Getting Ready For Hospice Survey In 2021 or 2022? Keep Your Eye On The Top 10 Accreditation Citations And Avoid Them!

August 16, 2021
Top 10 CHAP Hospice Survey Deficiencies In 2020:
The Community Health Accreditation Partner (CHAP) has compiled the top 10 list of deficiencies cited during hospice surveys in 2020  . These are the items listed in their reference materials as of May 20, 2021. 
  1. L626:  This L tag refers to the aide providing services in accordance with the plan of care and as ordered and permitted by training.  Tips:  Communication is key here. Make sure assigned tasks are completed frequency of visits is followed. Discuss this is IDG meetings and have a system in place to communicate changes to the aide.
  2. L545:  The standard states the is an individualized care plan with goals/ interventions based upon problems identified in the comprehensive assessment.  Tips: Here is where agencies should utilize the IDG to review identified problems and correlating intervention as well as goals. Auditing should be in place to make sure changes are updated within the care plan. Ultimately, what is documented in the comprehensive assessment should look like the same patient in goals and interventions. 
  3. L543:  This regulation states that h ospice care and services follow an individualized written plan of care.  Tips: This is all auditing to make sure your clinicians are following the plan of care. 
  4. L678:  This L tag states is about the clinical record being complete with all the required elements including the physician orders.  Tips:  This is another compliance issue that can be addressed and maintained through routine clinical auditing. 
  5. L530: L530 is the comprehensive assessment including a drug review.  Tips:  Make sure clinicians are capturing over-the-counter meds as well as herbals in the med list. This is something that needs addressed each visit to validate the current meds are still current with no additions or subtractions. Review the clinical documentation to make sure the med profile has all medications listed. 
  6. L553:  This L Tag refers to the revised plan of care including current information from latest assessment and progress towards outcomes. Tips:  All new and ongoing problems have to be addressed with interventions and goals. If there is no progress towards those goals, then you may need to look at different interventions to more effectively address the goals. This is where revision of your care plan is vital to make sure it addresses the patient "seen" in the assessment. 
  7. L625:  Written aide instructions are developed by the RN. Tips:  This is an ongoing record review item. Reviewer needs to make sure the aide instructions are specific to the needs of the patient. Again, the aide instructions should mirror the patient your documentation shows in the assessment. If there is a mismatch or no specificity, there will be a problem. Reviewer also needs to make sure the RN is the one that prepared the aide instructions. 
  8.   L523:  This tag is related to timing of the initial and comprehensive assessment. It can be completed no later than 5 days after the benefit election.  Tips:  You need a system in place to ensure all core disciplines are aware of when a patient was admitted. Use clinical auditing to ensure compliance and make sure that IDG members were involved in the completion of the assessment. 
  9. HIPC.9.1 L Tag: N/A:  This is not an L tag but a CHAP standard and part of the top ten. This is your TB screening per regulations and CDC guidelines. Tips:  Your surveyor will review your agency's TB program to ensure it is current with regulation/ CDC guidelines. If testing is required, then you need to have successful tracking to ensure you are following timeframes. 
  10.  L579: This L Tag references following standards of practice to prevent infections including standard precautions/ hand hygiene.  Tips:  This should be closely monitored during supervision visits in the field. This is also part of the top 10 on the home health citations. Do not take for granted staff knows and is practicing hand washing per your policy or following routine infection control. 
At Kenyon Homecare Consulting , we can help you prepare for state or accreditation survey. Call us today at 206-721-5091 or contact us online to see how we can help you with a successful survey outcome. Although the CHAP top 10 is cited here as as reference, these are a sample set indicative of citations seen in 2020 regardless of whether you are accredited or not. If you are accredited, please utilize the free reference material available to you from your accrediting body whether it is CHAP, JCO, or ACHC. 

Results Based Consulting

Did you find value in this blog post? Imagine what we can do for your home care or hospice agency. Fill out the form below to see how we're leading the industry with innovation, affordability, and experience.

