Staff competency on file for everyone who furnishes care
Hospices must assess the skills and competence of every person who furnishes care, by a method their written policy describes. Personnel Ledger tracks the first assessment and every repeat on your interval, with who did it and how, so the file shows it was done.
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Built from the federal hospice staffing rules, CMS guidance and CMS survey reports. General information, not legal advice. Confirm your specifics with your state and your accreditor.
Everyone who furnishes care, assessed by a written method
The hospice must assess the skills and competence of all individuals furnishing care, including volunteers furnishing services.
42 CFR §418.100(g)(3)The hospice must have written policies and procedures that describe how it assesses competency.
42 CFR §418.100(g)(3)The hospice keeps a written description of the in-service training it provided during the previous 12 months.
42 CFR §418.100(g)(3)The rule names no interval. CMS's own COVID-19 waiver document described it as an annual assessment, and in practice surveyors hold a hospice to its own written policy. Accreditor findings in 2025 quoted the same idea: competence assessed and documented once every three years, or more often if the organization's policy says so.
Some states set the interval for you. New York requires an annual performance and competency review, volunteers included, and Georgia expects the HR file to show skills competency every year. So each file needs two things: an initial assessment at hire or orientation, and a periodic one on the schedule your policy sets.
A finding on 149 surveys in 2025
By our count of CMS survey reports, 149 of the 2,031 hospice standard surveys in 2025 that found any deficiency cited L0663, the competency standard. The narratives describe files, not skills: the assessment may have happened, but the record was not there.
Source: our count of CMS QCOR hospice survey reports (Form CMS-2567), CY2024 and CY2025 standard surveys with at least one finding, state agencies and accreditors combined.
No skills check at orientation
Files for a registered nurse, an alternate director of nursing, a volunteer coordinator and a bereavement coordinator showed no discipline-specific competency done during orientation.
Annual checks years behind
A New Hampshire state survey found 7 of 11 personnel files whose "annual" evaluations were years old.
Volunteers left out
The rule names volunteers who furnish services, and accreditor findings cited volunteer files with no competency record.
Behind the hospice's own policy
Findings measured files against the hospice's own written schedule, and cited the ones that had fallen behind it.
An initial check, then the schedule your policy sets
Two requirements
An initial competency assessment that happens once, at hire or orientation, and a periodic one that repeats on the interval in your written policy. Twelve months is the suggested starting point.
Only the roles that furnish care
Apply it to the roles that furnish care, contracted clinicians included. Office roles that furnish no care simply do not carry it.
Due from the hire date
The initial assessment comes due a set number of days after hire, so a new nurse shows as due from day one.
The method beside the result
Record the date, who assessed the person, the method and the result, and attach the competency tool they completed.
A nudge before it lapses
Staff get an email before their next assessment is due, and managers see who is coming due in one weekly digest.
Three places your interval comes from
Personnel Ledger repeats the assessment on whatever interval you set. These are the sources to check before you set it.
Your written policy
The federal rule leaves the method and the schedule to your policy, so the requirement in your files should match what that policy says.
42 CFR §418.100(g)(3)Your state
New York and Georgia set a yearly review in state rules. Other states may add their own; see the state guide.
10 NYCRR 794.3; Ga. r. 111-8-37-.13Your accreditor
Accreditor findings in 2025 held hospices to "once every three years, or more frequently as required by organization policy."
Accreditor survey findingsHospice aides have their own evaluation, done by a registered nurse before they furnish care: see aide competency evaluation. State rules are in staff requirements by state.
Staff competency assessments, answered
Is an annual competency check a federal requirement for hospice staff?
The federal rule (42 CFR §418.100(g)(3)) requires a competency assessment for everyone who furnishes care but does not name an interval. CMS's COVID-19 waiver document described it as annual, and surveyors measure your files against your own written policy, so set the interval there and keep to it.
Who counts as furnishing care for this rule?
Everyone who furnishes care or services to patients: nurses, aides, social workers, counselors, therapists and physicians, contracted staff included, and volunteers who furnish services. Office staff who furnish no care are outside this rule, though they still need job-specific orientation.
How is this different from the hospice aide competency evaluation?
The aide evaluation (42 CFR §418.76(c)) is a specific skills evaluation done by a registered nurse before an aide furnishes care. The staff competency assessment covers everyone who furnishes care, aides included, using the method your written policy describes. Aides fall under both rules.
Do hospice volunteers need a competency assessment?
Yes. The rule names volunteers who furnish services. Volunteer files usually live with the volunteer program; Volunteer Ledger tracks volunteer requirements the same way.
What does the written competency policy need to cover?
The rule asks for written policies and procedures that describe your method or methods of assessing competency. Put the schedule in the same policy, because that is the standard a surveyor will check your files against.
What is the written description of in-service training?
The same rule asks the hospice to keep a written description of the in-service training it provided during the previous 12 months. Training sessions logged in Personnel Ledger, each with its date, topic and hours, give you the record to write it from.
This page is general information, not legal advice. Competency requirements come from federal regulation, your state's law, your accreditor and your own written policy, and they change. Confirm your specific obligations with your state licensing authority and your accreditor.
See whose competency check is due before it lapses
Personnel Ledger tracks initial and periodic competency for everyone who furnishes care, on the interval your policy sets. Start a free 45-day trial and add your team today.