California hospice agencies now have more specific Title 22 requirements governing applications, ownership changes, relocations, management changes, staff qualifications, office space, license renewals, and other reportable events.
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At The Home Health Consultant, we work with Medicare-certified home health and hospice agencies on licensing, Medicare enrollment, compliance, and ongoing regulatory readiness. We are breaking down these requirements to help hospice owners understand which changes require advance planning, how quickly certain events must be reported, and what agencies should review before submitting their next application.
This article was written in consultation with Kelly McCarthy & Mariam Treystman.
These requirements apply specifically to CDPH-licensed hospice agencies in California.
As Kelly McCarthy explained during our recent webinar:
“Planning and preparedness is really what's going to set you up for success in hospice now.”
That is particularly true when it comes to applications. Under the new requirements, many changes can no longer be implemented first and addressed with CDPH afterward.
Why Did California Change the Title 22 Requirements for Hospice Applications?
The new Title 22 requirements were developed in connection with California's efforts to strengthen oversight of hospice agencies and the requirements surrounding the state's hospice moratorium.
Among the changes are additional documentation requirements for new applicants, longer advance-notification periods for certain changes, more specific management qualification requirements, and clearer expectations surrounding hospice office locations.
The practical takeaway is that agency owners need to consider regulatory timelines before committing to a transaction, signing a lease, moving an office, changing management, or restructuring ownership.
What Will New California Hospice Applicants Need to Submit?
When new hospice applications are permitted, applicants should expect additional documentation requirements.
These include, but are not limited to:
- Proof of sufficient funds to operate the hospice for at least the first three months
- Proof of general liability insurance
- Proof of workers' compensation coverage
- A written volunteer recruitment and training plan
- Documentation supporting the hospice's Geographic Service Area, or GSA, calculations
These requirements mean that an applicant will need to demonstrate that the agency has the appropriate corporate and clinical structure. The applicant will also need to prove that they have the financial and operational resources to actually establish and operate the hospice.
How Far in Advance Must a California Hospice Report a Change of Ownership?
A 100% change of ownership, or CHOW, must be submitted at least four months before the intended effective date.
The existing owner must remain in control of the hospice until CDPH approves the transaction. The purchaser cannot simply take control of the agency on the contractual closing date if CDPH approval has not yet been obtained.
Following a 100% CHOW, the five-year ownership probationary period begins again.
The application also requires additional transaction documentation, including:
- A preliminary purchase agreement
- Documentation demonstrating that the purchaser has sufficient financial resources to complete the transaction
Another important consideration is processing time. The four-month filing requirement is an advance-notification requirement, not a guarantee that CDPH will approve the application within four months.
In our experience, hospice applications can take considerably longer to process, sometimes over a year.
Agencies should therefore structure purchase agreements and proposed effective dates around the possibility that regulatory approval may take substantially longer than the minimum filing period.
Which Other Hospice Changes Require Four Months' Advance Notice?
The advance-notification requirement is not limited to a 100% CHOW.
Other changes that may require submission at least four months before the intended effective date include:
- Stock transfers
- Indirect ownership changes
- Other ownership changes
- Certain changes to the hospice's Geographic Service Area
A hospice should not begin operating under a proposed ownership structure or begin providing care in a newly requested GSA before receiving the required approval.
For owners considering a sale, investment, stock transfer, or restructuring, this makes regulatory review an important part of transaction planning. It is not something to address after the business terms have already been finalized.
How Far in Advance Must a California Hospice Report a Change of Location?
A change of location generally must be submitted at least two months before the intended effective date.
In practical terms, that means the hospice should not move into a new office and then submit a change application afterward.
During our webinar, Kelly discussed limited circumstances involving infrastructure damage in which an expedited move may be necessary. In those situations, the hospice should be prepared to provide documentation supporting the circumstances, which may include photographs, insurance documentation, or other evidence of the damage.
Important Note: Agencies should not assume an exception applies simply because a move is urgent or convenient.
How Far in Advance Must a Hospice Report a Change in Services?
Changes to the hospice's approved services also generally require submission at least two months before the intended effective date.
Before adding, eliminating, or materially changing a licensed service, the agency should determine whether a CDPH application or notification is required and whether approval must occur before implementation.
This is another reason hospice owners should incorporate regulatory review into operational decision-making before a change takes place.
Which Hospice Changes Must Be Reported Within 10 Business Days?
Certain changes operate on a much shorter reporting timeline.
