A hospice volunteer program a surveyor can see on day one
The Hospice Volunteer Orientation & Operations Manual, Accreditation Ready Edition, gives your Volunteer Coordinator a written operating structure, a ten module training curriculum, 27 ready to use forms, and a workbook that calculates the 5 percent level of activity and cost savings. It is mapped to the Medicare volunteer standard, ACHC, and CHAP.
Five federal requirements, and each one needs proof on paper
- TrainingVolunteers receive orientation and training consistent with hospice industry standards before they serve. 42 CFR 418.78(a); 418.100(g)(3)
- RolesVolunteers work in day to day administrative roles, direct patient care roles, or both. 42 CFR 418.78(b)
- RecruitmentThe hospice shows a continuing effort to recruit and retain volunteers. 42 CFR 418.78(c)
- Cost savingsThe hospice documents the cost savings its volunteers produce, by identifying the positions they fill, the time they work, and what that work would have cost. 42 CFR 418.78(d)
- 5 percentVolunteer time equals at least 5 percent of total patient care hours of all paid hospice employees and contract staff, and the hospice tracks the expansion of care this volunteer time makes possible. 42 CFR 418.78(e)
The program gives each requirement a written process, a form, and a record a surveyor can review.
Three documents and one workbook, in the order a coordinator uses them
The Manual sets the rules. The Curriculum teaches them to volunteers. The Forms and Toolkit holds the records that prove both. The combined Word file runs 99 pages, and each part keeps its own page numbers.
Coordinator Manual
34 pages on the coordinator role, program structure, policies, and an accreditation crosswalk to ACHC and CHAP.
Training Curriculum
27 pages, ten modules, and 12.75 hours of general education, with a checklist that shows where every ACHC orientation topic is taught.
Forms and Toolkit
38 pages holding forms V1 through V27, from the first inquiry to the annual program review and leadership report.
Activity and Cost Savings workbook
An Excel workbook that logs hours by service type and calculates the 5 percent level and cost savings each month.
Screening and file audit
A volunteer file audit that includes the Form I-9, withholding statement, and a national sex offender registry check.
Surviving family members
Form V27 and handout text for family members who want to volunteer after a death, as ACHC standard HSP4-12B.01 requires.
Look inside before you buy
Three excerpts from the program. Each one names the requirement, cites its source, and shows the record a surveyor will ask for.
Monthly 5 percent level of activity
Divide volunteer hours by total patient care hours of paid employees and contract staff. Report the result to QAPI each quarter.
| Line | Item | Hours |
|---|---|---|
| A | Paid and contract patient care hours | 10,000 |
| B | Volunteer hours, all service types | 540 |
| C | Required minimum (A × 5%) 42 CFR 418.78(e) | 500 |
| D | Level of activity (B ÷ A) | 5.4% Met |
Workbook excerpt. Figures shown are a sample.
ACHC orientation topic checklist
Every topic listed in ACHC standard HSP4-4A is matched to the module that teaches it.
| Topic | Taught in |
|---|---|
| Advance directives | Module 2 |
| Common conditions, noticing and reporting pain | Module 5 |
| Agency emergency plan | Module 6 |
Curriculum excerpt. Ten modules, 765 minutes of general education.
Surviving family member volunteer interest and readiness
Federal rules set no waiting period. The agency sets its own and applies it consistently, with documented exceptions.
- Motivation and expectations
- Current grief support and bereavement services offered
- Possible reminders in the requested role or location
- Non patient and public relations options explained
- Bereavement coordinator consulted
- Plan for a check in after the first assignments
Form excerpt. One of 27 forms.
Built once, mapped to the standards your agency answers to
| Source | What the program maps to |
|---|---|
| Federal | The volunteer Condition of Participation (42 CFR 418.78), orientation and training (418.100(g)), and the surveyor guidance in CMS State Operations Manual Appendix M |
| ACHC | Hospice standards, including volunteer orientation topics (HSP4-4A), personnel file contents, and surviving family member involvement (HSP4-12B.01) |
| CHAP | The hospice standards manual, version 3.2.0, effective March 23, 2026 |
From adoption to survey ready in three phases
Each phase ends at a gate leadership can verify. I recommend a new coordinator work through all three before the next survey window.
Learn the program
- Read the Manual and the crosswalk
- List every active volunteer
- Audit each file against the checklist
- Pull 12 months of hours
Fix the foundation
- Close missing screening items
- Adopt the policies and forms
- Start the monthly hours log
- Schedule the next training class
Run it and prove it
- Teach the ten module course
- Report the 5 percent level
- Report cost savings to leadership
- Present volunteer data at QAPI
Take the program on your own, or with me beside you
The program kit is $295. Guided implementation and file audits are priced on request.
- New Volunteer Coordinators who inherited a program with no written structure
- Hospices seeking initial accreditation or changing accreditors
- Programs that cannot show their 5 percent level or cost savings from records
- Agencies rebuilding after a survey finding on volunteer services
- Every requirement points to a form and a record a surveyor can see
- Checked line by line against the ACHC and CHAP standards manuals
- Written by a hospice nurse who has run compliance across multiple states
Be ready before the surveyor knocks
Hospice surveys are unannounced. Give your Volunteer Coordinator a complete, current program before yours.
This program is an educational and operational template. It is not legal advice and does not guarantee an accreditation decision. Agencies should review the final program against their own state rules and accreditor before adoption.