Hospice Compliance Operations Center
California Hospice
Operations Bible
Complete CMS Medicare, California CDPH, and JCAHO-compliant reference for governing bodies, discipline workflows, IDT structure, visit requirements, and in-service training. Zero holes. Built for hospice crackdown season.
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Governing Bodies
CMS, CDPH, JCAHO, DEA, CURES — what each body does, their authority, and what they audit. Click any body to expand full detail.
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Chain of Command
Full organizational structure with reporting lines, escalation pathways, and decision authority at every level.
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RN Case Manager
Complete workflow with branching scenarios — patient home, patient not home, death calls, crisis response, and all required visit types.
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IDT Meeting Structure
CMS-compliant IDT meeting phases, required attendees, documentation standards, frequency requirements, and audit-ready protocols.
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24 Staff In-Services
Complete annual in-service curriculum — all 24 topics with objectives, regulatory citations, and content outlines. Audit-ready documentation.
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Visit Types & Frequency
Every required visit type for every discipline — frequency, documentation requirements, regulatory authority, and billing implications.
ACTIVE CMS HOSPICE CRACKDOWN — 2024–2025
CMS has increased hospice audit activity significantly. Focus areas: IDG documentation completeness, face-to-face encounter compliance, benefit period certification timelines, GIP criteria justification, and HHA supervision documentation. Every page in this system reflects current enforcement priorities. Zero gaps tolerated.
Authority & Oversight
Governing Bodies
Every regulatory authority that oversees your hospice — what they do, their enforcement powers, what they audit, and how to stay clean with each one.
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Authority & Jurisdiction
CMS administers the Medicare Hospice Benefit under 42 CFR Part 418 and is your primary federal regulator, payer, and certification authority. Every hospice accepting Medicare must comply with CMS Conditions of Participation (CoPs). Non-compliance can result in Medicare decertification — effectively the death of your agency.
Core Responsibilities
- Issues and maintains Medicare Provider Certification Numbers (CCN)
- Establishes and enforces Hospice Conditions of Participation (42 CFR 418)
- Sets Medicare Hospice per-diem reimbursement rates (updated annually via Hospice Final Rule)
- Administers the Medicare Aggregate Payment Cap (CAP) — limits total annual Medicare hospice payments per beneficiary
- Oversees Hospice Quality Reporting Program (HQRP) — Care Compare public reporting
- Conducts and contracts certification surveys (initial and recertification)
- Issues Conditions of Deficiency (CODs) and Enforcement Actions
What CMS Audits — Crackdown Focus Areas 2024–2025
| Audit Area | Regulation | Risk Level |
|---|---|---|
| IDG Documentation Completeness | 42 CFR 418.56 | CRITICAL |
| Face-to-Face Encounter (180-day) | 42 CFR 418.22(a)(4) | CRITICAL |
| Benefit Period Certification Timelines | 42 CFR 418.21 | CRITICAL |
| GIP/CHC Medical Necessity Justification | 42 CFR 418.302 | CRITICAL |
| Notice of Election (NOE) Timeliness | 42 CFR 418.24 | CRITICAL |
| HHA Supervision Documentation | 42 CFR 418.76 | CRITICAL |
| Volunteer Program (5% requirement) | 42 CFR 418.78 | HIGH |
| Bereavement 13-Month Documentation | 42 CFR 418.64(d) | HIGH |
| Comprehensive Assessment Timeliness | 42 CFR 418.54 | HIGH |
Medicare Benefit Periods
| Benefit Period | Duration | Certification Requirement |
|---|---|---|
| Period 1 | 90 days | MD/NP certifies prognosis ≤ 6 months if disease runs normal course |
| Period 2 | 90 days | Recertification required; face-to-face encounter NOT yet required |
| Period 3+ | 60 days each | Recertification + face-to-face encounter by MD/NP before certification is signed |
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Authority & Jurisdiction
CDPH is California's primary state licensing authority under CA HSC 1745–1756. All hospices operating in California must hold an active CDPH Hospice License regardless of Medicare/Medi-Cal participation. JCAHO deemed status satisfies some CDPH requirements but CDPH retains independent oversight and can conduct unannounced investigations at any time.
Core Responsibilities
- Issues and renews annual California Hospice License
- Conducts initial licensure inspections and complaint-driven investigations
- Approves Administrator of Record and Director of Patient Care Services named on license
- Enforces California-specific regulations that exceed federal CMS requirements
- Processes California Live Scan background check clearances
- Maintains CNA Registry (all CNA certifications verified through CDPH)
- Enforces California mandatory reporting obligations
California-Only Requirements (Beyond CMS)
- HSC 1280.15 — California background checks more extensive than federal requirements; Live Scan DOJ fingerprinting required
- HSC 123111 — Patient records access; 5-business-day response required (stricter than HIPAA)
- WIC 15600–15675 — Elder/Dependent Adult Abuse mandatory reporting; all hospice staff are mandated reporters
- Cal/OSHA §5199 — Aerosol Transmissible Diseases standard; written ATD Exposure Control Plan required
- Cal Labor Code 6401.7 — Written IIPP (Injury & Illness Prevention Program) required before first employee
- SB 553 (2024) — Workplace Violence Prevention Plan mandatory for all California employers
CDPH Survey Process
- Initial Licensure Survey: required before operating; CDPH may grant deemed status to JCAHO-accredited agencies
- Annual License Renewal: submit application + fee via CDPH SNAP portal 90 days before expiration
- Complaint Surveys: unannounced; can occur any time; triggered by patient/family complaints, mandatory reports, or referral tips
- Follow-Up Surveys: after deficiency findings; timelines set by severity of findings
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Authority & Jurisdiction
The Joint Commission is a private, nonprofit accrediting body. TJC Hospice accreditation grants CMS "deemed status" — meaning your agency is considered to meet CMS Conditions of Participation based on TJC standards (which equal or exceed CMS requirements). TJC accreditation is a significant quality differentiator in the California market.
What TJC Surveys
- National Patient Safety Goals (NPSGs) — hospice-specific
- Leadership structure and governance
- Human Resources — credentialing, training, competency assessment
- Care, Treatment, and Services — clinical protocols and care planning
- Infection Prevention and Control
- Medication Management
- Record of Care — documentation standards
- Performance Improvement (QAPI program)
- Environment of Care
- Emergency Management
TJC Survey Schedule
- Initial Accreditation Survey: typically 2–3 day on-site; within first year of operation
- Triennial Full Survey: every 3 years (unannounced within 18–36 months of prior survey)
- Focused Standards Assessments (FSA): targeted reviews triggered by complaints or findings
- Random Unannounced Surveys: 5% of accredited organizations receive random unannounced survey
Key TJC Hospice Standards (Compliance Priorities)
| Standard | Area | Common Finding |
|---|---|---|
| NPSG.03.04.01 | Medication Reconciliation | Incomplete medication lists at admission |
| NPSG.06.01.01 | Clinical Alarm Safety | Missing protocols for equipment alarms |
| RI.01.02.01 | Patient Rights | Advance directive not offered/documented |
| RC.02.01.01 | Medical Record Content | Missing required elements in care plan |
| HR.01.06.01 | Staff Competency | Annual competency assessments not documented |
| PI.01.01.01 | QAPI | No active PIPs (performance improvement projects) |
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Authority & Jurisdiction
The OIG enforces federal healthcare fraud, waste, and abuse laws including the False Claims Act, Anti-Kickback Statute, and Stark Law. The OIG maintains the List of Excluded Individuals/Entities (LEIE) — hiring any excluded individual and billing Medicare for their services results in mandatory fines and potential decertification.
