Care Planning Issues Top Lists of Hospice Survey Deficiencies

Amid rising regulatory scrutiny, issues related to care planning continue to top lists of the most common survey deficiencies among hospices.

The most frequently cited deficiency is the requirement that each patient should have a customized care plan developed by the interdisciplinary team with involvement from a physician as well as the patient and family, the Accreditation Commission for Health Care (ACHC) reported. The noncompliance rate was 66% for 2022.

While these data are based on results from ACHC-accredited organizations, it dovetails with industry-wide results. This standard has been at the top of the noncompliance list among all since at least 2018, according to the U.S. Centers for Medicare & Medicaid Services (CMS).


A common refrain in discussions of health care quality and compliance, the issue often lies with incomplete or inaccurate documentation, according to Susan Mills, a registered nurse and senior program director for the Home Health, Hospice and Home Infusion Accreditation Programs at ACHC.

“They’re specifically related to plan of care, accuracy and completion, as well as documentation of the records. So it’s not uncommon for documentation to be an area that requires constant attention,” Mills told Hospice News. “Ensuring that that plan of care is accurate, specific and the patient record is complete is really critical for providing quality care meeting regulatory requirements.”

Also among the top deficiencies is the requirement that the services the patient receives are aligned with the plan of care. The citations for this standard often relate to inconsistencies between clinician’s visit notes and the established plan of care.


Other common deficiencies included those related to management of aides, completion of medication profiles, management of patient records and comprehensive patient assessments. For the latter, many deficiencies occur because social work and bereavement care assessments are not conducted within the required time frame.

However, the frequency at which these standards were cited did decline in 2022 compared to prior years, Mills said.

“There’s six standards that were not compliant in probably more than 20% of surveys, and those same six are cited year after year,” Mills told Hospice News. “But this year, the frequency of citations was lower, although they were in the top 20. That really does indicate that hospices’ efforts to address those deficiencies and improve compliance have been effective.”

Almost across the board, improving documentation is critical to compliance. This is essential, but often difficult amid the realities of everyday clinical work, especially among understaffed providers.

“[Documentation] is usually what it is, and I don’t think it’s intentional. It’s just that people are busy and it’s hard to write down everything you see and think sometimes,” Mills said. “That’s what causes the errors at times. I know that [electronic medical records] helps with that but it only does what you put into it.”

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