California Title 22 Hospice Regulations: What Agencies Need to Know

California hospice providers are operating under a new state regulatory framework. 

On June 22, 2026, the California Department of Public Health (CDPH) put emergency regulations into effect under Title 22 of the California Code of Regulations, Division 5, Chapter 6.5. The rules, found in sections 74800 through 74908, establish detailed requirements for hospice licensing, geographic service areas, staffing, management qualifications, recordkeeping, training, inspections, and other areas of hospice operations.¹

For organizations accustomed to managing compliance primarily through federal Medicare Conditions of Participation and the California Hospice Licensure Act, the new rules add another layer of requirements that must be reflected in policies, staffing practices, documentation systems, and day-to-day operations.

Understanding the California Title 22 hospice regulations begins with knowing which requirements have changed and where state requirements go beyond the processes an agency may already have in place.

What are California Title 22 hospice regulations?

Title 22 is the portion of the California Code of Regulations that includes rules governing many health and social service programs. California’s hospice-specific provisions are now located in Title 22, Division 5, Chapter 6.5, covering sections 74800 through 74908.¹

The regulations became operative on June 22, 2026, following CDPH emergency rulemaking directed by California Health and Safety Code section 1753.1. CDPH stated that the regulations were intended to establish hospice industry standards, support patient care, and address fraud and abuse concerns identified within the state’s hospice sector.¹

The rules comprise five broad groups of requirements: definitions, licensure, hospice services, enforcement, and administration.

For hospice organizations, that means California Title 22 compliance now affects areas such as:

●      Geographic service areas

●      Licensing applications and changes

●      Nursing staffing and patient assignments

●      Director of Patient Care Services qualifications

●      Medical Director qualifications

●      Administrator requirements

●      Management education and orientation

●      Medical and personnel records

●      Electronic health record controls

●      Physical office requirements

●      CDPH surveys and enforcement

These state requirements exist alongside federal hospice requirements. Medicare-certified hospices still need to meet the federal Conditions of Participation in 42 CFR Part 418. The California rules do not replace those requirements.²

Organizations operating in the state may therefore benefit from maintaining a compliance framework that separately identifies federal requirements, California statutory requirements, and applicable Title 22 provisions.

1. Geographic service areas now carry specific operational requirements

One of the more significant changes under the California Title 22 hospice regulations concerns where a hospice can provide services.

Title 22 defines a hospice's geographic service area, or GSA, as the county or counties approved by CDPH in which the parent hospice and its approved multiple locations may provide hospice services.³

A hospice cannot simply identify counties it would like to serve based on referral opportunities. Its GSA needs to account for its ability to respond to patients within the required timeframes.

Under Title 22 section 74820, hospices must be capable of having a licensed nurse appear in person within two hours after receiving information that a patient has a medical need or a safety concern. Organizations must maintain documented policies describing how patients receive support while the nurse is traveling to the patient.³

CDPH also requires hospices to document how they calculated their service area. Licensing documentation may include county names, ZIP codes, a map of the proposed service area, and calculations supporting the agency's ability to serve that territory.⁴

For organizations seeking approval to serve multiple counties, Title 22 introduces additional requirements related to demonstrating an unmet need for hospice services in those counties.³

This makes service-area management a compliance issue as much as a growth decision. Before expanding referral relationships into a new county, an organization should confirm that the county falls within its approved GSA and that operational staffing can support the response-time requirements.

Example: A hospice based in Los Angeles County receives regular referrals from a neighboring county. Even if clinicians are willing to accept those patients, the hospice should first verify that the county is included in its CDPH-approved GSA. The organization must also be able to demonstrate that nursing coverage can satisfy Title 22's response expectations. Accepting patients outside the approved service area could create licensing concerns.

2. California sets specific hospice staffing and management standards

Staffing requirements are another major component of the new rules.

Title 22 section 74848 requires hospices to provide licensed nursing coverage 24 hours a day, seven days a week. A licensed nurse may generally be assigned no more than 12 patients at one time. The regulation defines a licensed nurse for this purpose as an RN or LVN who has primary responsibility for the patient's care within the nurse's scope of practice.⁵

Hospices must also implement a patient acuity system used to determine nursing needs. The system is intended to account for the nursing care required under each patient's plan of care rather than treating the 12-patient limit as the sole staffing calculation.⁵

The new regulations also establish qualification standards for several leadership positions.

For example, a Director of Patient Care Services must be an RN and meet one of two experience pathways: a bachelor's degree or higher in nursing or another health-related field plus at least two years of qualifying supervisory or managerial experience during the preceding five years, or at least four years of qualifying supervisory or managerial experience during that period.⁶

Title 22 also establishes qualification and employment requirements for Medical Directors and Administrators. CDPH's June 2026 guidance specifically directed hospices to review these positions and submit report-of-change applications when their existing structure did not meet the new requirements.³

For organizations managing workforce education across multiple roles or locations, a centralized hospice training and education program can help support consistent staff development alongside an agency's regulatory compliance processes.

3. Management training is now part of the regulatory framework

California's rules extend beyond verifying licenses and professional experience. Title 22 now contains formal education requirements for hospice management personnel.

