The Hospice Conditions of Participation (42 CFR §418.64: Core Services) requires that “A hospice must routinely provide substantially all core services directly by hospice employees. Core services include nursing services, medical social services, and counseling services. Hospices may contract for physician services.

This CoP further states that “A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances.” Hospices may also enter into a written arrangement with another Medicare-certified hospice program to assist in providing core services.

Nursing Shortage

In addition to its own employees, situations when a hospice may enter into a written arrangement with another provider for the provision of core services to supplement hospice employees include:

  • Unanticipated periods of high patient loads;
  • Staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and
  • Temporary travel of a patient outside of the hospice’s service area.

In these intermittent and/or temporary situations, hospices may supplement their provision of core services without any waiver or exemption from the State Survey Agency or the CMS Regional Office. However, surveyors are expected to be alert to situations where the provider is utilizing contracted core services, specifically nursing services, in place of direct staff.

As a result of the current labor statistics and the national nursing shortage, CMS has designated the nursing shortage as an extraordinary circumstance and has extended the time during which this designation exists until September 30, 2020. During this time, hospice agencies that are unable to provide a sufficient number of nursing staff directly to meet the needs of its patients may utilize contracted staff in addition to their full-time nursing staff. Agencies are not required to notify CMS of its use of contracted staff during this time.

This extension and waiver does not extend to counseling services and medical social services, other core hospice services.

Resource: CMS (December 21, 2018). Extension of the Designation of the Current Nursing Shortage as an “Extraordinary Circumstance” per 42 CFR 418.64 Core Services: Ref: QSO-19-03-Hospice. Available at: