California’s New Hospice Emergency Regulations: Strengthening Oversight, Access, and Accountability 

California’s (CA) hospice emergency regulations (CDPH-18-002E) were approved and are effective on June 22, 2026, and introduce major changes to curb fraud, strengthen oversight, and improve patient care; while placing new operational, staffing, documentation, and governance demands on hospice providers. All CA hospice providers are strongly encouraged to review the hospice emergency regulations (CDPH-18-002E) in detail to ensure understanding and compliance with all requirements.  

Lead Up to New Regulations 

In response to program integrity concerns, California enacted SB 664 and Health and Safety Code section 1751.70 in 2021, pausing new hospice licenses. A 2022 California State Auditor report found significant indicators of hospice fraud and abuse, especially in Los Angeles County, and urged immediate action to protect patients. AB 2673 authorized emergency regulations to implement the Auditor’s recommendations and extend the moratorium, while AB 177 later set January 1, 2026, as the deadline for issuing rules and January 1, 2027, or one year after adoption, as the moratorium end date. 

The emergency regulations strengthen the Department’s authority to deny, revoke, or refuse renewal of licenses; investigate complaints; and act against operators involved in fraud, overbilling, substandard care, or misuse of medical professionals’ identities. They also establish stricter standards for applications, staffing verification, patient protection, and oversight. 

The following are highlights of the emergency regulations. 

A More Restrictive and Transparent Licensing Environment 

• The regulations create a stricter licensing framework to remove bad actors from the environment and increase transparency. 

• Hospices may not admit patients, advertise, or begin services until fully licensed. They must also publicly display their license and obtain separate hospice licensure, even if operating as another health facility or home health agency. 

• Ownership rules are also tighter: changes of 50% or more require formal review, and ownership interests as low as 5% must be disclosed. 

• A five-year limit on ownership changes, with limited exceptions, is intended to stabilize the market and prevent rapid license turnover. 

Heightened Oversight and Enforcement Authority 

The rules significantly expand CDPH’s enforcement authority. Enforcements highlights include but are not limited to: 

• Hospices are subject to unannounced inspections at any time and must provide access to patient records, billing data, personnel files, and electronic systems. Noncompliance can lead to denial, suspension, or revocation of licensure. 

• Enforcement triggers include fraudulent billing, falsified documentation, improper eligibility decisions, prior discipline, privacy violations, and patient safety failures. 

• Together, these changes reflect a more aggressive focus on compliance and patient protection. 

Geographic Regulatory Highlights 

• Hospices must ensure 24/7 licensed nurse access within two hours for all patients in the service area, effectively limiting the geographic area they may serve. 

• Service areas must be calculated using actual driving time, peak traffic conditions, at least four time/distance samples, an average radius, and timestamped documentation. 

• Hospices may serve only counties with demonstrated unmet need, based on eligible hospice population and existing county capacity. 

• Approval is granted only when demand exceeds capacity, creating a data-driven limit on new entrants and expansion. 

• Cannot operate or advertise outside approved area. 

• Any expansion or modification must be pre-approved. 

Staffing and Leadership Expectations Raised 

The regulations raise expectations for staffing, clinical oversight, and leadership accountability. 

Staffing Requirements 

• 24/7 Nursing Coverage: Must provide licensed nursing services at all times  

• Caseload Limit: Max 12 patients per licensed nurse 

• 2-Hour Response: RN must be able to respond in person within 2 hours 

• Patient Acuity System Required: A hospice must develop, implement, and maintain documented policies and procedures that contain the criteria for determining patient acuity levels and nurse caseloads. 
  • Staffing must reflect patient complexity 
  • System must be reviewed at least annually 
  • Flexible Staffing: Add personnel (aides, volunteers) based on patient need 

Leadership Requirements 

• Defined roles: Administrator, Administrator designee, DPCS, Medical Director 

• The Administrator or the Administrator Designee must be on the premises of the hospice or accessible by telecommunication during their scheduled work hours 

• Must meet experience and licensure standards 

• Restrictions on working across multiple hospices 

• Vacancies must be filled within 60 days  

Clinical Care Standards: More Structure, More Accountability 

Overall, the regulations emphasize coordinated, accountable, and measurable care. 

