Hospice surveys—conducted by state agencies, CMS, or accrediting bodies—are designed to verify compliance with the Medicare Conditions of Participation (CoPs), ensure patient safety, and evaluate the agency’s overall quality of care. For many hospice providers, survey readiness is often associated with stress, operational disruption, and uncertainty. However, organizations with strong systems, proactive quality management, and consistent documentation practices can confidently aim to pass with zero deficiencies.
This comprehensive guide breaks down what surveyors focus on, the most common risk areas, and the strategies your hospice can implement today to remain survey-ready every single day.
1. Understanding the Purpose of Hospice Surveys
Hospice surveys serve several critical purposes:
Evaluate compliance with Medicare CoPs
Ensure accurate, complete, and timely documentation
Assess clinical competencies and care quality
Verify patient safety and appropriate use of hospice services
Protect the integrity of the Medicare benefit
Surveyors use real-time patient encounters, chart reviews, staff interviews, and operational assessments to determine how well an agency functions—not only during the survey window, but every day of operation.
Passing with zero deficiencies requires not only technical compliance, but also a culture of continuous readiness, quality improvement, and organizational accountability.
2. The Core Areas Surveyors Focus On
While surveyors review every regulatory domain, certain areas consistently carry higher scrutiny because they directly impact patient care, documentation accuracy, and compliance risk. Understanding these areas allows your agency to concentrate efforts where they matter most.
2.1 Comprehensive Assessment
Surveyors evaluate whether your agency completes and updates patient assessments within required timelines. They look for:
Accurate reflection of the patient's condition
Evidence of decline
Integration of IDG findings
Medication reconciliation
Pain and symptom management documentation
Discipline-specific notes that align with the plan of care
2.2 Plan of Care (POC) and IDG Coordination
Surveyors check whether the POC is:
Interdisciplinary
Individualized and measurable
Reviewed at least every 15 days
Consistent with documentation across all disciplines
The IDG must demonstrate active communication, coordinated care, and unified clinical decision-making.
2.3 Physician Orders and Certification/Recertification
One of the highest risk areas. Surveyors look for:
Timely, complete certifications and face-to-face documentation
Clear correlation between prognosis and clinical findings
Signed, dated, and authenticated physician orders
Orders matching what is documented in clinical notes
2.4 Medication Management
This is a major survey focus because medication errors create immediate jeopardy risks. Surveyors expect to see:
Medication reconciliation at every visit
Documentation of medication necessity
Monitoring of high-risk drugs
Correct administration and teaching
Evidence of symptom control
2.5 Aide Supervision and Competency
Hospice aide documentation is one of the most frequently cited areas. Surveyors evaluate:
Timely 14-day and 30-day supervisory visits
Accurate aide assignment sheets
Documentation matching POC tasks
Demonstrated competency validation
2.6 Emergency Preparedness
Surveyors require proof that your agency can safely function during disasters. This includes:
Updated emergency operations plan
Staff training and competency
Annual exercises and after-action reports
Continuity of operations plan
2.7 QAPI (Quality Assurance & Performance Improvement)
QAPI is now one of the most scrutinized areas of the hospice Conditions of Participation. Surveyors look for:
A written, data-driven, agencywide program
Measurable performance indicators
Evidence of interventions and follow-through
Quarterly and annual evaluation activities
Governing body oversight
3. The Most Common Deficiencies—and How to Avoid Them
Understanding the areas where agencies fail most often allows you to proactively strengthen your internal systems. High-risk deficiencies include:
3.1 Missing or Late RN Assessments
Failure to meet required reassessment timelines is a frequent citation.
Solution: Implement automated tracking alerts and weekly compliance audits.
3.2 Incomplete or Inaccurate POCs
Plans of care that are vague, outdated, or not individualized are major red flags.
Solution: Require interdisciplinary updates during every IDG and ensure staff chart according to the POC.
3.3 Documentation That Does Not Support Terminal Prognosis
Surveyors expect a clear clinical picture showing decline and terminal status.
Solution: Use negative-trend documentation, measurable data, and narrative clarity.
3.4 Inconsistent Documentation Across Disciplines
If the RN note says the patient is lethargic but the aide documents the patient as “alert and active,” the inconsistency will be cited.
Solution: Conduct interdisciplinary chart audits and address discrepancies immediately.
3.5 Missing Supervisory Visits
Home health aide supervision requirements are strict and commonly overlooked.
Solution: Create a supervisory calendar with built-in reminders and redundancy in staff scheduling.
3.6 Medication Errors and Poor Monitoring
Surveyors cite missing teaching, lack of monitoring, and incorrect doses.
