California Hospice Policy and Procedure Manual
For California hospices licensed by the California Department of Public Health (CDPH). The manual has 60 policies and 76 forms, written to Health and Safety Code sections 1745 to 1759, the hospice regulations in Title 22 (sections 74800 to 74908, in force as emergency regulations since June 22, 2026) and the federal hospice Conditions of Participation (42 CFR Part 418). Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your hospice's details. You get Word and PDF files to keep, and your team signs off on their phones.
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California · Hospice
60 policies written to the California rules, with 76 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 60
- Forms
- 76
- Categories
- 14
- Policy Pack · required
- $1,100one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $109 a month or $1,090 a year.
Read before you buy
3 free sample policies, shown in full for a sample agency.
CA-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how patients, families and anyone else can complain about the Agency, by any means and without needing any paperwork; how the Agency logs, acknowledges, investigates, resolves and follows up every complaint within its own time frames; how complaints that raise safety, abuse, criminal, privacy or billing issues are sent to the right process at once; the outside routes (CDPH, the Medicare quality improvement organization, the ombudsman, licensing boards); and the rule that no one suffers for complaining.
Read the full policy CA-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse of Elders, Dependent Adults and Children
Explains how staff recognize abuse, neglect, financial abuse, isolation and abandonment of elders and dependent adults and abuse or neglect of children, and how each staff member, as a mandated reporter, reports it personally: for elders and dependent adults outside a facility, to Adult Protective Services or law enforcement immediately by telephone or internet, with a written report within two working days; inside a long-term care facility, to law enforcement within two hours and in writing within 24 hours; for children, by telephone immediately and in writing within 36 hours. No supervisor may stop or delay a report.
Read the full policy CA-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program and Outbreak Reporting
Sets out the Agency's infection prevention and control program: education for staff, contractors, volunteers, patients and families; standard precautions, hand and respiratory hygiene and personal protective equipment; the aerosol transmissible diseases plan Cal/OSHA requires for home-based hospice; surveillance and monitoring; immediate reporting of outbreaks and unusual diseases to the local health officer and CDPH; outbreak investigation; and links to QAPI.
Read the full policy
California rules
What California's hospice rules ask your policies to cover
- Two-hour response. A licensed nurse appears in person, 24 hours a day, seven days a week, within two hours of learning that a patient has a medical need or a safety concern exists. 22 CCR §74820(a)
- Caseloads. No more than 12 patients for each RN case manager at any time, as CDPH enforces the rule, and a patient acuity system reviewed by a committee every year. 22 CCR §74848
- Assessments. A registered nurse's initial assessment within 48 hours of admission, a comprehensive assessment by the team within five days, and updates at least every 15 days. 22 CCR §74864
- Significant changes. Any staff member or volunteer who sees a significant change makes sure the attending physician, Medical Director or designee is told as soon as possible within 24 hours. 22 CCR §74868(h)
- Medical records. Kept 10 years from the most recent treatment or service, errors corrected within 48 hours, and each record completed within 30 days after discharge or death. 22 CCR §74896
- Bereavement. Services for at least one year after a death. Cal. Health & Safety Code §1746(a)
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
Show me last month's call log. Were all in-person responses within two hours?CA-HSP-SVC-0124-Hour Nursing, On-Call Service and Two-Hour In-Person Response
Show me each RN case manager's caseload today. Has any RN case manager had more than 12 assigned patients at any time this year?CA-HSP-NUR-01Nursing Services, RN Case Manager Caseload and Patient Acuity System
A hospice aide sees that a patient has suddenly become confused. What does the aide do, and how quickly is the physician told?CA-HSP-IDG-03Coordination of Care, Communication System, Orders and Significant Change Notification
Do you have any patient whose primary residence is outside your approved area?CA-HSP-GOV-03Geographic Service Area, Two-Hour Response Radius and Multiple Locations
If an aide suspects a patient in a residential care facility is being abused, who does she call, and how fast?CA-HSP-ANE-01Recognizing and Reporting Abuse of Elders, Dependent Adults and Children
The full pack
Browse all 60 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 60 policies
Client rights5
CA-HSP-CMP-01Free sample
Complaints and Grievances
Sets out how patients, families and anyone else can complain about the Agency, by any means and without needing any paperwork; how the Agency logs, acknowledges, investigates, resolves and follows up every complaint within its own time frames; how complaints that raise safety, abuse, criminal, privacy or billing issues are sent to the right process at once; the outside routes (CDPH, the Medicare quality improvement organization, the ombudsman, licensing boards); and the rule that no one suffers for complaining.
