California hospice regulations require every provider to hold a license from the California Department of Public Health (CDPH) and to meet both the state rules under Health and Safety Code Chapter 8.5 and the federal Medicare Conditions of Participation. Those two bodies of law govern staffing, care planning, patient rights, records, volunteer hours, and bereavement services. Noncompliance can bring civil fines, license suspension, criminal prosecution for abuse, and exclusion from Medicare and Medi-Cal.
Getting and Keeping a CDPH License
Health and Safety Code Section 1745 gives CDPH the authority to license hospice agencies and ensure the safety of terminally ill patients.1Justia. California Health and Safety Code Sections 1745-1746 Applicants submit documentation to CDPH, undergo a background check for prior healthcare violations or fraud, show financial capacity to sustain operations, and pay the licensing fee. For fiscal year 2025–26 the statewide hospice licensing fee is $2,780 for a two-year license period.2California Department of Public Health. Health Care Facility Licensing Fees
A hospice that intends to bill Medicare or Medi-Cal can use accreditation from an approved organization, such as The Joint Commission, in place of a state survey to meet licensing requirements. That option has to be selected on the initial license application.3The Joint Commission. Hospice Licensure Fact Sheet
Who Must Be on the Team
Medical Director
The medical director must hold a current license from the Medical Board of California or the Osteopathic Medical Board of California and must have at least two years of full-time supervisory or managerial experience in a hospice, home health agency, or palliative care setting within the preceding five years.4California Department of Public Health. DPH-18-002E Hospice Agencies Under federal rules the medical director certifies that each patient is terminally ill with a prognosis of six months or less, makes admission recommendations, and reviews care plans with the interdisciplinary group.
Nurses, Social Workers, and Counselors
Registered nurses must hold an active license from the California Board of Registered Nursing and complete specialized hospice training. Supervisory RNs in home health and hospice are generally expected to have at least one year of professional nursing experience.5California Department of Public Health. AFL-12-03 – Program Flexibility for Home Health Agencies Nursing Experience Requirements Social workers typically hold a master’s degree in social work from an accredited institution and are registered with the California Board of Behavioral Sciences. California does not require a specific state license for chaplains, though many hospices prefer board certification from the Association of Professional Chaplains.
Levels of Care and Daily Standards
Medicare defines four levels of hospice care that every certified hospice must be able to provide or arrange:
- Routine home care, the default for patients at home, in assisted living, or in a skilled nursing facility.
- Continuous home care, delivered primarily by nurses during brief crisis periods to manage acute symptoms in the home.
- General inpatient care, used when pain or symptoms cannot be managed elsewhere.
- Inpatient respite care, up to five consecutive days in an approved facility so a caregiver can rest.
These are the levels used across the Medicare hospice benefit.6Centers for Medicare & Medicaid Services. Hospice Levels of Care Misclassifying a patient’s level is a common billing error that draws audit scrutiny, so accurate documentation at each transition matters.
Every patient must have an individualized plan of care built by the interdisciplinary group, which includes at minimum a physician, registered nurse, social worker, and counselor. Federal rules require the plan to be reviewed and updated at least every 15 calendar days, or more often if the patient’s condition changes, and each revision must document progress toward the plan’s goals.7eCFR. 42 CFR 418.56 – Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services
Medication protocols must cover prescribing, storage, and administration, with tighter controls around controlled substances. Schedule II drugs like morphine and fentanyl need detailed tracking records for dispensation, administration, and destruction of unused doses. Gaps in those records are treated seriously during inspections.
California regulations require a registered nurse to be available on call 24 hours a day, and hospices must maintain crisis intervention protocols for severe pain or acute symptom episodes. Each agency must also run an infection prevention program covering sanitization procedures, staff training, and biohazardous waste handling. Because most hospice care happens in patients’ homes rather than clinical facilities, the program has to account for varied environments.
Patient Rights and the Election Statement
At the initial assessment visit, before care begins, the hospice must give the patient verbal and written notice of Medicare patient rights in a language the patient understands and obtain a signed acknowledgment.8eCFR. 42 CFR 418.52 – Condition of Participation: Patient’s Rights Those rights include effective pain and symptom control for the terminal illness, participation in developing the care plan, refusal of any care or treatment, choice of attending physician, confidentiality of clinical records, and freedom from mistreatment, neglect, and any form of physical, verbal, mental, or sexual abuse.
If an employee witnesses or suspects abuse, neglect, or misappropriation of patient property, the hospice must be notified immediately, must investigate, and must report verified violations to the appropriate state and local agencies within five working days.8eCFR. 42 CFR 418.52 – Condition of Participation: Patient’s Rights
The Medicare election statement carries its own requirements. It must include information about cost-sharing, a description of what the hospice will and will not cover, and notice that the patient can request an addendum listing any conditions, services, or drugs the hospice considers unrelated to the terminal illness. Patients who disagree with those determinations have the right to immediate advocacy through the Beneficiary and Family Centered Care Quality Improvement Organization.
