A hospice compliance program a surveyor can see on day one
The Hospice Compliance Program, Accreditation Ready Edition, is a complete, board ready compliance program built on the seven OIG elements and mapped to CHAP, ACHC, and The Joint Commission. Adopt it, customize it, and run it within about 90 days.
Templates written before October 2026 are already out of date
- Oct 1, 2026Every new hospice election now requires the election statement addendum, "Patient Notification of Hospice Non-Covered Items, Services, and Drugs," within the first 5 days, updated within 3 days of relevant plan of care changes. 42 CFR 418.24(c) and (d)
- Jan 31, 2026Telehealth face to face encounters for recertification are no longer allowed in hospice enrollment moratorium areas, for agencies under enhanced oversight, or by practitioners who are not Medicare enrolled or opted out. 42 CFR 418.22(a)(4)
- June 2026CMS resumed the hospice PEPPER with fiscal year 2025 data, and OIG estimated $255.1 million in payments for certain new hospice enrollees who did not meet eligibility requirements. OIG A-06-22-09003
- Jan 1, 2025The overpayment rule now lets a provider suspend the 60 day refund clock for up to 180 days during a timely, good faith investigation. 42 CFR 401.305
This program already reflects each of these changes in its policies, audit tool, and training plan.
Eight tabs, organized the way a surveyor reviews a hospice
Every one of OIG's seven elements has a plan section, at least one policy, and at least one tool or form, so you can show the rule, the practice, and the proof.
Overview and board resolution
How the program fits together, a 90 day roadmap, and a ready to sign governing body resolution.
Compliance Plan
The written program by OIG element, including Compliance Officer independence, Committee duties, and QAPI integration.
18 core policies
Certification, election and addendum, levels of care, overpayments, cap, referral sources, facilities, screening, and more.
Risk assessment and audit plan
18 hospice risk areas tied to OIG and CMS sources, an annual audit work plan, and 14 board metrics.
Chart audit tool
18 criteria with regulation citations and a Met, Not met, N/A result for each, built for eligibility and documentation review.
Standards crosswalk
Each component mapped to 42 CFR Part 418, CHAP, ACHC, and The Joint Commission's 2026 Home Care manual.
Six forms and templates
Code of Conduct attestation, conflict disclosure, concern intake and investigation log, Committee charter, screening and training logs, corrective action plan.
Survey readiness
A 20 item evidence binder checklist, a mock survey and home visit tracer, and a survey day plan from entrance to plan of correction.
Look inside before you buy
Three excerpts exactly as they appear in the program. Every page follows the same pattern: the requirement, the citation, and the evidence a surveyor will ask to see.
CP 06 Election, Revocation, Transfer, and Live Discharge
Policy. Patients elect, revoke, and transfer hospice by their own informed choice. The agency discharges a patient only for the reasons allowed in 42 CFR 418.26.
Procedure.
- The election statement includes every element in 42 CFR 418.24(b), including the patient's chosen attending physician, cost sharing information, and the right to immediate advocacy.
- New for elections on or after October 1, 2026: every patient receives the election statement addendum within the first 5 days of the election, updated within 3 days of any relevant plan of care change.
- File the Notice of Election within 5 calendar days after the election's effective date.
- Revocation is the patient's decision and must be in writing with an effective date.
Policy excerpt. One of 18 core policies.
Eligibility and documentation chart audit tool
Any "Not met" on items 1 through 10 is a potential payment error and goes to the Compliance Officer the same day.
| # | Criterion | Result |
|---|---|---|
| 2 | Addendum provided within 5 days of election 42 CFR 418.24(c), (d) | Met |
| 3 | NOE filed within 5 calendar days 42 CFR 418.24(e) | Met |
| 6 | Narrative is patient specific and composed by the physician 42 CFR 418.22(b)(3) | Not met |
| 7 | Face to face within 30 days before 3rd recertification 42 CFR 418.22(a)(4) | Met |
Audit tool excerpt. 18 criteria, each with its citation. Results shown are a sample.
Compliance Committee standing agenda
The Committee supports the Compliance Officer. It does not oversee or supervise the Compliance Officer. It meets at least quarterly.
- Call to order, quorum, approval of prior minutes
- Regulatory and enforcement update
- Hotline and investigation summary
- Audit and monitoring results against the work plan
- Compliance metrics dashboard
- Open corrective action plans and status
- Exclusion screening and training completion
- Overpayments identified and refunded
- Policies for approval
Form excerpt. One of six ready to use forms.
Built once, mapped to every standard your agency answers to
| Source | What the program maps to |
|---|---|
| Federal | Hospice Conditions of Participation (42 CFR Part 418), the OIG General Compliance Program Guidance (November 2023), the OIG Compliance Program Guidance for Hospices (1999), and current enrollment and overpayment rules |
| CHAP | The Compliance Program (CP) standards and the hospice leadership, patient rights, care planning, human resources, information management, and QAPI chapters |
| ACHC | Hospice sections HSP1 through HSP7, including governing body, compliance, fiscal, human resources, record, and QAPI expectations |
| The Joint Commission | The 2026 Comprehensive Accreditation Manual for Home Care, mapped at the chapter level after the Accreditation 360 renumbering |
| Your state | Available as a separate state addendum for every state and DC |
From adoption to survey ready in three phases
Each phase ends at a gate the board can verify. I recommend agencies wait to schedule the accreditation survey until the third gate is met.
Foundation
- Appoint the Compliance Officer
- Customize the Plan and Code of Conduct
- Start the hotline and monthly screening
- Form the Compliance Committee
Build
- Adopt policies CP 01 to CP 18
- Train every staff member
- Score the risk assessment
- Hold the first Committee meeting
Test and prove
- Run the first quarterly audits
- Conduct an unannounced mock survey
- Open corrective action plans
- Deliver the first board compliance report
Take the program on your own, or with me beside you
Pricing is provided on request and depends on the number of locations and states.
- Hospices seeking initial accreditation
- Agencies changing accreditors
- Programs rebuilding after a survey finding, change of ownership, or the loss of a compliance officer
- Newly enrolled hospices facing a provisional period of enhanced oversight
- Every policy names an owner, a frequency, and the evidence a surveyor will ask for
- Citations to the regulation or guidance behind each requirement
- Written by a hospice nurse who has run compliance across multiple states
Be ready before the surveyor knocks
Hospice surveys are unannounced. Let's talk about where your program stands today and what it will take to be ready.
This program is an educational and operational template. It is not legal advice and does not guarantee an accreditation decision. Agencies should have health care counsel review the final program before adoption.