During our webinar, Kelly identified changes that must be reported within 10 business days of their effective date, including changes involving but not limited to:
- Administrator
- Administrator Designee
- Director of Patient Care Services (DPCS)
- DPCS Designee
- Medical Director
- Medical Director Designee
- Provider or Medi-Cal status
- Governing board
- Agency name
- Mailing address
- Property owner
The important distinction is that not every hospice change follows the same timeline.
Some changes must be submitted months before they occur. Others must be reported shortly after they become effective.
Before implementing any major change, the agency should determine which category applies.
What Are the New California Hospice Office Requirements?
CDPH is looking for several specific elements in a hospice's physical office.
The hospice must have the following, including but not limited to:
- An unshared commercial space and a lease lasting at least 12 months. Month-to-month leases do not meet the requirement. The office also needs permanent interior and exterior signage, with business hours visible to the public.
- A telephone line answered 24/7, 365 days per year
- An employee physically present during business hours
- Secure storage for patient & personnel records, medications, medical supplies, and equipment
- Access to a restroom during business hours
Important Note: the restroom does not have to be private or located inside the hospice suite. A building restroom may be acceptable as long as it is accessible during business hours.
We also recommended making sure the agency's business hours are consistent across its website, office signage, and other public-facing information. Staffing schedules, attendance records, and visitor logs can also help demonstrate that the office is operational during those hours.
Because some of these requirements are relatively new, we have not seen how CDPH will verify these requirements yet. It could be through an application, an onsite visit, or another process, so your agency should be prepared for all options.
What Are the New Qualification Requirements for Hospice Administrators, DPCS, and Medical Directors?
Arguably some of the most important changes under Title 22, are the new management requirements. These affect agency leadership roles including your administrator, DPCS, Medical Director, and designees. This is an area your agencies should review immediately.
What are the Administrator Requirements?
For an Administrator or Administrator Designee, the individual must have:
A bachelor's degree or higher in a health-related field
At least two years of full-time supervisory or managerial experience in a hospice, home health agency, primary care clinic, or health facility within the preceding five years
No disciplinary action within the previous seven years
The individual cannot serve as an administrator for more than one hospice at a time. The same restriction applies to administrator designees, including across the two roles.
Example: If Jane Smith is the Administrator of ABC Hospice, she cannot simultaneously serve as the Administrator or Administrator Designee for another hospice. Likewise, an individual serving as an Administrator Designee for one hospice cannot serve as the Administrator of another hospice at the same time.
What are the DPCS requirements?
For a DPCS, Kelly described two qualification pathways in our recent webinar:
An RN with a bachelor's degree or higher in a health-related field, needs two years of full-time supervisory experience in home health or hospice within the previous five years.
An RN without a bachelor's degree needs four years of full-time supervisory experience.
A DPCS also cannot serve as the DPCS or DPCS Designee for more than one hospice at a time. This restriction applies across both roles.
Example: If Jane Smith is the DPCS for ABC Hospice, she cannot simultaneously serve as the DPCS or DPCS Designee for XYZ Hospice. Likewise, if she is the DPCS Designee for ABC Hospice, she cannot serve as the DPCS or DPCS Designee for another hospice at the same time.
*New Requirement: the emphasis on full-time experience is new.
What are the Medical Director requirements?
A Medical Director or Medical Director Designee must hold a current MD or DO license.
*New Requirement: An MD must now have at least two years of full-time supervisory or managerial experience in hospice, home health, or palliative care within the previous five years.
These individuals cannot have disciplinary action within the prior seven years and cannot serve in the covered role for more than one hospice.
The Medical Director Designee must now also be reported to CDPH. If the Medical Director or designee is contracted, Kelly explained that the contract must be submitted with the application.
A Medical Director (MD) also cannot serve as the MD or MD Designee for more than one hospice at a time. This restriction applies across both roles.
Example: If Jane Smith is the MD for ABC Hospice, she cannot simultaneously serve as the MD or MD Designee for XYZ Hospice. Likewise, if she is the MD Designee for ABC Hospice, she cannot serve as the MD or MD Designee for another hospice at the same time.
Can Hospice Management Staff Hold the Same Position at Multiple Agencies?
The one-agency limitation applies to serving in these positions at more than one hospice.
A hospice DPCS may also work as a DPCS for home health agencies, provided the individual meets the applicable home health requirements.
However, that could get tricky. It is likely best to aim to get a DPCS that only works for your agency.
There are exceptions for rural areas, but CDPH has not provided the complete regulatory criteria defining those exceptions. So, agencies should not assume that an exception applies without reviewing their circumstances.
What Must a Hospice Do When a Management Position Becomes Vacant?
A reportable management vacancy should generally be filled within 60 days.
