Every finding on record at Regional Hospice at Windber

Based on review of hospice bereavement program, clinical records (CR), and staff interviews, the hospice failed to ensure that bereavement services were made available to the family following the death of the patient, in accordance with the bereavement program, for two (2) of two (2) bereavement CR reviewed. (CR #1 & CR#2). Findings included: Review of Bereavement Program conducted on February 2, 2023, at approximately 1:00pm revealed: "... Bereavement-Services, Risk and Care Plan... POLICY: ... 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...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: Low Risk...Moderate Risk...High Risk..." "...Bereavement Files, Tracking and Evaluation...POLICY STATEMENT: A bereavement file is developed for each patient admitted to the Windber Hospice Program...PROCEDURES: ...2. The bereavement file contains: a. The bereavement risk assessment(s) and care plan(s) for the person for whom the hospice will provide bereavement services; b. the initial Bereavement Care plan created at the time of the hospice patient's death; ...3. The Bereavement Counselor or other Bereavement Team members update the information in the file as needed. Including documentation of dates of when each follow-up service is provided, as specified in the bereaved person's plan of care...6. The Bereavement Team retains and maintains the bereavement files in a secure location for thirteen months following the patient's death. 7. At the completion of bereavement services, the contents of the file are merged with the patient's clinical record. A review of clinical records conducted on February 2, 2024, between approximately 11:20am and 2:00pm and February 7, 2024, between approximately 9:30am and 12:00pm revealed the following: CR #1, start of care October 26, 2022, date of death May 6, 2023, CR failed to contain evidence of a post death assessment of the bereaved, the risk level identified, or a bereavement plan of care. Documentation revealed four (4) week follow up call placed 7/31/23, twelve (12) weeks and two (2) days post death. No bereavement file available for review. CR #2, start of care December 12, 2022, date of death April 17, 2023, CR failed to contain evidence of a post death assessment of the bereaved, the risk level identified, or a bereavement plan of care. No bereavement file available for review. Interview with Administrator and Bereavement Coordinator on February 2, 2024, at approximately 1:00pm confirmed findings. Unable to produce files for bereaved individuals to be reviewed.