42 CFR §418.52(b)(1)(iii)
CA-HSP-PR-01
Patient Rights and Responsibilities
Sets out how the Agency tells every patient, during the first visit and before any care, about their rights and responsibilities, spoken or signed and in writing, in a language and manner they understand; lists those rights under California and federal law; explains the responsibilities the Agency asks patients to share; and gives every route for questions and complaints, including CDPH, the Medicare quality improvement organization and the ombudsman.
Cal. Health & Safety Code §1751.100
CA-HSP-PR-02
Informed Consent, Election Counseling and Disclosure of Services and Charges
Explains how the Agency obtains informed consent to hospice care: who may counsel on hospice and complete the consent (only a registered nurse, licensed vocational nurse, medical social worker, chaplain or counselor employed by the Agency), what the patient is told about services, limits and charges, how capacity and representatives are handled, and how consent forms are provided in the patient's primary language.
22 CCR §74860(b)
CA-HSP-PR-03
Advance Directives, POLST and Health Care Decisions
Sets out how the Agency gives every patient, at admission and in their primary language, written materials on its advance directive policies and the benefits of advance directives; what goes in the record (a copy of the directive or a signed acknowledgment); how staff recognize and follow advance health care directives, powers of attorney for health care and POLST forms under the California Probate Code; and how changes are recorded.
22 CCR §74860(e)
CA-HSP-PR-04
California End of Life Option Act
States the Agency's position on the California End of Life Option Act (medical aid in dying), which the governing body chooses and records on Form CA-HSP-PR-04-B; how staff and contractors are given notice of it when they join and every year; how staff respond to a patient who asks about the Act; and the protections that apply whichever position the Agency takes, including that hospice care continues.
Cal. Health & Safety Code §443.15
Service delivery2
CA-HSP-SAF-01
Workplace Violence Prevention and Staff Safety in the Home
The Agency's Workplace Violence Prevention Plan under Cal/OSHA's violence prevention in health care standard, which applies to home-based hospice: who runs it, employee involvement, assessing risks at intake, the first visit and later visits when conditions change, patient-specific risk factors, correcting hazards, safe home visit practices, getting help from law enforcement without retaliation, post-incident response, the violent incident log, annual review, training and records.
8 CCR §3342
CA-HSP-SVC-01
24-Hour Nursing, On-Call Service and Two-Hour In-Person Response
Sets out how the Agency meets California's core guarantee that a licensed nurse appears in person, 24 hours a day, seven days a week, within two hours of receiving information that a patient has a medical need or a safety concern exists: the 24-hour telephone line, the on-call schedule, telephone triage, support for the patient until the nurse arrives, how on-call staff reach management, and the call log that proves every response.
22 CCR §74820(a)
Hospice care16
CA-HSP-ADM-01
Referral, Eligibility, Admission and Preliminary Services
Sets out how the Agency handles a referral from first call to completed admission: checking that the patient lives inside the approved counties and two-hour area, that the Agency can meet the patient's needs and staff the case, and that a physician has certified terminal illness; what happens at the admission visit; what the admission record must contain; and how preliminary services and palliative care may be offered under California law.