If the hospice is unable to fill the position within that period, Kelly explained that the agency must request an extension from CDPH.
Hospices should have a written process for vacancies that addresses the following, including but not limited to:
- The date the vacancy occurred
- Immediate posting of the open position
- Copies of advertisements and recruiting efforts
- An accurate job description
- Competitive compensation
- Interim coverage
- How patient care and agency operations will continue safely
Once a qualified replacement is hired, the new individual should be reported within the applicable 10-business-day reporting period.
Waiting until day 50 or 55 to begin recruiting creates unnecessary regulatory risk. The recruiting process should begin as soon as the vacancy becomes known.
Agencies should also maintain documentation showing their ongoing efforts to fill the position, including but not limited to:
- Job postings
- Recruiter communications
- Interview records
- Candidate correspondence
- Other evidence of active recruitment
This documentation can help demonstrate that the agency has been making timely, good-faith efforts to fill the vacancy.
When Does a California Hospice Need to Renew Its License?
California hospice licenses renew every two years.
The renewal application and applicable fee must be submitted at least 30 days before the license expires.
A hospice cannot legally operate without a current, valid license. Agencies should therefore treat the license expiration date as a firm operational deadline and take steps well in advance to avoid any lapse in licensure. If a license expires without a valid renewal in place, the hospice may not simply continue operating while the issue is being resolved.
A practical internal schedule is:
- 60 days before expiration: Confirm whether the renewal package has been received and begin reviewing agency information.
- 45 days before expiration: Follow up with CDPH if necessary and resolve discrepancies.
- 30 days before expiration: Submit the completed renewal and fee.
The hospice should also carefully review the information contained on its verification page.
Do Medicare-Certified Hospices Need to Coordinate CDPH Changes With PECOS?
Yes, but CDPH and Medicare enrollment should be treated as related processes, not as one filing.
A state licensing application does not automatically satisfy Medicare enrollment reporting requirements, and the timelines do not necessarily match.
During the Q&A following our webinar, Kelly was asked whether a hospice should wait for CDPH approval before reporting an applicable change through PECOS.
She explained that PECOS has its own reporting requirements and timelines.
The key takeaway for Medicare-certified hospices is to evaluate both processes whenever there is a change involving ownership, location, management, or other enrollment information.
The safest approach is to build a coordinated state-and-Medicare filing plan before implementing the change.
What Are the Most Common Questions About California Hospice Application Changes?
Can I complete a hospice ownership transaction and report it afterward?
No. A CHOW and certain other ownership changes require advance filing. A 100% CHOW must be submitted at least four months before the intended effective date, and the original owner remains in control until approval.
Can my hospice move and submit the CDPH application afterward?
Generally, no. A change of location must normally be submitted at least two months before the planned effective date.
Does someone actually have to be present in the hospice office?
Yes. An employee must be physically present during the hospice's approved business hours.
Can the Administrator, DPCS, or Medical Director work in the same position for two hospices?
The covered leadership positions are subject to restrictions preventing an individual from serving in that role for more than one hospice. Here is a list of the CDPH specified rural areas at the time of writing this article:
- Alpine County
- Amador County
- Calaveras County
- Colusa County
- Del Norte County
- Glenn County
- Humboldt County
- Inyo County
- Lake County
- Lassen County
- Mariposa County
- Mendocino County
- Modoc County
- Mono County
- Napa County
- Nevada County
- Plumas County
- San Benito County
- Sierra County
- Siskiyou County
- Sutter County
- Tehama County
- Trinity County
- Tuolumne County
- Yuba County
*Always check the CDPH website for the most up-to-date information.
How long does a hospice have to replace a management employee?
A reportable management vacancy should be filled within 60 days. If that cannot be accomplished, the agency should request an extension.
Should a Medicare-certified hospice automatically wait for CDPH approval before making a PECOS update?
No. Medicare enrollment and CDPH licensing requirements should be evaluated separately and then coordinated based on the specific change.
How Can California Hospices Make Title 22 Applications Easier to Manage?
The recurring theme behind these requirements is planning.
A hospice should not sign a transaction document today and determine its CDPH obligations tomorrow. It should not select a new office without first reviewing the licensing requirements. And it should not appoint management personnel without confirming that their education and experience satisfy the new standards.
Building regulatory review into the decision-making process makes these changes much easier to manage.
If your hospice is preparing for an ownership change, relocation, management change, GSA application, license renewal, Medicare enrollment update, or another reportable event, The Home Health Consultant can help identify the applications involved, review the required timelines, and prepare the documentation needed for submission.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
