human rights activists talks about herbook decision to challenge the saudi government ban on women drivers. anthe right to drive is not act of civil disobedience. we show that we are able and capable of driving and being in the driver seat of our own destiny of doing this act of civil disobedience. >> watch on c-span's q&a. she is with the health and human services department and is the assistant inspector general for valuation. welcome to the program. the --k you for having having me. you talk to us about

what you do. >> health and well-being of the people they serve. we do oversight and enforcement of the programs of the health and human services department. host: you turned your attention to the topic of hospice. what were you looking to find out? health and safety of medicare beneficiaries is one of our top priorities. they are a vulnerable population . we looked into information about deficiencies being cited to quality of care and patient harm. host: what did you find looking into this? guest: our report shed light on how common it is for hospice providers to be cited with efficiency with the quality of care they are providing and in some case very serious deficiencies. we uncovered gaps in patient protection. we issued a call to the medicare program by the centers for

medicare and medicaid services to help fix these problems. host: what were the worst case scenarios with the deficiencies when your department looked into this? guest: we did identify some worst-case scenarios where patients were seriously harmed by their care. in one egregious example, a hospice provider allowed to add that to fester around feeding to and he needed to house allies. that is -- needed to be hospitalized. that is an extreme case but should never happen. host: remind people what they toe -- what medicare pays hospices as far as dollars are concerned. guest: in total in 2016, medicare paid hospices $16.7 billion for serving approximately 1 million and half beneficiaries. the another -- number of patients electing hospice care

is growing and so are the dollars. hospice care is a program that patients can opt into when they are terminally ill and expected to have about six months or less in their life. it is a decision to forgo regular curative treatment for their terminal illness and instead focus on services to provide pain relief, symptom relief, comfort, and social and spiritual support to both the patient and loved ones. egregious and the washington post highlighted others, including some developing gangrene and requiring an amputation and other things -- why do these things happen? what is keeping folks from not taking care of the situations? identified in the patient protection systems. those are egregious examples. we found a three and four hospice providers inspected each

year are identified to have some level of deficiency but they are not all that serious. for about one in five, they are series deficiencies and 1% are the extremely serious deficiencies. one problem we identified is that information about these deficiencies and serious complaints that are investigated and substantiated is not made publicly available in an easily assessable space. so patience and love ones would have a difficult time finding the public information and some information is not public at all. had complaints against them and more than 300 were considered poor for -- poor performers. bound in such a way, what is their punishment? who dosurvey agencies

many of these inspections will work with the hospice to try to correct the problems. they are limited in the enforcement tools they have. right now, the only action the medicare program can take if hospice doesn't correct its problems is to terminate them or not allow them to participate in medicare. there are no other tools. this is in contrast to issues that might arise in a nursing home, where the medicare program has an array of tools to help remedy poor performance. we recommended the medicare program work with congress to get authority to take a range of enforcement actions. host: we will continue talking with our guest. if you have questions about hospice in the united states, (202) 748-8000 in the eastern and central time zones, (202) 748-8001 in the mountain and pacific's. if you've had expense with

hospice and want to share with viewers, (202) 748-8002. such a to why there is difference between money that medicare sends to nursing homes is that it sends to hospice care. guest: i can explain why there are the protections in the hospice lags behind. we think it is time for that to change. we have made a number of recommendations to strengthen protections for patients, transparency of information, enforcement tools available to bring hospice care more on par with other types of care. host: what prompted this report in the first place? guest: hospice issues have been assessed for more than a decade. we are focused and particularly concerned about quality of care and concerns about patient harm and abuse in a range of settings

a especially hospice being vulnerable population. host: is there a federal standard for what qualifies as a hospice when it comes to requirements for running one? guest: yes, medicare has conditions of participation for being hospice in that program. those are the conditions that the inspectors go out and look for. we talk about hospice being cited for a deficiency, it is related to not meeting one of the medicare requirements. host: such as? guest: such as taking appropriate steps to prevent infection control or quality assurance, appropriate training of hospice staff. for example, inadequate staff supervision and training is one of the most common efficiencies .hat get cited against hospices this can have real-world impact on patients.

