Is erin bliss, he was with health and Human Services department and is the assistant Inspector General for evaluation and inspections, welcome to the program. Good morning. Remind people of the role ofthe Inspector General office is in comparison to hhs itself. Our mission is to protect the integrity of health and Human Services programs such as medicare and the healthand wellbeing of the people that they serve. So we do oversight and enforcement of the programs of the health and Human Services department. You turn your attention recently to the topic of hospice. Why is that, what are you looking to find out . The health and safety of Medicare Beneficiaries is one of our Top Priorities and help is a particularly vulnerable population so we looked at information about deficiencies being cited at Health Providers related to quality of care and patient harm. Expand on that, what doyou find looking into this . A report shed light on how common it is to have as providers to be sided with some type of deficiency related to the quality of care theyre providing and in some cases these were very serious deficiencies. We also uncovered gaps in Patient Protections. So weve issued a call to the Medicare Program run by the centers for medicare and Medicaid Services or cms to help fix these problems. Lets start with the deficiencies, what were the worstcase scenario found when you were looking into this . We did identify some worstcase scenarios where patients were seriously harmed by their care. So in one egregious example, hospice provider allowed maggot infested pastor around the patient feeding to and they needed to behospitalized. Figure extreme case but anything should neverhappen. So when it comes to the medicare system itself, remind people what they pay or at least what medicare pays for the hospices as far as dollars are concerned . In total in 2016, medicare paid about 16. 7 billion for surveying approximately 1,000,000 and a half beneficiaries. The number of patients electing hospice care is growing and so likewise so are the dollars. Hospice care is a program that patients can opt into when they are terminally ill and expected to have about six months or less left in their life. Its a decision to forgo regular curative treatments for their terminal illness and instead focus on services to provide pain relief, symptom relief, comfort and social and spiritualsupport for both the patients and their loved ones. sbook about the degrees of egregious conditions, Washington Post highlighted a couple others including some developing gangrenewhich involved an application. Sometimes and other things as well. Why do these things , whats keeping from at least finding out aboutwere not taking care of these situations . Weve identified some gaps in the Patient Protection system. Those are egregiousexample. We found about three in four hospice providers who were infected each year are identified to have some level of deficiency or not all that serious for about one in five they are serious deficiencies and then at about one percent of these extremely serious called immediate jeopardy deficiency and one of the problems we identified is that inflammation about these deficiencies and about serious complaints are investigated and substantiated is not made publicly available and in an easily accessible space so patients and their loved ones without a difficult time finding the Public Information and some of the informationis not public at all. One third according toyour complaints filed againstthem when it comes off this providers, 300 considered poor performers, 20 percent had one or more serious deficiencies. If hospice is found in such a way , what is the remedy . Is there a punishment as well . Survey agencies who do many of the inspections will work with hospice to try to correct the problem. But medicare is very limited in the enforcement tool that it has. Right now the only action at the Medicare Program can take the hospicedoesnt correct his problems , its to terminate them or not allow them to participate in medicare. There are no other tools. This is in contract issues that might arise for example in the nursing home where the Medicare Program as an array of tools to help remedy for performance. So weve recommended that the Medicare Program work with congress to get authority to take a range of Enforcement Actions in these circumstances. We will continue talking with our guests, if you have questions about this report to look at the condition of hospices in the United States, 2027488000 if you live in the eastern and central time zones, 204 8000 in the central time zones, if you have experience with hospice care, 202 6488000 two. Go back to why as far as taking care of the issue, why is there such a difference between money that medicare since the Nursing Homes versus money sent to hospice care . Guest i cant explain why the protections in hospice line behind our other types of care providers but we think its time for that to change so weve made a number of recommendations to strengthen the protections for patients, the transparency of information, enforcement tools availableto bring hospice care more on par with other types of care. What prompted this report in the first place . Guest oag has been assessing hospice care for more than a decade and we are focused and concerned about quality of care and concern about patient harm and abuse in a range of settings, especially hospice being an incredibly vulnerable population of people at the most difficult times in their lives. Host is there a federal standard for what qualifies esas a hospice mark. Guest medicare does have conditions of participation for being a hospice in that program and those are the conditions that the inspectors go out and look for so when we talk about a hospice being cited for a deficiency, its related to not meeting one of those medicare requirements. Host such as . Guest such as taking appropriate steps to prevent Infection Control or quality assurance, appropriate training of hospice staff so for example, inadequate staff provision in training is one of the most common deficiencies that gets cited against hospices. This is not just a technical issue, this can have realworldimpact on patients. We cited a case where a patient in hospice and her leg broken because her aide was not properly trained and had a safely transfer her from her wheelchair to her bed. And does medicare provide somesort of standard of age or at least staff within hospice and what kind of level of education or training . There are standards around the qualifications and training that needs to have to provide hospice care. To let you know, that 1. 49 million Medicare Beneficiaries were enrolled in hospice care for a day or more in 2017. About 64. 2 percent of patients were 80 years of age or older. Most were female, 50. 4 percent versus 41. 6 percent male and the average length of Service Within hospice, 76. 1 is the National Hospice and palantir care organization. They respond to this report . Is that the agency or at least the people that represent hospices and how do they respond mark. Theres a lot of attention , you are finding within the dimedia and general public as well as the Hospice Association so i cant speak for this particular association. But theres certainly a shared mission between our office and the race and those associations and that were all working to try to protect patients, keep them safe and provide highquality care. In general they agree with your conclusions though . Guest i cant speak on behalf of the associations. I did see some industry opinions where they were reinforcing the need for adequate training. Transparency, and expressing concerns about the extreme example that we found. Erin bliss with health and Human Services, shes the assistant Inspector General for evaluation and inspection joining us to talk about the report on hospice violations. We thought with len in las vegas, independent line, go ahead. I was wanting to talk about healthcare for the elderly and we understand that the license, their 90 milligrams of morphine per day, per person. And she works in the elderly care and she works regularly with patients and hospice comes in and a minimum or a maximum is 10 milligrams per hour, in other words they can give a patient on hospice 240 milligrams of lethal dose. Just about everybody that gets put on hospice is dead within three days. They dont allow, shes a healthcare provider, hospice comes in, they can no longer do anything else for that epatient. They cant even give them a glass of water. Host okay len, thank you for calling. Guest certainly the use of opioids at this point is a National Epidemic so its something of great concern and the office of inspector d general has a large body of work looking at opioid misuse as well. The cdc does put out guidelines for safe dosages. Those are just guidelines it is built up to the patients physician to determine what is the most appropriate and effective treatment given their circumstances. I willsay that when we do our analysis , taking a look at high levels of opioid use, we do exclude hospice patients from that analysis with the recognition that there are special circumstances oftentimes in hospice and the purpose of that care is to provide comfort and pain and symptom relief at the end of life. That being said no, if your wife does have specific concerns that she witnessed or worried that there might be particular hospice providers who are being irresponsible orperhaps abusive , i do encourage her to report her concerns. To the state survey agency overseas hospices. If her concerns s go all the way to the potential criminal situation, i encourage her to reach out to local police. Was the report that you put out, specifically name the names of those providers found in violation . We do not name the providers in our example. And in fact, for the 300 poor performing hospices, we identified in number, not all that information we would even be to release. So hospices who off to be inspected by private and accrediting organizations rather than the stateagencies , the results of those inspections are protected from disclosure by law. So we recommended that the Medicare Program works with congress to get authority to share that information as well as the resultant survey done by the states. Clarified then, a hospice and decide to beinspected by the state or inspected by private agencies. E it has to be a cms approved by the accrediting agency but that is a hospices choice. And would your office recommended that the state is guthe better judgment to receive on higher than that, maybe a federal inspection of the second agencies . We dont have a basis to compare the quality of the inspections then done by the state Agency Versus the accrediting organization but the big difference that were concerned about is that state survey results are available to the public and the results of the accrediting organization surveys are not we think that needs to change. We think its important for all that information to be easily and readily accessible to the public. If theres a family receives hospice care, there wondering if there place where that care is taken in ending up in your report did they find out . It depends actually. On a hospice and how they wound up in our report. To hathe extent that it was based on information that was uncovered state survey agency, that information could be made available. If it was based on information that came from and accrediting organization survey , we would not be able to release that information. And thats a problem. This is esther, estherin california, youre on with our guest. Caller icon excuse me, im interested in how you can govern the care of a hospice patient if you do not have the patient