Unusually long durations of hospice services provided to individual patients. Release Date: Summer 2023 2022-006 Treasurer's Cash Count, June 30, 2022 In California, PublicHealth completes these certification inspections on behalf of CMS. It had more than six-and-a-half times the nationwide average number of hospice agencies relative to its aged population in 2019. Extension requests must be submitted directly to CDSS. I. Reviewed PublicHealths investigation process, policies, and practices to determine their adequacy and effectiveness. Provided in an approved facility on a shortterm basis to relieve the caregiver. To enable Public Health to better oversee the licensure of hospice agencies, the Legislature should require as a part of the licensure application financial information that is similar to the information required for home health agencies. Yet it has not taken action to suspend a license since 2015, thereby missing the opportunity to immediately halt the operation of hospice agencies that have serious deficiencies. Acting California State Auditor. After all hospice agencies have been inspected based on the new regulations, Public Health should begin reporting the quality of care ratings. .04 Government Code section 12410.6 requires districts to change auditors every six years. If you have any questions or concerns regarding this matter, you may contact me at the telephone number listed above. Further, CalHeath Find provides information about the process for submitting complaints against hospice agencies. Nonetheless, PublicHealth must make a meaningful effort to gather valuable information about deemedstatus hospice agencies to ensure the safety of their patients and to prevent fraud. Reviewed federal and state law and regulations related to hospice agency sanctions, as well as PublicHealths relevant procedures. In California (excluding Los Angeles County), the number of hospice agencies increased 383%, from 206 in 2010 to 995 in 2021, while the aged population increased 47%. As we previously indicate, hospice agencies have historically had the ability to receive their Medicare certification through national accreditors that CMS has approved rather than through PublicHealth. Building A appears to be a standard commercial office building. Public Health enforcement actions are levied against the licensed hospice agency. Collecting this information should be a high priority for PublicHealth, given the difficulty in determining the quality of care hospice agencies provide. Notwithstanding our current efforts, DHCS agrees with CSAs recommendation that the Legislature require collaboration among the California Department of Public Health, Department of Social Services and Department of Justice to conduct a more global risk assessment of the Medi-Cal hospice program statewide and to support increased efforts to identify, investigate and prosecute fraud and abuse by hospice agencies and providers. We find this response insufficient because not all hospice agencies are federally certified and the State needs appropriate standards of its own. The regulations should specifically include a process for verifying the identity and qualifications of hospice agency management personnel among other items. Additionally, in February 2022, the California Attorney General announced the arrests of 14 individuals who were charged in connection with two hospice companies based in San Bernardino County accused of stealing more than $4.2 million from Medicare and MediCal. Source:State law, hospice standards, and PublicHealths licensing application. 621 Capitol Mall, Suite 1200 Hospice is a specialized form of interdisciplinary health care primarily designed to provide palliative care and alleviate the physical, emotional, social, and spiritual discomforts of a person who is experiencing the last phases of life because of a terminal disease. To increase oversight of deemed status hospice agencies, the Legislature should amend state law to require Public Health to do the following: Collect and monitor full survey reports from accreditors for all deemed status hospice agencies. 3. When we reviewed a list of hospice fraudrelated complaints that DOJ had received, we found that DOJ did not investigate 29complaints that PublicHealth referred to it from 2016 through 2021. Recently, CMS made changes to federal hospice oversight that impose additional sanctions on hospice agencies that are similar to those for home health agencies, including the suspension of Medicare payments and the imposition of fines. However, state law does not have a corresponding requirement for hospice owners and administrators, which we believe places hospice patients safety atrisk. The California Department of Justice Office of the Attorney General investigates and prosecutes Medi-Cal provider fraud, as well as abuse or neglect of patients in health care facilities receiving Medi-Cal payments, while the California Department of Health Care Services determines Medi-Cal eligibility of patients, processes Medi-Cal payments, and investigates suspected Medi-Cal fraud. To address fraud that is likely occurring in Los Angeles County, the Legislature should require Public Health, Health Care Services, DOJ, and Social Services to immediately convene a taskforce to identify, investigate, and prosecute fraud and abuse by hospice agencies in that county. CDSS commits to partnering with CDPH to implement this recommendation upon the Legislature chaptering legislation. Guide for Annual Audits of K-12 Local Education Agencies and State Compliance Reporting Education Audit Appeals Panel 770 L Street, Suite 1100 Sacramento, California 95814 916.445.7745 fax 916.445.7626 www.eaap.ca.gov March 1, 2022 It receives complaints through a variety of channels, including telephone, mail, email, its website, and referrals from other entities. For example, if there's a change to your company's ownership, corporate titles, large payroll changes, or stock, it could affect your policy premium. Who We Are. From its enactment in 1990 until January 1, 2022, the Licensure Act has not required PublicHealth to assess the need for hospice services when issuing hospice licenses. About Us. An audit begins with the examination of records for a test year which is generally the most recent completed calendar year. In addition, accreditors perform certification/recertification for Medicare as well as perform licensing initial site visits as part of Medicare certification. 