Hospice Care Checklist
1
Yes
No
Comments
Is the hospice licensed or certified? If so, for what types of services?
2
3
Are services offered in the home?
4
5
Is the service insured against liability?
6
7
Is a written contract provided regarding eligibility, payment and staff training?
8
9
Is the care plan developed in consultation?
10
11
Are family members included in reviewing and contributing to the care plan?
12
13
Is the care plan completed in person with a nurse or social worker?
14
15
Will I have contact with a supervisor?
16
17
Is there a grievance or complaint process?
18
19
Are references available for all providers?
20
21
Types of services offered
Yes
No
Individualized service plan
22
23
Physician supervision
24
25
Nursing care
26
27
Overnight home care
28
29
Assistance with activities of daily living
30
31
Physical therapy
32
33
Massage therapy
34
35
Pain management
36
37
Ventilator care
38
39
Emergency care or arranging for hospitalization
40
41
Meal preparation or delivery
42
43
Spiritual counseling
44
45
Respite care
46
47
Counseling services
48
49
Assistance with advance directives
50
51
24-hour emergency contact
52
53
Telephone support
54
55
Patient or family advocacy
56
57
Medical supplies
58
59
Types of service providers available
Yes
No
Physician
60
61
Registered or licensed nurse
62
63
Physical therapist
64
65
Occupational therapist
66
67
Psychologist
68
69
Counselor or family therapist
70
71
Social worker or advocate
72
73
Home health aide
74
75
Home chore worker
76
77
Spiritual advisor
78
79
Volunteer
80
81
Cleanliness
82
83
Responsiveness
84
85
Friendliness
86
87
Submit
Should be Empty: