Hospice Surveys and Accreditation: Serious Deficiencies the Oversight System Missed

Hospice survey and accreditation oversight failures include overdue inspections, unchecked staff credentials and serious care deficiencies that reappear in later surveys. Medicare certification can sit beside missed nursing visits, unresolved complaints and records that tell a different story from the care patients received. If you work in a hospice, the difference may be familiar: what management presents for review and what happened on your shift.

The useful starting point for a hospice fraud inquiry is that difference. A certificate cannot make up for a nursing visit that never happened. Our whistleblower experts connect what staff saw with the records management presented and the care Medicare paid for.

What Hospice Surveys and Accreditation Test

Hospice surveys test compliance with Medicare’s health and safety requirements, known as Conditions of Participation. State survey agencies and accrediting organizations approved by the Centers for Medicare & Medicaid Services conduct the reviews. A hospice accredited through an approved program can qualify for Medicare participation through that accreditation, often called deemed status.

The Government Accountability Office names the Accreditation Commission for Health Care, Community Health Accreditation Partner and The Joint Commission as the approved accrediting organizations. Hospices choose between a state-agency survey and an approved accreditor. The Centers for Medicare & Medicaid Services requires accreditor standards and survey processes to meet or exceed those used by state agencies.

The May 2024 report describes a review built around a sample of patients. Surveyors examine the care those patients received against the standards. The HHS Office of Inspector General describes home visits, interviews with patients and staff, observations of operations and reviews of clinical records. The survey report records what they found.

That is a different examination from medical review of claims for payment. A survey asks whether the hospice meets participation standards. A claims review examines whether Medicare should pay for the care billed. Both can turn on the patient record, but the accreditation certificate does not answer the payment question.

The distinction matters because routine home care pays for an enrolled day. Payment continues even on days without a visit. A care plan, visit history and claim therefore answer different questions about the same patient: what the hospice promised to provide, what it delivered and what it billed.

Overdue Hospice Recertification Surveys Leave Years Unexamined

An overdue hospice recertification survey leaves a gap in oversight whether the last review came from a state agency or an accrediting organization. Accreditation does not supply the missing inspection.

The Government Accountability Office’s 2019 account of the survey system described the earlier interval as seven years, with a targeted sample surveyed sooner. Congress replaced that schedule with a three-year survey mandate beginning April 6, 2015. The later survey review showed that shortening the interval on paper had not ensured timely visits.

325

hospices had gone without a standard survey in the preceding 36 months at the end of May 2023.

10% of the hospices in the Government Accountability Office’s review that had been enrolled in Medicare for more than three years.

Government Accountability Office, Medicare Hospice, May 2024

Within that overdue group, 33 hospices had gone more than six years without a survey. The group also included 55 with a previous serious quality deficiency. The backlog included providers whose earlier problems already gave the government a reason to return.

The Centers for Medicare & Medicaid Services told state agencies to prioritize overdue surveys. The Government Accountability Office found that those instructions gave no priority to the longest delays or earlier quality failures. Most of the overdue surveys completed during the follow-up period went to hospices overdue for the shortest time.

What the Patient and Worker Files Revealed

Care planning, aide supervision and patient assessment were recurring failures in the Office of Inspector General’s July 2019 review. More than 80% of hospices surveyed from 2012 through 2016 had at least one deficiency. The examples explain what those findings meant at the bedside.

Surveyors distinguish a standard-level deficiency from a condition-level one. A condition-level finding means the failure substantially limits the hospice’s ability to provide adequate care or adversely affects patient health and safety.

One patient’s plan called for weekly nursing visits. The hospice supplied none for two consecutive weeks. Another hospice failed to address the needs of a patient who choked frequently and needed slow feeding with small bites. A plan existed, but it did not reliably govern the care.

Aide services had their own gaps. Surveyors found missing supervision, missing patient-specific instructions and aides without the necessary skills to help patients use the toilet or transfer safely. The Office of Inspector General also found assessments left unchanged for months.

The personnel file supplied another test. The Office of Inspector General found a hospice that had not obtained background checks for six employees who delivered care or had access to patient records. At another, 34 of 35 care employees lacked updated credentials. Staff had started work without abuse and neglect screening, and some lacked required professional licenses. A name on the staffing roster did not establish that the hospice had checked the person’s qualifications.

The failures reached beyond individual charts. The Office of Inspector General found a hospice and nursing facility holding different medication and treatment orders for the same patient. For a nurse or quality manager, that is a recognizable failure to coordinate care.

Complaints and Serious Deficiencies Kept Returning

A substantiated complaint means a surveyor found evidence verifying it. Severity is a separate question about the danger or extent of the alleged failure.

The Office of Inspector General found that some complaint investigations occurred months or years after filing. Some lower-priority complaints could wait until the next onsite survey. That delay matters when the investigation depends on what happened to a particular patient, on a particular shift, with particular staff.

In the Government Accountability Office’s later review, 740 hospices had at least one substantiated severe complaint from 2017 through 2022. Of those, 181 had more than one. The most common subjects included care and treatment, patient rights and nursing services.

Serious survey deficiencies clustered too. Among hospices in the Government Accountability Office’s survey sample with a serious deficiency in the 2020–2022 cycle, 240, or 50%, had five or more.

Repeat surveys did not always bring a new story. The Government Accountability Office found 83 hospices with the same serious deficiency in both survey cycles it examined. The correction promised after the earlier visit and the finding at the later one belong side by side. That comparison shows whether the problem actually went away.

Hospice Abuse and Neglect Reporting Gaps GAO Found

The Government Accountability Office found two gaps in federal hospice abuse and neglect reporting requirements in its December 2022 report. The rules limited which allegations reached state survey agencies and allowed the hospice’s own investigation to determine what it reported externally.

