Hospice's Top 10 Deficiencies of 2025

We break down the top 10 hospice deficiencies for 2025, why citations shifted toward aide compliance and volunteers, and how to align care plans with assessments to satisfy CMS and improve patient care. We also share new CHAP tools and practical steps to tighten supervision, documentation, and QuAPI.

• plan of care as the central compliance document
• comprehensive assessment driving timely care plan updates
• documentation beyond point and click to show necessity
• hospice aide scope, competency, and 14‑day supervision
• reporting status changes from aide to RN promptly
• state rules shaping permitted aide tasks
• volunteer 5% utilization tracking and recruitment evidence
• root cause analysis and data‑driven QuAPI
• RN case management and IDG accountability between meetings
• continuous survey readiness through mock surveys and policy reviews

After you listen to this podcast, click on some of the links to our resources: our top 10 hospice survey deficiency list, which includes our three-year comparison, and the medication reconciliation blog.  

Check out our course: Charting the Course: A Guide to Effective Care Planning in Home Health & Hospice

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Transcript

SPEAKER_01 0:14

Greetings and salutations. I'm Jennifer Kennedy, the lead for compliance and quality at CHAP, and welcome to CHAPCAST. Today we're going to talk about the top 10 hospice deficiencies that we found in 2025. And I am here with my good friend and co-worker and support system and all of the above, Kim Skian. Hi, Kim. Hi Jennifer, right back at you. All right, so we're gonna talk hospice deficiencies today. And these are the uh top 10 standard deficiencies that we found in all of the surveys that we did in 2025. And you know, actually, when I looked at these, I was a little bit surprised because it it didn't, I was thinking, oh yeah, here we go. It's gonna be like five items, care, uh, plan of care, comprehensive assessment. And, you know, it wasn't necessarily the run of the mill this year that that we've seen in other years. So um let's you know go ahead and and jump right into it and and do an overview of what we're gonna cover today. And you know, essentially, why does this matter, Kim? Why do we even care about this? Why should hospice providers care about this?

Trends That Surprised Us In 2025

SPEAKER_00 1:36

Absolutely, and um absolutely happy to be here. We know that these are the most common deficiencies, not just for CHAP, but for many state agencies, survey agencies, and also other AOs. Um, the reason it's so important is because these are just discussing what the top findings may be, but um hospices need to ensure that they are aware and and compliant with all conditions of participation and CMS standards as well as CHAP standards. Um, and I would say state regulations if applicable. Um it's it for hospices it's it's extremely more important because um, well, I would say I would say survey readiness is equally important for everyone. Um we know how I feel about it, uh as I've said for many years. Um everyone should be survey ready at all times. Um but isn't that your tagline? That's your tagline, right? Yeah, yeah, yeah. I'll probably say it at the end. Um, but you know, it's important to note that at least for these top 10, all of the findings have an associated CMS tag, which is uh uh expected since our CHAP standards closely monitor the COPs. And for hospice, even though the special focus program is on hold, there may be something similar in the future because it's still congressionally mandated unless there's a change in in the law, um, then uh SIP may come back or something similar in the future. So ensuring compliance with federal standards and mitigating the chances of um receiving condition level deficiencies is really a key.

SPEAKER_01 3:23

Absolutely. Um and it may come back with a vengeance, but we'll we'll save that for another chat for another day for sure. So far now. You know, I said I mentioned that I was a little bit surprised. Was there anything surprising to you when you looked at that list for the 25s?

