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Hospice Compliance Program
A compliance program you can adopt in 90 days and show a surveyor on day one.
The Hospice Compliance Program, Accreditation Ready Edition, gives your agency a complete, board ready compliance program built on the seven elements of the HHS OIG General Compliance Program Guidance and the hospice Conditions of Participation at 42 CFR Part 418. Every component is mapped to CHAP, ACHC, and The Joint Commission, so one program supports whichever accreditor you choose.
Each policy names an owner, a frequency, and the evidence a surveyor will ask to see. This program is written to be operated, not filed.
What’s included
Compliance Plan organized by the seven OIG elements, including Compliance Officer independence, Committee duties, board oversight, and QAPI integration
18 core policies covering certification and recertification, election and the new addendum, levels of care, claims accuracy, overpayments, cap monitoring, referral sources, facility relationships, exclusion screening, physician arrangements, documentation integrity, and privacy
Hospice risk assessment with 18 risk areas tied to OIG and CMS sources
Annual audit and monitoring work plan and 14 board level compliance metrics
18 point chart audit tool with a regulation citation for every criterion
Standards crosswalk mapping each component to federal rules, CHAP, ACHC, and The Joint Commission’s 2026 Home Care manual
Six ready to use forms: Code of Conduct attestation, conflict of interest disclosure, concern intake and investigation log, Committee charter and agenda, screening and training logs, and a corrective action plan
Survey readiness toolkit: a 20 item evidence binder checklist, a mock survey and home visit tracer, and a survey day plan
Board adoption resolution and a 90 day implementation roadmap
Current through October 2026
Templates written before this year are already out of date. This program reflects:
The election statement addendum required for every hospice election on or after October 1, 2026
New limits on telehealth face to face encounters for recertification
The 2025 overpayment rule allowing up to 180 days for a good faith investigation
Medicare enrollment requirements for certifying physicians
Who it’s for
Hospices preparing for initial accreditation
Agencies changing accreditors
Programs rebuilding after a survey finding, a change of ownership, or the loss of a compliance officer
Newly enrolled hospices facing a provisional period of enhanced oversight
What you receive
One editable Word document of about 42 pages, available to download immediately after purchase. Replace the bracketed fields with your agency’s information, add your state licensure requirements, and take it to your governing body for adoption. State addenda are available separately.
License
Each purchase covers use by one hospice under one Medicare provider number.
About the author
Tonia Barrier, MSN, RN, is the Founder and Principal Consultant of PAC Leadership Solutions and the former Chief Clinical & Compliance Officer of a multistate hospice organization, where she built the clinical, compliance, and training infrastructure from the ground up.
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.
A compliance program you can adopt in 90 days and show a surveyor on day one.
The Hospice Compliance Program, Accreditation Ready Edition, gives your agency a complete, board ready compliance program built on the seven elements of the HHS OIG General Compliance Program Guidance and the hospice Conditions of Participation at 42 CFR Part 418. Every component is mapped to CHAP, ACHC, and The Joint Commission, so one program supports whichever accreditor you choose.
Each policy names an owner, a frequency, and the evidence a surveyor will ask to see. This program is written to be operated, not filed.
What’s included
Compliance Plan organized by the seven OIG elements, including Compliance Officer independence, Committee duties, board oversight, and QAPI integration
18 core policies covering certification and recertification, election and the new addendum, levels of care, claims accuracy, overpayments, cap monitoring, referral sources, facility relationships, exclusion screening, physician arrangements, documentation integrity, and privacy
Hospice risk assessment with 18 risk areas tied to OIG and CMS sources
Annual audit and monitoring work plan and 14 board level compliance metrics
18 point chart audit tool with a regulation citation for every criterion
Standards crosswalk mapping each component to federal rules, CHAP, ACHC, and The Joint Commission’s 2026 Home Care manual
Six ready to use forms: Code of Conduct attestation, conflict of interest disclosure, concern intake and investigation log, Committee charter and agenda, screening and training logs, and a corrective action plan
Survey readiness toolkit: a 20 item evidence binder checklist, a mock survey and home visit tracer, and a survey day plan
Board adoption resolution and a 90 day implementation roadmap
Current through October 2026
Templates written before this year are already out of date. This program reflects:
The election statement addendum required for every hospice election on or after October 1, 2026
New limits on telehealth face to face encounters for recertification
The 2025 overpayment rule allowing up to 180 days for a good faith investigation
Medicare enrollment requirements for certifying physicians
Who it’s for
Hospices preparing for initial accreditation
Agencies changing accreditors
Programs rebuilding after a survey finding, a change of ownership, or the loss of a compliance officer
Newly enrolled hospices facing a provisional period of enhanced oversight
What you receive
One editable Word document of about 42 pages, available to download immediately after purchase. Replace the bracketed fields with your agency’s information, add your state licensure requirements, and take it to your governing body for adoption. State addenda are available separately.
License
Each purchase covers use by one hospice under one Medicare provider number.
About the author
Tonia Barrier, MSN, RN, is the Founder and Principal Consultant of PAC Leadership Solutions and the former Chief Clinical & Compliance Officer of a multistate hospice organization, where she built the clinical, compliance, and training infrastructure from the ground up.
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.