Admission and Discharge
Before a hospice can admit a patient and bill Medicare, two physicians must certify in writing that the patient has a life expectancy of six months or less if the illness runs its normal course. For the initial 90-day benefit period, that certification must come from both the hospice medical director (or a physician designee) and the patient’s attending physician, if one exists. For later benefit periods only one of the hospice’s physicians must recertify.9eCFR. 42 CFR 418.22 – Certification of Terminal Illness
Written certification must be in hand before the hospice submits a claim. If the written version cannot be completed within two calendar days of the start of a benefit period, an oral certification must at least be obtained within that window. Starting with the third benefit period, a hospice physician or nurse practitioner must have a face-to-face encounter with the patient no more than 30 calendar days before the recertification date.
Discharge is not a simple administrative choice. A hospice may discharge a patient who is no longer terminally ill, who revokes the hospice election, who moves out of the service area, or “for cause” when behavior seriously impairs the hospice’s ability to deliver care. Every discharge requires a written order from the hospice medical director.10eCFR. 42 CFR 418.26 – Discharge From Hospice Care A discharge for cause triggers extra steps: the hospice must tell the patient discharge is being considered, make a genuine effort to resolve the problem, confirm the discharge is not simply because the patient is using services they are entitled to, and document the process. The attending physician, if any, should be consulted before the decision is finalized.
Volunteer Hours and Bereavement Services
Medicare’s Conditions of Participation require every hospice to maintain a volunteer program in which volunteers provide administrative or direct patient care services equal to at least 5% of the total patient care hours logged by paid employees and contract staff. Hospices must demonstrate compliance annually and be ready to show the calculation during surveys.11eCFR. 42 CFR Part 418 – Hospice Care Falling short of the 5% threshold is a common deficiency.
Bereavement counseling must be offered to the patient’s family and other individuals named in the bereavement plan of care for up to one year after the patient’s death. Medicare does not reimburse it separately; the cost is built into the per diem rate. The program must be supervised by a qualified professional with education or experience in grief counseling.
Records and Patient Privacy
Records must document assessments, care plans, medication administration, and communications with physicians and family, and they must be accessible for CDPH surveys.4California Department of Public Health. DPH-18-002E Hospice Agencies Inadequate documentation is one of the fastest ways to draw a citation and jeopardize reimbursement.
Electronic health records must comply with both federal HIPAA rules and California’s Confidentiality of Medical Information Act. Cloud-based storage is permitted when HIPAA and CMIA-compliant security is in place. Hospices must use access controls, encryption, and audit logs, and staff who handle patient records must be trained on confidentiality obligations.
When a breach happens, California imposes its own framework separate from HIPAA. Under Health and Safety Code Section 1280.15, CDPH can assess an administrative penalty of up to $25,000 per patient whose information was accessed, used, or disclosed without authorization, plus up to $17,500 for each subsequent occurrence involving the same patient’s records.12California Legislative Information. California Health and Safety Code 1280.15 Written policies must cover how and when to report a confirmed or suspected breach.
Inspections and Plans of Correction
CDPH conducts routine inspections, and facilities with prior deficiencies face more frequent unannounced visits.13California Legislative Information. California Health and Safety Code 1747 Surveyors interview staff and patients, review care plans and medical records, observe clinical procedures, and assess emergency preparedness.
When inspectors find conditions that threaten patient health or safety, they issue a Statement of Deficiencies on federal Form CMS-2567 listing each cited deficiency with its regulatory reference.14Centers for Medicare & Medicaid Services. Statement of Deficiencies and Plan of Correction CMS-2567 The hospice then submits a written Plan of Correction explaining how each violation will be fixed and by when. These documents become publicly available within 14 days of the provider receiving them.15Centers for Medicare & Medicaid Services. Release of CMS-2567: Statement of Deficiencies and Plan of Correction Failure to correct on time can bring increased oversight, mandatory retraining, or loss of Medicare certification.
Fines, Criminal Charges, and Federal Exclusion
Under Health and Safety Code Section 1424, CDPH uses a tiered citation system. Administrative deficiencies carry lower fines, while citations involving direct threats to patient health or safety carry substantially larger penalties.16California Legislative Information. California Health and Safety Code 1424 Repeated violations can lead to suspension of new admissions or mandatory compliance monitoring.
Elder abuse by hospice staff or operators is prosecuted under California Penal Code Section 368. It is a “wobbler,” charged as a misdemeanor or a felony depending on severity. A felony conviction carries a sentence of two, three, or four years in prison, and if the victim suffers great bodily injury or dies, sentencing enhancements can add three to seven additional years.17California Legislative Information. California Penal Code 368
The most damaging penalty is federal exclusion. A hospice that submits claims for services provided by an individual or entity on the Office of Inspector General’s List of Excluded Individuals/Entities can face civil monetary penalties of up to $10,000 for each item or service on those claims, plus an assessment of up to three times the amount billed, and the hospice itself can be excluded from Medicare and Medi-Cal.18Office of Inspector General. The Effect of Exclusion From Participation in Federal Health Care Programs Providers have an affirmative duty to check the OIG exclusion list before hiring or contracting; the “knew or should have known” standard means failing to screen is not a defense. Fraudulent billing can also trigger prosecution under federal and state False Claims Acts, with penalties reaching into the millions.