335 0 obj <>stream Finally, the Cal Health Find website does not include indicators of performance quality. Compared the accreditors hospice licensing standards with the States standards. This count includes entityreported incidents, which are incidents reported by a care provider, such as a hospice agency in this case. 6Since 2015 DOJ also received 32 other complaints regarding hospice providers that it chose not to reviewfurther. Although DOJ and PublicHealth have also received complaints about fraud in other areas of the State, the number of those complaints is disproportionately lower than the number of fraudrelated complaints in LosAngeles County. One critical consideration that PublicHealth has failed to adequately address in its licensing process is a hospice agencys ability to respond promptly to patient care and safety concerns. However, before issuing a license to a deemed-status hospice agency, state law requires PublicHealth to receive from the accreditor copies of all accreditation reports or findings. Consequently, it cannot regulate whether a hospice agency can accommodate its proposed service area or adequately serve all of its patients. We found indicators of large-scale fraud that include likely fraudulent billing to Medicare and Medi-Cal and the apparent use of stolen identities of medical personnel to obtain licenses. california-state-auditor-exam-study-guide 1/1 Downloaded from coe.fsu.edu on June 16, 2023 by guest Read Online California State Auditor Exam Study Guide Thank you very much for reading california state auditor exam study guide. Source:State law, hospice standards, and PublicHealth license application. This lack of coordination appears to have resulted in significant flaws in a system that is designed to protect vulnerable hospice patients from harm and to guard the States MediCal system against fraud. Chief Assistant Attorney General We found Health Care Services MediCal data to be sufficiently reliable for the purpose of calculating the amount of MediCal feeforservice spending on hospice services but of undetermined reliability for the purpose of analyzing hospice services, providers, and beneficiaries for possible indicators of fraud. However, a general moratorium on licensing new hospice agencies in California took effect on January1, 2022, and will last until one year from the date this report is published, which will limit the number of new hospice agencies licensed from these more recent applications for the duration of the moratorium. Although the majority of hospice services were provided by nonprofit organizations in the past, this recent wave of growth is almost exclusively in forprofit companies. Data from PublicHealth indicate that it received roughly 2,100 complaints from January 2015 to August 2021, of which nearly 350 included allegations of fraud and abuse. Audit: California Hospice Licensure and Oversight: The States Weak Oversight of Hospice Agencies Has Created the Opportunity for Large-Scale Fraud and Abuse, Audit Entity: California State Auditor Response to Recommendation #4: Agree. Despite these widespread problems in the hospice program, PublicHealth and the two state agencies primarily responsible for identifying and investigating hospice fraud in MediCalthe California Department of Health Care Services (HealthCare Services) and the California Department of Justice (DOJ)have not sufficiently coordinated their efforts. To address fraud that is likely occurring in Los Angeles County, the Legislature should require Public Health, Health Care Services, DOJ, and Social Services to immediately convene a taskforce to identify, investigate, and prosecute fraud and abuse by hospice agencies in that county. PublicHealth performs its site visit before a new hospice agency is licensed and operating, which allows it to check for adequate office space and the ability to secure confidential personnel and medical files. For instance, probation for gross negligence or fraudulent billing should be a cause to deny a hospice agency's application, even if the medical director's license is currently active. The Licensure Act does not currently have monetary penalties that PublicHealth can use to sanction hospice agencies that exhibit deficiencies, andas we discuss further in Chapter 3it rarely uses its authoritative power of revoking a hospice agencys license. According to the assistant program administrator of Community Care Licensing at Social Services, the facilities themselves are responsible for coordinating with the hospice agencies that provide care to their residents. the records list several individuals as being the administrators for multiple hospice agencies in the suspicious clusters we previously discuss. We believe that the targeting of residents in longterm care facilities underscores the need for these state agencies to coordinate their efforts to notify residents of such risks. With California state taxes being the highest among the nation at 13.3 percent and with taking into account the . We found CMSs Medicare data to be of undetermined reliability for the purposes of calculating the average duration of hospice services, average live discharge rates, and average amount paid per patient. The departments existing process for inspecting hospices or investigating complaints already includes requirements for those visits to occur unannounced. In order to qualify for a hospice license, the Licensure Act requires applicants to be of good moral character, submit a completed application, satisfy the definition of a hospice, provide hospicerelated services, comply with the hospice standards mentioned in our Introduction, pay a fee, and demonstrate an ability to comply with the Licensure Act, along with any hospice licensing regulations issued by PublicHealth. Evaluate the factors contributing to the prevalence of deemed-status hospice agencies in the State and, to the extent possible, analyze its impact on hospice quality, oversight, and transparency. Even when PublicHealth finds instances of wrongdoing, it has limited recourse to sanction hospice agencies under current state law. The Licensure Act expressly requires accreditors to forward to Public Health copies of all accreditation reports or findings for hospice agencies that it licenses based on accreditation. Legislation would be necessary for Public Health to implement this recommendation. However, as we indicate previously, it rarely denies license applications. Across census tracts and geographic regions. Audit Program A. If a hospice agencys lengths of stay are significantly longer than these averages, it could indicate that the agency is admitting patients who do not need hospice care or is admitting them sooner than they require. Public Health agreed with most of our recommendations but indicated that some may require additional legislation. Although we did not identify a backlog, we discuss in Chapter 2 our concerns with PublicHealths timeframes for completinginvestigations. The hospice agency must obtain such written certification for each patient. Although its procedures require such checks for physicians and managing nurses, its staff did not document that they performed them for at least one medical position in eight of 10 licensing files we reviewed. Determine whether PublicHealth has a process for determining complainant satisfaction with its complaint investigations and findings on hospice complaints and how the process could be more effective. Audit Guidelines CDE Audit Guide, Revised 2021 (PDF; 1MB) Guidelines for independent auditors conducting audits of Child Care and Development, Nutrition, and Adult Education, and No Child Left Behind contracts administered by the California Department of Education (CDE). A high discharge rate of live patients could indicate misuse of the benefit in that the hospice agencies are enrolling patients who are not eligible for hospice services because they are not terminally ill. Consequently, these patients may not be receiving the curative care they need. The current MOU outlines the information necessary in a referral from DPH to DMFEA for multiple facility types, but does not specifically delineate hospice agencies. PublicHealth simply indicated that the hospice agency needed to submit a change of location request to update the address. A complaint can include multiple allegations. In one case, PublicHealth posted the results of a complaint investigation in Cal Health Find that concluded, in part, that a hospice agency was not at its stated address. Audit Guide. The State has a responsibility to ensure patient safety by ensuring that hospice agencies are qualified to provide services. Decrease Font Size Font Decrease. Each must have an administrator who manages the day-to-day operations as well as a business office where patient medical files and other documentation are kept. A rapid increase in the number of hospice agencies with no clear correlation to increasedneed. We found similar clusters in the cities and communities of Glendale, Burbank, and North Hollywood in Los Angeles County. We discuss in the next section the process through which hospice agencies are certified by accreditors. If PublicHealth receives complaints about deemedstatus hospice agencies that contain less serious allegations, it may advise the complainant to file the complaint with the accreditor or ask the complainants permission to release the information to the accreditor. * We estimated the statistics for 2021 aged population, 2021 deaths of the aged population, and the daily patients per hospice agency using historicalaverages. Establish time and distance standards that define the maximum time and distance hospice agency staff may travel to reach patients, taking into consideration typical traffic conditions and whether the hospice agency is serving patients in rural or urban areas. The law should require that the number of hospice agencies in a given geographic region closely aligns with measures of the need for hospice services. This guide will help you perform audits and address accessibility issues. However, the caregiver and patient indicated they were not aware that hospice patients will not be provided with curative treatment while receiving hospice services. Authority 3 B. . Although CMS maintains hospice quality data that includes selfreported surveys by hospice agencies, it generally requires responses only from those with more than 50 patients. Since 2019 state law has required PublicHealth to issue licenses to hospice agencies that have been approved by an accreditor as long as the hospice agency also files an application and pays fees. For instance, we reviewed an application in which the individual whom the hospice agency proposed would serve as its medical director was already the active or planned medical director for more than 30 other hospice agenciesa