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Hospice personnel file checklist: what the Medicare rules ask for

Short answer: a Medicare-certified hospice keeps proof that every person who gives care is qualified and that the proof is current. For everyone with patient contact, that means a current license where one is required, a criminal background check, orientation and a competency assessment. Hospice aides add a competency evaluation by a registered nurse, 12 hours of in-service training every 12 months and a yearly on-site observation. Volunteers need orientation and training too. The rules are in 42 CFR Part 418, and surveyors read them using CMS's State Operations Manual, Appendix M.

Updated October 23, 2026 · Checked against the official sources listed at the end

Where the rules come from

The Medicare Conditions of Participation for hospices are in 42 CFR Part 418. The personnel rules sit in a few places: 418.114 (personnel qualifications and criminal background checks), 418.76 (hospice aides), 418.78 (volunteers), 418.100(g) (orientation, competency and in-service training) and 418.64 (who provides core services).

CMS's survey guidance, Appendix M of the State Operations Manual, tells surveyors to review the personnel files of a sample of employees from each discipline: physicians, nurses, hospice aides, therapists and social workers. It also tells them to check that criminal background checks were done as the rule and your state require.

Your state's hospice license and your accreditor, if you have one, add their own items on top. This guide covers the federal floor.

Why it matters: in a July 2019 report, HHS's Office of Inspector General described one hospice that failed to ensure 34 of its 35 employees who provided care had updated credentials as state and local law required. Another had not done criminal background checks on six employees with direct patient care or access to records.

Keeping hospice or home health staff files by hand? Pact tracks every license, background check, aide competency evaluation, in-service hours, TB, CPR and hepatitis B record, with reminders 30, 14 and 7 days before anything expires and monthly OIG checks. Pact Compliance Review checks every upload, usually within minutes, 24/7. $10 per active staff member a month, $250 minimum, first month free. Home health and hospice staff files · Try the sample portal for 30 days · Get my price

For everyone who gives care

Licenses and qualifications. Every professional who furnishes services, directly, under an individual contract or under arrangements, must be licensed, certified or registered as federal, state and local law require, and work within that scope. The rule adds one sentence that drives most file work: all personnel qualifications must be kept current at all times (418.114(a)). That means tracking expiration dates, not just collecting a copy at hire.

Criminal background checks. The hospice must get a criminal background check on every employee who has direct patient contact or access to patient records (418.114(d)). Follow your state's rules on how and when. If your state has none, the check must be done within three months of the date of employment and cover every state the person lived or worked in during the past three years.

Orientation and competency. A hospice must give orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact, and an initial orientation on each employee's own job duties (418.100(g)(1) and (2)). It must assess the skills and competence of everyone furnishing care, including volunteers, provide in-service training where needed, keep written policies describing how competency is assessed, and keep a written description of the in-service training given in the previous 12 months (418.100(g)(3)).

Current license, certification or registration, with its expiration date.
Criminal background check, with the date and the states covered.
Hospice philosophy orientation and job-specific orientation, dated and signed.
Competency assessment for the person's role, with who assessed and when.
Records of in-service training attended.

Hospice aides

An aide qualifies in one of four ways under 418.76(a): a training program plus a competency evaluation, a competency evaluation program on its own, a state-approved nurse aide training and competency evaluation program with the aide currently in good standing on the state nurse aide registry, or a state licensure program. If an aide goes 24 months in a row without paid aide work since finishing the program, the aide must complete a new program before giving care.

The competency evaluation is done by a registered nurse, and some skills must be observed with a patient or pseudo-patient: communication, temperature, pulse and respiration, personal hygiene and grooming, safe transfers and range of motion. An aide is not competent in any task rated unsatisfactory and may not do it without direct RN supervision until retrained and re-evaluated (418.76(c)).

Each aide needs at least 12 hours of in-service training in every 12-month period, supervised by a registered nurse (418.76(d)). Appendix M says the hospice may count the 12 months by calendar year, by employment anniversary or on a rolling basis, as long as each aide meets it. Training can happen during the every-14-days supervisory visit in a patient's home, but the new skill or theory taught has to be documented.

A registered nurse must also make an annual on-site visit to observe and assess each aide while the aide is giving care (418.76(h)(2)). When a supervisory visit finds a concern and an on-site visit confirms it, the aide completes a new competency evaluation of the deficient skill and all related skills.

Proof of the qualifying program, or the registry listing in good standing, with the date it was checked.
The RN's competency evaluation: date, evaluator, each subject area and its rating.
Any unsatisfactory task, the retraining and the re-evaluation.
In-service hours for each 12-month period: dates, topics, hours and the supervising RN.
The annual on-site observation, dated, with the RN's name.

