Information gathering is a systematic process to assess the hospice’s compliance with CoPs,
consistently and accurately. During a hospice survey, surveyors gather information using a set of
procedures, common across provider types, including observations, interviews, and record
reviews. Surveyors gather information through home or facility visit observations, interviews
with patients, caregivers and families, hospice caregiving personnel including the IDG, as well as
reviews of clinical records and other hospice documents, such as relevant policies and
procedures. Surveyors validate all findings with additional hospice document review and/or
interviews with the hospice staff and administration. Check specific patient/family complaints
concerning the hospice’s delivery of items and services with the hospice to be sure that there are
no misunderstandings and that the patient’s plan of care implementation is as stated in the record.
Clinical Record and Other Hospice Documentation Review
Using the complaint log, requested during the Entrance Conference, verify that the hospice is
tracking complaints and review the documentation of complaints made by patients or patients’
families for the previous 12 months, to determine how the hospice received, recorded,
investigated, and resolved these complaints.
When surveyors identify concerns that indicate actual or potential findings of noncompliance,
surveyors should review additional documentation, as needed, to assist in making a compliance
determination. A few non-clinical documents are required in conjunction with specific CoP
guidance. However, not all non-clinical documents are routinely reviewed unless the surveyor(s)
identifies(y) concerns during interviews, home visits, and clinical record reviews, in which case
surveyors may review additional non-clinical documents such as service contracts, clinical
practice guidelines, CLIA waiver, and/or other materials.
The clinical record is the enduring evidence of care for patients and families. A review of the
record assures the surveyor that the hospice provides services in compliance with the plan of care
and CoPs.
If time permits, the surveyor should review the clinical record prior to the home visit to be
prepared to observe care and services (e.g., the most current plan of care, medication list, and
aide instructions). After the home visit, review the record in more detail to address concerns
identified during the home visit. Give special attention to the quality of care and coordination of
care, based on a person and family-centered plan of care with individualized goals of care.
Detailed guidance for clinical record reviews is presented in this Appendix, under the description
of §418.104 -Clinical Records.
Closed Record Review
A review will be conducted of closed clinical records for patients who are no longer in hospice
care due to death, revocation of the hospice benefit or transfer (live discharges). After the death
of the patient, the focus of the review is on care provided in the final days of life, post-death
bereavement counseling and services for the family and caregivers. For live discharges, explore
the circumstances leading to the cessation of hospice services.