What home health learned a decade ago, and what hospice leaders can prepare before the pressure peaks
If you've been a hospice leader for more than a few years, you've probably watched the home health side of post-acute care weather some difficult seasons. Tightening reimbursement. Escalating audit pressure. Third-party reviewers showing up with documentation checklists that felt like they were designed for a different industry entirely.
For a long time, hospice felt insulated from the worst of it. The nature of the work, quieter, more relational, built around comfort rather than recovery, didn't seem to invite the same scrutiny.
That window is closing.
Paul McMullen has been in post-acute healthcare for more than three decades. As Chief Operating Officer of Choice Health at Home, he oversees operations across nine states and three service lines: home health, hospice, and palliative care. He's seen documentation pressure cycles before, and the pattern he's watching develop in hospice right now is one he recognizes.
"The pressure we're sensing right now," he told a room of hospice leaders at a recent industry conference, "feels like home health ten years ago. The third parties are coming fast and furious for our documents."Paul McMullen, Chief Operating Officer of Choice Health at Home
What hospice audit pressure actually looks like inside and organization
It's easy to talk about audit risk in the abstract. It's harder to describe what it actually does to an organization, to the people inside it, when the pressure starts to build.
For field clinicians, it shows up as the tap on the shoulder. The manager conversation nobody wants to have. The note submitted in good faith, but flagged for something the clinician didn't know to document. For quality and compliance teams, it shows up as volume: more charts to review, faster, with less room for error. For leadership, it shows up as a strategic threat that sits just below the surface of every operational conversation.
McMullen describes the goal at Choice as building a buffer between that external pressure and the clinicians who are actually at the bedside. "For us, the audit risk is definitely one of the reasons we're leaning into technology," he said. "But we're doing it to provide a buffer for the staff, give them tools to do their job efficiently and effectively, without having to weather the stress of the audit. Let me deal with the stress of the audit. I'm going to help you audit-proof your documentation."
That framing, protecting clinicians from operational pressure so they can stay focused on patients, is increasingly the model forward-thinking hospice leaders are adopting. It's also the one that's hardest to build without the right infrastructure in place.
Hospice documentation gaps that create audit risk
Here's the part of this conversation that most hospice leaders find uncomfortable: the documentation failures that create the most audit risk aren't usually the ones that look like failures. They're the ones that look fine.
McMullen shared an example that stayed with the room. A chaplain at his organization had documented a patient visit in vivid, warm detail. The note was thorough. It reflected genuine care. It painted a picture of a meaningful encounter.
The problem was that the patient had been comatose for over a week.
"The chaplain visit was real," McMullen was clear on that. "The family was in a good place with the patient's passing. The chaplain was doing exactly what a chaplain should do. However, the way the note was written didn't match the clinical reality of what the nurse's notes showed about the patient's condition. And when a third-party auditor pulled those notes side by side, it created a problem."
The note wasn't dishonest. It wasn't even poorly written, but it was out of alignment with the broader clinical record in a way that a human reviewer, working through hundreds of charts, would never have caught.
This is the gap that most hospice documentation strategies miss entirely: the focus tends to go to the highest-acuity, highest-frequency notes. From the RN visit documentation to CTI accuracy and recertification language, those are the right priorities, but they're not the whole picture.
"I would apply automation to all note types," McMullen said, "so that you can be picking up on irregularities inside a note that might otherwise be a problem for you. Automation can hit things at speed and frequency that a human being could never do."
Why most hospice documentation tools fail audit requirements
The challenge for hospice leaders is that the documentation tools most agencies are using weren't designed with hospice encounters in mind.
The major platforms in the post-acute space have historically prioritized home health workflows, including OASIS documentation, outcome-based metrics, and the kind of structured, form-driven visits that home health is built around. Hospice documentation looks different. The visit types are different. A skilled nursing visit looks nothing like a chaplain visit, which looks nothing like an aide visit, which looks nothing like a social work note or an IDT summary. The clinical narrative matters in a way that structured forms don't fully capture.
In addition, ambient AI documentation tools, the AI scribes getting significant attention right now, were largely built for high-conversation encounters. They capture what's said, but plenty of hospice visits are quiet. A visit with a patient who can no longer communicate. An end-of-life vigil where the clinician's presence is the documentation. For those encounters, a tool that only captures conversations is only part of a solution.
What McMullen describes at Choice isn't a single technology fix. It's two tiers of capability working together: real-time feedback that helps clinicians get notes right at the point of care, and retrospective review that catches irregularities across the full chart, not just the note types that are easiest to automate.
"My goal with automation isn't reduction," he said. "I want my audit team to do more teaching and less policing. Take the audit results, sit with the clinician, teach them, not just flag and move on. I'd like the human being to do more teaching and less modeling."Paul McMullen, Chief Operating Officer of Choice Health at Home
Where hospice leaders should start
McMullen's advice for hospice leaders who are trying to get their arms around this is grounding in its practicality."Decide what you're trying to solve for," he said. "The amount of automation available in this space right now is a little overwhelming. You could make it your full-time job and not start on all things technology. Figure out what you're trying to solve for, get your baseline metrics, and then start taking demos."Paul McMullen, Chief Operating Officer of Choice Health at Home
The most important early investment, in his view, isn't in any specific technology; it's in understanding where the gaps actually are. That starts with an honest look at the full range of documentation your clinicians are producing: not just the notes that get audited most frequently, but the ones that rarely come up, until they do.
The chaplain's note is a useful reminder. Documentation risk in hospice doesn't always announce itself. It hides in the notes that look the most complete.
Audit-readiness checklist: questions to ask before the auditors do
Review your documentation picture across the full clinical team:
- RN visit notes: Are they capturing clinical decline clearly enough to support recertification?
- CTI documentation: Is physician language specific enough to withstand third-party scrutiny?
- Aide and social work notes: Are they consistent with the rest of the clinical record?
- Chaplain and spiritual care notes: Are they appropriately scoped to what's documentable — not just what was meaningful?
- IDT notes: Do they tell a coherent, consistent story across disciplines?
If any of those questions surface uncertainty, or if the answer is "we review some of these regularly but not all of them", that's worth examining before an auditor does it for you.
The audit storm that home health weathered a decade ago is forming on hospice's horizon. The organizations that will navigate it most successfully are the ones building the infrastructure now, before the pressure peaks.
nVoq works with hospice agencies to address documentation challenges across every encounter type and every clinician role — not just the visits that fit standard automation models.
If questions like the ones above surfaced some uncertainty about your current documentation approach, we'd welcome a conversation about where the gaps tend to show up and what it looks like to close them.
Request a Documentation Gap Assessment
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