Hospice Special Focus Program: How Survey Results Affect Enhanced Oversight Status

The Hospice Special Focus Program (SFP) was designed to identify the lowest-performing hospices in the country and place them under intensive oversight, with more frequent surveys and the possibility of termination from Medicare. Survey results were central to the program: condition-level deficiencies and substantiated complaints were two of the four inputs used to select hospices.

CMS finalized the SFP in the CY 2024 Home Health Prospective Payment System final rule and named the first hospices selected for the program in late 2024. After industry objections and a lawsuit by hospice associations, CMS announced on February 14, 2025 that it had ceased implementation of the SFP for calendar year 2025 so it could further evaluate the program. Reports through mid-2026 indicate the program has not been relaunched.

Even with the SFP paused, survey results matter more than ever. Surveys drive enforcement remedies, inform public reporting, and can influence a hospice's risk profile in an environment of nationwide enrollment moratoria, enhanced oversight of new hospices, and large-scale payment suspensions. This article explains how the SFP was designed, how survey results fed it, where the program stands, how surveys affect enforcement and enhanced oversight today, and how hospices can protect their survey records. It is educational and does not replace legal or professional advice.

The Legal Background

The Consolidated Appropriations Act, 2021

The Consolidated Appropriations Act, 2021 made significant changes to hospice survey and enforcement, including directing CMS to establish a special focus program for poor-performing hospices and to implement a range of enforcement remedies. It also strengthened survey processes, including requirements related to survey teams, the use of survey forms by accrediting organizations, and public reporting of survey results.

Hospice Survey Frequency

Medicare-certified hospices are surveyed by state survey agencies or CMS-approved accrediting organizations. Since the IMPACT Act of 2014, hospices are generally surveyed at least every 36 months. Complaint surveys may occur at any time.

Enforcement Remedies

CMS finalized hospice enforcement remedies in its regulations at 42 CFR Part 488, Subpart N. In addition to termination, available remedies for hospices with condition-level deficiencies include civil money penalties, suspension of payment for new admissions, temporary management, directed plans of correction, and directed in-service training.

How the SFP Was Designed

Purpose

CMS described the SFP as a program to identify poor-performing hospices, inform the public, and engage those hospices to improve their performance or face termination from Medicare.

The Algorithm

As finalized, the SFP used an algorithm based on four types of data:

• Condition-level deficiencies cited on surveys, using three years of survey data.

• Substantiated complaints, using three years of complaint survey data.

• The Hospice Care Index, a claims-based index from the Hospice Quality Reporting Program.

• A CAHPS Hospice Survey Index derived from four CAHPS Hospice Survey measures.

CMS standardized each indicator, combined them into a score, and used separate approaches for hospices with and without CAHPS data. Hospices in the bottom 10 percent of scores were considered for selection, and CMS selected a subset for the program.

Eligibility

Hospices were eligible for consideration if they had data for at least one algorithm indicator and were not currently under CMS enforcement action.

Program Requirements

As finalized, hospices selected for the SFP would be surveyed more frequently, at least every six months, and could graduate after meeting criteria such as consecutive surveys without condition-level deficiencies over a defined period. Hospices that failed to improve could face enforcement remedies or termination. CMS also planned to publish the list of SFP hospices.

Public Reporting

CMS published a user's guide describing the algorithm and public reporting, and maintains a Hospice Special Focus Program web page.

Why the SFP Was Paused

Industry groups supported the goal of identifying poor performers but objected to the algorithm's design, data sources, and potential to misidentify reputable hospices. In January 2025, a coalition of state hospice associations and hospices filed a lawsuit challenging the program. On February 14, 2025, CMS announced it was exercising enforcement discretion to cease implementing the SFP for calendar year 2025 and would further explore options for implementation and further rulemaking.

Hospices should monitor CMS's SFP page and rulemaking for any relaunch or redesign. A future program may use similar inputs, so survey results and quality data remain important.

How Survey Results Affect Oversight Today

Even without the SFP, survey results influence a hospice's oversight in several ways.

Condition-Level Deficiencies and Enforcement

When a survey finds a condition-level deficiency, the hospice must correct it under a plan of correction. If it does not, CMS may impose enforcement remedies or begin termination. Repeat or serious deficiencies increase enforcement risk.

Public Reporting

Survey results are publicly available, and accrediting organizations must use the same survey forms as state agencies. Patients, families, referral sources, and payers may review them.

