What California Hospice Agencies Need to Know About Title 22 Operational Requirements

California’s new Title 22 hospice requirements affect several parts of day-to-day hospice operations. This includes but is not limited to:

• nursing assignments,
• patient acuity,
• on-call coverage,
• management training,
• payroll records,
• and service-area compliance.

The new requirements became effective June 22, 2026 and apply to CDPH-licensed hospice agencies in California, including Medicare-certified hospices.

*This article was written in consultation with Mariam Treystman.

At The Home Health Consultant, we work with Medicare-certified home health and hospice agencies on ongoing compliance and regulatory readiness. These changes are important because many require agencies to build new processes into everyday operations rather than simply update a policy before a survey.

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What Changed Under California Title 22 for Hospice Operations?

The new California hospice requirements create several important operational changes that agency owners and clinical leaders need to address. Here’s a brief overview before we dive into the details:

• Hospice surveyors may now review payroll records, making employment classification more relevant during inspections
• Hospice management personnel have new training requirements
• Licensed nurses may be assigned no more than 12 hospice patients at one time
• Agencies must implement a patient acuity system and reassess acuity as patient needs change
• Hospices must also maintain an on-call nursing process that supports an in-person RN response within two hours when required

These changes are closely connected.

The 12-patient nursing limit establishes a maximum assignment, but it does not determine whether a caseload is actually manageable. Patient acuity may require a nurse to carry fewer patients. Geographic distance may affect how quickly the nurse can respond. After-hours coverage must also support the agency’s ability to provide care throughout its approved service area.

For agency owners, the bigger question is therefore not simply:

“How many nurses do we have?”

It is:

“Do our staffing, patient assignments, acuity, geography, and on-call coverage allow us to safely care for the patients we are accepting?”

The following requirements should be reviewed together as part of the hospice’s overall operational and compliance system.

Can Hospice Surveyors Review California Payroll Records?

One of the less publicized changes is that surveyors may now review payroll records.

Payroll records can help surveyors verify employment and determine whether personnel are classified consistently with applicable hospice requirements.

This means agencies should review their W-2 versus independent-contractor arrangements.

Ownership and management personnel, excluding the Medical Director, are expected to be employees. This includes positions such as the Administrator, Administrator Designee, DPCS, and DPCS Designee, as well as personnel responsible for required hospice core services.

Physicians and certain other disciplines may be contracted where permitted. Core services may be contracted in limited extraordinary circumstances.

Agencies should review these arrangements against both hospice regulations and applicable employment and tax requirements.

What New Training Is Required for Hospice Management?

The new requirements also establish formal training expectations for hospice management personnel.

These requirements apply to the:

• Administrator

• Administrator Designee

• DPCS

• DPCS Designee

• Medical Director

• Medical Director Designee

There are three major training timeframes.

A first-time hire, meaning someone serving in that particular management role for the first time in any hospice, must complete 24 hours of applicable management or clinical management education within 12 months.

A management employee who is newly hired by the organization must complete 20 hours of new-hire training within 60 days of hire, whether or not they have held the position elsewhere.

Management personnel must also complete 12 hours of annual retraining.

Important Note: These requirements may overlap. For example, someone serving as a hospice Administrator for the first time may need to complete the 20-hour new-hire requirement as well as the 24-hour first-time management requirement.

The deadlines should also be tracked based on the employee’s hire date, not the agency’s preferred calendar-year training schedule. If an agency conducts annual education from January through December, it still has to make sure each employee meets the regulatory deadline tied to their employment date.

For Administrators and Administrator Designees, first-time training includes areas such as hospice operations, administration, human resources, personnel onboarding, regulatory requirements, and QAPI.

DPCS and Medical Director training focuses more heavily on clinical management, leadership, communication, professional conduct, and hospice regulatory requirements.

How Should Management Training Be Documented?

Hospices should not treat management training as a simple annual in-service.

In our webinar, we emphasized maintaining documentation that includes the following, including but not limited to:

• training or certification program,

• participant name,

• content covered,

• training provider and contact information,

• instructor,

• dates,

• hours completed,

• and proof of completion.

The completion certificate should also include the required signatures, including the participant and the participant’s supervisor.

Competency may also need to be demonstrated through testing, assessment, or another verification process.

The goal is to create a formal management training and competency system, not simply collect sign-in sheets.

What Is the New Hospice Nursing Staffing Ratio?

One of the most significant changes involves nursing assignments.

A licensed nurse may not be assigned to more than 12 hospice patients at one time.

The word “assigned” is important. This applies to RNs and LVNs who are actually assigned responsibility for patients.

A nurse:

• temporarily covering a visit,
• providing a PRN visit,
• or assisting another clinician

…is not necessarily the same as the nurse formally assigned to that patient.

Hospices should review their current nursing assignment lists and make sure no licensed nurse exceeds the applicable limit.

Which Nurses Count Toward the Hospice Staffing Ratio Under Title 22?

Hospices should not just count every licensed nurse on the payroll.

The nurses considered in the staffing calculation should be those actually assigned to provide patient care.

