Every finding on record at Supreme Hospice Inc

Based on record review and interview, the agency failed to maintain a system of communication and integration, in accordance with the hospice's own policies to ensure that the interdisciplinary group maintained responsibility for the direction, coordination, and supervision of the care and services provided for 1 (#11) of 2 patient bereavement records reviewed, when the bereavement plan of care was not discussed at a interdisciplinary group meeting after the patient's death per the agency's policy. The failure placed the bereaved at risk that appropriate bereavement services would not be provided to family, caregivers, and other bereaved persons. --- The agency had a policy titled "Bereavement" that was labeled PC.130 and last reviewed on 10/01/2021. The policy read in part; "Purpose To ensure appropriate bereavement services are provided to hospice family member, caregivers and other bereaved persons. Policy...II. The purpose of the bereavement program is to facilitate a normal grieving process by providing counseling, coping strategies, and caring interventions...Procedures VII. After the death of the patient: A...develop a POC (Plan of Care) for bereavement services based on the re-assessment and the family and/or caregiver's willingness to receive services. This POC will be discussed at the next IDG/IDT (Interdisciplinary Group/Team) meeting..." Patient #11: Record review of Patient #11's clinical record revealed a Plan of Care dated 1/10/2024 to 3/9/2024. The Plan of Care indicated that Patient #11 started on the agency's services on 3/16/2023. The Plan of Care listed Senile Degeneration of the Brain (mental deterioration associated with aging) as the primary diagnosis. Registered Nurse D conducted a visit on 2/26/2024. Registered Nurse D documented Patient #11's date of death was 2/26/2024. The surveyor was unable to find that a bereavement plan of care had been discussed at a interdisciplinary team meeting after Patient #11's death. During an interview on 6/7/2023 at 2:38 p.m. with the Bereavement Coordinator, the surveyor asked how the Bereavement Coordinator demonstrated the Interdisciplinary Team involvement with the Bereavement Plan of Care. The Bereavement Coordinator informed the surveyor that a bereavement score would be assessed. The Interdisciplinary Team would be the first to know and discussed at the Interdisciplinary Team meeting. The bereavement assessment conducted on 2/26/2024 by the Bereavement Coordinator after Patient 11"s death was listed low. During an interview on 6/7/2024 at 3:10 p.m. with the Administrator (became Administrator of the agency 2/1/2024) and Supervising Nurse (Date of Hire 5/31/2024- not employed with the agency in February 2024), the surveyor discussed that the clinical record did not contain evidence that an interdisciplinary meeting, where a bereavement plan of care had been discussed, had occurred, after Patient #11's death. The Administrator and Supervising Nurse were going to look into the issue. During an interview on 6/10/2024 at 3:23 with the Supervising Nurse, the Supervising Nurse was able to show the surveyor a bereavement plan of care that included frequency, interventions, and goals. During an interview on 6/10/2024 at 4:55 p.m. with the Supervising Nurse, the Supervising Nurse informed the surveyor that no interdisciplinary group meeting was conducted regarding Patient #11 bereavement plan of care after Patient 11's death.