California Hospice Regulations: Licensing, Staffing, and Penalties

California hospice regulations sit on two tracks that run in parallel: a state licensing scheme administered by the California Department of Public Health (CDPH) under Health and Safety Code Chapter 8.5, and the federal Medicare Conditions of Participation that any hospice billing Medicare or Medi-Cal must also meet. Together they govern who can run a hospice, who can work in one, how patients are admitted and discharged, what rights patients have, how records are kept, and what happens when something goes wrong. Noncompliance can trigger state fines, loss of license, criminal charges for abuse or neglect, and exclusion from federal healthcare programs.

Getting and Keeping a CDPH License

Every hospice operating in California must hold a license from the CDPH under Health and Safety Code Section 1745.¹ Applicants submit documentation to CDPH, undergo background checks for prior healthcare violations or fraud, and demonstrate financial capacity to sustain operations. For fiscal year 2025–26, the statewide hospice licensing fee is $2,780 for a two-year license period.²

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 satisfy licensing requirements. That option has to be selected in the initial license application.³

Staffing Qualifications

Medical Director

The medical director must hold a current license from the Medical Board of California or the Osteopathic Medical Board of California and 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.⁴ Federally, the medical director certifies that each patient is terminally ill with a prognosis of six months or less, makes admission recommendations, and reviews each patient’s care plan with the interdisciplinary group.⁵

Registered Nurses

RNs providing hospice care must hold an active California Board of Registered Nursing license and complete specialized hospice training. Supervisory RNs in home health and hospice settings are generally expected to have at least one year of professional nursing experience.⁶ Certification from the Hospice and Palliative Credentialing Center is common but not a state mandate.

Social Workers and Chaplains

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.

Care Planning, Medications, and 24-Hour Coverage

Every patient needs an individualized plan of care built by the interdisciplinary group, which includes at minimum a physician, registered nurse, social worker, and counselor. Federal regulations require the plan to be reviewed and updated at least every 15 calendar days, or sooner if the patient’s condition changes, and each revision must document progress against the plan’s goals.⁷

Hospices must set protocols for prescribing, storing, and administering medications, with especially tight controls around Schedule II drugs such as morphine and fentanyl. Dispensation, administration, and destruction of unused doses all require detailed tracking records, and documentation gaps are treated seriously during inspections.

California also requires a registered nurse on call 24 hours a day for urgent medical concerns and coordination with attending physicians, along with crisis intervention protocols for severe pain or acute symptom episodes. Each agency must run an infection prevention program with documented sanitization procedures, staff training, and biohazardous waste protocols. Because most hospice care takes place in patients’ homes, the infection control program has to account for environments the agency does not control.

Admitting and Discharging Patients

Two physicians must certify in writing that a patient has a life expectancy of six months or less if the illness runs its normal course before a hospice admits the patient and bills Medicare. For the initial 90-day benefit period, the 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 hospice physician needs to recertify.⁸

Timing matters. Written certification must be in hand before the hospice submits a claim. If a written version cannot be completed within two calendar days of the start of a benefit period, the hospice must at least obtain an oral certification 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.⁸

Discharge is not an administrative decision. 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 medical director.⁹

A discharge for cause carries added 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 entire process. If the patient has an attending physician, that physician should be consulted before the decision is finalized.⁹

Patient Rights and the Election Statement

At the initial assessment visit, before any care begins, the hospice must give the patient both verbal and written notice of their rights in a language the patient understands and obtain a signed acknowledgment.¹⁰ Protected rights include effective pain and symptom control for conditions related to the terminal illness, participation in developing the plan of care, refusal of any care or treatment, choice of attending physician, a confidential clinical record, and freedom from mistreatment, neglect, and any form of physical, verbal, mental, or sexual abuse.

If a hospice employee witnesses or suspects abuse, neglect, or misappropriation of patient property, the hospice must be notified immediately, launch an investigation, and report verified violations to the appropriate state and local agencies within five working days.¹⁰

The hospice election statement has its own requirements. For Medicare beneficiaries, it must include cost-sharing information, a description of what the hospice will and will not cover, and notification 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.

