Valerian Home Health and Hospice

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 13 (54%) clinical records reviewed, the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/05/2026 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/06/2025 with a diagnosis of senile degeneration of the brain. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/29/2024 with a diagnosis of severe protein calorie malnutrition. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/13/2024 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/06/2026 with a diagnosis of hemiplegia. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/15/2025 with a diagnosis of Parkinson’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/11/2026 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. During an interview and joint clinical record reviews on 04/30/2026, the Administrator/Alternate Director of Patient Care Services (DPCS)/Registered Nurse (RN) stated that the clinical records were missing the initial bereavement assessment. The Administrator/Alternate DPCS/RN stated, “The initial bereavement assessment wasn’t completed because it was not being assigned to the Spiritual Counselor (SC)/Bereavement Coordinator (BC) at time of admission. There has been a newly hired SC/BC that has a strong desire to take the bereavement program to the next level.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed for deceased patients, the agency did not ensure a bereavement plan of care was developed. CLINICAL RECORD 4: The patient death was on 09/30/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 5: The patient death was on 09/28/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. During an interview and joint clinical record review on 04/30/2026, the Administrator/Alternate Director of Patient Care Services (DPCS)/Registered Nurse (RN) stated that the post-death bereavement plans of care were missing from the clinical records. The Administrator/Alternate DPCS/RN stated, “We hired a new Spiritual Counselor (SC)/Bereavement Coordinator (BC) on 04/06/2026 and orientation is in progress. I just spoke with the SC/BC, and he has a planned process to ensure to check-in with survivors of the two (2) patients that are listed above. He also reported with the next patient death, he has previous experience with this and will complete the post-death bereavement assessment and will develop a post-death plan of care based on survivor needs.””