OIG Enforcement Tools
- LEIE (List of Excluded Individuals/Entities) — must be checked monthly for all employees, vendors, and contractors
- Corporate Integrity Agreements (CIA) — imposed on organizations with fraud findings
- Civil Monetary Penalties (CMP) — up to $20,000+ per false claim
- False Claims Act referrals — triple damages + per-claim penalties
- Administrative exclusion from all federal healthcare programs
- Criminal referral for egregious fraud
OIG Hospice Work Plan Focus Areas (2024–2025)
- Hospices billing GIP for patients who don't meet medical necessity criteria
- Hospices with high rates of patients who die on the day of admission (potential for fraudulent late enrollment)
- Continuous Home Care (CHC) billing without documented nurse hours
- Hospices with high proportion of nursing facility patients (potential for kickback arrangements)
- Missing or inadequate physician certification documentation
- Hospices exceeding the Medicare Aggregate CAP
Required Compliance Program Elements
- Written Standards of Conduct and Compliance Policies
- Designated Compliance Officer with direct reporting to ownership/board
- Annual compliance training for all staff (documented)
- Anonymous reporting mechanism (hotline or web form)
- Monthly OIG LEIE exclusion screening for all employees and vendors
- Monthly California DHCS exclusion screening
- Internal monitoring, auditing, and documentation
- Prompt response and self-disclosure protocols
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DEA — Drug Enforcement Administration
Federal authority over controlled substance prescribing, dispensing, and disposal. Your Medical Director must hold an active DEA registration. Hospice comfort medication kits contain Schedule II–IV controlled substances — all are subject to DEA oversight.
DEA Hospice Requirements
- Medical Director must maintain active DEA registration — verify annually
- Controlled substance disposal after patient death must follow DEA regulations
- Schedule II drugs (morphine, oxycodone, fentanyl) require specific ordering and disposal protocols
- Electronic Prescribing for Controlled Substances (EPCS) — California mandates this in most cases
California CURES — Controlled Substance Utilization Review System
California's mandatory prescription drug monitoring program. All prescribers and dispensers of Schedule II–IV controlled substances must register and report. This is a California-only requirement on top of DEA rules.
CURES Requirements for Hospice
- Medical Director must be registered in CURES — verify at cures.doj.ca.gov
- All controlled substance prescriptions must be reported to CURES within 1 working day of dispensing
- Prescribers must check patient's CURES history before prescribing Schedule II–IV (in most clinical scenarios)
- Pharmacy partner must be registered and reporting in CURES
- Document CURES checks in clinical records when applicable
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Authority
DHCS (Department of Health Care Services) administers the California Medi-Cal program, the state equivalent of Medicaid. A significant proportion of California hospice patients are dual-eligible (Medicare + Medi-Cal). DHCS maintains its own provider exclusion list and conducts independent fraud investigations separate from CMS/OIG.
DHCS Hospice Requirements
- Separate Medi-Cal Provider Enrollment required — DHCS Provider Enrollment Division
- Monthly check of California DHCS Suspended and Ineligible Provider List — all employees and vendors
- Medi-Cal billing via California's Provider Web Portal — separate from Medicare billing system
- Medi-Cal claims submission within 12 months of date of service
- Medi-Cal managed care plans (L.A. Care, Health Net Medi-Cal) may require separate contracting
- DHCS conducts Medi-Cal audits separate from CMS audits — maintain documentation for both
Organizational Structure
Chain of Command
Complete organizational hierarchy with reporting lines, decision authority, escalation pathways, and accountability at every level — CMS and CDPH compliant.
Organizational Hierarchy
OWNERSHIP / GOVERNING BODY
Corporate / LLC / Board
ADMINISTRATOR
Named on CDPH License — Day-to-day operations
MEDICAL DIRECTOR
Clinical oversight; IDG lead
DIRECTOR OF PATIENT CARE
Clinical Director / DON; named on license
RN CASE MANAGERS
MEDICAL SOCIAL WORKER
CHAPLAIN
HHA / CNA
VOLUNTEER COORD.
BEREAVEMENT COORD.
Escalation & Decision Authority
| Situation | First Contact | Escalate To | Final Authority |
|---|---|---|---|
| Clinical emergency at home | Field RN | On-Call RN / Clinical Director | Medical Director (emergency MD orders) |
| Patient requests to revoke hospice | RN Case Manager | Clinical Director | Administrator; Billing (NOE revocation filed within 5 days) |
| Suspected patient abuse/neglect | Any staff member | Clinical Director immediately | Mandatory report to APS/CDPH within 2 hours; Administrator notified |
| Uncontrolled symptoms (GIP need) | RN Case Manager | Medical Director (order for GIP) | Clinical Director confirms placement; Billing notified for level change |
| Staff complaint / HR issue | Direct supervisor | Administrator | Compliance Officer if policy violation involved |
| Billing/compliance concern | Billing Specialist | Compliance Officer | Administrator; legal counsel if warranted |
| CDPH/CMS surveyor arrives | Receptionist / Office Manager | Administrator immediately | Administrator leads; Clinical Director available; no records released without Administrator direction |
| Patient death | On-Call RN (if after hours) | Pronouncing physician / MD | Clinical Director notified; Bereavement Coordinator activated within 24 hours |
Reporting Lines — Detailed
Medical Director Reports To
- Administrator (operational/contractual matters)
- Governing Body (clinical outcomes and quality)
Medical Director Oversees
- All clinical protocols and medical orders
- IDG meeting clinical leadership
- Face-to-face encounter documentation
- Controlled substance standing orders (comfort kits)
Clinical Director Reports To
- Administrator (daily operations)
- Medical Director (clinical protocols)
Clinical Director Oversees
- All RN, LVN, CNA/HHA field staff
- Social Worker, Chaplain, Bereavement Coordinator
- Clinical quality metrics and QAPI
- IDG meeting facilitation and documentation
- On-call protocols and after-hours coverage
Clinical Discipline
RN Case Manager
Complete workflows, branching visit scenarios, all required visit types, documentation requirements, and after-hours protocols. California-compliant.
Overview
Visit Workflows
Visit Types
After-Hours / On-Call
Documentation
Role Definition & Responsibilities
The RN Case Manager is the clinical coordinator and primary care coordinator for each hospice patient. They are the linchpin of the interdisciplinary team — assessing, planning, coordinating, and evaluating all care. In California, the RN Case Manager must hold an active California RN license verified through BreEZe and must comply with California Business and Professions Code §2700 et seq.