surrounded with governing bodies of individuals that are trained, that care, will protect their life to the end. And not speed up the expiration of life. Are you eliminating suffering or are you preserving life . Or there is a limitation as volunteered at . Guest thank you, you raise important questions about how does a Medicare Program, how do we oversee the quality of care provided to hospice patients who oftentimes are receiving treatment in their homes which is one of the benefits of hospice for patients who prefer to be at home youre right, its a very vulnerable population and thats why we think the safety net around needs to be strengthened. So at this point, hospices are overseen by either a state agency that goes out and inspects them and also investigates complaints against hospices or they may opt to use an incorrect accrediting agency but in any event, they need to meet certain quality and other requirements to participate in the Medicare Program and then medicare has a role in overseeing the states and the hospices to make sure that system is working. Cleveland ohio, this is tom. Id like to start off by mentioning that i recently discovered a couple months ago that the longterm care ombudsman for business, not allowed to be managed for reports of elder abuse and neglect. Also theyre not allowed to investigate complaints of elder abuse and neglect. Thats just a starting point. Ive been spending almost 30 years dealing with these kind of problems. Id like to you talk you off the record because i can go on or hours. Id like to connect with her. Im an associate of a lot of different groups that are complaining about problems. One for example thats known out in california is a foundation, aiding the elderly dealing with problems at Nursing Homes. Another is called the National Association to stop elder abuse, one of the objectives of that group is sonja arruda for faith, the organization run by carol herman, another run by doctor sam sugar is called aaa pg which stands for americans against abuse of torbay guardians. Beforewe let you go, is there an other specific, you like to discuss with our guest . Health issues in the community in the lido community and others has been with what they called mildly cognitive impairedindividuals. Youre talking about more than mildly cognitive impaired individuals and they are negligent of that area and disregard explicitly. We will let her go with that. Iq for raising these important issues. Patient abuse and neglect is a very serious concern and i a top priority for the office of Inspector General and weve done work looking at this issue across a range of settings. Specific to the recently reports looking at this issue g in hospice care, we have identified all her abilities in terms of limited reporting requirements to medicare in the hospice program. So for example, hospice providers are only required to report patient harm to medicare if they receive an allegation of harm. The harm was alleged to have been involved, someone who is providing services on their behalf hospice so not necessarily a Family Member or a caregiver. And that the hospice as basically investigated and substantiated the allegation and only then is it required that patient harm be reported to medicare so we recommended medicare minus its reporting requirements for hospice providers as well as for rtstate surveyors to identify potential harm and abuse that might be going on when theyre out conducting their surveys. There may be laws that require reporting, but were looking for some medicare requirements as well. So that the program has paul informations the into the problems happening and cant help ensure appropriate intervention. How many hospices does the report, did you look at in this report and how many compared to those at serious deficiencies . We look over a fiveyear period from 2012 to 2016. So about 4500 hospices fthat were surveyed during that time were inspected during that time. And about one in five were cited with a serious deficiency. When we look tephysically at poor performers in 2016, we identified almost one in five that either had a serious deficiency cited by a surveyor or an accrediting organization or had a serious complaint that was in fact substantiated by the state. Lets hear from steve in maryland, youre on with erin bliss of health and Human Services with the Inspector Generals office, go ahead. Iq for taking my call. Am i allowed to give a shout out to a specific hospice . Go ahead with your question or comment with the guest. I want to mention anything, they took real good care of icmy wife and her, and its because of the training that is done with st. Marys county and with the volunteers and with the staff. They took real good care and what i really like about this very comfortable setting, it was almost like eating in your own house. And what i really appreciated after my wife passed away, they offered grievance sessions for the spouse and that was very beneficial so i wanted to give a shout out to st. Marys county hospice program, thank you. Im sorry for your loss and i am so glad to hear about your good experience with hospice and im glad that you raise that because its an important point that many patients and their loved ones have very good experiences with hospice care. Were not looking to scare anyone awayfrom hospice care, its an important benefit. It brings great comfort to manypatients and their loved ones. We want information to be made available, not just about the problems that are found during these inspections but also information when the inspection turns up no problems. Thats just as important as knowing which hospices are struggling osis knowing which hospices are performing well and we know that the vast majority of hospice providers are working very hard. Theyre well intended and their goal is highquality and safe care as well. Is his ego, hes in maryland, id