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Abuse and Neglect: CMS Should Strengthen Reporting Requirements to Better Protect Individuals Receiving Hospice Care

GAO-23-105463 Published: Dec 12, 2022. Publicly Released: Jan 11, 2023.
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Fast Facts

Patients receiving care from Medicare- and Medicaid-certified hospice care providers could be better protected from abuse and neglect.

These providers aren't required to report abuse and neglect allegations if the perpetrator is unaffiliated with the hospice, such as a caregiver or family member. This makes it difficult for the Centers for Medicare & Medicaid Services to ensure that providers protect patients.

We recommended that CMS improve hospice reporting requirements to make them more like those that nursing homes follow. This includes reporting all abuse and neglect allegations immediately—even those involving unaffiliated perpetrators.

An image of an elderly person in a bed with a person's hand outstretched on the person's shoulder.

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What GAO Found

GAO's review of Centers for Medicare & Medicaid Services (CMS) requirements for reporting and responding to abuse and neglect allegations found two gaps in the requirements for hospices, compared with requirements for extended care provided in hospitals and nursing homes. Hospices, which can provide care in a patient's home or other settings, are required to report allegations to the state agencies responsible for monitoring them only if: (1) the alleged perpetrator is affiliated with the hospice; and (2) after the hospice has verified it as abuse or neglect based on an internal investigation that could take up to 5 days. In contrast, nursing homes and hospitals providing extended care are required to report all abuse and neglect allegations, regardless of whether the alleged perpetrator is affiliated with the hospice and prior to conducting an internal investigation.

Reporting Requirements for Allegations of Abuse and Neglect in Hospice Care


As a result of these gaps, hospice care providers' reporting may be less complete or timely than that of nursing homes and hospitals providing extended care. For example, hospices are not required to report allegations involving alleged perpetrators not affiliated with the hospice even though research suggests that most abuse of older individuals is committed in the home by an individual's caregivers, such as family members.

Immediately reporting all allegations to survey agencies before providers conduct investigations is important because the agencies use abuse and neglect allegations to inform decisions about the need to conduct their own unannounced on-site investigations of hospice providers. These investigations can ensure, for example, that the hospice has worked within the scope of its authority to protect individuals receiving care. Strengthening hospice reporting requirements to align with the requirements for nursing homes and hospitals providing extended care will provide CMS with the information necessary to ensure that hospice care providers are taking appropriate steps within the scope of their authority to protect vulnerable individuals.

Why GAO Did This Study

Vulnerable populations receiving extended (non-acute) care from Medicare- or Medicaid-certified hospitals, hospices, and nursing homes have the right to be free from abuse and neglect, according to CMS's requirements. These requirements include actions Medicare and Medicaid providers should take to report and respond to abuse and neglect allegations. CMS enters into agreements with state survey agencies to monitor providers' compliance with these requirements and investigate incidents reported to them.

GAO was asked to review CMS's abuse and neglect requirements. This report examines, among other issues, any differences in CMS's requirements for reporting and responding to abuse and neglect across these provider types.

GAO reviewed relevant CMS requirements contained in regulations and guidance and interviewed CMS officials about any differences in the requirements for reporting and responding to abuse and neglect among these provider types.


GAO recommends that CMS require hospice care providers to report all allegations of abuse and neglect immediately to survey agencies, regardless of whether the alleged perpetrator is affiliated with the hospice. HHS neither agreed nor disagreed with GAO's recommendation.

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS administrator should require, for individuals in hospice care, immediate reporting of all abuse and neglect allegations involving all perpetrators—including those not affiliated with the hospice—to the hospice administrator, a state survey agency, and other appropriate authorities. (Recommendation 1)
In February 2023, CMS issued an update to the State Operations Manual Appendix M, which provides guidance for state survey agencies for hospices. The updated Appendix M includes language about the need for hospice staff to be trained on the reporting requirements for abuse and neglect. In their July 2023 update on their efforts to address our recommendation, CMS officials also noted that an RN is part of a hospice survey review team and would be a mandatory reporter of any abuse or neglect witnessed in a survey. While this is helpful information for survey teams, these edits do not address the substance of our recommendation, which is focused on the need to require all hospice staff to immediately report allegations of abuse or neglect, including actions by individuals not affiliated with the hospice, to appropriate authorities. Therefore this recommendation remains open and we will continue to follow up with CMS regarding future updates.

Full Report

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Criminal investigationsElder abuseHospicesHospitalsMedicareReporting requirementsNursing homesPatient careCompliance oversightMedicaid