22 CCR §74860
CA-HSP-ASM-01
Initial and Comprehensive Assessment and Outcome Data
Sets out the assessment clocks and content: the registered nurse's initial assessment in the place of care within 48 hours of admission; the comprehensive assessment by all hospice employee members of the IDT, with the attending physician, within five days of admission; updates at least every 15 days; the factors each assessment must consider; and the Agency's patient outcome data elements, measured the same way for every patient. Where the federal clocks (which run from election) and the California clocks (which run from admission) differ, the earlier deadline is met.
22 CCR §74864
CA-HSP-BRV-01
Bereavement Services
Sets out the Agency's organized bereavement program: the bereavement assessment before death, the bereavement plan of care with the kind and frequency of services, services for at least one year after the death as California requires, risk levels and referrals, support for facility residents and staff, preliminary grief services, and records.
Cal. Health & Safety Code §1746(a)
CA-HSP-CNS-01
Spiritual, Dietary and Other Counseling
Sets out how the Agency provides spiritual counseling (assessment of spiritual needs, counseling that respects the patient's and family's beliefs, and help reaching their own clergy), dietary counseling by a qualified person when the plan of care calls for it, and other counseling for patients and families.
42 CFR §418.64(d)
CA-HSP-DC-01
Discharge, Transfer and Discharge Summary
Sets out when the Agency may discharge a living patient (a move out of the service area or a transfer, no longer terminally ill, or for cause after the required steps), the physician's discharge order from the Medical Director, consultation with the attending physician, discharge planning, the notices the patient receives (including the Medicare notice of termination and the right to a quick review by the BFCC-QIO), the live discharge or transfer summary California requires, what is sent to the next provider, and the 30-day record completion rule.
22 CCR §74892(w)(1)
CA-HSP-DTH-01
Death in the Home, Pronouncement of Death and Post-Death Care
Sets out what the Agency does when a patient dies at home or in a residence: the nurse visit, determination and pronouncement of an expected death by a registered nurse, when the coroner must be notified, the death certificate duties of the attending physician or nurse practitioner, notifications, respectful post-death care and release to the funeral home, disposal of controlled substances, equipment pickup, the bereavement handoff, and the discharge-by-death summary completed within 30 days.
22 CCR §74892(w)(2)
CA-HSP-ELC-01
Election of the Hospice Benefit, Election Statement Addendum and Notice of Election
Sets out how a patient elects the hospice benefit with the Agency: who may counsel and complete the election, what the election statement must contain, the election statement addendum ("Patient Notification of Hospice Non-Covered Items, Services, and Drugs") that must be given in writing for every election beginning on or after October 1, 2026 and updated within 3 days of plan of care changes that affect it, and filing the Notice of Election within 5 calendar days.
42 CFR §418.24
CA-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets out how terminal illness is certified and recertified: California's initial certification by the Medical Director or Medical Director Designee with a 12-month attestation and an individual narrative written immediately above the physician's signature; the Medicare 6-month certification, timing, sources and narrative rules; face-to-face encounters before the third and later benefit periods; and the safeguards that keep eligibility decisions honest.
22 CCR §74860(c)
CA-HSP-ELC-03
Revocation, Change of Designated Hospice and Change of Attending Physician
Sets out how a patient revokes the hospice election, changes to another hospice once in a benefit period, or changes attending physician; what each signed statement must contain; what the Agency sends to the receiving hospice and the attending physician; the notice it files with Medicare; and the rule that the Agency never asks or pressures a patient to revoke.
42 CFR §418.28
CA-HSP-FAC-01
Hospice Care for Residents of Nursing Facilities, ICF/IIDs and Residential Care Facilities
Sets out how the Agency cares for patients who live in skilled nursing facilities, nursing facilities, intermediate care facilities for individuals with intellectual disabilities and residential care facilities for the elderly. California hospice duties (two-hour in-person response, caseloads, assessments and plan of care) apply there in full, because a facility is the patient's residence. If the Agency is Medicare-certified, it signs the written agreement 42 CFR §418.112 requires before serving a nursing facility resident. In a residential care facility for the elderly, care is given only if the facility holds a CDSS hospice care waiver and an agreed hospice care plan is in place.
