Report 2021-123 Recommendations

To improve its ability to investigate possible fraud and abuse, DOJ should provide guidance to Public Health about the types of information Public Health should include when it refers complaints that allege fraud to DOJ. Further, DOJ should also document a procedure for following up on complaints that do not include adequate information.

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. It should also require those four departments to establish a working group to annually meet to conduct a risk assessment of the Medi-Cal hospice program statewide, including performing analyses similar to those we conducted during this audit regarding growth in the number of hospice agencies, clustering of hospice agencies, and instances of medical personnel working at multiple hospice 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. These departments should adjust their fraud prevention and detection efforts based on the results of this assessment.

The Legislature should require fraud training for any Public Health 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.

To help ensure that hospice owners and hospice management personnel are of good moral character, the Legislature should revise state law to require that each hospice agency's owners, and the hospice agency's administrator, director of patient care services, administrator/director of patient care services designee, and medical director (hospice
management personnel) submit electronic fingerprint images to DOJ for the furnishing of the person's criminal record to Public Health. The revision should also include a requirement that hospice owners and management personnel with certain criminal convictions, as determined by the Legislature, are prohibited from obtaining a license and are further prohibited from providing any hospice-related service before obtaining either a criminal record clearance or a criminal record exemption from Public Health.

To protect against excessive and fraudulent growth in the number of hospice agencies, the Legislature should revise state law to require new, previously unlicensed hospice agencies to demonstrate an unmet need for hospice services in an area where they wish to operate. 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. It should also define appropriate measures of need and identify the methodology hospice agencies must use to demonstrate need.

To enable Public Health to better oversee the licensure of hospice agencies, the Legislature should require as a part of the licensure application the inclusion of financial information that is similar to the information required for home health agencies.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the
regulations. The emergency regulations should do the following: 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.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the
regulations. The emergency regulations should do the following: Establish guidelines for assessing the appropriateness of a hospice agency's ratio of patients to nurses.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the
regulations. The emergency regulations should do the following: Establish a limit to the number of hospice agencies that hospice management personnel can be involved with concurrently.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the
regulations. The emergency regulations should do the following: Require hospice management personnel to have hospice-specific training or experience.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the
regulations. The emergency regulations should do the following: Require, as part of its review of the initial application, that Public Health verify that the hospice management personnel
listed on the licensing application are, in fact, associated with the hospice agency, such as by contacting them by phone, and verify the work history of hospice management personnel by speaking with these individuals' previous employers by phone.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the regulations. The emergency regulations should do the following: Require Public Health to verify the status of the professional licenses for all hospice medical personnel, including contracted medical directors, as part of the initial license application. 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. 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.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the regulations. The emergency regulations should do the following: Establish requirements for conducting an initial licensing site visit that include verifying the identities of all hospice
personnel and ensuring that the hospice agency is set up to provide adequate care. Public Health should develop specific requirements for hospice office space and verify compliance with those requirements during the initial site visit.

To protect the health and safety of current and prospective hospice patients, the Legislature should require Public Health to issue emergency regulations within one year, while maintaining the general moratorium on new hospice licenses until Public Health issues the regulations. The emergency regulations should do the following: Establish requirements for 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. These inspections should be unannounced and take place after the hospice agency has begun caring for patients. During these inspections, Public Health should visit patients, ensure that the certifications of terminal illness are accurate, confirm that the hospice agency is providing adequate care, check hospice personnel identities and medical licenses, and ensure that the hospice agency has reported any personnel changes.

To ensure that all licensed hospice agencies comply with Public Health's newly adopted regulations, the Legislature should revise state law to require Public Health to conduct a license renewal for all currently licensed hospice agencies within two years after the regulations are adopted. It should also revise state law to require Public Health to perform license renewal inspections for all licensed hospice agencies periodically. If it performs them at least every 18 months, every other cycle will coincide with Medicare recertification inspections, which are required at least every 36 months.

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 reports from accreditors for all current and future deemed-status hospice agencies.

To increase oversight of deemed-status hospice agencies, the Legislature should amend state law to require Public Health to do the following: Annually audit a selection of at least 5 percent of deemed-status hospice agencies and monitor these agencies to ensure that they
take any necessary corrective actions.

The Legislature should revise state law to include a system of sanctions for Public Health to levy, including fines or license revocation, for the following: Violations of state law, regulations, or hospice standards by a hospice agency, including improperly certifying a patient as
eligible for hospice care.

The Legislature should revise state law to include a system of sanctions for Public Health to levy, including fines or license revocation, for the following: Failure by hospice management personnel to be present for an inspection or complaint investigation.

The Legislature should revise state law to include a system of sanctions for Public Health to levy, including fines or license revocation, for the following: Failure by a hospice agency to report a change in owner, hospice management personnel, or location.

To ensure that Public Health appropriately addresses the complaints it receives, the Legislature should require it to do the following: Establish time frames within which Public Health must initiate and complete its investigations of hospice complaints.

To ensure that Public Health appropriately addresses the complaints it receives, the Legislature should require it to do the following: Develop a comprehensive training manual regarding performing investigations. The manual should include specific guidance for
interviewing witnesses, collecting and reviewing documents, and following up on discrepancies to properly and thoroughly address complaints.

To help ensure that residents of long-term care facilities are not taken advantage of by unscrupulous hospice agencies, the Legislature should require Public Health and Social Services to develop materials to educate current and future residents of these facilities and their families about common hospice fraud schemes, including efforts to mislead residents to sign up for hospice care. It should also require Public Health to include this information on
its website.

To ensure that the public has adequate information when selecting a hospice agency to provide care, the Legislature should require Public Health to revise its Cal Health Find website by October 2022, to include the following: Up-to-date information about the ownership and license status for each hospice agency licensed by Public Health.

To ensure that the public has adequate information when selecting a hospice agency to provide care, the Legislature should require Public Health to revise its Cal Health Find website by October 2022, to include the following: Specific identifiers to differentiate between complaints that were unsubstantiated based on a review of sufficient evidence and
complaints that were undetermined because it could not reach a conclusion because of lack of evidence.

To ensure that the public has adequate information when selecting a hospice agency to provide care, the Legislature should require Public Health to revise its Cal Health Find website by October 2022, to include the following: A quality-of-care rating system for hospice agencies similar to the one that CMS uses for Care Compare. After all hospices have been inspected based on the new regulations, Public Health should begin reporting the quality-of-care ratings.

To ensure that the public has adequate information when selecting a hospice agency to provide care, the Legislature should require Public Health to revise its Cal Health Find website by October 2022, to include the following: An indicator or icon identifying a hospice agency that has received citations for abuse and neglect in the past year.

Until such time as the Legislature authorizes Public Health to issue the emergency regulations described above, Public Health should pursue its standard regulatory authority to address these issues.