Understanding the Latest CMS Hospice Conditions of Participation (CoPs)

Understanding the Latest CMS Hospice Conditions of Participation (CoPs)

The regulatory environment for hospice — especially for providers delivering care in the home and across the continuum with home health and palliative programs — is more complex and more visible than ever. CMS has tightened oversight, refined survey protocols, and linked payment and public reporting more directly to quality and compliance with the Medicare Hospice Conditions of Participation (CoPs). Centers for Medicare & Medicaid Services

For owners, administrators, DONs, and clinical leaders, truly understanding the CoPs is no longer optional. It’s a core operational competency that impacts:

• Your ability to stay in the Medicare program

• Your survey outcomes and potential sanctions

• Your reimbursement under current and future payment rules

• Your public reputation in an environment of growing scrutiny
  

This article walks through the hospice CoP framework, highlights the most recent updates from CMS, and offers practical, implementation-focused guidance — especially for hospices operating in the home health and community-based space.

1. What Are the Hospice Conditions of Participation (CoPs)?

The Conditions of Participation are federal health and safety standards that all Medicare-certified hospices must meet to participate in the Medicare program. They are codified at 42 CFR Part 418, with Subparts C and D housing the hospice CoPs. eCFR

They apply to:

• The hospice as an entity (governance, administration, quality program, etc.)

• The care delivered to every individual under the hospice benefit

• The environment and systems that support that care (emergency preparedness, records, drugs/biologicals, etc.)
  

Failure to comply can result in deficiencies, plans of correction, directed education, civil monetary penalties, or even termination from Medicare in cases of serious or uncorrected noncompliance.

Key structure of the hospice CoPs

While Part 418 includes multiple subparts, providers most often work hands-on with CoPs in areas such as: GovInfo

• Patient rights and evaluation (e.g., election, revocation, and coverage)

• Initial and comprehensive assessment (§418.54) eCFR

• Plan of care and coordination of services

• Interdisciplinary group (IDG) and core services

• Hospice aide and volunteer services

• Quality Assessment and Performance Improvement (QAPI)

• Inpatient care, if provided directly

• Emergency preparedness (§418.113) Legal Information Institute

• Organizational governance, administration, and medical director

• Clinical records (§418.104) National Alliance for Care at Home
  

Surveyors use Appendix M of the State Operations Manual as their roadmap, which contains L-tags and interpretive guidelines for each CoP. National Alliance for Care at Home

2. Recent Regulatory and Survey Environment Shifts

While the core CoPs in 42 CFR Part 418 have been relatively stable, CMS has made significant moves since 2020 in how these regulations are enforced and how quality is measured and paid.

2.1 FY 2025 Hospice Final Rule: CoP and Quality Reporting Updates

In the FY 2025 Hospice Payment Rate Update Final Rule (CMS-1810-F), CMS: Centers for Medicare & Medicaid Services

• Updated the hospice wage index and payment rates (2.9% payment update for FY 2025).

• Finalized changes that affect how hospices collect and report quality data under the Hospice Quality Reporting Program (HQRP).

• Included specific hospice CoP-related updates and clarifications tied to quality and program integrity.
  

A major structural change is the transition from the Hospice Item Set (HIS) to the Hospice

Outcomes & Patient Evaluation (HOPE) tool:

• CMS finalized the collection of HOPE patient-level data beginning on or after October 1, 2025, which will replace the HIS as the primary clinical data collection tool for HQRP. Homecare Homebase

• Future process measures (for example: timely follow-up for pain and non-pain symptoms) will be based on HOPE data and are anticipated after FY 2028. Homecare Homebase
  

Operationally, this means your hospice — including any home-health-based hospice lines — must align assessment workflows, documentation, and staff competencies with HOPE, not just HIS, over the next few years.

2.2 Hospice Quality Reporting Program (HQRP) Penalties

The HQRP is no longer a “nice-to-have.” Hospices that fail to meet reporting requirements face a 4% reduction in their annual payment update (increased from 2%), creating a direct financial link between compliance and revenue. QAPIplus+1

Note: While HQRP is technically a quality program, not a CoP, your ability to meet HQRP requirements depends heavily on CoP-compliant assessment, documentation, and QAPI infrastructure.

2.3 Revised Appendix M: How Surveyors Look at CoP Compliance

CMS significantly revised Appendix M – Guidance for Surveyors: Hospice (QSO-23-08, January 2023). The updates include: Simitree Health Care+1

• A more robust two-phase survey approach focused on quality of care, with enhanced pre-survey review of data and prior survey history. CHAP

• Clearer interpretive guidelines for each CoP, making it more transparent what surveyors are looking for. National Alliance for Care at Home+1

• Heightened emphasis on key CoPs such as patient rights, plan of care, coordination of services, and QAPI.
  