42 CFR §418.112
CA-HSP-FAC-02
Short-Term Inpatient and Respite Care Arrangements
Sets out how the Agency arranges short inpatient stays, a basic service every California hospice must provide or arrange: general inpatient care for pain and symptoms that cannot be managed elsewhere, and inpatient respite when the caregiver needs relief. Covers the facilities that qualify, the written agreement with each facility, the Agency's continuing responsibility during the stay, the five-day respite limit and, if the Agency is Medicare-certified, the 20 percent inpatient day limit.
Cal. Health & Safety Code §1746(f)
CA-HSP-IDG-01
Interdisciplinary Team and Assigned Registered Nurse
Sets out who is on each patient's interdisciplinary team under California and federal rules, the assigned registered nurse who coordinates and supervises all care, how often the team meets and what a meeting must cover, and how each meeting is recorded (date and time, attendees and a summary).
22 CCR §74868(a)
CA-HSP-IDG-02
Plan of Care, 15-Day Review and Caregiver Education
Sets out how the individualized plan of care is written from the comprehensive assessment, the nineteen items California requires it to contain, who approves and signs it (the attending physician or, only if there is none or the attending is unavailable, the Medical Director or Designee), how changes are approved in writing before they are made, the review at least every 15 days, and how caregivers are taught and their teaching recorded.
22 CCR §74868(c)
CA-HSP-IDG-03
Coordination of Care, Communication System, Orders and Significant Change Notification
Sets out the Agency's documented system of communication among everyone who cares for a patient, in every setting and with non-hospice providers; the significant change rule (any staff member or volunteer who observes a significant change must see that the attending physician, Medical Director or Designee is told as soon as possible within 24 hours), with the required list of changes, people to notify, methods and timelines; and how physician orders, including verbal orders, are received and documented.
22 CCR §74868(h)
CA-HSP-LOC-01
Levels of Care: Routine Home Care, Continuous Home Care, Respite and General Inpatient Care
Defines the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care), when each may be used, who decides and how a change in level is ordered, documented and reviewed, and how the Agency arranges short inpatient stays under California's inpatient care arrangements requirement.
42 CFR §418.302
CA-HSP-PAIN-01
Pain and Symptom Management and Care of the Actively Dying Patient
Sets out how the Agency assesses, treats and reassesses pain and other symptoms, the plan of care content California requires, how sudden increases in pain and uncontrolled symptoms are escalated (significant change within 24 hours, the two-hour in-person response, continuous home care or inpatient care), safe opioid use, palliative sedation, and care of the patient who is actively dying and the family.
22 CCR §74868(c)(7)
Clinical tasks7
CA-HSP-AIDE-01
Home Health Aide and Homemaker Services
Sets out who may give home health aide services to the Agency's patients (CDPH-certified home health aides), the registry check before hire, certificate renewal and in-service hours, competency, how aides are assigned and instructed, what they may and may not do, supervisory visits and their documentation, and the duties and supervision of homemakers.
Cal. Health & Safety Code §1746(c)
CA-HSP-DME-01
Medical Supplies and Durable Medical Equipment
Sets out how the Agency provides the medical supplies and durable medical equipment the plan of care requires: ordering and delivery, the supplier standards, teaching with signed acknowledgment in the primary language, safety checks and maintenance, oxygen safety, recalls, office storage, and pickup after discharge or death.
22 CCR §74868(c)(9)
CA-HSP-MED-01
Drugs and Biologicals, Medication Administration and Legend Devices
Sets out how the Agency provides, orders, obtains, labels, stores and administers drugs and biologicals, how each patient's ability to self-administer is decided, what the medication administration record must show when Agency personnel give medications, how adverse reactions and errors are handled, and the annual review of the Agency's legend device policies by a physician, a pharmacist and a registered nurse.
