Hospice Checklist

Directions: Use this checklist to help evaluate hospice services to determine which one will work best for you and your family.

Phone Number:

Hospice Name:




General Information Yes No Comments
What services are provided?  
What kind of support is available to the family and caregiver?  
What roles do the attending physician and hospice play?  
What does the hospice volunteer do?  
How does hospice keep the patient comfortable?  
How are services provided outside of business hours?  
How and where does hospice provide short-term inpatient care?  
With which nursing homes or long-term care facilities does the hospice work?  
Can this service be brought into a nursing home or other living facility?  
How long does it typically take the hospice to enroll someone once the request for services is made?  
How does the physician work with the family and patient?  
Is the hospice licensed or certified? If so, for what types of services?
Are services offered in the home?
Is the service insured against liability?
Is a written contract provided regarding eligibility, payment and staff training?
Is the care plan developed in consultation with your loved one?s physician?
Are family members, including myself, included in reviewing and contributing to the care plan?
Is the care plan completed in person with a nurse or social worker?
Will I have contact with a supervisor?
Is there a grievance or complaint process?
Are references available for all providers?
Types of services offered Yes No Comments
Individualized service plan
Physician supervision
Nursing care
Overnight home care
Assistance with activities of daily living
Physical therapy
Massage therapy
Pain management
Ventilator care
Emergency care or arranging for hospitalization
Meal preparation or delivery
Spiritual counseling
Respite care (in home or day center)
Counseling services (family, individual)
Assistance with advance directives
24-hour emergency contact
Telephone support
Patient or family advocacy
Medical supplies
Types of service providers available Yes No Comments
Registered or licensed nurse
Physical therapist
Occupational therapist
Counselor or family therapist
Social worker or advocate
Home health aide
Home chore worker
Spiritual advisor
General rating on a scale of 1 (poor) to 5 (excellent):



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