Volunteer Utilization And Compliance Gaps

SPEAKER_00 3:42

You know, first of all, for years we have looked at the num at the um at the top 10 deficiencies, not just for chat, but for CMS. Um, certainly when QCOR was readily available. I know there's a migration to IKES at this point. For years, the majority of the findings, as you pointed out, usually like six of the top 10, were related to plan of care and comprehensive assessment, which again go really go hand in hand, even though there may not be findings. You have to make sure that the care plan reflects um um the um the comprehensive assessment and any updates. Um so this year it was I looked and there were four, um, four sorry, four for AIDS, hospice aids. And that, I mean, you and I both know that we have a perpetual you know um feeling about hospice aides being on the uh on the top 10, especially supervision. Um but I found that important, the I mean, an important change. And the other that was surprising to me was um how high up, if you will, I think it's number four, um, volunteers, the five percent utilization for volunteers. Now, at the moment, this is this is still a uh a requirement. And um, you know, we understood the challenges, of course, it was under waiver during COVID, but um I I think maybe hospices um are either having trouble tracking um the the 5% or continuing to have difficulty recruiting, um, you know, or we did find that there were there were some hospices that were unaware that the late waiver had been um you know had expired. Oh my god, for real?

SPEAKER_01 5:36

Mm-hmm. Mm-hmm. Wow, that's that's been a bit for sure. You know, I have um in my in my journeys with talking with providers about the volunteer piece, is that um either they they don't track it consistently, you know, that maybe they just wait till the end of the year and then they come up short, or um they may have had staffing changes, in which, you know, every time a staffing change happens, maybe something is dropped, or they just don't know how to do the calculation with the clinical hours correctly. Um, I'm sure you know things have gotten tougher since the pandemic with recruiting, but you have to be able to show um that you are actively trying to get volunteers in the door. So that's that's like an administrative documentation piece, I think, that maybe not uh may not be robust either. So I think you know it could be a handful of different things.

SPEAKER_00 6:39

Yeah, absolutely. And and I would just add here that um when it comes to recruitment and volunteer utilization, it it really does um um tra uh uh it it tra it crosses over, crosses through the entire service area of the hospice. So, you know, if there's difficulty recruiting in one particular location, then as a hospice they need to make sure that they can demonstrate number one evidence of recruitment and then what they're you know what they are doing from an operational standpoint to be able to, you know, um provide volunteer services if if they are needed. So again, we're not talking a lot about volunteers. We could probably do an entire session on volunteers. Um, but um, but I that you asked what was surprising, and I was just surprised at how high up on the top 10 um this one was.

SPEAKER_01 7:36

Well, Kim, even though the Planet Care and Comprehensive Assessment didn't dominate the last list, we should probably talk about it. Because it was the number one item. It was right up there.

SPEAKER_00 7:50

So I will talk about Planet Care and Comprehensive Assessment, and then I'm gonna pass it to you to talk about hospice aids. Um Thank you. We'll tag on our on these favorite topics. Um for um, you know, planet care, and I I say comprehensive assessment as well because um the drug profile, you know, medication review is is part of the comprehensive assessment. We know that uh care planning is a perpetual top deficiency for all service lines, not just hospice, um, and again, not just for CHAP, but and relates to many of the other top 10 findings. We have to continually remind staff that the care plan must reflect the patient's individual needs and that it's updated at least every 15 days or more frequently as needed. Now, some states have uh may have a tighter requirement, so you have to make sure your state, you know, your state regulations are met. But those changes, uh, the care plan and the updates are related to changes in the comprehensive assessment. And the other key with hospices, there is an RN primary uh primary nurse, right? A primary care nurse who is responsible for the overall ensuring that the care plan needs are met, service needs are met, and the care, you know, and and the patient's needs are met. Um however, a hospice has the interdisciplinary group. And the interdisciplinary group, each member is responsible for completing, ensuring that their care plan, as related to their their uh, their uh care treatment and services is reflected in the the care plan and updated as needed. And and updated in between the two IDG meetings, because it's in that window that often you'll find that there have been changes that identify the need for a change in the care plan that isn't always you know isn't always included in an update, um, and also obviously including the medical director and the attending physician, you know, if applicable.

SPEAKER_01 10:10

Yeah, and CMS um agree with everything, by the way. And CMS, you know, does consider that plan of care the most important document in in hospice care. So they're very focused on it. Um in federal regulation and just making sure that it is implemented the way it was intended and you know, what the rationale is. So um, I don't know. I mean, I feel like years and years they don't feel like providers know what they're doing with a plan of care, you know? Yeah.

SPEAKER_00 10:43

Well, I I would say this that um I think I know we'll talk about it a little bit later, but you know, um with documentation for the care for the care plan and documentation in general, you know, hospices really need to make sure that they're going, as you said, beyond the point and click, you know, and making sure that there really is that they are painting a picture of the patient and the family. Um, you know, what's mattering, what matters most to the patient and family, what are the um, you know, care, treatment, and services that are needed to effectively meet the patient and family needs. And I think that not having that, you know, uh thorough documentation um really you know puts a hospice at risk, not just from a survey perspective, missing the elements, but from a payer perspective with audits, you know, and denials, because the care plan does not appear from an audit. And again, we aren't pay, we don't conduct payer audits, but from a re uh denial perspective, you know, um the findings that the care plan doesn't it doesn't um it doesn't, you know, um sufficiently document the care plan in documentation doesn't apparent, doesn't meet patient and family uh medical necessity needs.

SPEAKER_01 12:01

Absolutely. And because it trended at uh number one, it means that you know most of our providers that get cited here need to do some performance improvement work on on this particular issue.

SPEAKER_00 12:16

Actually, yeah, I bel I agree, and and I would say that, and I know you'll say this as well, um, you know, with any of these top ten findings or any deficiency that a hospice may have, even if it's not on the top ten, but it was identified either through their OMOC survey or through a prior survey, um if they have a deficiency, they really need to it's recommended that they create a PIP performance improvement, you know, plan and process to be able to address uh any of these findings so that they can ensure that they are ready. Absolutely. All right.

SPEAKER_01 12:56

Should we talk about the elephant in the room? Yes, Jennifer. It's AIDS, boy, a lot of citations for AIDS. Uh that just I think that really surprised me the most. Um, things that uh popped up in the list were care plan instructions, meaning that the RN needs to write those instructions and then ensure that the AID is following the instructions and that they're only doing things on that care plan and and not things that are not on the care plan. And that doesn't mean uh the aid can't go back to the RN to say, hey, uh, can we add this? or I think this is a need, or the patient stated this. It just needs to be all aligned. Uh I'll say the the best for last. Um reporting changes to the um RN. Um if there are changes, that was another one that popped up. Um care ordered is in line with aid training. So, you know, that all training and competency is is huge to make sure that um all of your aides are checking the box that are um regulatorily required, not only with federal but with state regulations. And then finally, the supervision minimally every 14 days. Um, aid doesn't have to be present, um, and it needs to be documented. So to me, first of all, to me, all of these things could signal internal process issues. So um definitely um these things need to be looked at if they're a gap for an organization, and then work through their QuAPI program, obviously, um, to get uh better performance. And as you and I agree, why not just document supervision on every visit while you're out there? You know, I I when I was out in the field, Kim, I I don't know, maybe this is similar for you, and I had an aide working with me on a case. I didn't just ask the family when they were due for a supervision visit, hey, how's that aid doing? Is there anything else we need to talk about about the aid care plan? I talked about the aid performance and and what was happening on every visit, was part of the visit. So why not document it? What are your thoughts on that?

Hospice Aides: Training, Scope, Supervision

SPEAKER_00 15:22

I completely agree. And again, this is a chaff and Kim and Jennifer best practice recommendation. Um it's not regular, it's not required from a regulatory perspective to document a um uh supervision every visit by the RN, but it really does help eliminate the issue where this finding where supervision has not occurred in 14 days. The only other time that this may happen would be if the RN does not visit within 14 days, and that's another issue altogether, you know, in terms of seeing this looking at it from um um a hospice needs, you know, standpoint and appropriateness of care. So hospices that have a practice where the RN is only visiting every 14 days or less really need to look at at that process and the appropriateness, you know, of really what needs to happen to ensure appropriateness of the visits. Because CMS is looking at this not just from a regulatory standpoint, again, but a payer standpoint. And if, for example, you have an RN um scheduled every two weeks, every 14 days, if something happens and that nurse has to go out on the 15th day, you're out of compliance. So, you know, I think that's just a really important point. The other is um you talked about care being uh ordered in line with aid training. It's really important to understand the state regulatory requirements for scope of practice for the aid, because some states have delegation for um you know some advanced, you know, um care, such as maybe vents or you know, or you know, cleaning the vent, not in the vent care, but you know, cleaning around or some sort of a um a specific need. But many cases many um um agents, many many states, you know, don't have that. And even if they do, you want to make sure that there is um you have adequate training. But we have definitely seen situations where AIDS are um, for example, can um um applying UNA boots, um, and um, you know, which again is a wound care, you know, treatment, right? And right and other things, um, even compression stockings. It really does depend on you know the training of the aide and any state limitations. Um so it is it is really important that um that hospices look very closely at those requirements.

SPEAKER_01 18:11

Well, that's great um discussion there, Kim. So I'm gonna date myself and say let's uh flip to side B of the 45 record. Did you get that one? Did you used to have 45 records? I did, I did. I you want me to start? Yeah, sure. All right, let's do side B and talk performance improvement in some of these areas. So care planning, coordination of care, aid services.

Avoiding 14‑Day Supervision Pitfalls

SPEAKER_00 18:39

Well, I I think that we have discussed, you know, we've already, you know, we've given some um suggestions in our, you know, in this talk so far. Um, but I also would say that um a couple of things. One from performance improvement, um, you know, one of the key components for care planning and managing the care does uh relate to case management, and that would be case management by the RN. Even though in a hospice there is the IDG, it's still the RN's responsibility. And we did record a previous chapcast focusing on case management again to make sure that there is oversight of the care planning and ongoing communication between the physician and the IDG and the and the physician to ensure the individualization of uh care treatment and services, and certainly uh ongoing auditing, monitoring, um, to ensure that these care plans are reflective of the uh care treatment and services, and that all disciplines are included. Um in hospice with an IDG every 14 days, 15 days, um, the at Least there should be documentation that even for example, if the patient and family decline chaplain or social work, that they are revisit or volunteers, that they're revisiting those disciplines ongoing with each IDG in case there are changes, you know, in the patient's and family's needs or you know, willingness to accept the services, etc. So it's a living and breathing document that needs to reflect the the patient's needs.

SPEAKER_01 20:32

Absolutely, couldn't agree more on that. Um, and and when we're talking about some of the aid deficiencies, you know, I always, when I think quality, you have to go uh sort of uh through the checklist. Is this a single employee problem? Is this a system problem? Is this a documentation problem? You've got to work your way through those to figure out um if you're an organization that got cited with any of these, why, why did it happen? You know, uh even do a root cause analysis if you have to to make the correction. Uh and you know, we've given uh some good suggestions, I think, around the AIDS in terms of maybe documenting every visit when you're doing supervision and keeping on top of the monitoring of that care plan, uh, which goes along with every visit, you know, talking to the patient. Are we doing what you need us to do for you? Is there anything else we need you uh that we can do for you uh through the AID services? So, I mean, to me, all of that falls into the individualization of the care that the hospice is providing. And if we're letting some of this stuff drop, then are we really individualizing the plan of care that's been mapped out? Um, I have to go back to that.

SPEAKER_00 21:49

Absolutely, absolutely. And we found with um our our agencies, including hospices that have implemented age-friendly health care at home, um, that because the focus is on the forum, starting with what matters most to the patient, medication, mobility, and mentation, um, that what matters most to the patient and family drives the care plan and keeps the family and the patient at the center of you know that care plan. And um the one other thing I would say for AIDS is that it it all staff, but especially AIDS, we want to make sure that there's continual um education and support for the AIDS so that they truly understand the um their responsibility with the care plan, notifying the RN of any changes, and when they are not able to perform a task that exceeds either their training or scope, you know, a practice, um, because you know, there is a um sometimes any caregiver will go into the home and might feel, you know, uh a pressure, if you will, sometimes inadvertently, you know, unintended, a family member wanting, you know, um an aide or someone to help because they're there all the time, you know. So really making sure that um that they understand the boundaries of of their role, um, that's something that that that would that is important to continue, you know, to to communicate um with the aides.

