CMS Extends Hospice “Extraordinary Circumstance” Exemption

From the NAHC Report Article
Action a Result of Continuing Nursing Shortage

The Centers for Medicare & Medicaid Services (CMS) has once again extended the Extraordinary Circumstances Exemption based on concerns that hospices in some areas of the country continue to experience hardship in hiring nurses directly due to the nursing shortage. Under the exemption, hospices may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for the services. The hospice must also qualify itself as eligible for the exemption by notifying the state survey agency (SA) in writing that it intends to elect an exception under the “extraordinary circumstances” authority and provide an estimate of the number of nurses that it believes it will need to employ under contract, as well as the following information:


  1. An estimate of the number of patients that the agency has not been able to admit during the past three months due to the nursing shortage and the current and desired patient/nurse ratio for the agency;
  2. Evidence that the hospice has made a good faith effort to hire and retain nurses, including:
    • Copies of advertisements in local newspapers and Web postings that demonstrate recruitment efforts;
    • Copies of reports of telephone contacts with potential hires, professional schools and organizations, recruiting services, etc.;
    • Job descriptions for nurse employees;
    • Evidence that salary and benefits are competitive for the area;
    • Evidence of any other recruiting activities (e.g., recruiting efforts at health fairs, educational institutions, health care facilities, and contacts with nurses at other providers in the area); and
    • Ongoing self-analyses of the hospice’s trends in hiring and retaining qualified staff.
  3. The hospice must also demonstrate that it has a training program in place to assure that contracted staff is trained in the hospice philosophy and the provision of palliative care prior to patient contact.
  4. The hospice must assure that contracted staff is providing care that is consistent with the hospice philosophy and the patient’s plan of care.
  5. Contracted nurses are used to supplement the hospice nurses employed directly. Contracted nurses should not be used solely to provide the continuous nursing level of care or on call service.
  6. The hospice is expected to continue its recruitment efforts during the period that it is contracting for nurses.

The National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO) submitted a joint statement to CMS in support of extension of the exemption that incorporated examples of continuing hardship that hospices are having due to the nursing shortage. NAHC thanks all those individuals who submitted examples for inclusion in documentation to CMS. For additional information about the exemption, please go to: