Hospices Use Self-Audits to Prepare for CMS Survey

As regulators place increasing scrutiny on hospice providers, many are using a self-audit process to make sure they are ready when surveyors or auditors come knocking.

Increased spending due to rising hospice utilization have increasingly led regulators to focus their attention on hospice providers, including the U.S. Centers for Medicare & Medicare Services (CMS) and the U.S. Department of Health & Human Services Inspector General.

Issues such as live discharges, higher rates of recertifications for patients who survive longer than six months, insufficient documentation, and questions about the legitimacy of the six-month prognoses are leading issues attracting regulatory attention.


Many hospice providers express uncertainty about their ability to weather an audit. Fewer than 50% of hospices indicated that they were ready for a federal audit or additional document request, according to a recent survey  of 170 organizations by Optima Health.

Even if a hospice isn’t confronted an audit, the organization still must undergo its triennial recertification survey in order to continue to receive Medicare payments.

“CMS is always targeting survey deficiencies, and the Medicare administrative contractors are stepping up their targeted probe and educate audits, for sure, targeting agencies in an attempt to educate them on deficiencies and plans of correction,” Catherine Dehlin, director of Hospice Services, for consulting firm Fazzi Associates. “A hospice agency should always be in a state of readiness [for survey].”


In a self-audit, the organization puts itself through the paces of a survey to assess its own systems to ensure compliance and survey readiness. Industry organizations such as the National Hospice & Palliative Care Organization have developed tools that organizations can use to guide their self-assessments.  

A good starting point is to assess your organization’s compliance with thesurvey deficiencies that CMS cites most frequently. These issues change infrequently from year to year and tend to include issues with care planning, frequency of visits at the end of life, patient assessments, and completeness and accuracy of patient records. Hospices can benefit from reviewing their own survey findings from previous years.

“Continually examining processes and conducting self-audits is crucial to helping us highlight and respond to areas that need additional focus. For us it’s always about that: How do we continue to improve?” Interim Healthcare CEO Jennifer Sheets told Hospice News in April.

For many organizations the first step of a self-audit mirrors the beginning of an actual survey — ensuring that required written documentation is readily available. Surveyors often wish to contact or visit patients as part of their assessment. Among other information they will likely request the hospice’s daily patient census, patients’ diagnoses, and patient addresses.

“There are always proactive approaches that you can take. Hospices need to train staff in what their role is and what is expected of them when a surveyor comes to the door; then staff know exactly what to do, who to call, what to provide, and what reports to pull,” Dehline said. “Remember that compliance has to start at the top, with leaders, and should filter down to all staff. That is where a culture of compliance really starts.”

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