The first gap concerned who allegedly caused the harm. The hospice requirements covered allegations involving someone affiliated with the hospice. They did not require the same reporting to survey agencies when the alleged perpetrator was someone outside it, such as a family caregiver.

The second gap concerned who decided whether an allegation warranted outside attention. Even when the alleged perpetrator was affiliated with the hospice, external reporting followed the hospice’s internal verification. Administrators had up to five working days to report verified allegations. An allegation the hospice did not verify might never reach the survey agency for an independent assessment.

The Government Accountability Office contrasted that arrangement with requirements for nursing homes and hospitals providing extended care, where allegations reached the oversight agency before the provider finished its own investigation. It recommended immediate reporting of all hospice abuse and neglect allegations, regardless of the alleged perpetrator’s affiliation.

The practical issue is who controls what the regulator gets to see. A complaint log and the reports sent outside the hospice can contain different accounts of the same period. An insider who knows what management received can explain that difference.

Who Pays the Accreditor, and Who Can See Its Findings?

Hospices pay accrediting organizations to survey them. The Government Accountability Office also recorded that accrediting organizations historically could sell consulting services to the providers they surveyed. The Centers for Medicare & Medicaid Services acknowledged the potential conflict and proposed restrictions in February 2024.

The Government Accountability Office reported a 20% disparity rate between accrediting-organization and state-agency survey findings in fiscal 2020. The measure concerned missed serious deficiencies per survey in a sample of accreditation surveys.

The public view had problems of its own. As of December 2023, the Centers for Medicare & Medicaid Services had posted survey information, but the Government Accountability Office found it was difficult to find and understand and was not linked through Care Compare. Separate spreadsheets held deficiencies from a limited set of surveys.

That matters to competition as well as oversight. The March 2026 working paper Quality, Reputation, and Reimbursement Design in the Hospice Industry, from Kansas State University, models hospice competition using California data. It measures quality through visits per patient-day and finds that reputation influences patients’ choice of hospice.

The model makes the case for usable survey findings: better care becomes more valuable to a hospice when its reputation brings future patients. A buried spreadsheet does little work for the patient choosing a hospice or the provider investing in better care.

What Happened After the Survey?

For years, the Centers for Medicare & Medicaid Services’ hospice survey enforcement power centered on ending the provider’s Medicare agreement. The Consolidated Appropriations Act, 2021 added intermediate tools, including payment suspensions for new admissions, civil money penalties and temporary management.

Those tools were slow to reach providers. The Government Accountability Office found 981 hospices with a serious quality deficiency between 2017 and 2022. By January 2024, the Centers for Medicare & Medicaid Services reported using the new tools three times: two payment suspensions and one civil money penalty.

CMS said it terminated 18 hospices that failed to correct serious deficiencies promptly during the period the Government Accountability Office examined. Patients bear the care failures, and taxpayers pay for care the hospice is supposed to deliver.

The Government Accountability Office describes the required sequence for serious deficiencies: the hospice documents its corrective actions, and surveyors return onsite to confirm correction. When the same failure reappears, those documents help explain what management knew and whether its response reached patient care.

Are CMS and DOJ Investigating Hospice Fraud?

The Centers for Medicare & Medicaid Services has expanded claims review and enrollment controls, while the Justice Department has pursued civil cases involving false hospice records and payments.

Enhanced oversight brought medical review before payment to new hospices in selected states, then expanded to existing providers in those states. Unlike the survey of care standards, this review examines the claims themselves.

The Centers for Medicare & Medicaid Services also imposed a six-month nationwide moratorium on new hospice enrollment, effective May 13, 2026.

Hospice Special Focus Program Implementation Stopped

Hospice Special Focus Program implementation stopped for calendar 2025 effective February 14, 2025, according to the Centers for Medicare & Medicaid Services’ notice. The agency said it ceased implementation to evaluate the program further.

The program was designed to increase oversight of poorly performing hospices until they improved or left Medicare. The Centers for Medicare & Medicaid Services had finalized its details in November 2023.

What an Insider Can See Behind the Review

The most useful account connects the care, the records prepared for review and the decisions inside the hospice. Someone who supervised visits or prepared survey materials may know where those accounts diverged.

In the complaint against Care Alternatives, whistleblowers alleged that missing documents were recreated and that a consultant preparing records for a possible state audit or accreditation review instructed staff to rewrite them to support diagnoses. The complaint also alleged that management dismissed an admission problem because it expected surveyors to look only so far back:

That allegation connects survey preparation with the underlying eligibility record. The person who saw an instruction to rewrite a document can explain something the finished chart conceals.

A separate civil case shows the connection to billing for care the nursing record did not support. Compassionate Care Hospice of New York and Compassionate Care Hospice Group agreed to a combined $6 million settlement in 2015. A whistleblower brought the case, and the government joined it. The Justice Department alleged that nurses at the Bronx operation routinely missed required visits and falsified notes at management’s direction, with the group’s knowledge.

The settlement announcement recorded admissions about failures in individualized care, nursing availability and clinical records. The group accepted responsibility for insufficient oversight through its compliance audits. Oversight was part of the case itself: who reviewed the care, what the review missed and what management knew about the notes.

For hospice whistleblowers, those connections give personnel files, visit records, internal complaints and correction plans their value. We assess the care and payment evidence together, including the instructions behind the records. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When the Review Missed What You Saw

If you saw missed care disappear from survey materials or complaints close while the same failures continued, speak with our hospice fraud whistleblower experts. We build a case strategy around what you know and bring in hospice fraud whistleblower lawyers who understand Medicare billing and clinical records. We stay beside you as the case reaches the people who made those decisions.