How CMS Conducts a Hospice Recertification Survey

Hospice recertification surveys are conducted to determine whether a hospice agency continues to meet the Medicare Conditions of Participation under federal regulations. These surveys are not informal check-ins. They are structured, investigative, and evidence-driven evaluations of whether the hospice remains compliant with 42 CFR Part 418.

Hospice leaders must understand not only what surveyors review, but how they review it, how survey pathways are selected, and how deficiencies are determined.

Regulatory Authority

Hospices participating in Medicare are governed by the Conditions of Participation under 42 CFR Part 418, enforced by the Centers for Medicare & Medicaid Services (CMS). CMS conducts surveys directly or through state survey agencies.

The legal authority for hospice oversight is grounded in the Social Security Act and federal regulations.

Survey Cycle and Recertification Timing

Hospices are typically surveyed on a recertification cycle of approximately every 36 months. However, surveys may occur sooner if:

There are complaints
Condition-level deficiencies were previously cited
The hospice underwent ownership change
CMS identified program integrity concerns
Quality data triggered review

Recertification surveys are unannounced.

Pre-Survey Preparation by CMS

Before arriving onsite, CMS surveyors:

Review prior survey findings
Examine complaint history
Analyze Hospice Item Set (HIS) data
Review CAHPS Hospice Survey data
Analyze claims utilization trends
Identify potential risk indicators

This pre-survey data review often shapes which records and focus areas are prioritized.

The Survey Entrance Conference

Upon arrival, surveyors conduct an entrance conference with hospice leadership. During this meeting they typically request:

Organizational chart
Current census
Patient list with diagnosis and level of care
Personnel roster
Contracted services list
QAPI program documentation
Policies and procedures
Infection control plan
Emergency preparedness plan

Surveyors will begin selecting sample patient records at this stage.

Patient Sample Selection

CMS selects a sample of active patients and recently discharged patients. The sample typically includes:

Routine home care patients
Continuous home care patients
General inpatient level patients
Respite care patients
Patients recently deceased
Patients with extended lengths of stay

High-risk diagnoses or long length-of-stay patients are frequently included.

Clinical Record Review

Surveyors conduct a deep clinical review of selected records. This includes:

Initial certification and recertification documentation
Physician narratives supporting terminal prognosis
Evidence of decline
Comprehensive assessments
Plan of care
IDG documentation
Nursing visit notes
Social work notes
Spiritual care documentation
Medication profiles
Symptom management documentation
Coordination of care

Surveyors compare all disciplines’ documentation for consistency and alignment.

Hospice Eligibility and Recertification Focus

Recertification surveys focus heavily on whether patients meet eligibility criteria.

Surveyors evaluate:

Physician certification narrative specificity
Evidence of terminal illness
Documentation of decline or disease progression
Functional status measures (PPS, FAST, etc.)
Weight trends and nutritional status
Hospitalizations or clinical instability
Comorbid conditions

Deficiencies often occur when recertification narratives are vague or unsupported by the clinical record.

IDG Review Process

The interdisciplinary group (IDG) is central to hospice compliance. Surveyors review:

Evidence that IDG meetings occur at least every 15 days
Patient-specific discussion in IDG notes
Care plan updates reflecting change in condition
Physician involvement
Coordination among disciplines

Cloned IDG documentation is a common citation trigger.

Home Visits and Observations

Surveyors may accompany hospice staff on home visits to observe:

Infection control practices
Medication management
Patient assessment
Caregiver education
Communication skills
Adherence to plan of care

They evaluate whether actual practice matches documentation.

Staff Interviews

Surveyors interview:

Administrators
Clinical managers
Nurses
Social workers
Spiritual counselors
Medical directors
Volunteers (if applicable)

They assess knowledge of:

Patient rights
Abuse reporting
Emergency preparedness
Infection control
Symptom management
QAPI program

Inconsistent staff responses often signal compliance weaknesses.

QAPI Program Evaluation

CMS places significant emphasis on Quality Assessment and Performance Improvement.

Surveyors review:

Written QAPI plan
Performance improvement projects
Data collection methods
Analysis of adverse events
Corrective action tracking
Board or leadership oversight

Hospices frequently receive deficiencies when QAPI lacks measurable outcomes or documented follow-through.

Infection Control Review

Surveyors evaluate:

Infection control policies
Staff training records
PPE availability
Bag technique practices
Vaccination policies
Outbreak reporting

Since COVID-19, infection control scrutiny has increased substantially.

Emergency Preparedness Review

Hospices must maintain an emergency preparedness program including:

Risk assessment
Emergency plan
Policies and procedures
Communication plan
Training and testing
Drill documentation

Failure to conduct required drills often results in citation.

Condition-Level vs Standard-Level Deficiencies

CMS categorizes deficiencies as:

Standard-level
Condition-level

Condition-level deficiencies represent systemic noncompliance and can trigger:

Plan of correction
Directed plan of correction
Follow-up surveys
Termination risk if uncorrected

Exit Conference

At the conclusion of the survey, CMS conducts an exit conference to:

Summarize preliminary findings
Clarify areas of concern
Explain deficiency categories
Outline next steps

Formal findings are later issued in writing.

Post-Survey Plan of Correction

If deficiencies are cited, the hospice must submit a Plan of Correction detailing:

Corrective actions
Responsible individuals
Completion timeline
Monitoring methods
Sustainability strategy

Failure to submit an acceptable plan can escalate enforcement actions.

Common Recertification Survey Deficiency Areas

Hospice eligibility documentation
Physician recertification narratives
IDG documentation integrity
Care plan updates
QAPI implementation
Infection control compliance
Volunteer program oversight
Bereavement documentation
Medication management
Coordination of contracted services

Survey Readiness Best Practices

Hospices should maintain continuous readiness by:

Conducting mock surveys
Auditing IDG documentation
Reviewing eligibility narratives
Training staff on survey interview readiness
Maintaining organized clinical records
Monitoring recertification timelines
Auditing QAPI effectiveness

Recertification surveys evaluate both documentation and operational culture.

Conclusion

A CMS hospice recertification survey is a comprehensive evaluation of regulatory compliance under the Conditions of Participation. Surveyors assess eligibility documentation, interdisciplinary coordination, quality improvement systems, infection control, emergency preparedness, and clinical practice consistency.

Hospices that proactively audit documentation, strengthen IDG processes, and integrate QAPI findings into operations significantly reduce citation risk and protect Medicare certification.

If your hospice is preparing for recertification, responding to survey findings, or strengthening compliance systems, HealthBridge provides mock surveys, documentation audits, IDG training, QAPI restructuring, and regulatory alignment consulting tailored to hospice organizations.

Resource Links

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418
https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/hospices
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_m_hospice.pdf