Complaints

Substantiated complaints can lead to deficiency citations and follow-up surveys. Patterns of complaints may draw attention from surveyors and program integrity contractors.

Enhanced Oversight and Telehealth

Separate from the SFP, CMS has authority under Section 1866(j)(3) of the Social Security Act to impose enhanced oversight on certain providers. CMS has used a Provisional Period of Enhanced Oversight for newly enrolled hospices in Arizona, California, Georgia, Nevada, Ohio, and Texas. Under 42 CFR 418.22(a)(4), beginning January 31, 2026, telehealth may not be used for face-to-face recertification encounters when the hospice is subject to enhanced oversight. While enhanced oversight is not triggered by survey results in the same way as the SFP, a hospice's compliance record, including surveys, is part of its overall risk profile.

Program Integrity Data

Contractors and CMS use multiple data sources to identify hospices for review. CMS's Service and Spending Variation Index, finalized in the FY 2027 hospice final rule, focuses on claims data, but survey problems such as poor care coordination or inadequate visits often appear alongside the same documentation weaknesses that lead to claim denials.

Enrollment and Affiliations

CMS may deny or revoke enrollment based on certain affiliations under 42 CFR 424.519. Survey-related terminations and other actions involving affiliated providers can affect enrollment risk.

What Surveyors Look For

Surveyors evaluate compliance with the hospice Conditions of Participation at 42 CFR Part 418, using the State Operations Manual, Appendix M. Areas that frequently lead to deficiencies include:

• Patient rights, including the election and informed consent.

• Comprehensive assessment and updates.

• Interdisciplinary group, care planning, and coordination of services, including plan of care reviews at least every 15 days.

• Quality assessment and performance improvement.

• Infection control.

• Hospice aide and homemaker services, including supervision.

• Drugs, biologicals, medical supplies, and DME.

• Clinical records.

• Hospice care for residents of nursing facilities, including written agreements and coordination.

• Short-term inpatient care.

• Emergency preparedness.

Protecting Your Survey Record

Maintain Survey Readiness

• Conduct mock surveys using Appendix M.

• Review recent deficiency trends and focus on high-risk Conditions of Participation.

• Keep policies current and staff trained.

• Make sure clinical records are complete and accessible.

Respond to Surveys Effectively

• Designate a survey coordinator.

• Provide surveyors with requested information promptly.

• Take notes on surveyor questions and concerns.

• Address issues raised during the survey when possible.

Write Strong Plans of Correction

• Address each deficiency specifically.

• Identify root causes.

• Describe corrective actions, responsible staff, and completion dates.

• Describe how the hospice will monitor compliance.

• Implement the plan fully and document results.

Manage Complaints

• Have a clear complaint process for patients and families.

• Investigate and resolve complaints promptly.

• Document findings and corrective actions.

• Use complaint data in quality improvement.

Use Quality Data

• Monitor Hospice Care Index results.

• Monitor CAHPS Hospice Survey results and act on low scores.

• Integrate quality data into the quality assessment and performance improvement program.

Consider Informal Dispute Resolution

When a hospice disagrees with a deficiency, it may be able to request informal dispute resolution under the applicable state agency or accrediting organization processes, and may have formal appeal rights for certain enforcement remedies. Hospices should understand these options and deadlines.

Preparing for a Possible SFP Relaunch

If CMS relaunches the SFP, hospices with poor survey records or quality data could be selected. Hospices can prepare by:

• Reviewing the original SFP algorithm inputs and their own performance on each.

• Addressing condition-level deficiencies and complaint patterns.

• Improving Hospice Care Index and CAHPS results.

• Monitoring CMS rulemaking and the SFP web page.

Common Survey Deficiency Areas and Fixes

Plan of Care Updates

Problem: Plans of care not updated at least every 15 days or not individualized. Fix: Track interdisciplinary group reviews and use templates that require individualized updates.

Aide Supervision

Problem: Missing or late aide supervisory visits. Fix: Track supervision due dates and document visits.

Comprehensive Assessments

Problem: Assessments not completed on time or not updated. Fix: Use tracking systems and clinical manager review.

Nursing Facility Coordination

Problem: Missing written agreements or lack of coordinated plans of care. Fix: Inventory agreements and update templates.

Quality Program

Problem: Quality program lacks data-driven projects. Fix: Select measurable performance improvement projects and document results.

Infection Control and Emergency Preparedness

Problem: Outdated plans or training. Fix: Review annually and document drills and training.

Understanding the Hospice Care Index

The Hospice Care Index (HCI) is a claims-based measure in the Hospice Quality Reporting Program that combines multiple indicators of care processes into a single score. Indicators have included measures such as visits near death, levels of care provided, live discharge patterns, and Medicare spending. Because the HCI was one of the SFP inputs and reflects patterns also tracked by CMS's Service and Spending Variation Index, hospices should review their HCI results and understand which indicators affect their score.

Understanding the CAHPS Hospice Survey

The CAHPS Hospice Survey collects family caregiver experiences with hospice care. The SFP used four CAHPS measures to build its index. Low CAHPS scores can signal problems with communication, timely care, symptom management, or emotional support. Hospices should:

• Review CAHPS results regularly.

• Identify the measures with the lowest scores.

• Develop quality improvement projects to address them.

• Train staff on communication with patients and families.

How Accreditation Interacts With Surveys

Many hospices are surveyed by accrediting organizations rather than state agencies. Under the Consolidated Appropriations Act, 2021, accrediting organizations must use the same survey forms used by state agencies, which supports public reporting and consistency. Hospices that were selected for the SFP in 2024 were advised that if they had been deemed under an accrediting organization and wished to continue, they must contact the organization. Hospices should understand their accreditation status and how survey findings by their accrediting organization are reported.

Complaint Surveys

Complaint surveys can occur at any time and often focus on specific allegations, such as missed visits, poor symptom management, or communication failures. Hospices should:

• Respond to family concerns quickly and document resolution.

• Track complaint themes.

• Prepare staff for unannounced complaint surveys.

• Review the circumstances of every substantiated complaint and correct root causes.

Enforcement Remedies in Practice

When a hospice has condition-level deficiencies, CMS may impose remedies such as civil money penalties, suspension of payment for new admissions, temporary management, directed plans of correction, or directed in-service training, in addition to or instead of termination. Remedies may escalate when deficiencies are serious, repeated, or not corrected. Hospices facing enforcement should:

• Engage counsel experienced in survey and enforcement matters.

• Understand appeal rights and deadlines.

• Implement corrective actions quickly and document them.

• Communicate with the state agency or accrediting organization.

A Survey Readiness Checklist

• Mock survey completed in the past year.

• Policies reviewed and current.

• Interdisciplinary group reviews at least every 15 days, documented.

• Comprehensive assessments timely.

• Aide supervision documented.

• Nursing facility agreements current.

• Inpatient care arrangements documented.

• Quality assessment and performance improvement program active with documented projects.

• Infection control and emergency preparedness programs current.

• Complaint process functioning.

• Clinical records complete and accessible.

• Staff trained on survey procedures.

A Hypothetical Example

A hospice reviews the original SFP algorithm and realizes that it would have scored poorly because of two condition-level deficiencies in the past three years and below-average CAHPS results. One deficiency involved plans of care not updated every 15 days, and the other involved aide supervision.

The hospice implements interdisciplinary group tracking, adds supervisory visit alerts, conducts a mock survey, and launches a quality improvement project focused on communication with families. Its next survey finds no condition-level deficiencies, and its CAHPS scores improve. Although the SFP remains paused, the hospice's improved record reduces enforcement risk and strengthens its reputation with referral sources.

Roles and Responsibilities for Survey Readiness

• The administrator oversees survey readiness and responses.

• The clinical manager ensures clinical records and care processes meet the Conditions of Participation.

• The quality coordinator leads the quality assessment and performance improvement program and tracks quality data.

• The medical director participates in clinical quality and plan of care oversight.

• The compliance officer coordinates mock surveys, tracks corrective actions, and reports to leadership.

• The governing body reviews survey results, plans of correction, and quality data.

Questions Leadership Should Ask

• How many condition-level deficiencies have we received in the past three years, and were they fully corrected?

• How many substantiated complaints have we had, and what themes do they show?

• How do our Hospice Care Index and CAHPS results compare with peers?

• Are we subject to enhanced oversight?

• When was our last mock survey, and what did it find?

Communication With Families and Referral Sources

Survey results are public, and families and referral sources may ask about them. Hospices should be prepared to explain any deficiencies honestly, describe the corrective actions taken, and share improvements in quality results.

Survey Preparation Timeline

• Ongoing: monitor quality data, complaints, and corrective actions.

• Quarterly: review a sample of clinical records against key Conditions of Participation.

