This is the second installment of an ongoing series called “Business of Dying.” Read part one here .

— Inspectors showed up at a hospice agency here in March 2012, and then issued what amounted to a 161-page catalogue of end-of-life neglect.

A woman dying of liver cancer, battling nausea and breathing difficulties, waited weeks for someone to drain fluid from her swelling abdomen and died still waiting, according to records. Another cancer patient had a feeding tube that oozed pus where it pierced his skin and did not actually reach his stomach. He had received no fluids from it for five days, emergency room doctors said. At the same time, a patient complaining about chest pain waited two days for a recorded visit and eventually was taken to a emergency room and diagnosed with pleurisy.

In all, the state health inspectors found treatment problems in the records for nine of 14 patients from early 2012.

The discoveries at the hospice, known as Expect Care, highlight how weaknesses in the inspection system can allow agonizing lapses­ in care for the terminally ill.

Oversight of hospice facilities

The typical hospice in the United States undergoes a full government inspection about once every six years, according to federal figures, making it one of the least-scrutinized areas of U.S. health care — even though about half of older Americans receive hospice care at the ends of their lives. By contrast, nursing homes are inspected about once a year, and home health agencies every three years.

“It was horrible — we kept saying, ‘Oh my gosh,’ ” said Debbie Wetzel, one of the Alabama inspectors on the case.

The nature of hospice care makes ensuring its quality difficult. Hospices typically send nurses and other personnel to a patient’s residence — whether at a private home, a nursing home or an assisted-living facility.

The dispersal of patients makes oversight difficult to begin with, but the infrequency of inspections means shortcomings are even less likely to be detected.

Expect Care was not inspected when new owners took over in the second half of 2011. Under a normal schedule, the owners could have expected another five years to pass before their next visit from state inspectors. If not for a complaint by a former employee, the facility’s problems might never have been uncovered.

“Hospice is the most runaway program we’ve got,” said Carolyn Duck, the recently retired supervisor of the state group that inspects Alabama hospices, hospitals, dialysis clinics and home health agencies. “They’re out there doing whatever they want. When an inspector is in there every seven years, they may feel like no one’s looking.”

Seeking more oversight

The sparse scheduling of hospice inspections is dictated by the federal government, which sets the pace based on how much money the Medicare system has available to pay for the reviews. The Medicare program pays the states to perform inspections and directs how often they should be conducted.

As part of its annual budgeting reports, Medicare recently directed that hospices be inspected about every six years. Other years, the frequency of inspections is even more spaced out — in 2009, Medicare called for a frequency of just one per 10 years or longer.

The result: Even as the U.S. hospice industry has grown rapidly, caring for some of society’s most vulnerable, the companies that provide hospice services are rarely reviewed for competency.

It is impossible to say precisely how many hospice companies might be cited for violations if there were more scrutiny, but a significant portion of them appear to be providing scant care, Medicare statistics and interviews show.

●About 18 percent did not provide a single patient with “crisis care” during 2012, according to Medicare billings, meaning the hospice did not provide either continuous nursing care or inpatient treatments. Hospices are required to provide such services to patients whose symptoms are difficult to control.

●About 20 percent of hospices regularly failed to have a registered nurse visit patients in the 48 hours before death.

●Even though hospices aim to care for their patients until they die, about 20 percent of hospices discharge more than 1 in 4 patients alive, a sign that patients may be leaving a hospice to seek treatment elsewhere.

Separately, a government review in 2007 found that, when inspections are conducted, about half of the time inspectors turn up “deficiencies” in patient treatment, although some of these may have been shortfalls in record-keeping­.

Making inspections even more important is the reluctance of families to file complaints about bad care, experts said. The families are typically grieving and may feel ill-qualified to judge medical care. Moreover, they may not know where to file complaints.

At Expect Care in early 2012, for example, none of the patients described as receiving poor treatment filed complaints, officials said.

The infrequency of inspections has repeatedly drawn complaints and suggestions for reform.

In 2009, “many state officials” said inspections of hospices and other facilities should be conducted more often — at least every two or three years, according to a report from the Government Accountability Office.

In 2007 and again in 2013, the Office of the Inspector General for the Department of Health and Human Services likewise suggested that hospice inspections be conducted more frequently.

Even the National Hospice and Palliative Care Organization, a Washington-based trade group, has advocated for more frequent inspections.

“There are two kinds of hospices­ in America: the ones that get it right, and those that should be out of business,” Don Schumacher, president of the NHPCO, said in a statement.

Michael Osborn, who with his wife, Leta Parsons, purchased the Expect Care hospice in the second half of 2011 — less than a year before the bad inspection — said that the poor care reflected the problems accrued in the business under a former owner, who Osborn said racked up more than $1 million in debt and took on patients who were ineligible for hospice services.

Osborn and Parsons said the inspection opened their eyes to problems.

“In the end, we were grateful for the inspection, as hard as it was at the time,” Osborn said. “It let us know what we were up against. . . . It was being run into the ground.”

The hospice has since received better inspection reports.

A personnel issue

The U.S. hospice industry, which evolved from a community movement in the 1970s that was aimed at transforming the experience of dying, has grown rapidly in recent decades. For many Americans, it has become the last step before death.

More than 46 percent of the Medicare patients who died in 2012, for example, received some form of hospice care. And between 2000 and 2012, the number of Medicare patients receiving such services more than doubled to more than 1.2 million.

That growth stems in part from the preference of Americans, most of whom say they would prefer to die at home than in a hospital. Many families, moreover, have only reverential praise for the hospice services they have received.

“When I ran a hospice, the most common comment I got from families was, ‘I wish we’d started hospice sooner,’ ” Schumacher said.

But the industry’s growth may have outpaced its ability to maintain quality.

One significant problem, according to inspectors, is a lack of experienced personnel — in particular, trained hospice nurses. They are the backbone of the business, not only making the home visits, but also taking calls after regular hours and determining how serious the crisis is. Hospice nursing requires a distinct kind of medical knowledge, as well as the skills to deal with grieving patients and families.

“The biggest problem we see — and we see it over and over — is personnel. What we’ve always said is that we’ve got more hospices­ than experienced people to staff them,” said Duck, the Alabama inspector.

Another fundamental problem: Hospices can boost profits by short-changing patients. Medicare pays hospice companies per patient, per day of care. For a “routine” day of care, a hospice is paid about $150, regardless of how many services it provides. That means that stinting on nurse visits, for example, could boost profit margins.

If a hospice is failing its patients, the problem often shows up in the number of patients who withdraw from its services before dying.

A hospice is supposed to care for patients until they die, and that is what most of them do. At a typical hospice, about 1 in 10 patients is released alive. This is often because a patient’s condition improves unexpectedly, and the patient is no longer eligible for care.

But at hundreds of hospices — about 20 percent of them — more than 1 in 4 patients are discharged alive, according to Medicare statistics. Some of those hospices were too eager for business and signed up patients who are not dying, experts said. But it’s also a sign that some patients are getting poor care and leave.

Indeed, at Expect Care, two of the patients whose records were reviewed during the March 2012 inspection withdrew from the service.

The family of one heart patient declined to give a reason for withdrawing. But the patient had to be taken to an emergency room because of previously undiagnosed pleurisy, a painful inflammation of the lining of the lungs and chest. When asked if they ever called for help after hours, a family member said, “Yes, and on some occasions I never got a call back.”

“I got rid of the agency,” said a relative of a patient who was dying of end-stage dementia. “We just felt they weren’t doing us any good.”

To prevent lapses in hospice care, Medicare pays the states to conduct inspections. During the reviews, inspectors select a sample of patients. Some cases are reviewed by analyzing the associated paperwork; for some, the inspectors make home visits.

But the funding for inspections and their relative infrequency have been a long-running, if little-noted, complaint from the state inspection agencies. Led in part by delays in certifying hospices, some hospices pay accreditation agencies, which aim for inspections every three years, to perform their reviews.

The amount of money that Medicare sets aside for the state hospice inspections has shrunk by 9 percent in real terms over the past five years, even as the number of hospices and number of hospice patients have surged.

For 2014, Medicare budgeted $6.6 million for hospice inspections; in 2010, that figure was $7.2 million, in inflation-adjusted dollars.

A similar shrinkage has affected the overall Medicare inspection budget, too, meaning that the state budgets for inspections of all medical facilities — not just hospices — is lean and that the shortfall in the hospice budget is unlikely to be made up elsewhere. In 2014, Medicare budgeted $375 million for inspections of medical facilities; five years ago, that figure was $377 million, in inflation-adjusted dollars.

These budget constraints have made it hard for states to hire enough qualified inspectors to complete required inspections.

“Workforce instability due to noncompetitive [inspector] salaries and hiring freezes hindered their workload completion,” state officials told the GAO in 2009.

Problems at Expect Care

Osborn and Parsons acquired Expect Care in the second half of 2011. Osborn is a retired real estate developer; Parsons owned a medical and clerical staffing business. Neither had experience owning or managing a hospice.

Shortly before the couple invested in the business, in March 2011, the hospice had an inspection — its first in six years.

Inspectors discovered problems. The hospice lacked documentation to show that “employees were competent to perform their job skills and received training in the hospice’s philosophy and care,” they wrote. Moreover, inspectors found that much of the time that spring, when a patient called the hospice after hours, the person answering was not a registered nurse, as required.

