Care Plans Will Be a Key Issue as CMS Updates Hospice Survey Processes

Hospices should be paying close attention to effective development and adherence to care plans when it comes to compliance in 2023.

The U.S. Centers for Medicare & Medicaid Services (CMS) has implemented significant changes to the hospice survey process effective Jan. 1, including new requirements for surveyor training and assessment tools and conflict-of-interest protocols.

With regulatory scrutiny intensifying for hospices, providers can benefit from self-assessments that focus on some of the most commonly occurring survey deficiencies. For hospices, incomplete plans of care are among the most common items cited on surveys, according to Susan Mills, senior program director for the Home Health, Hospice and Home Infusion Accreditation Programs for the Accreditation Commission for Health Care (ACHC).


“The top deficiency is always the plan of care is not complete, like maybe there’s a missing [visit] frequency or part of a medication order,” Mills told Hospice News. “Ensuring that those are enforced with the patient is a big one, and then also following the plan of care, providing visits as required, or not documenting a missed visit or a change in order is usually the reason.”

The subject of completing and adhering to care plans will be a centerpiece of the new surveyor training requirements, as well as patients’ rights and quality assessments, according to CMS. The agency has not yet released its updated guide for surveyor training, Mills indicated.

CMS included the hospice survey changes in its home health final rule for 2022. Congress mandated many of these provisions in the Consolidated Appropriations Act of 2021. Legislators added the hospice language in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS).


The OIG report indicated that about 20% of hospices surveyed by regulators or accreditors between 2012 and 2016 had a condition-level deficiency that posed a serious safety risk and included detailed examples.

The updated regulations require hospice surveys to be conducted by multidisciplinary teams when more than one surveyor is involved. The revisions also contain stronger protections against surveyor conflicts of interest.

Surveyors from accreditation organizations with deeming authority will now have to undergo the same training as those employed by government agencies and use similar assessment forms during surveys. Three accreditors currently have this authority: ACHC, Community Health Accreditation Partner (CHAP) and The Joint Commission.

Hospices may have to take extra care to ensure compliance, as human error among hyper-extended staff may be proliferating due to the workforce shortage.

“I know why a lot of these happen; it is because they’re so stressed now. Everyone’s short-staffed, and they just have a lot more responsibilities,” Mills said. “There are even leaders that have taken more of a bedside role, so there’s not as much oversight in the offices or in the charts and auditing. That’s really affected our industry.”

ACHC, which accredits more than 2,700 hospices, has developed a new “Quality Review Edition” of its publication The Surveyor that includes detailed analyses of survey results for hospice, home health and home infusion agencies, including data on survey findings, frequently cited deficiencies and compliance improvement strategies.

“This allows you to take a look at past surveys, and you can compare your results to this document,” Mills said. “So it can help you determine if you need to do something proactive to prevent further deficiencies, or if you need to put something in place now to improve your current processes.”

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