questionable number for a person who is charged with the responsibility of developing plans of care, directing the interdisciplinary teams, consulting with the patients attending physicians, and liaising with other physicians in the community to coordinate efforts to ensure that each patient receives quality care. The OIG indicated it has been involved in a number of hospice fraud and abuse cases that included hospice agencies that enrolled beneficiaries who were not terminally ill; these agencies also altered patient records, falsified documentation, and billed for services notprovided. Public Health lacks requirements related to criminal background checks of key hospice agency personnel, verifying the need for hospice agencies in proposed location, the size of the hospice agency's service area, the ratio of nurses to patients, and staff employment by multiple hospice agencies. We agree with the audit recommendations to address and improve States ability to improve and investigate hospice care fraud discussed in this report. State Compliance Resources for completing the State compliance requirements of the Audit Guide. Skip to Main Content. Acting California State Auditor A long length of service for patients could indicate that hospices are admitting patients who are not terminally ill and therefore not qualified for hospice care. Establish requirements for conducting follow-up inspections to the initial site visits within one year of initial licensing to verify that hospice agencies are complying with those hospice standards that cannot be assessed before the agencies begin providing care to patients. But to know what you need to improve, you need to know where you are. As directed by the Joint Legislative Audit Committee, my office conducted an audit of the States licensure and oversight of hospice agencies and found that the States weak controls have created the opportunity for large-scale fraud and abuse. Hospice agencies providing long lengths of service could be an indicator as well. We find this lack of response concerning. Additionally, one hospice agency suite number was included on a door with 13 different suite numbers, and one hospice agency suite had unopened mail visibly piling up on the floor inside a glass door. Require hospice management personnel to have hospice-specific training or experience. The accreditors then have jurisdiction for overseeing the hospice agencies ongoing compliance with federalrequirements. Abnormally high rates of still-living patients discharged from hospice care. OSAE also performs non-audit services. For example, PublicHealth has not issued regulations governing the size of the geographic area that a hospice agency can serve or the ratio of nurses to patients. Note:Because hospice patients are in the last stages of their lives, a high live discharge rate and a long duration of services suggest that some hospices are admitting and billing for patients who are not actually terminally ill and who do not qualify for hospice care. It should also require Public Health to include this information on its website. Medi-Cal is Californias Medicaid program. Source:PublicHealths data visualization website. Venus D. Johnson In fact, its practice is to not seek more information in such situations during the renewal process. Audits & Investigations Missio n Audits and Investigations Division (A&I) is the designated Program Integrity Unit (PIU) for the Medi-Cal program. The State Controllers Office, in consultation with the Department of Finance, the State Department of Education, and representatives of specified organizations, proposes the content of a guide for the required annual financial and compliance audits of school districts, offices of county superintendents of schools, and other local education agencies. Because the fraud indicators we identified frequently also involved home health agencies, the four departments should also consider risks related to home health agencies. However, as Figure 12 shows, Cal Health Finds website lacks key information that would help members of the public make wellinformed decisions when choosing a hospice agency. However, it performs these inconsistently because its policy suggests they should happen as needed, which is an ambiguous guideline. The lack of such coordination has resulted in gaps in the system, which is designed to protect hospice patients from harm and to guard the States MediCal system against fraud. We believe that a coordinated effort by PublicHealth, Health Care Services, DOJ, and Social Services is necessary not only to respond to instances of fraud and abuse, but also to proactively prevent future occurrences. This technique allows law enforcement to gather intel, ask questions, and observe what is in plain view. Because hospice services are designed to provide care to terminally ill patients, we would expect the number of hospice agencies in an area to generally align with the predicted needs of terminally ill patients, namely the size of the aged population and number of deaths among the aged population. We disagree with Public Healths statement that it cannot implement the recommendation to collect and monitor full reports from accreditors. Past Medicare fraud schemes have involved perpetrators using stolen identities of medical personnel to fraudulently bill for services performed by the purported employees. We present the complete list of our recommendations later in the Conclusions and Recommendations section. The U.S. Government Accountability Office, whose standards we are statutorily obligated to follow, requires us to assess the sufficiency and appropriateness of computerprocessed information we use to support our findings, conclusions, and recommendations. Determine how often and under what