GAO: CMS Should Step Up Hospice Oversight, Surveys

The U.S. Government Accountability Office (GAO) in a new report indicated that the U.S. Centers for Medicare & Medicaid Services (CMS) should beef up hospice oversight, including addressing overdue surveys.

To date, CMS has fully implemented five and partially implemented three of eight provisions of the Consolidated Appropriations Act, 2021 (CAA), though quality issues persist in the hospice space. Nearly 15% of surveyed hospices were cited with serious quality issues between 2020 and 2022, according to the GAO. Most had multiple deficiencies.

“CMS has not issued planned internal guidance that would enable consistent use of new enforcement tools for hospices not complying with quality standards,” GAO noted in the report. “Implementing these provisions would help ensure CMS meets its statutory obligations for hospice oversight.”


Among the provisions that CMS is still working on is the addition of new enforcement tools, including fines, to bring hospices into compliance with laws and regulations.

GAO also cited the large backlog of hospice surveys left undone by state agencies (SAs) and accreditors (AOs). Close to 10% of hospices were overdue for a survey as of May 2023, GAO reported, largely due to staffing issues and funding. About 25% have not had a survey within at least five years.

The agency made four recommendations to CMS:

  • The CMS Administrator should fully implement the new enforcement tools, including issuing planned internal guidance, to enable the agency to use these tools to address hospices out of compliance with Medicare quality standards.
  • The CMS Administrator should make hospice survey results publicly available on Care Compare such that the information is prominent, easily accessible and readily understandable. 
  • The CMS Administrator should fully implement efforts to measure and reduce inconsistency in survey results among all surveyors, including SAs and AOs.
  • The CMS Administrator should instruct SAs and AOs to prioritize the completion of standard surveys for hospices that are overdue for a survey based on potential risk factors, which could include the amount of time overdue or evidence of past quality issues.

“CMS defines survey priorities each year, but does not provide any direction to prioritize among overdue surveys,” GAO indicated in the report. “CMS has noted that funding and staffing issues at state agencies, which conduct the surveys, as well as the COVID-19 public health emergency, have constrained the timely completion of surveys. Prioritizing among overdue standard surveys for hospices based on potential risk factors, such as previous quality issues, could help target such hospices.”

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