Core Responsibilities 42 CFR 418.56
- Conduct and document initial comprehensive assessment within 5 days of admission 42 CFR 418.54(a)
- Develop and maintain individualized care plan in collaboration with the IDG
- Conduct all required routine home care visits per the care plan
- Assess and manage pain, dyspnea, nausea, anxiety, and other symptoms
- Educate patient and family on disease progression, comfort care, and medication administration
- Supervise HHA/CNA care — required written supervisory visit every 14 days minimum 42 CFR 418.76(h)
- Coordinate with all IDG members — communicate changes in patient condition
- Document all visits in EMR — required same day or no later than midnight of visit date
- Respond to after-hours crisis calls as part of on-call rotation
- Notify physician and Clinical Director of any significant clinical change
California-Specific Requirements
- Active California RN license — verified via BreEZe (breeze.ca.gov); employer must verify quarterly
- California mandatory reporter — all hospice RNs are mandated reporters under WIC 15630; report elder/dependent adult abuse within 2 hours of suspicion (immediately by phone; written report within 2 business days)
- TB clearance — two-step TST or IGRA annually; documented in personnel file
- California driver's license and documented personal auto insurance — field staff drive to patient homes
- CURES awareness — RNs may not prescribe but must understand CURES implications for controlled substance administration education to families
- California cell phone reimbursement — employer must reimburse for work use of personal phone (CA Labor Code 2802)
Routine Home Visit Workflow — Patient Is Home
BRANCH A — PATIENT IS HOME AND ACCESSIBLE
ARRIVE AT HOME
Knock/ring; identify self. Check surroundings for safety hazards before entering (California home environment safety assessment). Note any emergency vehicles, unusual activity.
HAND HYGIENE & PPE
Perform hand hygiene before patient contact. Don appropriate PPE per California ATD standard (Cal/OSHA §5199). Assess infection control needs.
PATIENT ASSESSMENT
Full head-to-toe assessment. Vital signs (if appropriate per care plan). Pain assessment using validated tool (numeric, PAINAD for cognitive impairment). Symptom review: dyspnea, nausea, anxiety, bowel, skin. Mental status. Functional status change. Caregiver assessment — is caregiver coping?
CLINICAL DECISION POINT
Is condition stable? Are symptoms controlled? Does care plan need updating? Is patient/family in crisis?
IF STABLE
STABLE — ROUTINE VISIT CONTINUATION
Continue planned care. Review medications — assess for side effects, effectiveness, controlled substance reconciliation. Comfort kit: verify medications available, dated, stored correctly (cool, dark, locked). Wound care if applicable. Patient/family education on disease progression. Advance directive review if not done.
IF UNSTABLE / SYMPTOMATIC
UNSTABLE — ESCALATE
Notify Medical Director IMMEDIATELY. Implement comfort measures from kit if orders exist. If no orders: call MD for verbal orders (document within 24 hours per CA BPC and CMS). Assess for need for Continuous Home Care (CHC — 8+ hours nursing). Assess for GIP transfer if symptoms uncontrolled at home.
FAMILY/CAREGIVER INTERACTION
Assess caregiver burnout — critical California issue due to high cost of additional care. Address family questions. Provide education on: medication administration, signs of approaching death, when to call the hospice. Discuss advance directives if not in place. Assess safety of home environment for patient and caregiver.
WOUND UP & PPE OFF
Dispose of any sharps in patient's sharps container. Bag and secure any contaminated materials. Remove PPE in correct order. Hand hygiene on exit.
DOCUMENT VISIT IN EMR
Document same day — required for billing and compliance. Include: time in/time out, patient present, assessment findings, interventions, education provided, response to care, plan, next visit date. If verbal MD orders obtained: document in EMR; physician must co-sign within 48 hours.
COORDINATE WITH IDG
Communicate any significant findings to Social Worker, Chaplain, or Clinical Director as appropriate. Update care plan if condition change. Place orders via EMR for any new interventions.
Visit Workflow — Patient Is NOT Home
DOCUMENTATION CRITICAL — MISSED VISIT
A missed visit must be documented clearly in the EMR. It is NOT simply skipped. Failure to document a missed visit and the response is a compliance deficiency. CMS and JCAHO surveyors look specifically for missed visit management.
BRANCH B — PATIENT IS NOT HOME / NOT ACCESSIBLE
ARRIVE — PATIENT NOT HOME
No answer at door. Attempt to reach patient/family by phone. Try primary caregiver number. Try emergency contact. Allow 10–15 minutes before leaving.
REACHED BY PHONE?
Did patient/family respond to phone calls?
YES — REACHED BY PHONE
CONDUCT PHONE ASSESSMENT
Perform verbal assessment of patient status. Document phone call as contact in EMR. Reschedule in-person visit. Note reason patient was unavailable. Document patient's reported status and any concerns.
NO — CANNOT REACH
ESCALATE — WELFARE CHECK PROTOCOL
Notify Clinical Director immediately. Attempt neighbor contact if safe to do so. If patient is high-acuity or recently unstable: consider welfare check request via local law enforcement. Document ALL attempts: time, number called, result. Document in EMR: "Attempted visit, patient not home, unable to reach. Clinical Director notified. Following agency missed visit protocol."
RESCHEDULE & FOLLOW UP
Reschedule visit within 24–48 hours. Clinical Director documents review of missed visit. If pattern of missed visits: care plan review required. Multiple missed visits without contact: assess appropriateness of continued hospice (patient may be in facility or deceased).
DOCUMENT MISSED VISIT IN EMR
Document every attempt made. Time of arrival, duration waited, phone attempts with timestamps, supervisory notification. NEVER leave this blank or undocumented. This is an audit finding waiting to happen if missed.
Death Call Workflow
PATIENT DEATH — AFTER-HOURS OR ON-CALL RN RESPONSE
FAMILY CALLS — PATIENT HAS DIED (OR APPEARS TO HAVE DIED)
On-call RN receives call. Obtain: patient name, address, who is present, whether patient was expected to die. Notify Clinical Director per agency protocol. Dispatch to home if within on-call service area.
ARRIVE AT HOME — FAMILY SUPPORT
Greet family with compassion. This is the most important moment of your entire relationship with this family. Take your time. Do not rush. Sit with them before any clinical tasks.
CLINICAL PRONOUNCEMENT
Assess patient: absent respirations, absent heartbeat, fixed and dilated pupils, absent response to stimulation. Note time of death. Document clinical findings. In California: RN may pronounce death if standing orders are in place from MD. Confirm with your agency's protocol — some counties require MD pronouncement or coroner notification.
NOTIFICATIONS — REQUIRED AND ORDERED
1. Notify attending physician / Medical Director (document time and response). 2. California coroner: if death is unexpected, violent, suspicious, or unattended — know your county's coroner notification requirements. 3. Clinical Director if not already notified. 4. Funeral home — family's chosen; DO NOT call without family permission. 5. Pharmacy — notify for comfort kit pickup/destruction. 6. DME company — equipment pickup arrangement.
CONTROLLED SUBSTANCE DISPOSITION — CRITICAL
Comfort kit medications must be destroyed or retrieved. NEVER leave controlled substances in the home unattended after death. California DEA regulations: RN may assist family in destroying Schedule II–IV drugs (flushing is approved for hospice per California guidelines). Document exact drugs destroyed, amounts, and witness. Ideally a second person witnesses destruction. This is a major audit area.