circumstances PublicHealth applies sanctions to hospice agencies. Uptodate information about the ownership and license status for each hospice agency licensed by PublicHealth. Because hospice agencies provide services to a specific geographic area, large clusters of providers in one location suggest that the supply of providers may exceed the patient needs in that location and that the providers may actually be billing for services to patients not located in the area or who are not eligible for hospice services. State agencies have not adequately coordinated their fraud preventionefforts. Below, we have numbered and provided responses to each of the recommendations included in the audit report. To evaluate whether some of these individuals might be the victims of identity theft, we reviewed their state wage data. Response to Recommendation #6, bullet 7: Partially Agree. As a result, there is a high risk that the hospice agencies located in these clusters may be billing for services to patients who are either ineligible for hospice care, or who were misled and may not even know they have signed up for hospice services. Moreover, we reviewed cases in which PublicHealth became aware of possible fraud during the licensing process and instead of denying the licenses, it granted licenses to these hospice agencies. We did not revise this text as Social Services suggests because we determined that Social Services does not identify or analyze hospice complaints, fraud-related or otherwise. They can then fraudulently bill for services purportedly performed by these individuals, who may not be aware they are named as working at the hospice agency. Except for Child Development program contractors on conditional status, Title 5, California Code of Regulations (5 CCR), Section 18073, allows a one-time-only per year, 30-calendar-day extension of the audit due date, provided the inability of the contractor to submit the audit report by the due date was beyond the fault and control of the contractor. As a result of its subsequent investigation, PublicHealth found that the hospice agency was no longer operating. While the Audit team considers data with each step, documentation is key as it allows others to walk along the beaten path and build upon the concepts for further improvement. Settings Default. The regulations should also establish guidelines for when Public Health must deny the application of a hospice agency that is proposing to use medical personnel whose professional license records indicate the imposition of a disciplinary action. While Public Health agrees that affiliation of key members of the management team should be verified, requiring phone calls and reference checks of work history would result in a significant workload for the department. In recent years, a significant and disproportionate amount of this growth has been concentrated in LosAngeles County. This recommendation would require Public Health to establish a followup inspection to the initial site visit to verify the hospice agencys compliance with those standards that cannot be assessed before it begins to provide care to patients. (Example: "1998, 2006-09") (Example: "Water Resources") A More Accountable California. It does not: Additionally, although Cal Health Find includes details of substantiated complaints, it provides limited information about unsubstantiated complaints, which includes cases where the investigation results lacked sufficient evidence to conclusively support the allegation. We analyzed hospice complaints and found many that allege hospice agencies had targeted residents of long-term care facilities to become hospice patients, sometimes through fraudulent means. Although we focused on other urban areas, such as Sacramento County, the Bay Area, and San Diego County, we did not identify similar clusters of hospice agencies at a single address. Copyright document.write(new Date().getFullYear()) State of California, Statutes and Regulations Governing Appeals and Requests for Summary Review. Evaluate the growth of hospice agencies in California over the last decade, including the potential factors that led to this growth, and determine whether other states have experienced any such growth and taken steps to address it. The Legislature should require fraud training for any PublicHealth staff who are responsible for licensing and certifying hospice agencies, including training about the types of information that are necessary for making referrals to DOJ when they suspect fraud is occurring. Public Health misunderstands our recommendation. The Controller submits the proposed audit guide to the Education Audit Appeals Panel for review and possible amendment. County building records show that the building has 22,500 square feet of space, and even less space is available for business offices after excluding the common areas of the building. Hospice care consists of services and supplies, such as nursing services; medical supplies, which include drugs for pain management; homemaker services; and spiritual and grief counseling. We refer to PublicHealths initial visit to a hospice agencys office before it is licensed as an initial site visit and all subsequent visits as inspections. Live discharges from hospice care are infrequent nationwide. Another indicator is stolen identities in hospice personnel. We believe that the targeting of residents in longterm care facilities underscores the need for these state agencies to coordinate their efforts to notify residents of such risks. Moreover, we believe such verification is crucial to ascertaining the qualifications of hospice management personnel who have significant responsibility for the health and safety of vulnerable patients.
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