we cited a case where a patient in hospice at her leg broken because her aid was not properly trained in how to safely transfer her from her wheelchair to her bed. host: does medicare provides a standard for the staff within a hospice and what kind of neville or education training they have to have? are standardsere around the qualifications and staff need to have to provide hospice care. point four 9 million medicare beneficiaries were enrolled in hospice care for a day or more in 2017. about 64.2 percent were 80 years of age or older. 58.4 percent.le, the average length of service within hospice, 76.1 percent. that is from the national hospice and palliative care organization. did they respond to this report and are they the agency that

represents hospices and how did they respond? there was attention to findings, both in the media and general public as well as the hospice association. i cannot speak for this particular association but there is certainly a shared mission between our office and the issues we have raised in those associations and we are all working to protect patients and keep them safe and provide high-quality care. host: in general, do they agree with your conclusions? speak onreally cannot behalf of the association's but i did see some opinions in the industry where they were reinforcing the need for adequate training, transparency, and expressing concerns about the extreme examples that we talked about. we are joined to talk about the report on hospice violations. en inll start off with l

las vegas. he is an independent. go ahead. caller: i was just wanting to make a comment. i understand that there is a license for 90 milligrams of morphine per day per person. she works regularly with patients and hospice comes in and there maximum is 10 milligrams per hour. they can give a patient on milligrams come close to a lethal dose.

don't -- she is a health care provider and hospice comes in and they can no longer do anything else for that patient. they can't even give them a glass of water. thank you for calling. atst: the use of opioids this point is a national of endemic and is something of great concern and the office of inspector general has a large body looking at opioid misuse as well. out guidelinest for safe dosages. those are just guidelines. it is up to the patient physician to determine what is the most appropriate and effective treatment given their circumstances. i will say that when we do our analysis, taking a look at high levels of opioid use, we do exclude hospice patients from that analysis with the

recognition that there are special circumstances in hospice and the purpose of that care is to provide comfort and pain and symptom relief at the end of life. with that being said, if your wife does have specific concerns that she has witnessed or were there might be particular hospice providers who are being responsible for perhaps abusive, i do encourage her to report her concerns to the state survey agency that oversees hospices. a her concerns go to potential criminal situation, i encourage her to reach out to local lease. host: the report that you put out -- doesn't name the names of providers found in violation? thet: no, we did not name providers in our examples. 300 poor performing

hospices that we identified, not all of that information we would the able to release. if offices laughed to be inspected by private accrediting organization rather than the state agency, result of our protected from disclosure by law. we recommended that the medicare program work with congress to get authority to share that information as well of the results of those done by the states. clarify, hospice can decide to be inspected by the state or a private agent? guest: has to be a cms approved accrediting agency that is the hospice's choice. host: would you argue that the state is better and maybe even higher than that, federal, is better than these agencies? guest: we do not have a basis to compare the state versus the

credit dated, -- credi accredited ones. we think it is important for all information to be easily and readily accessible for the public. host: is there a family who receives hospice care and is wondering if there place is ending up in the report, can they find out? on thewell, it depends hospice and how they wound up in the report. to the extent it was based on information uncovered to a state agency, that information can be made available. if it was based on information that came from an accreditation survey, we would not be able to release that information, and that is a problem. host: this is esther in california. go ahead. you are on with our guest. caller: i am interested in how

you can govern the care of hospice patient if you do not have the patient surrounded with governing bodies of individuals that are trained and care and will protect their life to the theand not speed up expiration of life. are you eliminating suffering? are you preserving life? there is a limitation as volunteer death. guest: you raise important questions about how does the medicare program and how do we oversee the quality of care provided to hospice patients who oftentimes are receiving treatment in their homes? oft is one of the benefits hospice for patients who prefer to be at home.

right. it is a very vulnerable population and hospices are right. it is a veryoverseen by state ao investigates them and investigates complaints or they use an accreditation agency. they need to meet certain quality and other requirements to participate in the medicare program. inicare has a role overseeing the states and the hospices to make sure they are working. host: cleave and ohio is next. this is tom. caller: i would like to mention that i recently discovered a couple months ago that long-term care is not allowed to be mandatory reporters of elder abuse and neglect. they are not allowed to

investigate complaints of elder abuse and neglect. that is just starting point. i spent 30 years in dealing with this kind of problems. i would like to know how to connect and talk. i have different groups .omplaining about problems one is in california and a foundation dealing with problems in nursing homes. where the objectives of another and another group run by a g.ctor is called aaap host: before we let you go, is there another specific you like to discuss with our guest?

community and others, there have been mildly cognitive impaired individuals. you are talking about more than mildly cognitive impaired individuals and they disregard it. that.will let you go with raisinghank you for these important issues. patient abuse and neglect is a very serious concern. it is atop priority for the -- forof investor -- this office. looking at this issue, we have identified vulnerabilities in terms of limited reporting requirements to medicare in the hospice program. for example, hospice providers are only required to report patient harm to medicare if they

receive an allegation the harm was alleged to have been involved, someone providing services on their behalf of the hospice and not necessarily a family member or caregiver and that the hospice has basically self investigated and substantiated the allegation and only then is it required that the patient harm beat reported to medicare. we recommended that medicare strengthen its reporting requirements for hospice providers as well as for state surveyors who identify potential harm and abuse that might be going on when they are conducting surveys. there may be state laws that require reporting, but we are looking for medicare requirements as well so the program has full information into the problems happening and can help ensure appropriate intervention. you: how many hospices did

look at in this report and how many compared to those had series deficiencies? serious deficiencies? guest: willett from 2012 to 2016, 4500 hospices surveyed and inspected during that time. one in five were cited -- we looked from 2012 to 2016, 45 hundred hospices surveyed and one in five were cited with by aus deficiency cited surveyor or accrediting organization or had a serious plaint that was in fact substantiated by the state. host: let's hear from steve in maryland. you are on with the inspector general's office with health and human services. go ahead. thank you for giving my call. am i allowed to give a shout out to. host: go ahead with your question if you don't mind.

tookr: i had hospice that good care of my wife in her final phases and that was because of the training that was done with st. mary's county and with the volunteers and staff are they took real good care. i liked about it was it was a comfortable setting and almost like being in your own house. what i appreciated is after my wife asked away, they offered grievance sessions for the spouse, and that was very beneficial. i wanted to give a shout out to saint mary county hospice program. guest: i am sorry for your loss and i am so glad to hear about your good experience with hospice and i am glad that you raised that. it is an important point that many patients and loved ones have very good experiences with hospice care. we are not looking to scare anyone away from hospice care.

it is a really important benefit. to many great comfort patients and loved one spirit we want information to be made available, not just about the problems found during these inspections but also for mission when the inspection turns up no problems. that is just as important knowing which ones are struggling as much as which ones are doing well. the vast majority of hospice providers are working hard and well intended and the goal is high quality and safe care as well. is maryland who identifies as the president of hospital in palliative care. ofler: i am the president the organization that started right in 1978 at the beginning of the hospice movement. muchd large, we agree with that is in the report.

additional oversight of folks who are persistently bad, not just having a bad day at our persistently bad is a good thing. additional oversight of those folks is a good thing. additional education is a good thingwe want consumers to be ind and we want people to be getting .he best care that they can get that is what i wanted to say. we are here to work the oig on improving. host: did you largely agree with the conclusions of the report? themr: no, but a lot of peered the themes we agree with. we do not think that folks complying with the law you're out and you're in and complying with the law should be treating -- treated the same as those who are failing every day. there is room for the oversight

to be tightened up and appropriately administered as it is needed. host: would like to address a question to our guest? caller: no, we look forward and have requested a meeting with the oig and look forward to meeting with the oig and comparing notes, as we have with congress and cms to talk about how we can work together and i hope they will schedule that meeting in short order and talk to us about how we can work together. address ah like to question to the caller? caller: i pushing the work -- guest: hyper shake the work you are doing and i will be attending the meeting. we look forward to a fruitful partnership to decking patients and families. host: if making things better is the ultimate goal, what is the positive definite first step your organization and hospices can take?

isler: a good first step sunshine. thereg has pointed out are about 300 persistently bad performers. you want that list to be made public and to help inform folks in making an informed decision. host: thank you. any response? we agree weuest: think that empowering patients and loved ones with access to good, clear, convincing information is a crucial step. host: let's hear from anna in new york. go ahead, you are on with our guest. caller: have two very quick questions and then a brief comment. my first question is, if your guest could explain if there is a distinguished mitt between what she has reference to as

state health department or cms oversight of a hospice versus what is more common in our area, which are to comfort homes. the reason for the two bed restriction is because my understanding is they do not come under state health apartment oversight -- department oversight. are much more restrictive in the types of medical conditions that residences of their in the final care -- residents in final care. caller, we have to cut off because of your cutting in and out and because of time. i apologize. caller: i am not familiar with a two bedroom.