42 CFR §418.106
CA-HSP-MED-02
Controlled Substances in the Home: Management, Accountability and Disposal
Sets out how the Agency manages controlled substances in patients' homes: the written policy given to and discussed with the family when a controlled substance is first ordered, signed acknowledgment in the primary language, prescribing, receipt and reconciliation counts, safe storage, signs of diversion and what to do, and disposal by trained Agency staff after a death or when a drug has expired, with the record federal law requires.
22 CCR §74880(d)(4)(F)
CA-HSP-NUR-01
Nursing Services, RN Case Manager Caseload and Patient Acuity System
Sets out how the Agency staffs licensed nurses around the clock, keeps every RN case manager at 12 or fewer assigned patients at all times, runs the patient acuity system California requires (including the annual reliability review by a committee appointed by the Director of Patient Care Services), assigns aides and volunteers by acuity, and handles contracted nursing and laboratory testing.
22 CCR §74848
CA-HSP-SW-01
Medical Social Services
Sets out how the Agency provides medical social services: who may provide them, the psychosocial part of the comprehensive assessment and its 15-day updates, the help social workers give with caregiving, finances, benefits, advance care planning, safety and bereavement risk, and how social work is documented and supervised.
42 CFR §418.64(c)
CA-HSP-THR-01
Physical Therapy, Occupational Therapy and Speech-Language Pathology
Sets out how the Agency makes physical therapy, occupational therapy and speech-language pathology available for comfort, safety and function, who may provide them, how they are ordered, planned and documented, and the CDPH approval needed before adding, deleting or suspending an optional service.
42 CFR §418.72
Safeguarding2
CA-HSP-ANE-01Free sample
Recognizing and Reporting Abuse of Elders, Dependent Adults and Children
Explains how staff recognize abuse, neglect, financial abuse, isolation and abandonment of elders and dependent adults and abuse or neglect of children, and how each staff member, as a mandated reporter, reports it personally: for elders and dependent adults outside a facility, to Adult Protective Services or law enforcement immediately by telephone or internet, with a written report within two working days; inside a long-term care facility, to law enforcement within two hours and in writing within 24 hours; for children, by telephone immediately and in writing within 36 hours. No supervisor may stop or delay a report.
Cal. Welf. & Inst. Code §15630
CA-HSP-ANE-02
Investigation of Alleged Violations, Protection of Patients and Criminal Misconduct
Sets out what the Agency does when anyone furnishing services on its behalf is accused of mistreatment, neglect, abuse, causing an injury of unknown source or taking a patient's property: immediate report to the Administrator, immediate protection of the patient (including removing the accused from patient contact), a prompt documented investigation, corrective action, and, if the violation is verified, a report to CDPH and other bodies with jurisdiction within 5 working days. It also covers criminal misconduct, cooperation with CDPH and law enforcement, and protection from retaliation.
42 CFR §418.52(b)(4)
Infection control2
CA-HSP-IC-01Free sample
Infection Prevention and Control Program and Outbreak Reporting
Sets out the Agency's infection prevention and control program: education for staff, contractors, volunteers, patients and families; standard precautions, hand and respiratory hygiene and personal protective equipment; the aerosol transmissible diseases plan Cal/OSHA requires for home-based hospice; surveillance and monitoring; immediate reporting of outbreaks and unusual diseases to the local health officer and CDPH; outbreak investigation; and links to QAPI.
22 CCR §74880(d)(4)(B)
CA-HSP-IC-02
Bloodborne Pathogens Exposure Control Plan
The Agency's written Bloodborne Pathogens Exposure Control Plan under Cal/OSHA's standard: exposure determination, universal precautions, needleless systems and engineered sharps protection, safe sharps handling and containers, PPE, hepatitis B vaccination within 10 working days of initial assignment, immediate post-exposure evaluation, the Sharps Injury Log, training, annual review with employee input, and records.
