A significant number of Medicare hospice programs were not checked by state inspectors for nine years and were long overdue for certification, according to a federal report released Tuesday.

Three states — California, Illinois and Michigan — were furthest behind, accounting for 41 percent of the past-due certifications, according to the report by the inspector general's office of the U.S. Department of Health and Human Services.

Of the hospices surveyed, 46 percent were cited for at least one health deficiency, such as missing or inadequate patient-care plans.

Visits by state surveyors are the main way the federal government tracks the quality of care in hospices that get Medicare funding.

Medicare payments to hospices overdue for inspection averaged $2.7 million each in 2004, the report said.

Hospices give care, including pain management, to people with terminal illnesses. Most care takes place in a dying patient's home, with hospice staff members making regular home visits and being on call to families.

"We've been calling for more frequent surveys for some time," said Judi Lund Person of the National Hospice and Palliative Care Organization, which has 3,100 member hospices.

State surveys give "a chance to make sure providers and staff know what regulators are looking for," Person said. Currently, a hospice staff can turn over completely without a certification survey, she said.

The federal government, which contracts with states to do the hospice surveys, sets the priorities, said Bill Bell, who heads the Illinois Department of Public Health division responsible for the surveys. Hospital surveys and complaints have top priority in that system, Bell said. Even complaints from citizens about hospices go through the federal government, Bell said.

"If the federal government feels the complaint significant enough to investigate, they'll say, 'Go do this investigation,'" Bell said.

During a survey, a state can cite a hospice for problems with patient care. If problems are severe, a hospice can be eliminated from the Medicare program, but that is the only enforcement tool available to the federal government.

In contrast, the government can fine or deny Medicare payments to a nursing home with problems. The report recommends changes in the law to allow other enforcement tools for hospices. The report also recommends more frequent surveys.

The report was based on data from 2,537 active hospice providers in 2005.

"Hospice facilities should be surveyed timely so that problems can be detected and addressed," said Daniel Levinson, inspector general of the Health and Human Services Department, in a prepared statement.

The Centers for Medicare and Medicaid Services sets the frequency of hospice certification as part of its budget process. In fiscal year 2005, the centers required hospice certification surveys every six years, a standard in effect since 2000.

In 2006, the agency changed the frequency requirement to every eight years.

As of July 2005, according to the report, 14 percent of Medicare hospices were past due for certification, the report said. On average, they had not been surveyed for nine years, which was three years longer than the centers' standard at the time.

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On the Net:

HHS Office of Inspector General: http://www.oig.hhs.gov/

National Hospice and Palliative Care Organization: http://www.nhpco.org