Solution: Implement medication-specific teaching templates and cross-validate medication profiles.
3.7 Weak QAPI Programs
A QAPI program that exists only on paper is not enough.
Solution: Use ongoing data collection, quarterly QAPI meetings, and documentation of improvement cycles.
4. Building a Culture of Continuous Survey Readiness
Passing with zero deficiencies requires more than correcting problems right before a survey. It demands a mindset shift where compliance is part of the agency’s daily operations.
4.1 Leaders Must Reinforce Accountability
Leadership engagement is the strongest predictor of survey success. Administrators, DONs, and clinical managers must:
Monitor compliance data
Act immediately on deficiencies
Provide staff training and oversight
Maintain open communication
4.2 Staff Education and Competency
Regular staff education is essential. Implement:
Orientation that reviews key CoPs
Competency-based annual training
Real-time remediation
Task-specific coaching (e.g., aide notes, RN assessments, medication teaching)
4.3 Internal Audits and Mock Surveys
The highest-performing hospices conduct audits at least monthly. Areas to include:
Mock surveys should simulate a real survey, including interviews and home visits.
4.4 Strong Policies and Procedures
Policies must reflect CMS regulations and guide staff on standard processes. They should be reviewed annually and updated when:
4.5 Documentation That Tells the Story
Surveyors should be able to read any patient chart and immediately understand:
Why the patient is hospice appropriate
How they are declining
How the team is managing symptoms
How care is coordinated
Whether the family is supported
Whether risk areas are actively managed
Charts that tell a consistent clinical story rarely result in deficiencies.
5. Strategies to Achieve Zero Deficiencies
Here are actionable steps your agency can implement immediately to strengthen compliance and survey readiness:
5.1 Standardize Clinical Documentation
Use templates and structured fields to ensure consistency, especially for:
RN assessments
IDG updates
Hospice aide notes
Medication reconciliation
Negative-trend narratives
Symptom management documentation
Visit frequencies and changes
5.2 Strengthen IDG Processes
IDG must reflect true interdisciplinary work. Improve your IDG by:
Using structured agendas
Documenting decline and clinical reasoning
Reviewing POC updates collaboratively
Ensuring each discipline addresses changes in condition
5.3 Implement a Daily Compliance Snapshot
Create a dashboard tracking:
Missed visits
Supervisory visit deadlines
F2F and recert due dates
Order signature delays
Visit frequency compliance
Medication issues
High-risk patients (falls, wounds, agitation, medication changes)
5.4 Conduct Real-Time Chart Correction
Instead of reviewing charts monthly, conduct audits:
Corrections must not alter past documentation but add clarifying addendums as allowed.
5.5 Enhance Communication Across Departments
Surveyors consistently cite agencies with siloed communication. To prevent this:
Hold daily clinical huddles
Use secure messaging to ensure alignment
Address discrepancies as soon as they occur
5.6 Strengthen Your QAPI Framework
A strong QAPI program includes:
A well-run QAPI program is one of the strongest defenses during surveys.
6. Final Tips for Zero-Deficiency Success
Be survey-ready every day, not only when surveyors arrive.
Train staff continuously, not annually.
Use data—not assumptions—to guide improvements.
Monitor compliance daily and address issues immediately.
Focus on documentation accuracy, timeliness, and consistency.
Support your IDG; it is the core of hospice operations.
Strengthen leadership visibility and engagement.
Organizations that achieve zero deficiencies do so intentionally, through strong systems, proactive oversight, and a culture committed to excellence.
Partner With HealthBridge for Zero-Deficiency Success
If your hospice agency needs help preparing for surveys, improving clinical documentation, strengthening QAPI programs, or ensuring compliance with the Medicare Conditions of Participation, HealthBridge provides full-service consulting and operational management solutions.
From mock surveys to chart audits, staff training, policy development, and ongoing compliance programs, HealthBridge ensures your organization operates at the highest standard—every day, not just during surveys.
References:
Centers for Medicare & Medicaid Services (CMS). Medicare State Operations Manual – Appendix M: Hospice.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
Centers for Medicare & Medicaid Services (CMS). 42 CFR Part 418 – Hospice Care Conditions of Participation.
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-418
Centers for Medicare & Medicaid Services (CMS). CMS Hospice Quality Reporting Program (HQRP).
https://www.cms.gov/medicare/quality/hospice-compare/hospice-quality-reporting
Centers for Medicare & Medicaid Services (CMS). Hospice Final Rule – Payment Policies and Rate Update.
https://www.cms.gov/newsroom/fact-sheets/hospice-final-rule