if they are providers that participate in the medicare program, then there would be some type of conditions of participation or standards and requirements that at that level. if they are not providers that participate in medicare, then there may be requirements at the state level if they participate in the medicaid program. i am not semi you're with that entity and i will have to work -- i am not familiar with that entity and i will have to look into that. host: what do you do in terms of follow-up? guest: we are in constant dialogue and they are making progress on recommendations. we also take the opportunities we have two brief congress on our work and findings in particularly the two recommendations that would require congressional intervention to actually make

happen, both given the medicare more enforcement tools and allowing them to this the results of inspections conducted by accreditation organizations. we are continuing our work. their work underway right now looking at investigations of complaints against hospices and whether the state agencies that conduct those investigations are meeting the required timeframe. we will continue to push for momentum on the work we have done and recommendations we have made as well as continue to overturn new stones and look for new issues. host: she is the assistant director for inspections of health and human services. you can find the report they did on their website. thank you for giving us time. guest: i pushing the opportunity to talk about these issues. >> we go live next to the roseville room at the white house. president trump is set to make

an announcement about trade with the european union. his comments getting underway shortly, we understand. we will stay here live as we wait for the president. cnbc writes that the administration has been pursuing new trade deals with europe, china, and others as part of the america first agenda. the announcement coming on the heels of tweets and announcement of yesterday on additional tariffs on china. the president signed a budget deal passed by the senate, a two-year budget deal passed by house and senate and the think the debt ceiling through 2021 passed by the white house. we want to keep you posted that we will be repairing our interview with president trump held earlier this week tomorrow morning here on c-span at 10:00 p.m. -- 10:00 eastern.

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>> the president is expected to announce a trade deal with the eu, thus the eu fight is there backed by the -- backed by the mental. the president will head to new jersey for the weekend. he had signed the bill passed by the house and senate, the budget deal. the two-year budget deal listing spending and raising the debt ceiling through summer of 2021. the president this week we interviewed at their wearing house, we will be air that tomorrow at 10:00 a.m. eastern. democraticair the

debates from this week hosted by cnn. the first night, night number one will air tomorrow morning at 10:30 a.m. eastern and night number two on c-span sunday at 10:30 a.m. eastern. [indistinct conversations]

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>> president trump should be out shortly. there is news from the white house tweeting this, last week the director of national intelligence announcing his intention to step down in early august and the word was the president would nominate john

ratcliffe, a republican, texas republican in the u.s. house and the president tweeting just now, our great republican congress and john ratcliffe is being treated very unfairly by the tream media. i explained how miserable it would be for him and his family to deal with these people. that het trump tweeting decided to stay in congress where he is done such an outstanding job representing the people of texas and our country. i will be announcing my nomination for dni shortly. ago.tweet a minute or two we are for his announcement at the white house on this european union trade deal. well we wait, we will show you journal"he "washington and be here live when the event gets underway.

>> they are trying to create a digital currency. not necessarily a government currency but a private currency that people can use and ship to one another in different parts of the world. the reason why they are doing this is a little bit complex ,ecause no one knows exactly they explicitly said that they want to and i am reading this because i think it is useful for your listeners to hear, to currencysimple global and financial infrastructure that empowers billions of people. there are some financial motives

as well. host: as far as the current system, what would facebook's plan do that others do not? tost: facebook is planning create this global currency and established aas consortium of different kinds of larger global technology companies and a couple of nonprofits. the global currency is called the libra currency. the consortium is called the libra association. through this libra association they are trying to will doubt a platform that would enable different kinds of uses for the global, this new private global currency and also to help to assist in the adoption and memorialization of bookkeeping of transactions based on that currency. host: one of the examples, if a person wanted to send someone

money in it country that did not have a strong banking system, is that the goal? money acrossg borders is expensive. up to 7% of the money can be eaten up in fees and the concept of the idea of a faster, cheaper global payments system is one that a lot of people have been interested in. there are some real goals and benefits particularly for forfits -- four people -- people -- [indistinct conversations]