• Strict Admission Criteria: 
  • Physician certification required 
  • Life expectancy ≤ 12 months 

• Defined Assessment Timeline: 
  • Initial assessment within 48 hours 
  • Comprehensive assessment within 5 days 
  • Reassessment at least every 15 days 

• Interdisciplinary Care Model 
  • Care must be delivered by a full interdisciplinary team 
  • Includes clinical, psychosocial, and spiritual support 
  • Patient and family involvement required 

• Plan of Care Requirements 
  • Must be individualized, physician-approved, and updated every 15 days. 
  • Must include goals, treatments, symptoms, services, pain management, and safety measures. 

• Ongoing Monitoring and Coordination 
  • Continuous evaluation of patient condition 
  • The interdisciplinary team must update care plans and communicate significant changes within 24 hours. 

Documentation and Medical Records: A New Level of Detail 

The regulations set higher expectations for documentation and recordkeeping. 

• Hospices must maintain complete records covering assessments, care plans, medications, and interdisciplinary communications. 

Records must be: 

• Documentation and medical records must fully reflect all care provided, including assessments, plans of care, medications, interdisciplinary team activity, and discharge information. 

• Records must be available 24/7 for patient care, regulatory review, and patient access requests. 

• Hospices are required to retain records for a minimum of 10 years, with extended requirements for minors. 

• Electronic records must include audit trails, user authentication, and regular backups to ensure accuracy and traceability. 

• All entries must be timely, clearly documented, and authenticated, with corrections properly explained and tracked. 

• Strict compliance with HIPAA and CA privacy laws is required, including secure storage, controlled access, and breach reporting. 

• Records must be organized, retrievable, and protected from loss, destruction, or unauthorized access, including when stored off-site or electronically. 

• Patients have the right to access, obtain copies of, and request changes to their records within required timeframes. 

• Overall, documentation must support clinical care, demonstrate compliance, and withstand regulatory scrutiny at any time. 

• Electronic systems must include audit trails, authentication, and backups to protect data integrity and access. 

• Documentation must support both care delivery and regulatory review. 

Training, Compliance, and Organizational Readiness 

• Training requirements are expanded for hospice leadership, with first-time administrators, medical directors, and clinical leaders required to complete formal education or certification focused on operations, clinical management, compliance, and quality oversight within their first year. 
  • First-time administrators, medical directors, and clinical leaders must complete 24 hours of specialized training in their first year. Management personnel must also complete: 
    • 20 hours of orientation training 
    • 12 hours of annual continuing education 

• All hospice management personnel must complete structured onboarding training shortly after hire. 
  • Training covers compliance, fraud prevention, infection control, patient rights, clinical care standards, and emergency preparedness 

• Ongoing competency is reinforced through required annual training to ensure continued focus on compliance, patient care quality, and operational standards. 

• Compliance expectations are embedded in daily operations through required policies, procedures, and documentation systems that address clinical care, staffing, infection control, complaint management, and fraud prevention. 

• Organizations must demonstrate the ability to identify deficiencies, implement corrective actions, and sustain improvements through formal oversight processes such as plans of correction and internal monitoring systems. 

• Leadership accountability is emphasized, with responsibility for ensuring regulatory compliance, maintaining accurate documentation, and overseeing operational performance. 

• Organizational readiness requires strong infrastructure, including systems for documentation accuracy, regulatory reporting, staff competency validation, and continuous survey readiness. 

• Overall, the regulations establish a disciplined, compliance-driven operating model that requires active leadership oversight and continuous organizational monitoring. 

What This Means for Hospice Providers 

The emergency regulations mark a major shift in California hospice oversight and create a more controlled, performance-driven environment focused on quality, accountability, and patient-centered care. The overarching themes are clear: 

• Stronger guardrails against fraud and abuse 

• Staffing considerations to enhance quality of care 

• Greater transparency in ownership and operations 

• Data-driven limitations on market growth 

• Increased accountability for leadership and clinical care 

• Elevated expectations for documentation and compliance systems 

Providers will need updated policies, stronger infrastructure, focused training, and governance practices that support sustained compliance. Organizations that align quickly will be better positioned to maintain compliance in a changing hospice landscape. 

Questions about the content of this rule? Contact CHAP  

References 

California Department of Public Health. (2026, June 1). Finding of emergency: Emergency regulations for hospice agencies (DPH-18-002E). 

California Department of Public Health. (2026). Emergency regulations for hospice agencies (CDPH-18-002E).