Section 74880 requires first-time California hospice Administrators or Administrator Designees to complete either 24 hours of specified hospice management education or an applicable hospice certification program within their first 12 months. Similar training provisions apply to first-time Medical Directors and other designated hospice management personnel.⁷

The regulation also requires hospice management personnel subject to the rule to receive at least 20 hours of new-hire orientation within 60 days of hire. Required topics include state and federal oversight agencies, California hospice licensing requirements, basic hospice services, administration, regulatory compliance, patient care, and related responsibilities.⁷

These provisions make training documentation especially important.

An organization may provide valuable education to its team yet still have difficulty demonstrating compliance during a survey if completion dates, course topics, attendance records, or employee roles are stored across several systems.

A practical approach is to map required education to each regulated position and maintain records showing:

●      Employee role

●      Hire or appointment date

●      Applicable training requirement

●      Required completion date

●      Course or program completed

●      Training hours

●      Completion documentation

This approach can make it easier to identify upcoming deadlines before they become a survey finding.

Organizations managing both hospice and home health operations may also benefit from a shared approach to home health and hospice workforce education, while still maintaining role-specific regulatory requirements.

4. Documentation and electronic records need to support survey readiness

California Title 22 places considerable emphasis on records.

Section 74888 requires hospices to establish a medical record system in which care and services are completely and accurately documented, readily accessible, and organized so information can be retrieved. The regulation also calls for safeguards around authentication, record security, information governance, corrections, and record destruction.⁸

Electronic health records receive separate attention under section 74900.

Hospices using an EHR must maintain access controls identifying who can view or modify records. They must also be able to track documentation activity such as dates, times, authors, corrections, amendments, addenda, changes, and late entries. This information needs to support an audit trail that CDPH may request.⁹

That makes documentation governance broader than simply confirming that clinical notes have been completed.

Hospices may want to review their EHR and documentation policies by asking questions such as:

●      Can the system identify who created or changed an entry?

●      Are late entries clearly differentiated from original documentation?

●      Can audit trails be produced during a CDPH request?

●      Are access permissions tied to job responsibilities?

●      Are record-retention practices documented?

●      Are patient and personnel files stored securely?

●      Do written policies match what staff actually do?

Title 22 also establishes requirements for hospice office space, including secure storage for medical records, medications, equipment, supplies, and personnel records.¹⁰

These requirements reinforce a central theme throughout the new California hospice regulations: organizations need to be able to demonstrate their processes through documentation.

Preparing for California Title 22 hospice compliance

The 2026 California Title 22 hospice regulations give CDPH more detailed standards against which hospice operations can be surveyed. As a result, organizations may need to look beyond individual policies and assess how staffing, education, licensing, service areas, recordkeeping, and management oversight work together.

A useful starting point is a structured Title 22 gap assessment. Compare current policies and operational practices against each section of Division 5, Chapter 6.5, assign responsibility for identified gaps, document corrective actions, and periodically repeat the review.

Priority areas may include nursing assignments, patient acuity processes, management qualifications, geographic service area documentation, training records, EHR audit capabilities, office requirements, and reportable organizational changes.

The regulatory status of these rules should also be monitored. The current hospice provisions were adopted through California's emergency rulemaking process, and CDPH's rulemaking page should be reviewed for extensions, readoption, replacement regulations, or other updates.¹

California hospice regulation has changed considerably with the introduction of the new Title 22 framework. Building the requirements into routine operations now can make compliance less dependent on last-minute preparation when a survey or licensing action occurs.

Medbridge helps hospice organizations assign and manage staff education from one platform. Leaders can deliver onboarding and ongoing training, monitor completion, and maintain records that support internal reviews and survey preparation. Medbridge also provides hospice-focused courses and clinical procedure training designed to help teams apply consistent practices across roles and locations.

Learn how Medbridge supports hospice workforce education and training.

This article is intended for general informational purposes and does not constitute legal or regulatory advice. Hospice organizations should review current CDPH requirements and consult qualified regulatory or legal counsel when interpreting requirements for their specific operations.

References

1. California Department of Public Health. DPH-18-002E Hospice Agency Emergency Regulations. https://www.cdph.ca.gov/Programs/OLS/Pages/DPH-18-002E.aspx

2. Electronic Code of Federal Regulations. 42 CFR Part 418: Hospice Care. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418

3. California Department of Public Health. AFL 26-20: Compliance with Hospice Emergency Regulations. https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-26-20.aspx

4. California Code of Regulations. Title 22, Section 74812: Content of Application.

5. California Code of Regulations. Title 22, Section 74848: Nursing.

6. California Code of Regulations. Title 22, Section 74852: Director of Patient Care Services.

7. California Code of Regulations. Title 22, Section 74880: Hospice Management Orientation and Annual Training Requirements.

8. California Code of Regulations. Title 22, Section 74888: Medical Record Service.

9. California Code of Regulations. Title 22, Section 74900: Electronic Health Records.

10. California Code of Regulations. Title 22, Section 74908: Hospice Office Space.