Contact Us

beyond the snapshot
By Ginny Kenyon May 18, 2026
The HOPE tool captures clinical, psychosocial, and spiritual patient needs patient at multiple intervals. This is better than the HIS for the entire clinical picture
policy and procedure manual
By Ginny Kenyon May 9, 2026
In 2026, an updated home health or home care P&P manual serves as defense against litigation, a blueprint for operations, and a mandate for federal reimbursement.
Starting a home care agency
By Ginny Kenyon May 5, 2026
Here is the "ABC" guide to building a successful foundation for your starting your new home health, home care or hospice agency. It is necessary for success.
policy and procedure manual
By Ginny Kenyon May 2, 2026
An up-to-date manual the bridge between high-level vision and daily execution. A current, living P&P manual is critical for any successful agency or business.
controlling chronic diseases
By Ginny Kenyon April 25, 2026
In the rapidly evolving landscape of healthcare, the burden of care is increasingly shifting from clinical facilities to the home. As the population ages, the prevalence of chronic conditions—such as heart disease, diabetes, and respiratory disorders—has reached unprecedented levels. For home care agencies, the quality of service is no longer just about assistance with daily living; it is more and more defined by the clinical competencies and disease-specific knowledge of your field staff. Chronic disease education for home care staff is not a luxury, is a strategic necessity that directly impacts patient outcomes, caregiver confidence, and the business’s bottom line. 1. Enhancing Clinical Outcomes and Safety Home care staff are the "eyes and ears" of the healthcare system. When aides and clinicians are highly educated on chronic disease processes, they can identify subtle shifts in a patient's condition before they escalate into emergencies. · Early Intervention: An educated caregiver can recognize the early signs of fluid retention in a Congestive Heart Failure (CHF) patient or skin changes in a diabetic patient, allowing for proactive adjustments rather than reactive ER visits. · Medication Adherence: Understanding why a medication is prescribed for a specific chronic condition helps staff reinforce the importance of adherence to the patient, reducing the risk of complications. 2. Reducing Hospital Readmissions Hospital readmission rates are a primary metric for home health success. Chronic diseases are the leading cause of "revolving door" hospitalizations. By providing specialized education, agencies empower their staff to implement Evidence-Based Practices at the bedside. When staff can effectively manage symptoms and educate patients on self-care, the likelihood of a patient staying stable at home increases dramatically. This not only benefits the patient but also strengthens the agency’s reputation with referral sources like hospitals and physician groups. 3. Boosting Staff Confidence and Retention The home care industry faces significant challenges with staff turnover. Often, burnout is fueled by the stress of feeling unprepared for complex patient needs. Knowledge is Empowerment: When staff members receive robust training, they feel more confident in their roles. This professional growth fosters a sense of value and belonging within the organization, leading to higher job satisfaction and lower turnover rates. 4. Improving Documentation Accuracy In an era of increased regulatory scrutiny, clinical documentation must be precise. Education on chronic diseases ensures that staff members use the correct terminology and focus on the most relevant clinical indicators during their assessments. · OASIS Accuracy: For Medicare-certified agencies, a deep understanding of chronic conditions leads to more accurate OASIS scoring, which directly influences reimbursement and quality ratings. · Audit Readiness: Well-educated staff produce notes that clearly reflect the necessity of care, making the agency much more resilient during regulatory surveys or audits. 5. Bridging the Communication Gap Effective chronic disease management requires a multidisciplinary approach. A caregiver who understands the nuances of a disease can communicate more effectively with: · Physicians: Providing clear, clinical updates that help doctors make informed decisions. · Family Members: Offering clear explanations and peace of mind to stressed family caregivers. · The Internal Team: Ensuring a seamless transition of care and consistent messaging across all disciplines. Conclusion Investing in chronic disease education is an investment in the agency’s future. By elevating the knowledge of the frontline workforce, home care providers can transform from basic service agencies into high-value clinical partners. In the end, the goal is simple: providing the highest quality of life for patients in the comfort of their own homes, a goal that can only be met through a highly trained and knowledgeable staff. If you do not know where to get comprehensive education for Chronic diseases, contact Kenyon Homecare Consulting at gkenyon@kenyonhcc.com or call 206-721-5091. We are here to help
call to action
By Ginny Kenyon April 11, 2026
In the world of digital marketing, the most critical moment of the entire customer journey often comes down to a tiny rectangle: the Call-to-Action (CTA) button.
job descriptions
By Ginny Kenyon April 7, 2026
When you're recruiting talent for your agency finding people with the required technical skills is the baseline, but vibe and vision are the differentiators.
business plan
By Ginny Kenyon April 1, 2026
Whether you're pitching to investors or just trying to keep your own head on straight, a professional business plan is vital. Here's help in putting one into place.
firingiring
By Ginny Kenyon April 1, 2026
Hiring the "right" person isn't just about finding someone who can do the job; it's about finding someone who makes the rest of the team better. Headcount matters.
sales and marketing strategy
By Ginny Kenyon March 28, 2026
In the modern business world, sales have evolved beyond a mere transaction. It is a sophisticated blend of psychology, problem-solving, and relationship management.