SPEAKER_01 23:25

Absolutely. And I think mapping out expectation not only for the aid, but also for the RN when they're working together with a patient in the family is really important. Um we know that there's there's turnover out there in hospice right now. You know, we have um RNs going from one hospice to another, aides might be doing the same. And just because you did some uh you did a process at one hospice doesn't mean that process transfers to the current hospice that you're working at. So I think um mapping out those expectations is hugely important as well.

SPEAKER_00 24:02

Absolutely.

SPEAKER_01 24:04

Jennifer I'm really excited to talk about our new tools, Kim.

Case Management And IDG Accountability

SPEAKER_00 24:11

That's what I was saying. I was I was just gonna tee that up for you before we get to have your big announcement. I did want to say a tool that I do want to make sure we give um a shout-out for is our Center for Excellence Learning Solutions, does have an on-demand course for uh care planning. It's called uh Charting the Course, a guide for effect to effective care planning in home health and hospice. So I just want to say that's that's another, you know, um uh tool in the resource bucket. But drumroll please.

SPEAKER_01 24:47

There it is, drumroll please. So we're really excited um to push out some different tools with um our top ten uh this year. So not only are we going to give you the top 10 um hospice standard deficiency list, but that list will also include a breakout of those uh deficiencies into domains and then analyses of each domain, um, which include rationale, why is the the standard or domain important, um action items, and then performance improvement suggestions. So we're trying to up the ante, if you will, on um telling you not only what what the top uh deficiencies were, but giving you a little more meat to the bone, if you will, uh, on those top 10. And then we also developed another tool, which is a three-year comparison. So 23, 24, and 25 top 10 deficiencies for hospice. And then with that list, there is an analysis or a trend analysis uh of the deficiencies of those three years and an overall interpretation. So really um cool uh tools that we're pushing out the door this year, and we're gonna continue to do things like that in 2026 and moving forward to make sure that hospice providers have the most insight that they can have uh as we push these um top tens out the door.

SPEAKER_00 26:25

So pretty excited about these tools, Kim. And you absolutely should be. They are excellent. I know they will be uh made available, I believe, as early as today, and um and uh they are incredible. The other key point here is that it they are really user-friendly, um, easy for um hospices to be able to review and then implement training or processes to be able to um you know uh facilitate compliance, but also the data. The data available, the the data that has been pulled together is just so important, especially that trending over time, to be able to have a hospice compare, you know, yourself, your own findings to the trending and and also to other data sources in the industry. So, you know, we know that QuAPI, you know, we want to make sure that it is a data-driven Quapi program, and this certainly is uh one aspect um of uh support in that area. So great job, Jennifer. And they are for all service lines. Um I personally am very excited for when they they are launched.

Root Cause, QuAPI, And Performance Improvement

SPEAKER_01 27:40

Yeah, yes. So they're gonna be on the website. Um, they'll be downloadable, so please go and check those out. Uh and again, with the uh uh plan of care resource we mentioned from our um CFE side of the house, all of those are are really important to making sure that uh you're compliant uh and you're providing good quality care. So, Kim, as we close our time out here, any last thoughts?

SPEAKER_00 28:09

Well, you know, this is my tagline for every time anyone has ever heard me talk about survey over the decades. Um I strongly recommend ongoing survey readiness by the agency, not just these top 10 deficiencies, but um really conducting a mock survey and policy procedure review, um, but at least annually, especially if there are changes in staff or management, because we do find that this is sometimes where there are some gaps where an agency prior, you know, prior to the staffing change, you know, was had demonstrated compliance, and then there were some gaps also if a um uh an ADS is added, and certainly if an inpatient unit is added as well. But you know, nothing, nothing um replaces um proactive readiness and you know on an ongoing basis. Couldn't agree more.

SPEAKER_01 29:10

So thank you, Kim, for teaming up with me today to talk about the top 10 hospice deficiencies for 2025. Appreciate you very much. Right back at you. All righty. So we also want to thank um all of you for taking time um out of your busy day to plug into our chapcast. From Kim, me, and the entire chap staff, keep turning the corner on better performance, stay safe and well, and thanks for all you do.