Every finding on record at Shepherd Hospice

Based on staff interview and bereavement log review, and the review of the Quality Assurance performance Improvement (QAPI) meeting minutes dated 04/16/2023 the facility failed to develop a bereavement plan of care that notes the kind of bereavement services offered and the frequency of the service delivery for two (2) of two (2) bereavement records reviewed; Patient #13, Patient #14. --- An interview with the facility Administrator, Director of Nursing and Staff Nurse on 09/26/2023 at 02:00 p.m. confirmed the facility does not have a Bereavement plan of care for Patient #13 and Patient #14. No Bereavement record review for Patient #13 and #14; no bereavement records presented for review. Review of the "Quality Assurance Performance Improvement (QAPI) meeting minutes", dated 04/16/2023, Item #8 revealed, ";...Bereavement patient should have a plan of care as soon as bereavement assessment is completed. Monitor the bereavement logbook weekly..." Review of the "Bereavement Logbook" confirmed no documented evidence of a "Plan of Care" completed for Patient #13 and Patient #14. During the exit conference on 09/27/2023 at 4:15 p.m. with the facility Administrator, Director of Nursing, Staff Nurse, and Office Manager, survey findings were discussed, and no further documentation was submitted for review.