Ensuring quality care and regulatory compliance is a top priority for hospice agencies—and that’s why unannounced surveys by the Centers for Medicare & Medicaid Services (CMS) or state agencies are so critical. One of the most important parts of the survey process is the Entrance Conference, which sets the tone and structure for the entire review.
Understanding what happens during this stage—and how your team should be prepared—can make a major difference in the survey’s outcome.
What Is the Entrance Conference in a Hospice Survey?
The entrance conference is the initial meeting between the hospice agency’s leadership and the survey team. It occurs at the start of the survey process and establishes the expectations, logistics, and communication methods that will guide the remainder of the inspection.
Key Components of the Entrance Conference
During the entrance conference, surveyors will outline how they plan to conduct the review and request specific support from your hospice team. Here are the critical aspects you should be ready for:
1. Introduction of the Survey Team
If more than one surveyor is present, each member will introduce themselves and explain their responsibilities. This helps the hospice staff understand who to approach for different areas of the review.
2. Overview of the Survey Process
The surveyors will explain:
The estimated length of the survey
Whether additional branch locations will be visited
The general flow of the evaluation, including interviews, record reviews, and home visit observations
This information gives the hospice team a framework to coordinate their time and personnel accordingly.
Assistance Requested from the Hospice Administrator
To facilitate a smooth process, surveyors will ask for specific logistical support. These include:
• • A Dedicated Work Space
Provide a quiet and private area where surveyors can conduct their work without interruption.
• Access to Office Equipment
Surveyors may request instructions for using office equipment like copiers, printers, and fax machines.
• Assigned Point-of-Contact Staff
Designate team members who can:
Answer questions from the survey team
Retrieve records or documentation quickly
Provide clarification or additional context when needed
Clinical and Administrative Contacts to Be Identified
It’s essential to have staff available who are knowledgeable in the following areas:
• Clinical Oversight
Staff who understand clinical supervision protocols and can explain how care decisions are made and monitored.
• In-Service Training
Personnel familiar with staff training processes, including ongoing education and onboarding.
• Hospice Aide Oversight
Employees who can describe how hospice aides are supervised and how their performance is evaluated.
• EHR Navigation
Assign a staff member who can help surveyors access electronic health records promptly. They should be fluent in navigating the system and able to locate documentation such as:
Orientation to Clinical Records
Whether your agency uses paper charts, electronic records, or both, be prepared to guide surveyors through your documentation system. They’ll be reviewing:
Comprehensive assessments
Individualized plans of care
Medical and physician documentation
Home visit logs and progress notes
Properly labeled and organized records will demonstrate your agency’s compliance and commitment to quality care.
Final Tips for a Successful Hospice Survey Entrance Conference
Stay Calm and Professional: Approach the entrance conference with confidence. Surveyors are there to assess compliance, not to penalize without cause.
Be Organized: Ensure records are up-to-date and easily accessible before surveyors arrive.
Designate the Right Staff: Identify the most knowledgeable team members in advance and brief them on their roles during the survey.
Ask Questions: Don’t hesitate to seek clarification from surveyors if you're unsure about any part of the process.
Why This Matters
A successful entrance conference sets the stage for a smoother survey process. It shows your agency is organized, cooperative, and dedicated to high standards of care. Being prepared for this critical interaction not only helps ensure regulatory compliance—it also reinforces your agency’s commitment to excellence in hospice services.