The result: it’s not enough to “have a policy.” Surveyors expect live, demonstrable processes, consistent documentation, and staff who can explain the “why” behind what they do.

3. Core Hospice CoPs Every Provider Should Re-Review Now

Below are selected CoPs that hospices — especially those integrated with home health operations — should prioritize as they align to the latest environment.

3.1 Comprehensive Assessment – §418.54

The comprehensive assessment must: eCFR

• Be patient-specific, timely, and documented in writing.

• Address the physical, psychosocial, emotional, and spiritual needs of the patient and family.

• Drive the plan of care and be updated as the patient’s condition changes.
  

With HOPE replacing HIS, hospices will need to ensure their comprehensive assessment process captures all required HOPE elements and supports the quality measures CMS uses for public reporting and payment.

Practical tips:

• Map your current assessment forms and workflows to HOPE data requirements.

• Ensure RNs, social workers, chaplains, and therapies understand their role and how their assessments feed the IDG plan of care.

• For agencies that also operate home health: avoid “copy-paste” from OASIS; hospice assessment must be distinct, terminal-illness focused, and CoP-driven.
  

3.2 Plan of Care and IDG Coordination

The plan of care (POC) must be:

• Interdisciplinary – developed, reviewed, and updated by the IDG.

• Patient- and family-centered, reflecting goals of care and changing needs.

• Actionable – with measurable interventions, frequencies, and responsible disciplines.
  

The IDG meetings, documentation, and POC updates are a major survey focus under Appendix M. Surveyors frequently track: National Alliance for Care at Home+1

• Whether the POC actually matches what staff are doing in the home or inpatient setting

• How symptoms (pain, dyspnea, agitation, nausea, etc.) are assessed, addressed, and re-evaluated

• Whether there is clear coordination with attending physicians and other providers (e.g., SNFs, hospitals, home health)
  

If your organization runs both home health and hospice, careful boundary setting is critical:

• Hospices must ensure that all care for the terminal illness and related conditions is being coordinated by hospice, not left to “home health side” documentation.

• Orders, medication changes, and POC revisions must be captured in one coherent hospice plan of care.
  

3.3 Hospice Aide and Volunteer CoPs

Hospice aide supervision and competency validation are common survey vulnerabilities. Under hospice CoPs, aides must have:

• Documented training and competency evaluations for all tasks they perform.

• Ongoing supervision by an RN, with on-site visits and documentation at required intervals.

Volunteers are required under the CoPs (e.g., 5% of total patient care hours must be furnished by volunteers), and surveyors often examine: GovInfo+1

• Whether the hospice has an active volunteer program, including training and role descriptions

• How volunteer activities are documented and counted toward the 5% requirement

• How volunteers are integrated into the IDG when relevant
  

3.4 QAPI – Quality Assessment and Performance Improvement

The QAPI CoP requires a data-driven, ongoing program that focuses on high-risk, high-volume, or problem-prone areas, and measures the effectiveness of performance improvement activities.

Given the HQRP penalty structure, your QAPI now must visibly connect: QAPIplus+1

• Clinical outcomes and symptom management

• Patient/family experience (e.g., CAHPS Hospice Survey)

• Survey deficiencies and complaint trends

• Corrective actions and sustained improvement, not one-time fixes
  

For hospices operating within larger home health organizations, QAPI should be:

• Program-specific – hospice must have its own QAPI plan, data, and projects.

• Aligned but not identical – you can share infrastructure (e.g., committees, data teams), but hospice indicators must reflect Part 418 requirements and hospice-specific risk areas.
  

3.5 Emergency Preparedness – §418.113

Hospice CoPs require a comprehensive emergency preparedness program that includes: Legal Information Institute

• Risk assessment and planning

• Policies and procedures

• Communication plan

• Training and testing program (e.g., drills and exercises), reviewed at least every 2 years
  

Surveyors increasingly test whether:

• Your emergency plan is specific to community-based hospice operations, including home visits, oxygen-dependent patients, and geographically dispersed caseloads.

• There is evidence that staff are trained and know what to do in real events (wildfires, hurricanes, winter storms, pandemics).

• Communication workflows with home health, SNFs, and hospitals are clearly defined in shared emergencies.
  

3.6 Clinical Records – §418.104

The clinical records CoP requires that records are:

• Complete, promptly and accurately documented, and organized to facilitate care and review. National Alliance for Care at Home

• Protected for confidentiality but readily retrievable for survey, care coordination, and quality review.

• Inclusive of key items like the discharge summary, last physician orders, and the POC at discharge or transfer.
  

In the current environment, weak documentation isn’t just a clinical risk; it directly impacts:

• Survey outcomes (deficiencies, condition-level findings)

• HQRP compliance

• Medical review and payment integrity audits
  

4. How the Hospice CoPs Intersect With Home Health and Community-Based Care

Many organizations now operate home health, hospice, palliative, and personal care under one corporate umbrella. That can be a strategic advantage — if you implement clear CoP-aligned structures.