8 CCR §5193
Emergency preparedness1
Records2
CA-HSP-REC-01
Medical Record Service, Content and Authentication
Sets up the Agency's medical record service: one complete, accurate and organized record for every patient, open to authorized individuals 24 hours a day; the information governance policies the governing body approves; the eight record activities California requires (retrieval, reconciliation, deficiency analysis, coding, filing, indexing, quality and content control, release of information); everything the record must contain under 22 CCR §74892; and how entries are authenticated.
22 CCR §74888
CA-HSP-REC-02
Medical Record Retention, Storage, Corrections, Electronic Health Records and Patient Access
Sets the rules for keeping and protecting medical records: 10-year retention (longer for minors); where hard copy records may be stored and when CDPH must approve off-site storage or an off-premises server; the electronic health record controls California requires, including backups at least every 24 hours and a downtime procedure; corrections within 48 hours and record completion within 30 days; patients' rights to inspect (within five working days), copy (within 15 days) and amend their records; and disposal, with notice to CDPH within 24 hours if records are destroyed early.
22 CCR §74896
Privacy3
CA-HSP-PRV-01
HIPAA Privacy and California Confidentiality Laws
Protects the privacy of patients' health information under the HIPAA Privacy Rule and California's Confidentiality of Medical Information Act, which is often stricter. Sets out when information may and may not be shared (including with family, for abuse reports, with CDPH and for immigration enforcement), what a valid California authorization must look like, the Notice of Privacy Practices, patients' privacy rights, safeguards in the home and the field, business associates, and privacy complaints.
45 CFR Part 164, Subpart E
CA-HSP-PRV-02
HIPAA Security
Protects the Agency's electronic patient information under the HIPAA Security Rule and California's electronic health record rules: a written risk analysis and risk management plan, a named security official, access levels and prompt removal of access, unique identifiers, encryption of phones, tablets and laptops used in homes, audit logs, backups at least every 24 hours, a contingency and downtime plan, security incident response, business associate safeguards and safe disposal of devices.
45 CFR Part 164, Subpart C
CA-HSP-PRV-03
Breach Notification: HIPAA and Health & Safety Code §1280.15
Sets out how and when the Agency reports a privacy breach. California's rule is stricter and faster than HIPAA: any unlawful or unauthorized access to, use or disclosure of a patient's medical information is reported to CDPH and to the patient or representative no later than 15 business days after it is detected (Health & Safety Code §1280.15), with daily penalties for late reports. HIPAA breach notices to individuals (within 60 calendar days), to HHS and, for large breaches, to the media follow, and California's computerized data breach law can also apply.
Cal. Health & Safety Code §1280.15
Human resources7
CA-HSP-HR-01
Hospice Management Personnel Orientation and Annual Training
Sets out California's training rules for the six hospice management personnel: 24 hours of hospice management training (or a certification program) within 12 months for anyone new to the role in California, at least 20 hours of new-hire orientation within 60 days with minimum hours by topic, at least 12 hours every year from the date of hire, which training methods and providers count, and the records CDPH expects.
22 CCR §74880
CA-HSP-HR-02
Staff Orientation, Competency and In-Service Training
Sets out the orientation every employee, contracted staff member and volunteer receives before working with patients, how the Agency assesses competency before independent work and every year, the in-service and refresher training California and federal rules require (infection control, fraud, waste and abuse, aerosol transmissible diseases, bloodborne pathogens, workplace violence, emergency preparedness), and the training records kept.
42 CFR §418.100(g)
CA-HSP-HR-03
Personnel Qualifications, Licenses and Certifications
Sets out the license, certification or other qualification required for each kind of staff member (California physician, nurse, behavioral health and therapy licenses; CDPH home health aide certification; federal social worker and therapist qualifications), how the Agency verifies them with the issuing body before hire, and how it keeps them current.
