Contracted hospice staff, with files a surveyor can check
Contracted therapists, agency nurses and aides under arrangement all appear on the personnel list surveyors ask for. Personnel Ledger keeps their licenses, orientation, competency and training beside your employees' files, and shows which rules apply to them.
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Built from the federal hospice staffing rules, CMS surveyor guidance and CMS survey reports. General information, not legal advice. Confirm your specifics with your state and your accreditor.
Which staff-file rules reach contracted staff
Many federal staff-file rules reach contracted staff as well as employees, and a few are written for employees only. This is how they divide.
| Item | Contracted staff | Rule |
|---|---|---|
| Current license or certification | Yes, for anyone furnishing services directly, under an individual contract or under arrangements. | §418.114(a) |
| Orientation to hospice philosophy | Yes, when they have patient and family contact. | §418.100(g)(1) |
| Job-specific orientation | No. The rule is written for each employee. | §418.100(g)(2) |
| Skills and competency assessment | Yes, for everyone furnishing care. | §418.100(g)(3) |
| Emergency preparedness training | Yes, individuals providing services under arrangement are included. | §418.113(d)(1)(i) |
| Infection control education | Yes, contracted providers are included. | §418.60(c) |
| Criminal background check | Through the contract: it must require the contracted entity to obtain the checks. | §418.114(d)(1) |
| Aide competency and the rest of the aide file | Competency, yes: CMS surveyor guidance says aides under arrangement must also be competency-checked. Keeping their in-service hours and annual observation on file too is the safer reading. | §418.76; IG at L0616 |
At the entrance conference, CMS surveyor guidance has surveyors ask for a current personnel list that includes all staff under contract, with names and titles.
The background check lives in the contract
"Hospice contracts must require that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records" (42 CFR §418.114(d)(1)). When the clause is missing, the finding lands on the background check tag, L0795, which was cited on 107 hospice standard surveys in 2025 by our count.
Therapy contracts without the clause
Two 2025 accreditor findings cited therapy contracts that never required the contracted entity to run background checks.
Equipment contracts count too
A durable medical equipment contract was cited for the same missing clause.
A clause with no owner
Another contract was cited because it did not say who would obtain the checks.
The proof sits in two places
The signed agreement with the clause, and each contracted person's file showing how their check is covered.
Core services stay mostly in house
Core services
Nursing, medical social services and counseling must be provided substantially all by hospice employees. Contracted staff may supplement them only in extraordinary or other non-routine circumstances.
42 CFR §418.64Physician services
Physician services may be contracted, and so may highly specialized nursing services.
42 CFR §418.64(a), (b)(3)Everything under arrangement
Whoever furnishes the service, the hospice keeps administrative and financial management and oversight of staff and services.
42 CFR §418.100(e)The non-routine circumstances the rule describes include unanticipated high patient loads, staffing shortages due to illness or other short-term temporary situations, and a patient's temporary travel outside the service area. Keep a note of the circumstance and the dates whenever contracted staff fill in for a core service.
One list, with each person's employment type
Employment type on every person
Employees, per-diem staff and contractors sit in one list, each marked with how they work for you.
Requirements follow the role
A contracted therapist carries the therapy license, orientation, competency and training their role needs, just like an employee in the same role.
Not required, with the reason
Job-specific orientation can be marked not required for a contractor, with the reason written down, so it never reads as missing.
The clause as the evidence
Attach the agreement to the contracted person's background check requirement and note how their check is covered.
On the list a surveyor asks for
Contracted staff are part of the staff list and print in a binder alongside your employees.
Contracted staff files, answered
Which hospice staff-file rules apply to staff under arrangement?
Current licensure, orientation to the hospice philosophy if they have patient and family contact, competency assessment if they furnish care, emergency preparedness training and infection control education. Their background checks are covered through the contract. Job-specific orientation is the one federal item written for employees only.
Who obtains background checks on contracted hospice staff?
The contracted entity does. Hospice contracts must require it to obtain criminal background checks on its employees who have direct patient contact or access to patient records (42 CFR §418.114(d)(1)). Keep the signed agreement with that clause.
Does a contractor need job-specific orientation?
Not under the federal rule, which is written for each employee (42 CFR §418.100(g)(2)). A contractor with patient and family contact still needs orientation to the hospice philosophy, and your own policy can ask for more.
Do agency aides need their own in-service hours and competency evaluation?
Their competency, yes: CMS surveyor guidance says aides furnished under arrangement must also have their competency checked. The safer reading is to keep their in-service hours and annual observation in the file as well. Confirm how your accreditor reads it.
Can a hospice contract out nursing or social work?
Only to supplement its own staff in extraordinary or other non-routine circumstances, because nursing, medical social services and counseling are core services provided substantially all by employees (42 CFR §418.64). Physician services and highly specialized nursing may be contracted.
Do surveyors ask about contracted staff?
Yes. At the entrance conference, CMS surveyor guidance has them ask for a current personnel list that includes all staff under contract, along with the list of contracts and agreements.
This page is general information, not legal advice. Requirements for contracted staff come from federal regulation, your state's law, your accreditor and your contracts, and they change. Confirm your specific obligations with your state licensing authority and your accreditor.
Keep contracted staff files as current as your own
Personnel Ledger tracks contracted staff and staff under arrangement in the same list as your employees. Start a free 45-day trial and add your contracted team today.