The Most Common Hospice CoP Violations and How to Correct Them Before Survey

Hospice agencies operating under Medicare are governed by the Conditions of Participation (CoPs) outlined in 42 CFR Part 418. These regulations establish the minimum standards for patient care, operational oversight, and quality assurance. Surveyors acting on behalf of the Centers for Medicare & Medicaid Services routinely assess hospice agencies to ensure compliance.

Failure to meet CoP requirements can result in deficiencies, corrective action plans, or even termination from the Medicare program. Many of the most common violations are not isolated errors, but systemic issues that can be prevented through structured compliance programs.

This article outlines the most frequently cited hospice CoP violations and provides actionable strategies to correct them before a survey.

Understanding Hospice Survey Expectations

Hospice surveys evaluate both documentation and implementation. Surveyors assess whether:

• Care is consistent with the plan of care

• Interdisciplinary Group (IDG) functions effectively

• Documentation supports eligibility and services

• Quality programs are active and data-driven

Agencies must demonstrate sustained compliance, not temporary readiness.

Most Common Hospice CoP Violations

1. Plan of Care (POC) Deficiencies (§418.56)

The hospice plan of care is one of the most cited areas of non-compliance.

Common issues include:

• Missing measurable goals

• Lack of individualized interventions

• Failure to update the POC every 15 days

• Interventions not aligned with patient needs

How to Correct Before Survey:

• Standardize POC templates with required elements

• Ensure IDG reviews and updates plans every 15 days

• Conduct chart audits to verify alignment between care and documentation

• Train clinicians on goal-oriented care planning

2. Interdisciplinary Group (IDG) Failures (§418.56)

The IDG is central to hospice care delivery.

Surveyors frequently cite:

• Missing required IDG members (RN, physician, social worker, counselor)

• Lack of documented IDG discussions

• Failure to review each patient every 15 days

How to Correct Before Survey:

• Maintain a complete IDG roster

• Document all IDG meetings and patient discussions

• Ensure consistent attendance by required disciplines

• Conduct internal IDG audits

3. Certification of Terminal Illness (CTI) Deficiencies (§418.22)

CTI documentation must support hospice eligibility.

Common violations include:

• Missing physician narratives

• Late certifications

• Generic or non-specific documentation

• Lack of clinical support for prognosis

How to Correct Before Survey:

• Implement CTI documentation templates

• Audit all certifications for timeliness and completeness

• Train physicians on narrative requirements

• Ensure documentation supports a six-month prognosis

4. Hospice Aide Supervision Issues (§418.76)

Hospice aide supervision is a frequently cited deficiency.

Surveyors identify:

• Missing supervisory visits (every 14 days)

• No documentation of aide competency

• Lack of RN oversight

How to Correct Before Survey:

• Track aide supervision schedules

• Conduct and document supervisory visits consistently

• Maintain competency evaluations

• Audit aide documentation regularly

5. Clinical Documentation Deficiencies (§418.110)

Clinical records must accurately reflect care provided.

Common findings include:

• Missing visit notes

• Late documentation

• Inconsistent narratives

• Lack of authentication

How to Correct Before Survey:

• Enforce same-day documentation policies

• Conduct routine chart audits

• Standardize documentation practices

• Provide clinician training on defensible documentation

6. QAPI Program Failures (§418.58)

Quality Assessment and Performance Improvement (QAPI) is a major survey focus.

Surveyors often find:

• Lack of measurable quality indicators

• No active performance improvement projects (PIPs)

• Missing documentation of meetings

• No evidence of data analysis

How to Correct Before Survey:

• Establish a structured QAPI program

• Track key performance indicators

• Conduct regular QAPI meetings with documented minutes

• Implement and monitor performance improvement projects

7. Infection Control Deficiencies (§418.60)

Infection prevention is a critical compliance area.

Common violations include:

• No infection control program

• Lack of infection tracking

• Missing staff training

• Improper use of PPE

How to Correct Before Survey:

• Develop a formal infection control program

• Assign an infection control coordinator

• Conduct staff training and competency checks

• Maintain infection logs and reports

8. Patient Rights Violations (§418.52)

Hospice agencies must protect patient rights.

Surveyors frequently cite:

• Failure to provide written rights

• Lack of documentation of patient education

• Inadequate grievance processes

How to Correct Before Survey:

• Provide patient rights at admission

• Obtain signed acknowledgments

• Maintain complaint logs

• Train staff on patient rights policies

9. Volunteer Program Deficiencies (§418.78)

Hospice regulations require an active volunteer program.

Common issues include:

• Failure to meet the 5% volunteer requirement

• Lack of volunteer training

• Missing documentation of volunteer services

How to Correct Before Survey:

• Track volunteer hours and participation

• Provide structured volunteer training

• Maintain volunteer records

• Monitor compliance with the 5% requirement

10. Medication Management Issues (§418.106)

Medication management must ensure patient safety.

Surveyors identify:

• Improper medication reconciliation

• Lack of documentation for medication administration

• Unsafe storage practices

How to Correct Before Survey:

• Standardize medication reconciliation processes

• Train staff on medication documentation

• Conduct medication audits

• Ensure safe storage practices

Root Causes of Hospice CoP Violations

Repeated violations typically stem from:

• Weak compliance infrastructure

• Inconsistent staff training

• Lack of leadership oversight

• Poor documentation systems

• Absence of ongoing audits

Addressing these root causes is essential to achieving sustainable compliance.

How to Prepare for a Hospice Survey

1. Conduct a Mock Survey

Mock surveys simulate real inspections and identify deficiencies in advance.

2. Perform Comprehensive Chart Audits

Review:

• CTIs

• Plans of care

• Visit notes

• IDG documentation

3. Strengthen Staff Training

Ensure staff understand:

• CoP requirements

• Documentation expectations

• Patient care protocols

4. Implement Real-Time Compliance Monitoring

Track compliance continuously rather than preparing only before surveys.

5. Ensure Leadership Involvement

Administrators and clinical leaders must actively oversee compliance efforts.

Why Correcting Violations Before Survey Matters

Failure to correct deficiencies can result in:

• Condition-level deficiencies

• Plans of Correction (POCs)

• Follow-up surveys

• Civil monetary penalties

• Termination from Medicare

Proactive correction reduces risk and ensures operational stability.

Final Thoughts

Hospice CoP violations are predictable and preventable when agencies implement structured compliance systems. The most successful hospice agencies focus on continuous monitoring, staff education, and leadership accountability.

Survey readiness is not a one-time effort. It requires consistent attention to documentation, care delivery, and regulatory requirements.

Work With Experts in Hospice Compliance

At HealthBridge, we specialize in helping hospice agencies achieve full compliance with Medicare Conditions of Participation and successfully pass surveys.

Our services include:

• Mock surveys and deficiency prevention

• Plan of Correction development

• QAPI program implementation

• Clinical documentation audits

• Staff training and compliance systems

Whether you are preparing for a survey or addressing deficiencies, HealthBridge provides the expertise and structure needed to succeed.

URL Links

https://www.myhbconsulting.com
https://www.cms.gov