22 CCR §74868(a)(1)(A)
CA-HSP-HR-04
Background Checks, Exclusion Screening and Fair Chance Hiring
Sets out the checks the Agency runs on everyone who works for it: clearance from the federal exclusion list before employment and monthly, criminal background checks for anyone with patient contact or access to records, the CDPH aide registry, and the steps California's Fair Chance Act requires before the Agency may deny a job because of a conviction.
22 CCR §74884(b)(13)
CA-HSP-HR-05
Personnel Records, Hours Worked, Confidentiality Agreements and Conflict of Interest Forms
Lists what California requires in every personnel record, including a confidentiality agreement signed by the Administrator, proof of exclusion clearance before employment, conflict of interest forms, performance evaluations and training records; how long records are kept (four years after separation), the 12-month record of hours worked, confidential storage, and producing records to CDPH within 24 hours.
22 CCR §74884
CA-HSP-HR-06
Employee Health, Tuberculosis Assessment and Vaccinations
Sets out employee health protections for a California hospice: tuberculosis screening at hire and at least annually under Cal/OSHA's aerosol transmissible diseases standard, the vaccines the Agency must offer (including hepatitis B and seasonal influenza) and the declination forms, staying home when ill, and keeping employee medical records confidential and separate.
8 CCR §5199(h)
CA-HSP-VOL-01
Volunteer Program
Sets out how the Agency recruits, screens, trains, assigns and supervises volunteers, a basic service under California law and a member of every interdisciplinary team; what volunteers may and may not do; their duty to report significant changes; and, if the Agency is Medicare-certified, the 5 percent level of activity and the cost savings records.
Cal. Health & Safety Code §1749(d)(5)
Governance8
CA-HSP-GOV-01
Governing Body, Administrator and Hospice Management Personnel
Sets out who governs the Agency, the six management positions California requires and who appoints each in writing, what the governing body decides itself, what the Administrator does day to day, how leadership stays reachable, and how the Agency receives a CDPH inspector.
22 CCR §74876(a)
CA-HSP-GOV-02
Management Personnel Qualifications, Concurrent Employment and Vacancies
Sets the qualifications for each of the six management positions, the seven-year disciplinary history bar, the limits on working for more than one hospice, how a vacancy is filled within 60 days and reported to CDPH within 10 business days, when to ask CDPH for an extension, and what the Agency keeps to prove it.
22 CCR §74876(b)
CA-HSP-GOV-03
Geographic Service Area, Two-Hour Response Radius and Multiple Locations
Explains how the Agency calculates and keeps its CDPH-approved geographic service area: the area a licensed nurse can reach in person within two hours of the parent office, limited to counties with an unmet need for hospice care. Covers the drive-time samples, the unmet need formula, changes that need CDPH approval first, multiple locations, and the intake and marketing controls that keep the Agency inside its area.
22 CCR §74820
CA-HSP-GOV-04
Licensure, Inspections, Plans of Correction, Report of Changes and Annual Reports
Keeps the Agency's California hospice license valid: posting, renewal every 24 months, CDPH inspections, the 10-day plan of correction on the State-2567, every change that must be approved in advance or reported (120 days, 60 days or 10 business days), the annual utilization report due March 15, program flexibility, and the grounds and appeal windows for denial, suspension and revocation.
22 CCR §74828
CA-HSP-GOV-05
Hospice Office Space, Business Hours, 24-Hour Telephone and License Posting
Sets out California's office space rules for hospices: an unshared commercial office the Agency alone occupies, owned or leased for at least 12 consecutive months, with signage, posted business hours, a telephone answered 24 hours a day, staff, and secure storage for records, medications, personnel files, equipment and supplies; and how the Agency checks it every month and keeps it when moving.
22 CCR §74908
CA-HSP-GOV-06
Change of Ownership, Closure, Voluntary Cancellation and Records After Closure
Covers what happens when the Agency changes hands or stops operating: the five-year bar on changes of ownership, the 120-day application and record storage statement, the 60-day closure notice to CDPH, CMS and accreditors, the discharge statement, safe transfer of every patient, the 24-hour notice to CDPH of where records are stored, and keeping records after closure for the full retention period (at least 10 years from each patient's most recent service).
