What CMS 2022 Hospice Survey Reform Means for Compliance Programs


Compliance & Risk Management

As of January 1, 2022, changes to the Centers for Medicare & Medicaid Services (CMS) survey and enforcement process for hospice programs became effective. If you’re responsible for compliance at a CCRC that provides hospice-level care, here’s what you need to know.

  • Multidisciplinary survey teams are now required.
  • Surveyors must complete revised CMS-based training.
  • Survey findings must be documented and made public using form CMS-2567.
  • State survey agencies must implement a Hospice Program Complaint Hotline.

The changes are part of new regulations in CMS’ Final Rule. They stem from OIG reports indicating quality-of-care issues among Medicare-certified hospice programs in recent years.

Read on for further detail on the new survey processes, and how they impact hospice compliance efforts.

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Multidisciplinary Survey Team

In the past, hospice surveys were performed by a single surveyor. Now, CMS requires a multidisciplinary survey team reflecting the diverse range of services offered (e.g., social worker, chaplain, bereavement coordinator). One member must be a registered nurse.

Compliance impacts:

  • A multidisciplinary team means that hospice programs will face increased scrutiny in their documentation of various specialties represented by the surveyors.

All Surveyors Will Undergo Revised CMS-Based Training

CMS will provide training for state and federal surveyors, as well as those employed by Accrediting Organizations (AOs), within the first 60 days of 2022. No surveyor is allowed to perform a survey before completing the CMS training and competency test.

The training focuses on the four hospice program conditions of participation (CoPs):

  • Patient's rights
  • Initial and comprehensive assessment
  • Care planning and coordination of care
  • Quality assessment and performance improvement

The 8-module training course is freely available to surveyors, hospice providers and the public through the CMS Quality, Safety & Education Portal (QSEP). 

Compliance Impact:

  • The revised training emphasizes individual written plans of care, as well as regular updates that involve the patient, family and interdisciplinary team.

Using Form CMS-2567

CMS now requires that surveyors document results using Form CMS-2567. The form must be:

  • Posted prominently
  • Easily accessible to the general public
  • Searchable and understandable to the general public
  • Updated continuously and promptly

Compliance Impact:

  • Hospices are still allowed to document plans of correction (POCs) in their preferred format. This can include the format used by their surveying AO – but all elements of an acceptable POC are still required, CMS says.

Hospice Complaint Hotline

The final rule also required establishment of a hospice complaint hotline by December 27, 2021. The complaint hotline serves to collect and update information on certified hospices, receive complaints and answer questions.

Compliance Impact:

  • Make sure that consent forms are updated to include the Hospice Complaint Hotline number (it varies by state).

Additional Preparation Steps

A robust compliance program is the best way to ensure good survey outcomes, and can affect remedies and the amount of civil monetary penalties imposed for any deficiencies found.

In fact, when selecting sanctions, CMS states that it may consider evidence that the hospice program has a “built-in, self-regulating quality assessment and performance improvement system to provide proper care, prevent poor outcomes, control patient injury, enhance quality, promote safety, and avoid risks to patients on a sustainable basis that indicates the ability to meet the conditions of participation and to ensure patient health and safety.” 

In addition to reviewing the compliance impacts above, here other ways to ensure preparedness for your next survey:

Friends Services Alliance (FSA) is a national professional association of values-aligned organizations that serve seniors. Our support services include a team of Compliance and Risk Management experts who have supported organizations in developing and maintaining effective Compliance and Ethics Programs for over 20 years.