DOCUMENTATION
Time of death. Clinical pronouncement findings. All notifications with timestamps and responses. Controlled substance destruction log. Family education provided (bereavement resources). Funeral home name and time of arrival. Document your time with the family. Bereavement Coordinator activation noted.
BEREAVEMENT ACTIVATION
Bereavement Coordinator must be notified by next business day. 13-month bereavement follow-up begins from date of death. Initial bereavement contact within 30 days of death — required by CMS. Document activation in EMR.
All Required RN Visit Types
Admission / Initial Comprehensive Assessment
Within 48 hrs of admission
Full head-to-toe assessment. Completion of all admission documentation, consent forms, California AHCD, POLST. Medication reconciliation. Comfort kit delivery and education. Initiate care plan. Notify all IDG members.
42 CFR 418.54(a) · JCAHO RC.02.01.01
Routine Home Care (RHC) Visit
Per care plan frequency — at minimum weekly
Ongoing assessment, symptom management, medication review, caregiver education and support. Must match care plan frequency. Document any changes in condition. Controlled substance reconciliation on each visit.
42 CFR 418.64(a) · Medicare Part A billing
Comprehensive Assessment Update
Every 15 days (first 90 days); every 30 days thereafter
Full reassessment to support IDG meeting documentation. Updated care plan. Condition trajectory review. Updated goals of care discussion if warranted. Must be completed before IDG meeting.
42 CFR 418.54(b)
HHA Supervisory Visit
Minimum every 14 days
RN must observe HHA/CNA care in the patient's presence. Assess: quality of personal care, patient response, HHA skill level. Document observation findings. This is a heavily audited area — do NOT skip.
42 CFR 418.76(h) — CRITICAL COMPLIANCE AREA
Crisis / Unscheduled Visit
As needed — symptom crisis or family distress
Respond to after-hours calls requiring in-person visit. Uncontrolled pain, agitation, respiratory distress, family can't manage. Assess for CHC or GIP eligibility. Escalate to MD immediately.
42 CFR 418.64(a) · CHC criteria 42 CFR 418.302
Actively Dying / Imminent Death Visit
As needed — within 24 hrs of expected death
Assess signs of active dying. Educate family on what to expect. Ensure comfort medications are available and family knows how to administer. Consider continuous presence if criteria met. Support family emotionally.
42 CFR 418.64(a) · California CON laws
Discharge / Revocation Visit
Required upon revocation or transfer
When patient revokes hospice or is discharged for improvement. Provide transition summary. Educate on re-election process. Return comfort medications per DEA/CURES protocol. File Notice of Termination/Revocation (NOTR) within 5 days.
42 CFR 418.26 · 42 CFR 418.28
Inpatient / GIP Coordination Visit
Within 24 hrs of GIP admission; every 48–72 hrs during GIP
Coordinate with facility nursing staff during GIP stay. Ensure hospice care plan is followed by facility. Assess symptom control. Plan transition back to home when symptoms controlled. Bill Medicare GIP rate — document medical necessity carefully.
42 CFR 418.302(b)(2) — GIP medical necessity
After-Hours / On-Call Protocol
CMS REQUIREMENT — 42 CFR 418.64(d)(2)
Hospices must provide 24-hour access to a Registered Nurse who can provide consultation and/or make home visits when necessary. This is non-negotiable. An answering service alone does NOT satisfy this requirement.
After-Hours Call Workflow
AFTER-HOURS CALL RECEIVED BY ON-CALL RN
CALL RECEIVED
Answer within 3 rings (agency standard). Identify self: "This is [Name], RN, on call for [Agency]. How can I help?" Pull up patient chart in EMR immediately.
TRIAGE ASSESSMENT BY PHONE
What is the concern? How long has this been occurring? Current vital signs if family can assess. Current comfort medication availability. Level of family/caregiver distress. Is patient actively dying?
DISPOSITION DECISION
Can this be managed by phone with instructions? Or is in-person visit required?
PHONE MANAGEMENT — LOWER ACUITY
PHONE MANAGEMENT
Provide clinical guidance. Instruct family on comfort medication administration from kit (if orders in place). Stay on phone until situation is stabilized. Offer call-back in 30–60 minutes. Notify Medical Director if any medication orders given. Document ENTIRE call in EMR within 1 hour.
IN-PERSON VISIT — HIGHER ACUITY
DISPATCH TO HOME
Notify Clinical Director you are dispatching. ETA to family. Ensure comfort kit is in your vehicle. Bring PPE. Assess on arrival. Contact Medical Director for verbal orders if needed during visit. Document real-time if possible.
MANDATORY DOCUMENTATION — ALL CALLS
Every call must be documented: time call received, caller, patient status reported, clinical assessment, interventions/instructions given, outcome, follow-up plan. "Phone triage visit" note in EMR. Do NOT let undocumented calls accumulate.
California On-Call Law Considerations
- On-call pay: California may require compensation for restricted on-call time — consult labor attorney about your on-call structure
- Daily overtime: if RN is called in during on-call and works more than 8 hours in a calendar day, California daily overtime applies
- Rest periods: if RN works an extended on-call response, ensure adequate rest before next scheduled shift
- Document on-call hours in your timekeeping system — California wage and hour compliance
Documentation Standards
DOCUMENTATION = CARE. IF IT ISN'T DOCUMENTED, IT DIDN'T HAPPEN.
CMS, CDPH, and JCAHO audit documentation. The most common finding across all hospice surveys is incomplete or late documentation. Every visit note must be completed same-day. Every verbal order must be documented immediately and physician co-signature obtained within 48 hours.
Required Elements — Every RN Visit Note
- Date, time in, time out (exact — billing depends on this)
- Patient present and accessible (or document if not)
- Caregiver(s) present — name and relationship
- Pain assessment — validated scale score, location, quality, relieving/aggravating factors
- Respiratory assessment (rate, quality, any distress)
- Neurological / mental status assessment
- GI assessment (appetite, nausea, bowel last BM date)
- GU assessment (urinary output, any catheters)
- Skin/wound assessment (if applicable)
- Current medications reviewed — effectiveness, side effects, availability
- Comfort kit: present, medications listed, storage appropriate
- Patient/family education provided — topic, person taught, response to teaching
- Goals of care discussed (especially if condition changing)
- Interventions performed this visit
- Patient/family response to interventions
- Coordination with IDG: any communications, referrals, notifications
- Clinical decisions made and rationale
- Plan: next visit date, any follow-up actions, MD notifications
- RN signature with license number (California requirement)
Clinical Leadership
Medical Director
Responsibilities, certification requirements, IDG leadership, face-to-face encounter protocols, and California CURES/DEA compliance.