No major patient issues were reported, however.

Osborn and Parsons said employees told them that former administrators had strategically limited what they showed to inspectors. If hospices present an incomplete patient list to inspectors, they can hide problems.

The number of patient records that inspectors reviewed was not disclosed. It’s possible that inspectors missed trouble because they review only a sampling of patient records, not all of them.

Whatever the case, in May 2011, inspectors found, without revisiting the hospice, that it had come into “substantial compliance” with regulations.

A few months later, Osborn and Parsons took an initial stake and they became full owners before the end of the year, according to documents and interviews.

No new inspection was required with the change in ownership. After receiving a complaint from a former employee in October, inspectors conducted an “abbreviated” inspection. They found problems in employee training, as before, but little else.

Then, in early 2012, former employees tipped inspectors that the hospice had more severe troubles. That’s when Wetzel and another inspector visited the hospice, staying for three days.

One of the first things inspectors noted was that neither of the two doctors on staff — the medical director and the backup medical director — had hospice training, which is required. Their credentials showed no “hospice education or certification in hospice palliative care,” inspectors wrote. Both doctors were hired in 2009, but it is not clear why this problem was not flagged in the previous inspections.

Similarly, for two registered nurses at the hospice, there was no documentation of “hospice competency skills.”

“The new owners inherited a problem, and they did not have the hospice experience to know they had a problem,” said Julia Gooch, a hospice expert that the state recommended for turning around the business. “They trusted some of the people who had been working there, and they shouldn’t have.”

The previous hospice owner did not respond to messages left with their attorney. Former administrators did not return phone calls.

But Wes Gandy, who worked for three years as the hospice’s volunteer coordinator, said the business that Osborn and Parsons inherited was well-managed and that key personnel left the company shortly after they took control.

“They’d never run a hospice company,” Gandy said. “They didn’t know what they were doing, and the people who did quit soon after they bought it.”

Whatever the case, the inspectors in March 2012 repeatedly found records of patients whose calls for assistance were received by an inattentive staff, if they were received at all.

When the family of the man with the feeding tube that was oozing pus called one Sunday morning, for example, he did not receive a visit from a skilled nurse. The hospice told them to wait a day — until Monday morning — to bring the man to the doctor. Apparently deciding that the situation demanded urgency, the family took him to a hospital, where an examination showed that his feeding tube did not reach his stomach, according to the inspectors’ report. He died days later.

When a frail older woman complained of various problems — head and chest pains, an oxygen tank that was not working — there was no documented response by the hospice, either. Indeed, when the patient’s caregiver suggested the patient had a bladder infection, the hospice nurse dismissed the suspicion, according to records. A full week later, a lab test confirmed that it was an infection.

Finally, the hospice repeatedly struggled in its efforts to help a woman with breast cancer that had spread to her liver. She repeatedly reported suffering from nausea, vomiting, breathing difficulties and pain. Despite requests over several weeks, the hospice refused to transport her to a hospital to tap the fluids that were building in her abdomen, according to the nursing notes.

On Jan. 4, “abdomen is tighter this visit,” according to the notes. On Jan. 18 and again Jan. 23, “abdomen [is becoming tighter] with each visit,” the nurse noted. On Jan. 29, the day before she died, “stomach is very firm & it is impeding effort to breathe.”

In response to the family’s request that the fluids be drained, hospice workers said it would be difficult to get the patient safely to the hospital, and besides, the fluids might return rapidly, according to the patient’s daughter, who was interviewed by inspectors.

The day before her mother died, the patient’s daughter called the hospice, but “they did not want to come out,” according to the inspection report. With the patient in “a lot of pain,” a nurse came, ordered morphine and then left.

“I expected them to stay with us when it’s critical. It kind of frustrated me. We called and we didn’t know what was going on. I didn’t know what to do,” the daughter told inspectors.

Eventually, after her mother started “gurgling” a few hours before her death, a nurse visited the house.

After the poor inspection, Expect Care’s license was downgraded to “probational” status. The state limited the number of patients it could accept. The hospice was required to hire a consultant for two years.

The company replaced the medical directors who lacked hospice experience with one who did.

“We are dedicated to turning this business around,” Osborn said, noting that it still loses money. “After that inspection, we could have quit. A lot of people would have. We had to change the culture of the place, and I think we have.”

For Wetzel and Duck, who said they regularly saw both the good and bad of hospice care, the need for more frequent inspections seems obvious.

“Once a hospice opens and gets inspected, well, six years is a long time,” Wetzel said. “They can cut staff. They can cut corners. And unfortunately, whether it’s because they don’t know any better, or they just look at it as a business, that is what some of them will do. There is no way of knowing.”