Hospice Survey Essentials: Documentation and Staff Records Required During Compliance Reviews

Be fully prepared for your next hospice survey. Discover the full list of essential documents, staff roles, policies, and certifications that surveyors request during compliance inspections.

6/9/20252 min read

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assorted-color book lot

Hospice providers are held to high standards of care, compliance, and documentation. During a federal or state survey, especially at the entrance conference, surveyors will ask for a comprehensive set of records, certifications, and policy documents to evaluate how your agency delivers services and maintains compliance with federal regulations.

Being proactive in collecting and organizing these materials ensures your agency demonstrates transparency, quality, and accountability from the start.

Key Personnel and Role-Based Information

Surveyors will want to understand your agency’s leadership structure and how responsibilities are distributed across care teams. Prepare the following:

• RN Coordinators List

A complete list of registered nurse coordinators who oversee the coordination of hospice services and the execution of the interdisciplinary plan of care.

• Key Staff Contacts

Names and titles of staff members who are most knowledgeable in these areas:

  • Hospice aide and homemaker services

  • Volunteer coordination

  • Spiritual/pastoral care

  • Infection control and QAPI (Quality Assessment and Performance Improvement)

  • Staff training and education

  • Clinical supervision and bereavement services

This list helps surveyors direct questions and assess operational oversight.

Training and Competency Documentation

Ensure you have the following training-related records:

• Hospice Aide Training and Evaluations

  • Initial training documentation

  • Competency assessments

  • Ongoing in-service education records

• Core Services Waivers

If your agency has received a waiver for core nursing services, or for therapy or dietary counseling services (such as physical therapy, speech-language pathology, occupational therapy), include the approval documents with issue dates.

Agreements and Contracts

To evaluate how external providers are integrated into your care model, surveyors will review:

• Active Contracts

Agreements with third-party service providers such as:

  • Skilled nursing facilities (SNF/NF)

  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs)

  • Durable medical equipment (DME) suppliers

  • Pharmacies

  • Inpatient hospice facilities

• Facility Agreements

Written agreements with long-term care facilities where your hospice agency provides services.

Laboratory Services and CLIA Compliance

If your agency performs any laboratory testing, you must show compliance with Clinical Laboratory Improvement Amendments (CLIA) standards. Be ready to present:

  • A valid CLIA Certificate of Waiver

  • Additional CLIA documentation depending on the testing level, such as:

    • Provider-performed microscopy certificate

    • Accreditation or compliance certificates

    • Registration certificate if applicable

Also include certificates or licenses for any outside clinical laboratories that handle your agency’s specimens.

Policies, Procedures, and Compliance Records

These documents serve as the foundation of your operational integrity. Surveyors will request:

• Emergency Preparedness Plan

Include documentation of emergency drills or preparedness exercises conducted as part of CMS requirements.

• Patient Admission Materials

Provide examples of the materials given to patients upon hospice admission, such as:

  • Explanation of services

  • Rights and responsibilities

  • Contact information for emergencies or grievances

• Abuse Prevention Protocols

  • Policies on preventing abuse, neglect, and exploitation

  • Documentation of staff training in these areas

• QAPI Records

Evidence of participation in Quality Assessment and Performance Improvement activities, including:

  • Goals and improvement initiatives

  • Infection control monitoring and mitigation strategies

  • Summary of recent performance improvement projects

Key Policies to Have Available

Surveyors will review your agency’s written policies for the following operational areas:

  • Advance directives and patient rights

  • Interdisciplinary coordination and care planning

  • Infection prevention and control

  • Clinical documentation and recordkeeping

  • Safe handling and disposal of controlled substances

  • Equipment maintenance and usage

  • Pain and symptom management protocols

  • Staff training programs and procedures

  • Emergency preparedness and crisis response

Inpatient Care Records

If your agency provides short-term inpatient hospice care, include documentation that reflects:

  • Eligibility assessments

  • Medical necessity documentation

  • Records of care provided during inpatient stays

  • Coordination of discharge back to home or another care setting

Conclusion: Be Ready, Stay Compliant

A well-prepared hospice agency demonstrates not just regulatory compliance—but a deep commitment to high-quality, compassionate care. Having these records readily accessible, organized, and up-to-date gives your team confidence during any hospice survey and reinforces the trust of patients and partners alike.