Core Responsibilities
| Responsibility | Frequency | Regulation |
|---|---|---|
| Certify terminal prognosis (≤6 months if disease runs normal course) | At admission | 42 CFR 418.22(b) |
| Recertify terminal prognosis each benefit period | Every 90/60 days | 42 CFR 418.21 |
| Face-to-face encounter with patient before 3rd+ benefit period certification | Every 60-day period (3rd+) | 42 CFR 418.22(a)(4) |
| Lead and participate in IDG meetings | Every 15/30 days | 42 CFR 418.56(c) |
| Review and approve all clinical protocols and care plan updates | Ongoing | 42 CFR 418.100 |
| Sign all standing orders including comfort medication kit orders | Annual + PRN | 42 CFR 418.106 |
| CURES check before prescribing Schedule II–IV (California) | Per prescription | CA BPC 2241.5 |
| Respond to clinical consultations from field RNs | As needed / 24/7 | 42 CFR 418.64(d) |
| Supervise NP conducting face-to-face encounters (if delegated) | As applicable | 42 CFR 418.22(a)(4)(ii) |
Face-to-Face Encounter Protocol
FACE-TO-FACE ENCOUNTER — MOST AUDITED CERTIFICATION REQUIREMENT
Beginning with the 3rd benefit period (day 181+), a face-to-face encounter with the patient must occur BEFORE the certification is signed. The certifying physician (or NP under physician supervision) must document clinical findings from the face-to-face that support the terminal prognosis. Missing or late face-to-face = denied claims.
FACE-TO-FACE ENCOUNTER WORKFLOW (3rd Benefit Period Onward)
SCHEDULE — 14 DAYS BEFORE BENEFIT PERIOD END
Clinical Director or Case Manager identifies patients approaching end of benefit period. Schedule F2F encounter minimum 7 days before benefit period expiration to allow time for documentation and certification signing.
CONDUCT ENCOUNTER
MD or NP (under MD supervision) visits patient in person. Assess patient's current clinical status. Review disease trajectory. Assess functional decline, weight loss, symptom burden. Discuss goals of care. Cannot be done by phone or telehealth — must be IN PERSON.
DOCUMENT F2F — SPECIFIC REQUIREMENTS
Documentation must include: patient name, date of encounter, clinical findings supporting terminal prognosis, how findings support prognosis of ≤6 months. Must be SIGNED by certifying physician BEFORE certification is signed. NP who conducts F2F must note that supervising physician reviewed. Cannot be a generic template — must be patient-specific narrative.
SIGN CERTIFICATION
Certification signed AFTER F2F documentation is complete. Both documents go into patient chart. Billing team submits benefit period claim only after certification and F2F are both documented and signed.
California CURES Compliance Workflow
- Before prescribing any Schedule II–IV controlled substance: check patient's CURES history at cures.doj.ca.gov
- Document CURES check in clinical record (date checked, findings, prescriber name)
- If CURES shows concerning pattern: document clinical rationale for proceeding with prescription
- All controlled substance prescriptions reported to CURES within 1 working day of dispensing (pharmacy obligation — verify your pharmacy partner is compliant)
- Comfort kit standing orders: these are standing orders, not individual prescriptions — consult your pharmacy partner on CURES reporting for standing order medications
Clinical Discipline
Medical Social Worker
Psychosocial assessment, resource navigation, advance care planning, family counseling, and California community resource integration.
Responsibilities & Visit Requirements
| Responsibility | Frequency | Regulation |
|---|---|---|
| Initial psychosocial assessment | Within 5 days of admission | 42 CFR 418.54(a)(6) |
| Advance Health Care Directive (AHCD) — California-specific | At admission; update as needed | CA HSC 4670 |
| POLST facilitation | At admission if not in place | CA POLST Form |
| IDG participation — psychosocial updates | Every 15/30 days | 42 CFR 418.56(c) |
| Medi-Cal eligibility screening and benefits counseling | At admission; ongoing | CA DHCS |
| Family counseling and caregiver support | Per care plan; minimum every 30 days | 42 CFR 418.64(b) |
| Community resource referral (IHSS, APS, housing, food) | As needed | CA HSC |
| Elder/dependent adult abuse assessment and mandatory reporting | Ongoing; report within 2 hours of suspicion | CA WIC 15630 |
| Bereavement risk assessment | At admission and each visit | 42 CFR 418.64(d) |
| VA benefits counseling (California veteran population) | As applicable | 38 CFR Part 17 |
SW Visit Workflow
SOCIAL WORKER VISIT WORKFLOW
ARRIVE — REVIEW CHART BEFORE VISIT
Review last RN visit note for any clinical changes. Review any family concerns documented. Review advance directive status.
PSYCHOSOCIAL ASSESSMENT
Emotional status of patient. Coping: How is patient coping with diagnosis and decline? Spiritual needs (in coordination with chaplain). Caregiver stress and burnout assessment. Financial concerns. Safety: is there elder abuse, neglect, or unsafe environment? Cultural needs and preferences.
ADVANCE CARE PLANNING
Is California AHCD in place? Is POLST (pink form) in place and current? Do goals of care on POLST match current care plan? Has patient had opportunity to discuss wishes with family? Document all conversations about goals of care.
RESOURCE NAVIGATION
California-specific resources: IHSS (In-Home Supportive Services) — apply if not enrolled. Area Agency on Aging referral. Meals on Wheels / Meals and More. Housing resources if needed (significant California issue). Veterans' benefits (CalVet, VA community care). Financial assistance programs. Funeral pre-planning resources.
DOCUMENT & COMMUNICATE
Document visit in EMR same day. Communicate any safety concerns to Clinical Director immediately. Update care plan if goals or needs have changed. Bereavement risk assessment updated.
California-Specific MSW Obligations
- California BBS License: LCSW or ASW (under supervisor); verify active quarterly via BBS license lookup
- Mandatory reporter: Elder/Dependent Adult abuse — report to APS within 2 hours by phone; written report within 2 business days to local APS or CDPH
- IHSS Navigation: Many California hospice patients qualify for IHSS (free in-home support services funded by Medi-Cal) — MSW should screen every eligible patient and assist with application
- Medi-Cal share of cost: Counsel families on how Medi-Cal share of cost affects hospice coverage for dual-eligible patients
- Unhoused patients: California has significant unhoused population; MSW must know resources for patients without stable housing who are on hospice
Spiritual Care
Chaplain / Spiritual Care
Spiritual care requirements, interfaith competency in California's diverse population, visit protocols, and documentation standards.
Spiritual Care — CMS Requirement
REQUIRED SERVICE — 42 CFR 418.64(c)
Hospices must provide spiritual care services to patients and families who want them. Spiritual care is NOT optional and NOT only for religious patients. Every patient/family has the right to spiritual care regardless of religious affiliation or lack thereof. Failure to provide or offer spiritual care is a compliance deficiency.
Visit Requirements
| Visit Type | Frequency | Documentation Required |
|---|---|---|
| Initial Spiritual Assessment | Within 5 days of admission | Spiritual history, faith tradition, spiritual needs, goals of spiritual care |
| Routine Spiritual Care Visit | Per care plan; minimum every 30 days | Spiritual assessment update, interventions, patient/family response |
| IDG Participation | Every 15/30 days | Verbal and written report to IDG |
| Crisis Spiritual Care | As needed — existential crisis, family conflict | Document nature of crisis, response, outcome |
| Active Dying Support | As requested — patient/family | Presence, rituals performed, prayers, family support |
| Memorial / After-Death Support | As requested | Document support provided |
California Interfaith Competency Requirements
California is the most ethnically and religiously diverse state in the United States. Your chaplain MUST be genuinely interfaith — not just religion-tolerant. Cultural competency in spiritual care is both a California regulatory expectation and an ethical obligation.
