Top Hospice Survey Deficiencies Cited by CMS

Introduction: Understanding the Hospice Survey Deficiency Landscape

The hospice industry has faced increasing regulatory scrutiny over the past decade as CMS and its state survey partners have intensified oversight in response to concerns about quality of care, eligibility documentation, and billing practices. Survey deficiencies — findings of noncompliance with the Hospice Conditions of Participation — are not rare events. They are a regular feature of the hospice regulatory landscape, and agencies that fail to anticipate and address common deficiency areas expose themselves to serious operational, financial, and reputational risk.

Understanding the top deficiencies cited during hospice surveys is the first step in building a proactive compliance program. This article examines the most frequently cited hospice survey deficiencies based on CMS data and industry experience, explains why they occur, and provides practical guidance for prevention.

Deficiency 1: Plan of Care Deficiencies

Plan of care deficiencies are consistently among the most frequently cited findings in hospice surveys. CMS requires that each patient have a written plan of care established before services are provided, developed collaboratively by the interdisciplinary group, addressing the patient's and family's identified needs, goals, and preferences, updated by the IDG at least every 15 days, and reflecting the patient's current condition, symptoms, and response to interventions.

Common plan of care deficiencies include plans that are templated and not individualized to the specific patient, plans that have not been updated following IDG review, discrepancies between the plan of care and the services actually documented as provided, and plans that fail to reflect changes in the patient's condition or new symptoms. Prevention requires investment in IDG processes that support individualized, dynamic care planning and clinician education on the relationship between assessment findings and plan of care content.

Deficiency 2: Interdisciplinary Group Meeting Requirements

The interdisciplinary group is the clinical governance structure of the hospice program, and survey deficiencies related to IDG composition, meeting frequency, and documentation are common. Required IDG members include the attending physician, registered nurse, medical social worker, and pastoral or counseling services provider. All required disciplines must be represented, and the IDG must meet at least every 15 days to review and update each patient's plan of care.

Surveyors frequently cite deficiencies when IDG meeting documentation does not reflect active clinical discussion, when required disciplines are absent from meetings without a documented reason, when plans of care reviewed at IDG meetings are not updated to reflect the IDG's determinations, or when IDG meetings occur but are not held within the required timeframe. Agencies can prevent these deficiencies through structured IDG meeting formats, clear documentation templates, and supervisory review of meeting minutes.

Deficiency 3: Physician Certification and Recertification Documentation

Inadequate physician certification and recertification documentation is a major driver of both survey deficiencies and Medicare ADR denials in hospice. CMS requires that a hospice physician or attending physician certify at the time of admission that the patient has a terminal prognosis of six months or less if the disease follows its normal course. Recertification is required at 90 days, then at 60-day intervals thereafter. Since 2011, CMS has also required a face-to-face encounter with the patient conducted by the hospice physician or nurse practitioner before the third benefit period and each subsequent recertification.

Common deficiencies include certification narratives that are vague, generic, or not based on patient-specific clinical information; face-to-face encounter documentation that does not include a clinical summary supporting the terminal prognosis; recertification completed after the deadline; and documentation of the face-to-face encounter that does not meet the regulatory requirements for content. Prevention requires physician and NP education on certification documentation standards and regular audit of certification documentation quality.

Deficiency 4: Registered Nurse Supervision of Aide Services

Hospice aides provide personal care services under the direction of the registered nurse, and proper supervision of aide services is a frequent survey focus. CMS requires that a registered nurse make a supervisory visit to the patient's home at least every 14 days to observe and assess the aide's performance. The supervisory visit must occur while the aide is present and providing care.

Deficiencies in this area arise when supervisory visits do not occur within the required 14-day interval, when visits occur without the aide present, or when documentation of supervisory visits is incomplete. Many hospices struggle with aide supervision logistics when patients are spread across large geographic areas or when caseloads are high. Prevention requires proactive scheduling of supervisory visits, supervisory visit tracking tools, and management oversight of completion rates.

Deficiency 5: Bereavement Services

Bereavement services are a required component of the hospice benefit, and deficiencies in bereavement program management are cited regularly. CMS requires that the hospice provide bereavement services to the surviving family for at least thirteen months following the patient's death, with a program directed by a qualified professional, individualized to each family's needs, and documented in the clinical record.

Common deficiencies include bereavement programs that are not individualized, families who are lost to follow-up after the patient's death, inadequate documentation of bereavement contacts, and lack of a mechanism to identify families at risk for complicated grief. Building a robust bereavement program requires dedicated staffing, a tracking system for all bereaved families, and regular supervisory review of bereavement documentation.

Deficiency 6: Volunteer Program Requirements

CMS requires that hospices use volunteers to provide administrative and direct patient care services, with volunteers contributing no less than five percent of total patient care hours in the aggregate across the hospice. Surveyors will evaluate whether the agency has an active volunteer program, whether volunteers are adequately trained and supervised, and whether the agency can demonstrate through data that it is meeting the five percent threshold.

Many hospices, particularly smaller agencies or those with high patient census growth, struggle to maintain the volunteer threshold. Prevention requires a proactive volunteer recruitment, training, and scheduling program with regular monitoring of volunteer hours against patient care hours.

Deficiency 7: Emergency Preparedness

Since CMS implemented updated Emergency Preparedness Requirements across all provider types, emergency preparedness deficiencies have increased in hospice surveys. Agencies must have a comprehensive emergency preparedness plan, a communication plan, policies addressing continuity of operations during disasters, and an annual training and testing program. Surveyors evaluate not just whether the plan exists but whether staff are trained on it and whether it reflects the specific risks present in the agency's geographic service area.

Building a Deficiency Prevention Program

The most effective deficiency prevention strategy is a robust internal audit and QAPI program that treats each of the above areas as ongoing quality indicators. Agencies should conduct monthly or quarterly internal audits of plan of care quality, IDG meeting documentation, certification documentation, aide supervision, bereavement program management, and volunteer tracking. Audit findings should be reported to the QAPI committee, trended over time, and used to drive targeted performance improvement projects.

How HealthBridge Can Help

Navigating the complexities of home health, hospice, assisted living, FQHC operations, or any healthcare regulatory environment requires experienced partners who understand the landscape. HealthBridge offers comprehensive consulting and management solutions tailored to healthcare providers at every stage — whether you are launching a new agency, responding to a survey deficiency, defending an audit, or building long-term operational excellence.

HealthBridge consultants bring hands-on expertise in regulatory compliance, clinical documentation, QAPI design, survey preparation, billing defense, staff training, and strategic operations. From start-up licensing to complex audit defense, HealthBridge provides the guidance, tools, and support your organization needs to succeed.

Contact HealthBridge today to learn how their consulting and management solutions can protect your agency, elevate your care quality, and position you for long-term regulatory and financial success.

References

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418
https://www.cms.gov/files/document/cms-hospice-conditions-participation.pdf
https://www.cms.gov/files/document/hospice-interpretive-guidelines.pdf
https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospice
https://www.cms.gov/files/document/qso-21-08-hospice.pdf
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000478.asp
https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/hospice