Hospice and Palliative Care Association (CHAPCA). Regulatory changes such as these would be particularly significant in detecting maleficence in regions like California, which have a rise in program integrity challenges, the organization stated in a recent letter to Congress shared with Hospice News.


“The number of hospice organizations has grown exponentially in recent years, and many hospice providers have had experiences with one of the three [accrediting organizations (AOs)] with deemed status for hospice,” CHAPCA indicated in the letter. “We believe that additional oversight of the three accrediting organizations is crucial for the three AOs approved to offer deemed status surveys for hospices.”

Rising concerns about maleficence among accredited hospice organizations was a leading reason that CMS cited for the proposed increased oversight. CMS indicated factors such as a need for more direct observation and review of accredited hospice programs.

States such as California, Arizona, Nevada and Texas have seen numerous reports of unethical or illegal practices emerging in recent years. Hundreds of newly licensed hospices have cropped up in these regions, some operating from the same location. Additionally, patients in some instances were admitted to hospice without their knowledge, while others eligible for care never received it.


More clusters of hospices are arising in California, despite regulatory efforts growing to curb growth. Roughly 210 licensed hospices are located within one mile of one another in a region of Los Angeles County as of 2022, according to a report from the state’s auditing department.

“We do not want other states to have the experience of California hospice growth and plead with CMS to take decisive action,” Clark stated.

Safety and quality concerns in hospice began surfacing in two 2019 reports from the U.S. Department of Health & Human Services Office of the Inspector General (OIG). The first report indicated that roughly 20% of hospices surveyed by regulators or accreditors from 2012 to 2016 had a condition-level deficiency posing a safety risk. The second report included specific safety risk examples.

California and Texas in particular have seen the most serious deficiencies related to poor hospice quality and patient safety risks, the OIG indicated.

CMS’ proposed changes included provisions to conflict of interest policies, adding definitions for unannounced surveys and strengthening accreditation survey processes among Medicare-certified hospices.

“This proposed rule proposes multiple provisions to further strengthen our oversight and enforcement capabilities of the AOs,” CMS wrote in a statement. “We are proposing changes to § 488.5(a)(10) to require the AO to have policies and procedures for the prevention, handling of and notification

of CMS when conflicts of interest arise, because on several occasions, AOs have failed to notify CMS of such conflicts of interest. These changes would broaden our oversight of the AOs’ handling and

reporting of conflicts of interests.”

The proposed changes also stipulate the development of an AO crosswalk requirement, which would provide closer alignment between Medicare Conditions of Payment (CoPs) and AO standards. CMS also proposed that AO surveyors be required to take CMS surveyor training to ensure compliance with ongoing updates in hospice regulations.

Provisions also included adding requirements for hospice management employees to be onsite during both state agency and accrediting organization surveys.

“To address some of the hospice fraud and beneficiary harm issues, the survey process is key,” Clark said. “Having a surveyor on site, in the office, is key. State and federal partners, as well as CMS contractors and other stakeholders, are all part of the solution.”

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