Important Note: An RN working solely in quality assurance, administration, or another office-based position does not automatically increase the number of patients the hospice can support.

For example, a DPCS who does not carry patient assignments should not simply be counted as another field nurse.

Agencies should be able to clearly identify which patients are assigned to which nurses.

Does Being Under 12 Patients Mean a Hospice Nurse Has an Appropriate Caseload?

The 12-patient requirement is a maximum. It does not mean every nurse should automatically carry 12 patients.

One nurse may have 10 relatively stable patients living within a small geographic area. Another nurse may have 10 patients with uncontrolled symptoms, frequent after-hours calls, complex caregiver needs, or long travel distances.

Both nurses are under the numerical limit, but their workloads may be very different.

That is why the new patient acuity system is so important.

What Is a Patient Acuity System?

A patient acuity system helps the hospice determine how much care and nursing attention each patient currently requires.

Rather than looking only at census, the agency evaluates factors including but not limited to:

• severity of the terminal illness
• clinical complexity
• specialized equipment or treatments
• safety risks
• cognitive or communication limitations
• symptom-management needs
• psychosocial concerns
• the level of clinical intervention required.

During our webinar, we gave an example of a sample system using a 0-to-3 scale. The scale ranged from minimal need to high, unstable, or complex needs requiring frequent intervention. Agencies should use a similar type of system to analyze patient factors to determine how much care and nursing attention they need.

The acuity system should help the hospice make better decisions about caseloads, visit frequency, staffing, and admissions.

When Should Patient Acuity Be Reassessed?

Acuity should not be determined once at admission and then forgotten.

There are multiple points over the course of a patient’s care when reassessment may be necessary, including:

• Admission
• Initial and comprehensive plan of care
• IDG review and plan-of-care updates
• Significant changes in condition
• Hospitalization or emergency-room visits
• Falls, injuries, medication issues, or wounds
• Behavioral or safety concerns
• Increased requests for symptom management
• Two or more after-hours calls within seven days
• Changes in caregiver availability or ability
• Transitioning or actively dying patients
• Changes in nursing visit frequency

As our co-founder Mariam summarized during the webinar:

“Pretty much anything that happens, we have to reassess acuity.”

The operational goal is to make sure staffing continues to reflect the patient’s current needs.

What Happens When a Patient Needs Immediate Intervention?

An acuity system should not create delays when a patient clearly needs immediate attention.

The sample system discussed during the webinar included override situations for circumstances including but not limited to:

• an actively dying patient requiring frequent nursing assessment,
• uncontrolled pain or symptoms despite current interventions,
• or repeated symptom-management needs

In those situations, the agency should not allow the scoring process itself to delay care.

The system should be structured enough to support consistent staffing decisions, but flexible enough to allow clinicians to respond immediately when a patient’s condition requires it.

What Does Title 22 Require for On-Call Nursing?

Hospice agencies must also maintain an effective after-hours nursing system.

Policies and procedures must address on-call nursing services and allow an RN to appear in person within two hours after receiving information that a patient has a medical need or safety concern requiring nursing services.

Important Note: Telephone availability alone is not enough.

The agency needs a realistic system for determining when an RN must go to the patient’s home, dispatch the nurse, provide backup coverage, and escalate after-hours issues to hospice management when necessary.

The written policy should match the agency’s actual staffing.

How Does the Two-Hour Requirement Affect the Hospice’s GSA?

Although establishing or changing a Geographic Service Area is primarily an application issue, GSA compliance also affects everyday operations.

You can check out our companion article on the new application and change requirements for hospice under title 22.

A hospice should only provide care within its currently approved GSA.

The two-hour RN response requirement makes geography especially important. Intake and marketing staff should know where the agency is approved to operate and should not accept a patient outside that area simply because the hospice believes it has a nurse nearby.

At the time of writing this article, CDPH had not announced that every existing hospice must automatically recalculate or resubmit its current GSA.

For now, the important operational issue is making sure the hospice is actually operating within the GSA already approved.

What Should California Hospices Review Now?

Hospice owners and clinical leaders should review their current operations in several areas.

• Confirm that employment and contractor arrangements are appropriate
• Identify management personnel who need new-hire, first-time, or annual training
• Create a system for continually tracking each management member’s training deadlines from the applicable hire date

• Review every RN and LVN patient assignment

• Implement and document a patient acuity process
• Make sure acuity is reassessed when patient needs change
• Test your after-hours response system

Specifically regarding, the after-hours response system, ask:

If a patient develops an urgent medical or safety need tonight, who receives the call? Who decides whether an in-person visit is necessary? Which RN goes to the home? What happens if that nurse is unavailable? Can the agency realistically respond within two hours?

Finally, make sure intake and marketing staff understand the agency’s approved GSA.

These are not just survey-preparation questions, they affect how the hospice operates every day.

If your hospice needs help implementing the new Title 22 operational requirements, The Home Health Consultant can help review your staffing processes, patient acuity system, management training, on-call procedures, and other compliance requirements. We are currently implementing these systems for our hospice compliance customers. Don’t risk your license status!