Key integration risks to manage

1. Blurring program boundaries

   • Patients must be clearly enrolled in the Medicare hospice benefit or other programs; you can’t “mix” home health documentation for a hospice episode.

2. Different regulatory frameworks

   • Home health CoPs (42 CFR Part 484) and hospice CoPs (42 CFR Part 418) are not interchangeable. Assessment tools, frequencies, care coordination expectations, and survey approaches differ.

3. Shared staff and leadership

   • RNs, CNAs, and managers who work across both programs need program-specific orientation and competencies. A single policy manual is not enough; hospice must have distinct policies that satisfy its CoPs.

4. EMR configuration

   • Your EMR must clearly support hospice workflows: IDG, hospice POC, terminal prognosis documentation, CTI/narratives, HOPE data elements, and hospice-specific orders.
     

When done right, integration allows shared compliance infrastructure, education, and QAPI resources, but hospices still need their own CoP compliance story.

5. Practical Steps to Align With the Latest CoPs and CMS Expectations

Here are concrete actions your hospice leadership team can take over the next 6–12 months:

5.1 Perform a CoP-Gap Assessment

• Use 42 CFR Part 418 and the latest Appendix M as your master checklist. eCFR+2National Alliance for Care at Home

• Map each CoP to:

  • Policies and procedures

  • Actual workflow (what staff really do)

  • EMR forms and templates

  • Staff roles and competencies

• Prioritize gaps that:

  • Are directly tied to patient safety (e.g., assessment, POC, medications)

  • Have high deficiency rates nationally (aides, QAPI, clinical records, emergency preparedness)

  • Could impact HQRP performance and payment
    

5.2 Prepare for HOPE and HQRP Evolution

• Identify a HOPE transition team (clinical, IT, QA, education).

• Review CMS HOPE specifications and crosswalk them to your current assessment tools and hospice workflows. Homecare Homebase+1

• Integrate HOPE-related data collection into your QAPI plan now so your team sees it as operational, not just “extra paperwork.”
  

5.3 Tighten Survey Readiness as a Year-Round Process

• Conduct mock surveys using the updated survey protocol and Appendix M interpretive guidelines. CHAP

• Train staff to answer surveyor questions clearly and confidently, linking their practice back to:

  • The POC

  • The CoPs

  • The hospice’s policies

• Build a survey readiness binder or dashboard with:

  • Key policies

  • Organizational chart and contracts

  • QAPI plan and data

  • Emergency preparedness documentation

  • Clinical record samples and tracking logs
    

5.4 Strengthen Documentation and Interdisciplinary Communication

• Create discipline-specific documentation standards that reflect both CoPs and HOPE/HQRP expectations.

• Ensure IDG minutes, POCs, and visit notes tell the same story:

  • What was the problem?

  • What did we do?

  • How did the patient respond?

  • What changed in the plan as a result?

5.5 Integrate Home Health–Hospice Governance Without Diluting CoP Compliance

• If you operate both home health and hospice, ensure:

  • Separate, CoP-specific Governing Body minutes reflect hospice oversight.

  • Hospice has a clear Medical Director role with defined responsibilities under Part 418.

  • Joint committees (e.g., Quality, Infection Control, Ethics) have hospice-specific agenda items.
    

6. The Bottom Line

CMS hospice CoPs are not static checkboxes; they are a living framework that now sits at the center of:

• Survey methodology (Appendix M revisions)

• Quality reporting and public transparency (HQRP, HOPE)

• Payment and financial viability (4% penalties, annual rule updates)

For hospices and integrated home health–hospice systems, success in 2025 and beyond means:

• Translating the regulatory language of Part 418 into clean, repeatable workflows

• Ensuring documentation reflects reality and supports both surveys and quality reporting

• Treating CoP compliance as a strategic, cross-departmental initiative, not just a clinical or QA task
  

How HealthBridge Can Help

Staying aligned with the latest CMS hospice CoPs while running day-to-day operations is a heavy lift — especially if you are also managing home health, palliative care, or other service lines.

HealthBridge provides end-to-end consulting and management solutions for home health and hospice agencies, including:

• CoP-based gap assessments and action plans

• Development and customization of policies, procedures, and tools aligned with 42 CFR Part 418 and Appendix M

• Mock surveys and survey response coaching

• QAPI program design, data dashboards, and project support

• Workflow and documentation optimization for HOPE, HQRP, and EMR configuration

• Ongoing compliance mentorship for leadership and frontline teams
  

If your hospice or home health–based hospice needs structured support to navigate the evolving CMS landscape, reduce survey risk, and protect Medicare revenue, partnering with HealthBridge can give you a ready-made framework and expert guidance rather than starting from scratch.