22 CCR §74840
CA-HSP-GOV-07
Hospice Program, Basic Services and Policy Index
Describes the hospice program the Agency runs: the seven basic services California requires every hospice to provide or arrange, the Medicare core and other services, optional and preliminary services, where care is given, how services are added or dropped, the description of services given to families, and an index mapping every written-policy duty in the California hospice law and regulations to the policy in this manual that meets it.
Cal. Health & Safety Code §1749(d)
CA-HSP-MD-01
Medical Director, Medical Director Designee and Physician Services
Sets out how the Medical Director and Medical Director Designee are appointed and contracted, what they must do under California's hospice regulations (certification of terminal illness with an individual narrative, approving plans of care when there is no attending physician, receiving significant change reports, after-hours support, discharge orders), and how other physicians work under their supervision.
22 CCR §74856
Quality2
CA-HSP-QA-01
Quality Assessment and Performance Improvement
Sets up the Agency's hospice-wide, data-driven quality assessment and performance improvement (QAPI) program: governing body oversight and annual evaluation, the QAPI lead and committee, the indicators the Agency measures (including California's own clocks: the two-hour in-person response, caseloads of 12 or fewer, 48-hour and 5-day assessments, 15-day updates and 24-hour significant change notices), outcome data, adverse events, performance improvement projects, the Hospice Quality Reporting Program, and the California reviews that feed the program (acuity system, legend devices, plans of correction).
42 CFR §418.58
CA-HSP-QA-02
Incident Management and Reports to Outside Agencies
Sets one internal process for reporting, reviewing and learning from incidents, and a single table of the outside reports that California and federal law require, each with its own clock: abuse reports (immediately, with written follow-up), verified violations (5 working days), privacy breaches (15 business days), early destruction of records (24 hours), outbreaks, serious employee injuries to Cal/OSHA (within 8 hours), and others. California has no general incident-reporting rule for hospices, but CDPH may inspect the Agency's incident reports.
22 CCR §74808(e)(8)
Business2
CA-HSP-CON-01
Contracted Services and Professional Management Responsibility
Sets out how the Agency uses contractors without giving up responsibility: which services must be provided directly, the terms every written agreement must contain, special California contract terms (Medical Director contracts, off-site record storage, record destruction), checks before signing, oversight during the contract, and the contract register.
Cal. Health & Safety Code §1749(d)
CA-HSP-FIN-01
Insurance, Billing Integrity, Continuation of Care and Notices to Medicare
Covers the Agency's financial duties: the liability and workers' compensation insurance stated for licensure, paying licensing fees on time, never reducing care because a Medicare or Medi-Cal patient cannot pay, telling patients about cost-sharing, filing Notices of Election and termination within 5 calendar days, managing the Medicare aggregate cap, billing accurately and returning overpayments.
42 CFR §418.100(d)
Ethics1
Questions
Questions about this manual
Is this the right manual for my license?
It is for hospices licensed by CDPH. Home health agencies need the California home health manual, and home care organizations licensed by the Department of Social Services need the California home care manual.
What about CDPH's proposed permanent hospice regulations?
CDPH noticed proposed permanent text (DPH-18-002) on October 30, 2026. It was not in force when this manual was last reviewed, so the policies follow the emergency regulations in force since June 22, 2026.
Who may counsel a patient on electing hospice?
Only a registered nurse, licensed vocational nurse, medical social worker, chaplain or counselor employed by the hospice may counsel on election and complete the consent. A hospice may not pay referral sources, and staff paid for referrals or admissions may not counsel patients (Health and Safety Code §1746.50).
What do the 60 policies cover?
Client rights (5), service delivery (2), hospice care (16), clinical tasks (7), safeguarding (2), infection control (2), emergency preparedness (1), records (2), privacy (3), human resources (7), governance (8), quality (2), business (2) and ethics (1).
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