“A man’s house burns down. The smoking wreckage represents only a ruined home that was dear through years of use and pleasant associations. By and by, as the days and weeks go on, first he misses this, then that, then the other thing. And when he casts about for it he finds that it was in that house. Always it is an essential – there was but one of its kind. It cannot be replaced. It was in that house. It is irrevocably lost … It will be years before the tale of lost essentials is complete, and not till then can he truly know the magnitude of his disaster.” – Mark Twain

All of us would agree that at the very core of defining the value of hospice care is the comfort and support provided to patients and families at the end of life. And we would agree that the grieving process is seldom quick. That’s why it may be so surprising to learn that one of the top ten deficiencies cited under the federal Hospice Conditions of Participation is that agencies often fail nationally, and in North Carolina, to provide proper and compliant bereavement counseling.

CMS, at the 2007 NAHC Policy Conference, shared from its national data that deficiency citations have included having no bereavement plans at all; failing to provide timely bereavement counseling; and approaching bereavement counseling with a one-size-fits-all plan by listing the same interventions for all agency patients. North Carolina survey data also identifies lack of bereavement counseling as a top deficiency.  

Pennsylvania is one of the states that actually posts hospice agency deficiencies on the Department of Health Web site. In the fall of 2008, one agency’s Health Inspection Results revealed that the agency was found not to be in compliance with Standard 418.88 (a): The plan of care for bereavement counseling services should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery (up to one year following the death of the patient).

As the surveyor reviewed the agency’s records and policy manual and conducted staff interviews, she found the agency out of compliance with its own procedures in that it failed to ensure that a bereavement plan of care was established for all six of the patients who had expired. The agency’s policy had stated:  

“After death has occurred, the initial bereavement assessment will be reviewed/revised and the family/caregiver needs will be discussed at the next interdisciplinary group meeting.” and “The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement risk assessment and input from the Interdisciplinary Team.”  

In addressing the deficiencies in the required Plan of Correction, the hospice agency indicated that it would take the following actions:  

A comprehensive Plan of Care will be developed and implemented to assure the appropriate documentation of bereavement services in the Medical Record. Education to staff and implementation of the new process will be completed by October 1, 2008. Compliance will be monitored and demonstrated through employee education records. Focused record review will be completed by hospice staff and members of the Quality Management team. Deficiencies noted in the record review will be addressed with the individual employee by the Clinical Practice Supervisors. Focused record review will target patients with admission dates of October 1, 2008, or later. Evidence of compliance will be monitored through record review with a target observation rate of 95%. The Clinical Director of Hospice Services is responsible for the completion of all elements of this Plan of Correction.  

But note, a plan of correction under the new COPs may need to include several critical elements missing above – as cued by the draft interpretative guidelines. The new COPs better outline the fundamentals essential to the hospice agency’s efforts to provide quality bereavement services.  

While it is too early to tell what problems hospices may have with the new 418.64 (d) Standard: Counseling Services, the CMS aim seems the same – plans that are individualized, well documented, timely and meaningful.  

L595 – Counseling services must be available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process.

If your hospice has had a deficiency citation in the past for bereavement counseling or if your agency believes that this is an area for enhancement as you develop your quality improvement plans, consider that the new COP requires the following of hospice counseling services:

1.  An organized program for the provision of bereavement services must be furnished under the supervision of a qualified professional with experience or education in grief or loss counseling.
2. The services must be made available to the family or other individuals in the plan of care up to one year following the patient’s death – including residents of the SNF or ICF/MR when appropriate and identified in the plan of care.
3. The agency must ensure that the services reflect the needs of the bereaved.
4. The plan of care must note the kind and frequency of bereavement services to be offered.

Of special interest to the hospice quality improvement staff in your agency is that the draft interpretative guidelines include probing surveyor questions that provide excellent ideas for important measures to include in your QAPI efforts.

1. 1. What services does the hospice provide to reflect the needs of the family and other individuals on the bereavement plan of care?
2. 2. How does the hospice evaluate the outcomes and effectiveness of the bereavement services they provide?
3. 3. Was the bereavement follow-up appropriate and provided within identified time frames? Did the bereavement services provided reflect the needs of the bereaved? 

QAPI Tip: As you develop your quality assessment and performance improvement plans, consider that the agency’s past deficiency citations and the new interpretative guidelines provide you with some ideas of what to tackle and what to measure!  

For more information about bereavement counseling, please contact Cindy Morgan at 919.971.8731 or cindymorgan@homeandhospicecare.org.