Social workers, therapists and other disciplines

418.114(b) sets qualifications by discipline. A social worker, for example, needs a master's degree in social work from a CSWE-accredited school, or a bachelor's in social work or a related field with MSW supervision, plus one year of social work experience in a healthcare setting. Physical, occupational and speech therapists and their assistants have their own education and licensure tests. Keep the diploma or transcript where the rule depends on one, along with the license.

Where your state has no licensing law for a profession, the rule falls back to education: a registered nurse must be a graduate of a school of professional nursing, and a licensed practical nurse must have completed a practical nursing program (418.114(c)).

Volunteers

A hospice must maintain, document and provide volunteer orientation and training consistent with hospice industry standards (418.78(a)). Appendix M says the training should fit the tasks each volunteer does, and that a volunteer who provides professional services must meet that profession's requirements, including a state license where one is required.

The competency rule in 418.100(g)(3) names volunteers who furnish services. The background check rule in 418.114(d) names employees and contracted employees, so check your state's rules and your own policy for volunteers. Many hospices check them too. Keep each volunteer's role and time worked as well, since volunteer hours must equal at least 5 percent of paid patient care hours (418.78(e)).

Contracted staff

Nursing, medical social services and counseling are core services that a hospice must routinely provide through its own employees (418.64). Contracted staff may supplement them in extraordinary or other non-routine circumstances, such as unexpected high patient loads or short-term staffing shortages.

When you use contracted staff, the hospice keeps responsibility. Arranged services must be furnished by qualified personnel under a written agreement (418.100(e)). Hospice contracts must require the contracted entity to get criminal background checks on its employees with patient contact or record access (418.114(d)). Contracted staff with patient and family contact also get the hospice philosophy orientation. Ask the agency for proof, and keep it.

Items most files have that come from other rules

Exclusion checks: OIG's exclusion list and your state's Medicaid list. OIG says no law requires checking its list, but that checking monthly best minimizes the risk of liability for paying an excluded person.
Hepatitis B: OSHA's Bloodborne Pathogens standard requires the employer to offer the vaccine to workers with occupational exposure, and a worker who declines signs the Appendix A statement (29 CFR 1910.1030(f)).
Bloodborne pathogens training at initial assignment and within one year of the last training (1910.1030(g)(2)).
TB screening at hire, following CDC's 2019 recommendations unless your state asks for more.
CPR or BLS cards, if your policy requires them, with their expiration dates.
Form I-9, which USCIS requires for every employee.

How Pact helps

Pact keeps each staff member's file in one place: licenses, background checks, aide competency evaluations, in-service hours, the annual on-site observation, TB, CPR, hepatitis B and monthly OIG and state exclusion checks, each with its date. Staff send documents from their phone with no app or password, and Pact Compliance Review checks every upload, usually within minutes, 24/7. Reminders go out 30, 14 and 7 days before anything expires, and every Monday you get one email with who's expired and who's coming up.

Pact doesn't do the competency evaluation or the RN supervisory visits, and it doesn't record patient visits. Those stay with your nurses and your EHR. It's $10 per active staff member a month, $250 minimum, month to month. You can try a sample portal yourself for 30 days before you decide.

Common questions

Does every hospice employee need a criminal background check?

Every hospice employee with direct patient contact or access to patient records does (42 CFR 418.114(d)). Follow your state's rules for timing and type. If your state has none, get the check within three months of the date of employment, covering every state the person lived or worked in for the past three years.

How many in-service hours does a hospice aide need?

At least 12 hours in each 12-month period, supervised by a registered nurse (418.76(d)). CMS's Appendix M lets you count the 12 months by calendar year, employment anniversary or a rolling 12 months, as long as each aide meets it.

Can in-service training happen during a patient visit?

Yes. The rule allows in-service training while the aide is caring for a patient. Appendix M says it can happen during the every-14-days supervisory visit, but the new skill or theory taught must be documented, and it shouldn't repeat a basic skill.

What if an aide hasn't worked for pay in two years?

If there has been a continuous 24-month period without paid aide services since the aide's most recent program, the aide must complete another qualifying program before giving care again (418.76(a)(2)).

Do hospice volunteers need a personnel file?

They need documented orientation and training (418.78(a)) and a competency assessment if they furnish services (418.100(g)(3)). A volunteer who provides a professional service must meet that profession's requirements, including a license. Background checks for volunteers depend on your state and your policy.

Does Pact do the competency evaluation or the supervisory visits?

No. A registered nurse does the competency evaluation and the supervisory visits. Pact keeps the dated record of each evaluation and observation in the aide's file, with reminders, and doesn't record patient visits or connect to your EHR.

Sources

Related guides

Run a home health agency or hospice? Staff send documents from their phone with no app, Pact Compliance Review checks each one, and every staff member is checked against OIG's exclusion list monthly. $10 per active staff member a month, $250 minimum, first month free, month to month. Home health and hospice staff files · Home care agencies · Free in-service training · Try the sample portal for 30 days · Get my price · 901-666-6970