Hospice Survey Readiness Checklist: What to Review Before CMS or Accreditation Arrives

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.

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💬 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.