California Population Spiritual Needs
- Spanish-speaking Catholic: Sacraments (Last Rites, Anointing of the Sick), rosary, family prayer, priest connection — coordinate with local Catholic parishes
- Buddhist (Chinese, Vietnamese, Thai, Japanese, Korean): Peaceful environment for dying, no rush, family rituals, chanting — chaplain must understand that these vary significantly by Buddhist tradition
- Filipino Catholic / Protestant: Prayer, novenas, community support, deep family involvement in care
- South Asian (Hindu, Sikh, Muslim): Sacred rituals at time of death, specific body positioning after death, family-only presence during dying — coordinate well in advance
- Korean/Vietnamese/Chinese Buddhist/Taoist: Ancestor veneration, paper burning, specific death rituals — coordinate with family
- LGBTQ+ patients: Ensure non-judgmental spiritual care; many LGBTQ+ elders have been harmed by religious institutions — approach with particular sensitivity and explicit affirmation
- Secular / Atheist / Agnostic: Spiritual care = meaning, legacy, relationship closure, values — does NOT require religious framing. Chaplain must be skilled in secular existential support
- Indigenous / Native American: Specific tribal traditions; may involve tribal elders or healers; always defer to family's direction
Personal Care
HHA / CNA
Personal care duties, California CNA Registry requirements, supervision requirements, scope of practice, and visit documentation.
Scope of Practice
SCOPE BOUNDARY — CRITICAL FOR CALIFORNIA
HHA/CNAs may ONLY perform duties specified in the care plan and ordered by the supervising RN. They may NOT assess, administer medications, make clinical decisions, or change the care plan. In California, scope of practice violations are serious and can result in CNA certification revocation and agency liability.
Authorized Duties
- Personal hygiene: bathing (bed bath, shower assist, tub assist), hair care, nail care, oral care
- Grooming: shaving, dressing, positioning
- Skin care: application of non-prescription lotions, repositioning for pressure prevention
- Ambulation assistance with assistive devices (per care plan)
- Light housekeeping RELATED to patient care (patient's area only)
- Meal preparation (simple; not complex cooking)
- Vital signs observation and reporting (if trained and in care plan)
- Companionship and emotional support to patient
- Report any changes in patient condition to supervising RN IMMEDIATELY
NOT Within HHA/CNA Scope
- Administering any medication (including over-the-counter)
- Performing wound care beyond simple dressing reinforcement
- Inserting or managing IV lines, catheters, or feeding tubes
- Making clinical assessments or judgments
- Changing the care plan
- Speaking to physicians or pharmacists about clinical issues (must route to RN)
- Transporting patient in personal vehicle (major liability — California)
Supervision Requirements — CRITICAL AUDIT AREA
42 CFR 418.76(h) — HHA SUPERVISION IS A TOP AUDIT FINDING
RN must make a supervisory visit to the patient's home while the HHA/CNA is providing care, at a minimum every 14 days. This is NOT a phone call. This is NOT just reviewing documentation. The RN must be physically present while the HHA is caring for the patient. Document: date, time, HHA name, observations made, assessment findings, any instructions given to HHA.
California CNA Registry Requirements
- Active certification in California CNA Registry — verify at californiaCNAregistry.org before hire and quarterly thereafter
- No substantiated findings of abuse, neglect, or misappropriation on CNA registry — must be a clean record
- Live Scan fingerprint background check (California DOJ) — required; must be cleared before patient contact
- TB clearance — two-step TST or IGRA; annually documented
- CPR/BLS certification — current; copy in personnel file
- Annual competency assessment — California and JCAHO require documented skills competency annually
HHA Visit Documentation
- Date, time in, time out
- Patient present and accessible
- Care tasks performed (specific — not just "personal care")
- Patient tolerance and response to care
- Any concerns or changes observed — reported to RN (document time and RN notified)
- HHA signature with CNA certification number
Volunteer Program
Volunteer Coordinator
5% volunteer hour requirement, California screening requirements, training program, documentation standards, and volunteer management workflow.
5% VOLUNTEER HOUR REQUIREMENT — MANDATORY
42 CFR 418.78 requires that a minimum of 5% of total patient care hours be provided by trained volunteers. This is measured annually and audited. Failure to meet 5% can result in compliance deficiency. Track volunteer hours monthly — do NOT discover a shortfall at year end.
Volunteer Pre-Service Requirements — California
- California DOJ Live Scan fingerprint background check — required for all volunteers with patient contact; cannot have patient contact until cleared
- TB clearance — two-step TST or IGRA
- OIG LEIE exclusion check — yes, for volunteers too if they provide services billed to Medicare
- Minimum 8 hours pre-service training 42 CFR 418.78(a)
- HIPAA training and confidentiality agreement signed
- Hospice philosophy orientation
- Personal safety and home visit protocol training
Volunteer Pre-Service Training — Required Curriculum
| Training Topic | Min. Time | Requirement Source |
|---|---|---|
| Hospice philosophy and Medicare benefit overview | 60 min | 42 CFR 418.78 |
| HIPAA and patient confidentiality | 30 min | HIPAA / CMIA |
| Volunteer scope of role vs. clinical staff | 30 min | 42 CFR 418.78 |
| Communication skills — talking with dying patients and families | 60 min | 42 CFR 418.78 |
| Grief and bereavement awareness | 45 min | 42 CFR 418.78 |
| Personal safety — home visit protocol | 30 min | Cal/OSHA |
| Standard precautions and infection control basics | 30 min | Cal/OSHA §5193 |
| Mandatory reporting awareness (California) | 15 min | CA WIC 15630 |
| Cultural competency basics | 30 min | CA CDPH |
Volunteer Hour Tracking — Monthly Minimum
Track volunteer hours monthly in your EMR or volunteer management system. Calculate: Total Volunteer Hours ÷ Total Patient Care Hours = must be ≥ 5%. Report at every QAPI meeting. If trending below 5%: increase volunteer recruitment and hours immediately — do not wait until December.
Grief Services
Bereavement Program
13-month required bereavement follow-up, risk assessment, contact timelines, California grief resources, and documentation standards.
13-MONTH BEREAVEMENT REQUIRED — 42 CFR 418.64(d)
CMS requires bereavement services to be made available to families for 13 months following the patient's death. This is not optional. You must have a system to track every deceased patient's family and provide documented outreach. This is an active CMS audit area.
Bereavement Timeline — Required Contacts
| Timeframe | Contact Type | Requirement |
|---|---|---|
| Day of Death | RN on-call presence and support | Provide bereavement resources at time of death |
| Within 30 days | Phone call or visit by Bereavement Coordinator | REQUIRED — document date, contact made, response |
| 3 months post-death | Phone, letter, card, or visit | Assess grief status; document outreach attempt |
| 6 months post-death | Phone or visit | Assess for complicated grief; document |
| 9 months post-death | Phone or letter | Document contact or attempt |
| 13 months post-death | Final contact | Document completion of 13-month program; close bereavement record |
| Anniversary of death | Card or call | Best practice; strongly recommended; document |
Bereavement Risk Assessment
Bereavement risk assessment begins at admission and continues throughout the patient's enrollment. High-risk bereaved family members may need referral to individual counseling, support groups, or mental health services.
