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Plan of Correction:

Plan of Correction:

Windber Hospice bereavement team will provide initial risk assessment and establish a bereavement plan of care for the survivors of hospice patients within five (5) days of death and bereavement interventions will be performed within the timeframes as stated in policy- B-1 Bereavement- Services, Risk, and Care Plan and documented within the electronic health record.

Hospice policy B-1- Bereavement- Services, Risk, and Care Plan was revised to reflect the risk assessment and bereavement care plan formation and clarified interventions for patients who are classified at low, moderate and high risk.

Hospice Policy B-2- Bereavement Record, Tracking and Evaluation was revised to state all bereavement documentation will be performed and maintained within the electronic health record instead of a physical file.

Hospice director will provide in-service to bereavement team on bereavement risk assessment, establishment of the bereavement plan of care, and documentation of interventions in the electronic health record. A sign in sheet will be obtained as documentation of attendance.

Within four (4) weeks of in-service, bereavement coordinator and social workers will re-evaluate risk assessment, establish bereavement plan of care, and document ongoing bereavement activities in the electronic health record for survivors of hospice patients with date of death prior to February 21, 2024 and after January 31, 2023.

Bereavement coordinator and social workers will perform risk assessment and establish plan of care within 5 days of death and document bereavement interventions directly in the electronic health record based on plan of care for survivors of hospice patients with date of death of February 21, 2024 and future.

The bereavement coordinator will audit three (3) random bereavement records monthly for twelve (12) months for:

-Risk assessment performed and bereavement plan of care established within five (5) days of death

-Interventions performed timely as per bereavement plan of care and documented in electronic health record

WINDBER HOSPITAL, INC.
HOSPICE POLICIES AND PROCEDURES

Policy Number: B-1
Page: 1 of 2

Subject: Bereavement-Services, Risk and Care Plan
Effective Date: Oct 1989
Revised: Oct 2019, Feb 2024
________________________________________________________________________

PURPOSE:
1. Windber Hospice has an organized program for the provision of bereavement services available to the hospice patient's family members, caregivers and significant others and to the community at large. Hospice patients and significant family members and other caregivers are assessed for grief and bereavement needs before and after the patient's death. A bereavement care plan is established to meet the individualized needs of surviving family members. The care plan is established by members of the Interdisciplinary Team (IDT).


POLICY:
- The hospice's bereavement program is under the supervision of the Bereavement Counselor who is a qualified professional with experience in grief and loss counseling.
- The hospice provides bereavement services to the family, caregivers and/or significant others of deceased hospice patients for thirteen months following the patient's death.
- The bereavement services provided are based on the assessed needs of the deceased's survivors and are in accordance with a bereavement plan of care formulated after the patient's death.
- Bereavement services provided include, but are not limited to:
o letters and supportive information provided monthly for thirteen (13) months after the patient's death;
o support groups;
o memorial services;
o bereavement visits and/or phone calls
- Bereavement services are also provided to members of the community and may include support groups, community education, crisis counseling, and working with schools or businesses impacted by loss.
- During the initial comprehensive assessment of the patient, bereavement risk factors and needs of family members, caregivers, and significant others are identified and documented by Bereavement Team members in collaboration with other IDT members, to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death.
- Findings from the initial bereavement risk assessment are incorporated into the patient's plan of care and considered in the bereavement plan of care.
- Throughout the course of the patient's care, members of the IDT reassess, document and address the anticipatory mourning needs of the patient, the patient's family, caregivers and significant others.

WINDBER HOSPITAL, INC.
HOSPICE POLICIES AND PROCEDURES

Policy Number: B-1
Page: 2 of 2

Subject: Bereavement-Services, Risk and Care Plan
Effective Date: Oct 1989
Revised: Oct 2019, Feb 2024
________________________________________________________________________
- Initial bereavement program enrollment call will occur within five days of death during which the counselor will re-evaluate the survivor risk assessment and establish the bereavement plan of care based off of this assessment. Assessment of the survivor's needs is ongoing and the bereavement care plan may be changed based off of this assessment at any time during the thirteen month bereavement program.
- Each person designated to receive bereavement services is categorized according to level of risk for complicated grief reactions and receives appropriate interventions according to identified need.
- The interventions associated with the three levels of risk are as follows:
o Low risk –
 initial sympathy card;
 initial bereavement program mailing;
 counselor or volunteer visit (at the funeral home, if appropriate) to deliver hospice rose;
 phone calls within four (4) weeks and six (6) months of the patient's death;
 invitations to bereavement support groups and memorial services;
 monthly mailings to include the 13 months following the patient's death.
o Moderate risk –
 all low risk interventions
 follow-up phone calls within two (2) weeks and twelve (12) months of patient's death
 assign a bereavement volunteer for phone calls and additional mailings as needed if survivor is accepting;
 continued assessment of need for additional services.
o High risk –
 all low and moderate risk interventions;
 scheduled visit offered within two (2) weeks of patient's death;
 additional information regarding community resources, bereavement literature;
 referral to appropriate professional assistance.
- If the needs of the bereaved are beyond the scope of the service provided by the hospice, referrals are made to appropriate community resources or practitioners.
- Family members, caregivers and significant others have the right to refuse bereavement services and support at any time.


WINDBER HOSPITAL, INC.
HOSPICE POLICIES AND PROCEDURES

Policy Number: B-2
Page: 1 of 1

Subject: Bereavement Record, Tracking and Evaluation
Effective Date: Jan 2009
Revised: Oct 2019, Feb 2024
________________________________________________________________________

POLICY STATEMENT:
A bereavement record is developed for each patient admitted to the Windber Hospice Program.


PROCEDURES:
1. A bereavement record is initiated for each patient by the Bereavement Counselor and other Bereavement Team members. The record is maintained for thirteen months after the patient's death. The program is individualized to meet the needs of the persons served.
2. The bereavement record contains:
a. The bereavement risk assessment(s) and care plan(s) for the person(s) for whom the hospice will provide bereavement services;
b. the initial Bereavement Care plan created at the time of the hospice patient's death;
c. bereavement notes documenting all services to and contact with the bereaved person(s);
d. any other documents used to support the relationships or contact information of the bereaved.
3. The Bereavement Counselor or other Bereavement Team members update information in the record as needed. Including documentation of dates of when each follow-up service is provided, as specified in the bereaved person's plan of care.
4. Family members, caregivers and significant others have the right to refuse bereavement services and support at any time.
5. The evaluation of the hospice's bereavement services is conducted in a survey sent at the end of bereavement services. This data is used to improve the bereavement services offered by the hospice.
6. The Bereavement Team retains and maintains the bereavement documentation in the electronic health record.

Plan of Correction:

Plan of Correction: