After a patient dies, family members and caregivers may need different kinds of support. Texas and federal rules require your hospice to assess those needs, create an appropriate bereavement plan and keep records showing how the program responds.
Focus on these five documentation areas:
1. Initial bereavement assessment
Your care team must complete the patient’s initial comprehensive assessment, including a review of initial grief-related needs, within five calendar days after the patient chooses hospice care. The team may include medical, nursing, social work and counseling staff.
The review must consider social, faith-based and cultural factors that may affect how they cope with the patient’s death. Examples include religious mourning customs, language barriers, cultural views on death or little support from family and friends.
2. Findings included in the plan of care
Include the assessment findings in the patient’s overall care plan. You must also consider those findings when developing the separate bereavement plan.
Records should identify the people who may need support and the needs revealed during the assessment.
3. Services and how often you will provide them
The written bereavement plan must state:
- The kinds of services the hospice will offer
- How often you will provide those services
Services may include counseling, support groups, calls, written materials or referrals based on each person’s needs.
4. Who will oversee the program
A qualified professional must oversee your hospice’s bereavement program. Document the supervisor’s education or experience in grief and loss counseling, along with their role in overseeing the program.
5. Support offered after the patient’s death
You must make bereavement services available for up to one year after the patient dies. Keep records of attempts to contact family members or caregivers, accepted or declined services, reassessments and changes in support.
Make documentation part of your compliance strategy
Bereavement records can reveal whether the hospice has clear procedures for assigning responsibilities, meeting deadlines and addressing gaps in care. A health care attorney can compare your policies, forms and staff procedures with Texas requirements and the federal Medicare Conditions of Participation, or Medicare compliance requirements. This review may help you identify inconsistencies before they become an issue during a survey, audit or regulatory investigation.