High-Risk Bereavement Factors — Assess at Admission and Each Visit
- Sudden or traumatic death even within hospice context
- Caregiver who is also grieving a recent loss
- Lack of social support system
- History of depression, anxiety, or substance use in the caregiver
- Complicated relationship with the dying patient (estrangement, conflict)
- Young children in the household losing a parent
- Caregiver who has expressed they cannot cope without the patient
- Death of a child or young adult
- Financial instability after death (loss of breadwinner)
California Grief Support Resources
- California Hospice Network — statewide grief support referral network
- Local grief centers and support groups (hospice should maintain current list by county served)
- Faith community grief ministries — coordinate with chaplain
- UCLA, UCSF, Stanford hospital palliative care and bereavement programs
- Spanish-language grief support programs — critical for California's Spanish-speaking population
- Veterans' grief support — CalVet, VA bereavement services
- LGBTQ+ affirming grief counselors — maintain referral list
Interdisciplinary Team
IDT Meeting Structure
CMS-compliant IDT meeting protocol — required frequency, attendees, phases, documentation, and audit-ready standards. Zero gaps.
IDT Meeting Requirements — CMS
42 CFR 418.56(c) — IDG MEETING REQUIREMENTS ARE NON-NEGOTIABLE
The interdisciplinary group must review each patient's care plan at specific intervals. Missing or improperly documented IDG meetings is a top CMS deficiency finding. Every meeting must be documented with required elements. "We had the meeting but forgot to document" is not acceptable.
| Timeframe | Meeting Frequency | Regulation |
|---|---|---|
| First 90 days (Benefit Periods 1 & 2) | Every 15 days | 42 CFR 418.56(c) |
| After 90 days (Benefit Period 3+) | Every 30 days | 42 CFR 418.56(c) |
| Upon significant change in condition | Ad hoc / unscheduled | 42 CFR 418.56(b) |
| Upon patient/family request | As requested | 42 CFR 418.52 |
Required IDT Meeting Attendees
- Medical Director or attending physician — required; may attend by phone/telehealth if geographic barriers
- RN Case Manager — required; clinical case presentation
- Medical Social Worker — required
- Chaplain / Spiritual Care Representative — required
- Bereavement Coordinator — required or represented
- Volunteer Coordinator — required
- Patient and/or family — highly encouraged; document if invited and whether attended; if not present, document reason
- HHA/CNA — encouraged to participate for patients they serve
- Other IDG members as clinically relevant (dietitian, PT, OT, pharmacist)
IDT Meeting — Phase-by-Phase Structure
1
Meeting Open & Quorum Verification
5 min
- Call meeting to order — Clinical Director or RN facilitates
- Record meeting date, time, location (or telehealth platform)
- Record all attendees present (full name and discipline) — EVERY person must be listed
- Verify quorum: Medical Director (or physician rep), RN, MSW, Chaplain present
- Note any required attendees absent and reason
- Review agenda — patient list for review today
2
Patient Review — New Admissions
5–10 min per new patient
- RN presents: diagnosis, prognosis, current clinical status, symptom burden
- Medical Director: confirm terminal prognosis; review/confirm plan of care
- Social Worker: psychosocial assessment summary; family dynamics; advance directives in place
- Chaplain: spiritual assessment; any spiritual needs identified
- Volunteer Coordinator: volunteer assignment made or pending
- Care plan reviewed by all disciplines: goals, interventions, frequency of visits
- Patient/family goals of care: what are they? Are they documented? Are all disciplines aligned?
- Document care plan approval by IDG
3
Patient Review — Ongoing Patients
3–7 min per patient
- RN Case Manager: clinical update since last IDG — any changes in condition, new symptoms, hospitalizations, ER visits
- Symptom control update: pain controlled? Dyspnea? Nausea? Anxiety?
- Medication changes: any new medications, dose changes, comfort kit changes — Medical Director confirms/approves
- Functional status: trajectory — is patient declining? Stable? Improving?
- Social Worker: family update, caregiver stress, any new psychosocial needs, resource referrals made
- Chaplain: spiritual care update; any new spiritual or existential concerns
- HHA report: any observations from personal care visits (if HHA attending)
- Volunteer update: hours provided, any volunteer concerns
- Care plan update: does care plan need revision? Who will make revisions? Timeline?
- Prognosis discussion: Is patient still appropriate for hospice? Has condition changed significantly?
- Benefit period certification: is recertification due? Is face-to-face needed?
4
Recent Deaths Review
5–10 min
- Review each patient who died since last IDG meeting
- Death location: was it in preferred location (home, ALF, inpatient)? Document
- Was death peaceful? Were symptoms controlled at time of death?
- Family support at time of death — was someone present?
- Bereavement Coordinator: activation confirmed; 30-day contact scheduled
- Any concerns or learning opportunities from this death?
- Honor the patient — many IDGs include a moment of silence or acknowledgment ritual here
5
Quality & Operations Review
5–10 min
- Current census report
- QAPI updates: any quality metrics to review; any performance improvement projects active
- Admissions in pipeline: any pending referrals or admissions
- Staff updates: any new staff, training completed, scheduling issues
- Compliance updates: any audit findings, policy changes, regulatory updates
- Volunteer hours tracking: are we meeting 5%? If not — action plan
6
Meeting Close & Documentation
5 min
- Summarize action items with assigned owner and due date
- Confirm next IDG meeting date — must be scheduled before leaving
- All attendees sign attendance log (physical or electronic)
- IDG minutes completed in EMR within 24 hours of meeting — NOT a week later
- All care plan updates documented in EMR and sent to relevant disciplines
- Patients reviewed count confirmed — every active patient must have IDG documentation on schedule
IDT Documentation — Required Elements in Every IDG Note
- Date, start time, end time, location or telehealth platform used
- Complete attendee list — name AND discipline for each person
- Patient name and MRN for each patient reviewed
- Clinical update for each discipline (RN, SW, Chaplain)
- Care plan review: goals, interventions, any changes made
- Prognosis discussion: Medical Director statement on continued appropriateness for hospice
- Medication changes reviewed and approved by Medical Director
- Patient/family participation: invited? Present? If not, why?
- Benefit period status: days on service, recertification due date
- Action items with owner and due date
- Next IDG date confirmed
- Signatures: facilitator + Medical Director (or his/her documented review)
AUDIT-READINESS TIP
CMS surveyors will pull your IDG documentation and ask: "Show me the IDG notes for this patient." They will count the days between meetings. They will check that all required disciplines attended or have documented absence. They will check that care plan updates are reflected in subsequent visit notes. Your IDG notes must be complete, timely, and discipline-specific — not generic template filler.
Visit Requirements
Visit Types & Frequency
Every required visit type for every discipline — regulatory authority, frequency, documentation, and billing implications.
