Hospice personnel files with the evidence already in them
When surveyors cite a hospice staff file, the finding usually reads "no evidence in the personnel file." Personnel Ledger keeps each person's licenses, competencies, orientation, background check and training together, and prints the file the moment it is asked for.
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Built from CMS survey reports, the federal hospice rules and CMS surveyor guidance. General information, not legal advice. Confirm your specifics with your state and your accreditor.
Three staff-file items lead the list
By our count of CMS survey reports, about one in four 2025 hospice standard surveys that found any deficiency cited at least one staff-file item. These three were cited most often.
Skills not shown as evaluated, an evaluation not done by a registered nurse, or no evaluation in the file at all.
42 CFR §418.76(c)Checks missing, obtained late, or not covering every state the person lived or worked in.
42 CFR §418.114(d)No skills check at hire, or periodic assessments that fell years behind the agency's own policy.
42 CFR §418.100(g)(3)Others that recur: orientation, emergency preparedness training, aide in-service hours and the annual on-site aide observation. The narratives behind these citations mostly read the same way: the evidence was not in the personnel file. To a surveyor, an item with no evidence in the file is an item that was not done.
The federal staff file, role by role
Your state and your accreditor can add to this. The federal hospice Conditions of Participation set the floor.
| Who | What the file needs | Rule |
|---|---|---|
| Every employee | Job-specific orientation, emergency preparedness training, infection control education, and a current license wherever the job requires one. | §418.100(g)(2), §418.113(d), §418.60(c), §418.114(a) |
| Anyone with patient contact or access to patient records | A criminal background check, plus orientation to hospice philosophy for those with patient and family contact. | §418.114(d), §418.100(g)(1) |
| Anyone who furnishes care | A skills and competency assessment, at hire and on the schedule your written policy sets. | §418.100(g)(3) |
| Hospice aides | A qualifying training path, a competency evaluation by a registered nurse, 12 in-service hours in each 12 months, and an annual on-site observation by an RN. | §418.76 |
| Contracted staff | Licenses, orientation and competency as above. Their background checks can be covered by a contract clause that requires the contracted entity to obtain them. | §418.114(a), §418.114(d)(1) |
What each state adds on top of this is in hospice staff requirements by state. To print it for one person, role by role, use the free personnel file checklist.
What surveyors ask for, and how fast you can hand it over
At the entrance conference, CMS surveyor guidance has surveyors ask for a current personnel list that includes contracted staff, and for documentation of aide training, competency evaluations and in-service training. Then they pick files.
One file per person
Every requirement for that person in one place: what applies to them, its status, its dates and the document that proves it.
Status you can explain
Each item reads current, due soon, overdue or exempt, and an exempt item says why, so nothing is silently left out of a file.
Documents next to the dates
Attach the license, the card or the signed form to the requirement it proves.
Print on request
Print the file of anyone a surveyor picks, or a binder for several people, under your agency's name and logo.
Fewer surprises in the first place
Staff are emailed before their items expire, and managers get one weekly email listing what is due for their team.
Hospice personnel files, answered
What do hospice surveyors look for in personnel files?
Evidence that each person meets the requirements for their role: current licenses, a criminal background check obtained on time, orientation, competency assessments and, for aides, the competency evaluation, in-service hours and annual on-site observation. In 2025 standard surveys, aide competency evaluations, criminal background checks and staff competency assessments were the staff-file items cited most.
What does "no evidence in the personnel file" mean?
It is the surveyor's way of saying the documentation was not there when they looked. The training may have happened and the check may have been run, but without the record in the file the requirement is treated as not met.
How often should hospice staff competency be assessed?
The federal rule (42 CFR §418.100(g)(3)) requires assessing the skills and competence of everyone who furnishes care, but it sets no interval. Surveyors hold you to your own written policy, which is commonly annual, and some states, such as New York and Georgia, require a yearly review.
Do contracted staff need personnel files too?
Yes. Contracted staff need current licenses, orientation if they have patient and family contact, competency assessment if they furnish care, and emergency preparedness and infection control training. Their criminal background checks can be covered by a contract clause that requires the contracted entity to obtain them (42 CFR §418.114(d)(1)).
Does Personnel Ledger store patient information from aide observations?
No. For the annual on-site observation it records the aide, the observing RN, the date and the results, never the patient.
Can we print files for just the staff a surveyor selects?
Yes. Print one person's file, or select several people and print their files together as a binder.
This page is general information, not legal advice. Hospice personnel requirements come from federal regulation, your state's law and your accreditor, and they change. Confirm your specific obligations with your state licensing authority and your accreditor.
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