Hospice Care Checklist
Rows
Yes
No
Comments
Is the hospice licensed or certified? If so, for what types of services?
1
2
Are services offered in the home?
3
4
Is the service insured against liability?
5
6
Is a written contract provided regarding eligibility, payment and staff training?
7
8
Is the care plan developed in consultation?
9
10
Are family members included in reviewing and contributing to the care plan?
11
12
Is the care plan completed in person with a nurse or social worker?
13
14
Will I have contact with a supervisor?
15
16
Is there a grievance or complaint process?
17
18
Are references available for all providers?
19
20
Types of services offered
Rows
Yes
No
Individualized service plan
21
22
Physician supervision
23
24
Nursing care
25
26
Overnight home care
27
28
Assistance with activities of daily living
29
30
Physical therapy
31
32
Massage therapy
33
34
Pain management
35
36
Ventilator care
37
38
Emergency care or arranging for hospitalization
39
40
Meal preparation or delivery
41
42
Spiritual counseling
43
44
Respite care
45
46
Counseling services
47
48
Assistance with advance directives
49
50
24-hour emergency contact
51
52
Telephone support
53
54
Patient or family advocacy
55
56
Medical supplies
57
58
Types of service providers available
Rows
Yes
No
Physician
59
60
Registered or licensed nurse
61
62
Physical therapist
63
64
Occupational therapist
65
66
Psychologist
67
68
Counselor or family therapist
69
70
Social worker or advocate
71
72
Home health aide
73
74
Home chore worker
75
76
Spiritual advisor
77
78
Volunteer
79
80
Cleanliness
81
82
Responsiveness
83
84
Friendliness
85
86
Submit
Should be Empty: