Surveys are one of the most stressful—and most important—moments in the life of a hospice agency. Whether it's a routine CMS survey, state inspection, or accreditation review, your agency must be prepared to show compliance, consistency, and quality on demand.
Unfortunately, many teams wait until they receive a 15-day window or unannounced visit to start preparing. That’s where things get missed—and where deficiencies arise.
At Solutions for Care, our hospice consulting team has helped dozens of agencies prepare for successful surveys. This checklist highlights the most critical areas to review before the surveyor walks through your door.
✅ Hospice Survey Readiness Checklist
🔒 1. Patient Eligibility Documentation
Complete initial physician certification and narrative
Supporting documentation for terminal prognosis (<6 months)
Clear documentation of primary hospice diagnosis
IDG notes aligning with patient decline or stabilization
👉 Pro Tip: Missing or vague eligibility documentation is one of the top deficiency triggers.
📁 2. Comprehensive Assessments & Care Plans
Initial comprehensive assessment completed within required timeline
Care plan created within 5 days of admission
Evidence of interdisciplinary team (IDT) collaboration
Care plan updated with any change in condition
👉 Pro Tip: Surveyors often compare assessment findings with care plan interventions. They must align.
🖊 3. IDG Meeting Documentation
Consistent IDG meetings every 15 calendar days
Attendance from all required disciplines (RN, SW, Chaplain, MD/NP)
Progress notes that reflect changes, goals, and interventions
Family involvement documented, when applicable
👉 Pro Tip: Surveyors may ask for documentation that shows the IDG made active decisions—not just met to review.
🧠 4. Staff Competency & Training Records
Orientation records for all clinical staff
Annual competencies (e.g., pain management, infection control, documentation)
Licensure and certification up to date
Proof of ongoing education and performance reviews
👉 Pro Tip: A well-documented staff file is your first line of defense in demonstrating compliance.
🩺 5. Clinical Documentation & Visit Notes
Timely documentation of all visits (nursing, social work, aide, spiritual)
Accurate symptom assessment and pain management
Notes reflecting patient goals and interventions
Missed visits and declined services properly explained
👉 Pro Tip: Surveyors often pick random patient charts to review—make sure every one tells a clear clinical story.
📦 6. Medication Management
Medication profiles accurate and current
MAR documentation matches ordered medications
Medication education documented in the record
Proper handling, storage, and disposal procedures followed
👉 Pro Tip: Improper medication reconciliation is a frequent citation during hospice surveys.
🧾 7. Bereavement Services
Initial bereavement risk assessments completed
Follow-up contact within 2 weeks of patient death
13-month bereavement plan of care created
Documentation of outreach and support provided
👉 Pro Tip: Surveyors want to see that bereavement services are proactive and structured—not just symbolic.
🔍 8. Emergency Preparedness
Emergency plan policies and procedures reviewed annually
Evidence of staff training and drills
Communication plan and patient tracking systems in place
Infection control measures (especially post-COVID) documented
👉 Pro Tip: Be prepared to discuss how you responded to real-world emergencies or outbreaks.
📝 9. QAPI Program
Written QAPI plan with defined goals
Meeting minutes and progress notes
Data collection and performance metrics reviewed regularly
Evidence of action taken on findings
👉 Pro Tip: Surveyors will ask how your agency identifies trends and what you’re doing to improve.
📌 Final Thoughts
Survey readiness isn’t about scrambling last-minute—it’s about building ongoing systems of excellence. Use this checklist as a self-assessment tool or integrate it into your mock survey process.
If your agency needs a fresh pair of eyes or hands-on help getting compliant, this is where hospice consulting becomes invaluable. From documentation audits to on-site training, consultants can help turn survey anxiety into confidence.
💬 Need support preparing for an upcoming survey? Our Hospice Consulting team can conduct a full mock survey, help build your Plan of Correction, and support your staff through every step.
