A hospice needs written policies for everything the hospice Conditions of Participation (42 CFR Part 418) and its state's rules regulate: certification and election, patient rights, assessment, the interdisciplinary group and plan of care, quality improvement (QAPI), infection control, core services such as nursing and bereavement, hospice aides and volunteers, drugs and medical supplies, inpatient care, care for patients in nursing facilities, emergency preparedness, clinical records and personnel. A Medicare-certified hospice must meet the federal rules, and most states add hospice rules of their own.
What the federal Conditions of Participation require
| Section | What your policies set out |
|---|---|
| §418.22 and §418.24 Certification and election | Certifying terminal illness, the election statement and its addendum, and changing or revoking the election |
| §418.52 Patient's rights | The notice of rights and responsibilities, how patients complain, and how the hospice investigates alleged violations |
| §418.54 Assessment | An initial assessment within 48 hours after the election of hospice care is complete, and a comprehensive assessment no later than 5 calendar days after the election |
| §418.56 Interdisciplinary group and plan of care | The interdisciplinary group, the written plan of care, and its review at least every 15 calendar days |
| §418.58 QAPI | A quality assessment and performance improvement program driven by data |
| §418.60 Infection control | Standard precautions, an infection control program, and education for staff, patients and caregivers |
| §418.64 Core services | Nursing, medical social services, physician services and counseling, including bereavement services for up to one year after the patient's death |
| §418.76 Hospice aide and homemaker services | Aide training and competency, assignments, and registered nurse supervisory visits every 14 days |
| §418.78 Volunteers | Volunteer training and roles, and the level of volunteer activity the hospice keeps |
| §418.100 Organization and administration | The governing body, the administrator, and services available around the clock |
| §418.102 Medical director | The medical director's role, including certifying terminal illness |
| §418.104 Clinical records | What each record contains, and how it is signed, kept and protected |
| §418.106 Drugs, supplies and equipment | Managing drugs and biologicals, including disposal of controlled drugs in the home, and medical supplies and equipment |
| §418.108 Short-term inpatient care | Inpatient care for pain and symptom management, and respite care |
| §418.112 Care in nursing facilities | Written agreements with facilities and coordinating care for their residents |
| §418.113 Emergency preparedness | A risk assessment, the emergency plan, a communication plan, training and testing |
| §418.114 Personnel qualifications | The qualifications for each role, and criminal background checks |
Who licenses hospice in each state
Each state names its own license and rules. Missouri certifies hospices rather than licensing them. Washington, DC has adopted no hospice licensing rules, so a District hospice operates on its Medicare certification and, where the law requires one, a Certificate of Need. In Michigan the hospice rules in force are R 325.45101 to R 325.45385; the older rules were rescinded in 2020.
| State | License | Rules | Policies |
|---|---|---|---|
| Texas | HCSSA license, Hospice services | 26 TAC Chapter 558 and 42 CFR 418 | 59 |
| Pennsylvania | Pennsylvania hospice license | 42 CFR 418 and Pennsylvania licensing law | 60 |
| Georgia | Georgia hospice license | Rules 111-8-37 and 42 CFR 418 | 60 |
| Florida | Florida hospice license | Rule 59A-38 and 42 CFR 418 | 60 |
| California | California hospice license | Title 22 CCR and 42 CFR 418 | 60 |
| North Carolina | North Carolina hospice license | 10A NCAC 13K and 42 CFR 418 | 60 |
| Ohio | Ohio hospice care program license | OAC 3701-19 and 42 CFR 418 | 60 |
| Louisiana | Louisiana hospice license | LAC 48:I Chapter 82 and 42 CFR 418 | 60 |
| Missouri | Missouri hospice certificate | 19 CSR 30-35 and 42 CFR 418 | 59 |
| Michigan | Michigan hospice license | Michigan hospice rules (R 325.45) and 42 CFR 418 | 59 |
| Washington, DC | Medicare-certified hospice (no District of Columbia license) | 42 CFR 418 | 60 |
Where state rules go further than Medicare
Several states set stricter or extra requirements. A few examples from the manuals:
- Georgia: a nurse on site within one hour in a symptom-management crisis, and bereavement services for at least one year (Rules 111-8-37-.18(1) and -.19). See the Georgia hospice manual.
- California: a licensed nurse appears in person, 24 hours a day, within two hours of learning that a patient has a medical need or a safety concern exists (22 CCR §74820(a)). See the California hospice manual.
- Missouri: the interdisciplinary group reviews the plan of care at least every two weeks rather than every 15 days, and emergency preparedness policies are reviewed every year (19 CSR 30-35.010). See the Missouri hospice manual.
- Florida: inpatient days for all patients in any 12-month period may not exceed 20 percent of total hospice days, separate from the Medicare limit (s. 400.609(4), F.S.). See the Florida hospice manual.
- Ohio: inpatient respite on an occasional basis for no more than seven consecutive days, where Medicare pays for no more than five at a time (OAC 3701-19-22(E)(2)). See the Ohio hospice manual.
Federal and state rules together
A hospice that bills Medicare must meet the federal Conditions of Participation, and its state's rules apply as well. Where the two differ, as in the examples above, each policy in a Cura Core hospice manual says which rule it follows.
A policy only counts if your team follows it
Surveyors ask nurses, aides and other team members how they follow your policies, not only whether the manual exists. Have each team member read and sign the policies for their role, and keep the dated record. See how staff sign-off works.
Next step
Pick your state in the table above to see its hospice manual and read three of its policies free, or see all hospice manuals.