• Annually: conduct a full mock survey and review policies.

• Before the 36-month survey window: confirm all corrective actions are complete and records are organized.

• After every survey: implement and monitor the plan of correction.

Staff Training for Surveys

• Explain the survey process and what surveyors may ask.

• Teach staff where to find policies and records.

• Encourage honest, accurate answers.

• Review recent deficiencies and corrective actions with staff.

• Practice through mock interviews and record reviews.

Common Myths

• "Since the SFP is paused, surveys matter less." Surveys still drive enforcement, public reporting, and reputation.

• "Accredited hospices are not affected." Accrediting organization surveys use the same forms and results are reported.

• "One condition-level deficiency is minor." Condition-level deficiencies can lead to enforcement remedies and would have counted heavily in the SFP algorithm.

Staying Focused on Quality

Strong survey results come from strong care. Hospices that focus on timely visits, effective symptom management, clear communication with families, and careful documentation will see the results in surveys, CAHPS scores, and every form of oversight.

Watching for Changes

CMS has said it would explore options for SFP implementation and further rulemaking. Watch the annual home health and hospice proposed rules, the CMS SFP web page, and survey guidance updates for changes that could bring back a special focus program in a new form.

Key Takeaways

• The SFP was designed to identify poor performers using survey, complaint, claims, and CAHPS data.

• CMS paused the SFP on February 14, 2025, and reports through mid-2026 indicate no relaunch.

• Surveys still drive enforcement remedies, public reporting, and overall risk.

• Enhanced oversight limits telehealth for face-to-face recertification encounters.

• Survey readiness, strong plans of correction, complaint management, and quality data protect a hospice's record.

Frequently Asked Questions

Is the Hospice Special Focus Program in effect?

CMS ceased implementation for calendar year 2025 on February 14, 2025 to further evaluate the program. Reports through mid-2026 indicate no relaunch has been announced. Check CMS's SFP page for current status.

What data did the SFP use?

Condition-level deficiencies, substantiated complaints, the Hospice Care Index, and a CAHPS Hospice Survey Index.

How often are hospices surveyed?

Generally at least every 36 months, plus complaint surveys as needed. The SFP would have required surveys at least every six months for selected hospices.

What enforcement remedies apply to hospices?

In addition to termination, remedies include civil money penalties, suspension of payment for new admissions, temporary management, directed plans of correction, and directed in-service training.

Does enhanced oversight limit telehealth?

Yes. Beginning January 31, 2026, telehealth may not be used for face-to-face recertification encounters for hospices subject to enhanced oversight.

Conclusion

The Hospice Special Focus Program is paused, but the forces behind it remain. Survey results, complaints, and quality data still shape enforcement, public perception, and a hospice's overall risk in a period of intense oversight. Hospices that maintain survey readiness, correct deficiencies thoroughly, manage complaints, use quality data, and monitor CMS's plans for the SFP will be well positioned whatever form future oversight takes.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices prepare for surveys through mock surveys, Conditions of Participation gap analyses, plan of correction support, quality program development, and analysis of quality and survey data. If you want to strengthen your survey record, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Hospice Special Focus Program. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/hospice-special-focus-program

• Centers for Medicare & Medicaid Services. Hospice Special Focus Program User's Guide: Algorithm and Public Reporting. https://www.cms.gov/files/document/hospice-special-focus-program-users-guide-algorithm-and-public-reporting01082025.pdf

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix M, Guidance to Surveyors: Hospice. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

• Electronic Code of Federal Regulations. 42 CFR Part 418, Hospice Care. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418

• Electronic Code of Federal Regulations. 42 CFR Part 488, Subpart N, Enforcement Procedures for Hospices. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-N

• Electronic Code of Federal Regulations. 42 CFR 424.519, Disclosure of Affiliations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-P/section-424.519

• Centers for Medicare & Medicaid Services. Provisional Period of Enhanced Oversight for New Hospices in Arizona, California, Nevada, and Texas (MLN7867599). https://www.cms.gov/files/document/mln7867599-period-enhanced-oversight-new-hospices-arizona-california-nevada-texas.pdf

• Federal Register. Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements (August 3, 2026). https://www.federalregister.gov/documents/2026/08/03/2026-15686/medicare-program-fy-2027-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

• U.S. Social Security Administration. Social Security Act, Section 1866. https://www.ssa.gov/OP_Home/ssact/title18/1866.htm