Volunteers and Bereavement

Medicare’s Conditions of Participation require every hospice to maintain a volunteer program where volunteers provide administrative or direct patient care services equal to at least 5% of total patient care hours logged by paid employees and contract staff. Hospices must demonstrate compliance annually and show their calculations during surveys.¹¹ Falling short of 5% is a frequent survey 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, covering emotional, psychosocial, and spiritual support related to grief and loss. Medicare does not reimburse bereavement services separately; the cost is built into the per diem rates. The program must be supervised by a qualified professional with education or experience in grief counseling.¹¹

Records and Privacy

Hospices must maintain complete records of assessments, care plans, medication administration, and communications with physicians and family. California’s hospice regulations require those records to be accessible for CDPH surveys and departmental requests.⁴ Inadequate documentation is one of the fastest routes to a deficiency citation and jeopardized reimbursement.

Electronic health records must comply with HIPAA and California’s Confidentiality of Medical Information Act. Cloud-based storage is permitted if HIPAA- and CMIA-compliant security precautions are in place, which means access controls, encryption, and audit logs.⁴ Staff who handle patient records must receive training on HIPAA privacy and security rules and California-specific protections.

California adds its own breach penalties on top of 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.¹² Written policies covering how and when to report a confirmed or suspected breach are also required.

Inspections and Plans of Correction

CDPH conducts routine inspections, and facilities with prior deficiencies face more frequent unannounced visits.¹³ 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 citation with its regulatory reference.¹⁴ The hospice then submits a written Plan of Correction explaining how each violation will be fixed and when. These documents become publicly available within 14 days of the provider receiving them.¹⁵ Failing to correct deficiencies on time can lead to increased oversight, mandatory retraining, or loss of Medicare certification.

Penalties

State Civil Penalties

CDPH uses a tiered citation system under Health and Safety Code Section 1424. Violations are classified by severity, with administrative deficiencies drawing smaller fines and citations involving direct threats to patient health or safety carrying substantially larger penalties.¹⁶ Repeated violations can lead to suspension of new admissions or mandatory compliance monitoring.

Criminal Liability

Staff or operators who commit elder abuse face prosecution under California Penal Code Section 368. Elder abuse is a wobbler, chargeable as a misdemeanor or felony depending on severity. A felony conviction carries a sentence of two, three, or four years in prison. If the victim suffers great bodily injury or dies, sentencing enhancements add three to seven additional years.¹⁷

Federal Exclusion and False Claims

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. The hospice itself can also be excluded from Medicare and Medi-Cal.¹⁸

Providers have an affirmative duty to check the OIG exclusion list before hiring or contracting with any individual. The “knew or should have known” standard means failing to screen is not a defense. In practice, exclusion ends most hospice operations, since the bulk of hospice revenue flows through Medicare.¹⁸ Fraudulent billing can also trigger prosecution under federal and state False Claims Acts, with penalties reaching into the millions. For any hospice facing a compliance issue, swift corrective action is the difference between a manageable citation and the kind of cascading enforcement that ends an organization.

1
Justia. California Health and Safety Code Sections 1745-1746
2
California Department of Public Health. Health Care Facility Licensing Fees
3
The Joint Commission. Hospice Licensure Fact Sheet
4
California Department of Public Health. DPH-18-002E Hospice Agencies
5
Federal Register. Medicare Program FY 2026 Hospice Wage Index and Payment Rate Update
6
California Department of Public Health. AFL-12-03 – Program Flexibility for Home Health Agencies Nursing Experience Requirements
7
eCFR. 42 CFR 418.56 – Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services
8
eCFR. 42 CFR 418.22 – Certification of Terminal Illness
9
eCFR. 42 CFR 418.26 – Discharge From Hospice Care
10
eCFR. 42 CFR 418.52 – Condition of Participation: Patient’s Rights
11
eCFR. 42 CFR Part 418 – Hospice Care
12
California Legislative Information. California Health and Safety Code 1280.15
13
California Legislative Information. California Health and Safety Code 1747
14
Centers for Medicare & Medicaid Services. Statement of Deficiencies and Plan of Correction CMS-2567
15
Centers for Medicare & Medicaid Services. Release of CMS-2567: Statement of Deficiencies and Plan of Correction
16
California Legislative Information. California Health and Safety Code 1424
17
California Legislative Information. California Penal Code 368
18
Office of Inspector General. The Effect of Exclusion From Participation in Federal Health Care Programs