Complete Visit Frequency Matrix
| Discipline | Visit Type | Required Frequency | Regulation | Documentation |
|---|---|---|---|---|
| RN | Admission Assessment | Within 48 hrs | 418.54(a) | Full comprehensive assessment |
| RN | Routine Home Care | Per care plan; minimum 1x/week | 418.64(a) | Full visit note — see checklist |
| RN | Comprehensive Assessment Update | Every 15 days (first 90 days); every 30 days | 418.54(b) | Full reassessment + care plan update |
| RN | HHA Supervisory Visit | Minimum every 14 days — IN PERSON WITH HHA | 418.76(h) | Observation of HHA care; findings documented |
| RN | Crisis / Unscheduled Visit | As clinically needed | 418.64(d)(2) | Crisis note; escalations documented |
| MD/NP | IDG Participation | Every 15/30 days | 418.56(c) | IDG note — MD attestation |
| MD/NP | Face-to-Face Encounter | Before 3rd+ benefit period (day 181+) | 418.22(a)(4) | F2F narrative — specific clinical findings |
| MSW | Initial Psychosocial Assessment | Within 5 days of admission | 418.54(a)(6) | Full psychosocial assessment + AHCD/POLST |
| MSW | Routine SW Visit | Per care plan; minimum every 30 days | 418.64(b) | Psychosocial update; resource referrals |
| Chaplain | Initial Spiritual Assessment | Within 5 days of admission | 418.64(c) | Spiritual history; needs; goals of spiritual care |
| Chaplain | Routine Spiritual Care | Per care plan; minimum every 30 days | 418.64(c) | Spiritual assessment update; interventions |
| HHA/CNA | Personal Care Visit | Per care plan; 3–7 days/week typical | 418.76 | Tasks performed; patient response; concerns reported |
| Bereavement | Post-Death Follow-Up | Within 30 days; 3, 6, 9, 13 months post-death | 418.64(d) | Contact log; grief status; referrals |
| Volunteer | Patient/Family Support Visit | Per volunteer agreement / care plan | 418.78 | Hours logged; activities; patient response |
| Dietitian (contracted) | Nutritional Consult | Per physician order; as needed | 418.64(a) | Nutritional assessment; recommendations |
| PT/OT/ST (contracted) | Functional Maintenance | Per physician order; as needed | 418.64(a) | Functional assessment; maintenance plan (NOT rehabilitation goals) |
VISIT FREQUENCY AND CARE PLAN MUST MATCH
If your care plan says RN visits 3x/week, your RN must visit 3x/week. If they visit only 1x/week, that's a care plan deviation that must be documented with clinical rationale. Unresolved care plan deviations are a compliance deficiency. Review care plan vs. actual visit frequencies monthly.
Annual Training
24 Staff In-Services
Complete annual in-service curriculum — all 24 required topics with objectives, content outlines, regulatory citations, and documentation requirements. Click any in-service to expand full details.
Documentation Requirements for All In-Services
Every in-service must be documented: date, topic, presenter/facilitator credentials, attendees (name + signature + discipline + license number), pre/post test if applicable, and learning objectives met. Retain for minimum 3 years. JCAHO will ask for in-service attendance records. Do NOT have undocumented training sessions.
HHA Training
HHA In-Services
California and CMS-required in-service training for Home Health Aides and CNAs — competency-based, audit-ready.
42 CFR 418.76(b) — HHA TRAINING REQUIREMENTS
HHAs must receive training in areas specific to hospice care. Annual competency evaluations are required. California CNA Registry requires CNAs to complete 48 hours of continuing education every 24 months. Your in-service program must satisfy BOTH CMS hospice HHA training requirements AND California CNA CE requirements.
CMS-Required HHA Training Areas 42 CFR 418.76(b)(1)
| # | Training Topic | Frequency | Notes |
|---|---|---|---|
| HHA-01 | Hospice Philosophy — Comfort-Focused Care | Annual | Core hospice mission; how HHA role fits; dignity of dying |
| HHA-02 | Observation, Reporting & Documentation | Annual | What to observe, what to report immediately to RN, how to document |
| HHA-03 | Communicating with Terminally Ill Patients | Annual | Active listening; appropriate conversation; what NOT to say |
| HHA-04 | Personal Hygiene & Basic Nursing Skills | Annual + competency | Bathing, grooming, oral care, skin care — return demonstration required |
| HHA-05 | Infection Control — Standard Precautions | Annual | Hand hygiene, PPE, Cal/OSHA §5193 compliance |
| HHA-06 | Safe Patient Handling & Body Mechanics | Annual | Cal/OSHA ergonomics; repositioning techniques; lift assist devices |
| HHA-07 | Recognizing & Reporting Abuse and Neglect | Annual | California mandatory reporter training; WIC 15630; reporting timelines |
| HHA-08 | Pain and Symptom Recognition | Annual | Signs of pain, dyspnea, agitation — when and how to report |
| HHA-09 | Understanding the Dying Process | Annual | Signs of approaching death; what family may experience; HHA's role |
| HHA-10 | Cultural Sensitivity & Diversity | Annual | California population diversity; religious/cultural practices in personal care |
| HHA-11 | Nutrition & Hydration in Hospice | Annual | Changing appetite at end of life; family education; oral care for anorexic patients |
| HHA-12 | Scope of Practice & Boundaries | Annual | What HHA CAN and CANNOT do; medication administration prohibition; reporting chain |
| HHA-13 | HIPAA & Patient Confidentiality | Annual | California CMIA; social media prohibitions; PHI handling |
| HHA-14 | Emergency Procedures in the Home | Annual | Who to call; what to do; 911 vs. hospice line; DNR in the home; POLST |
| HHA-15 | Emotional Self-Care & Grief for HHAs | Annual | Vicarious grief; HHA's own emotional health; when to ask for support |
| HHA-16 | Home Safety Assessment for HHAs | Annual | Fall hazards, fire safety, personal safety in the home, environmental assessment |
| HHA-17 | Skin Integrity & Pressure Injury Prevention | Annual + competency | Repositioning schedule, skin assessment reporting, moisture management |
| HHA-18 | Oral Care for Hospice Patients | Annual + competency | Mouth care for anorexic/dysphagia patients; family education |
| HHA-19 | Controlled Substance Awareness (HHA Role) | Annual | Comfort kit awareness; HHA does NOT administer; reporting if medications are missing |
| HHA-20 | Working with Diverse Family Systems | Annual | Family conflict, caregiver dynamics, appropriate boundaries with family |
| HHA-21 | Vital Signs — Observation and Reporting | Annual + competency | When ordered; normal vs. concerning findings; how to report to RN |
| HHA-22 | Bloodborne Pathogens | Annual | Cal/OSHA §5193; required annual training with documentation |
| HHA-23 | Fire Safety & Oxygen Use in the Home | Annual | Home oxygen safety rules; fire evacuation; California fire hazard awareness |
| HHA-24 | Compassion Fatigue & HHA Wellbeing | Annual | Signs of burnout; resources available; EAP; peer support |
Annual Competency Evaluation Requirements
In addition to in-services, every HHA/CNA must complete an annual skills competency evaluation. This is a JCAHO and CMS requirement. Document the evaluator (must be RN), date, skills tested, performance rating, and any remediation plan.
Required Annual Competency Skills (Return Demonstration)
- Hand hygiene technique
- Donning and doffing PPE correctly
- Bed bath — complete and partial
- Oral care — standard and modified for dysphagia
- Repositioning and turning technique (2-person if applicable)
- Transfer — bed to chair (with and without assist device)
- Skin inspection and reporting pressure injury stages
- Vital signs measurement (if in scope per care plan)
- Denture care
- Catheter care (observation only — NOT insertion)