Every finding on record at Grace Hospice of New Orleans, LLC

Based on interviews and record reviews, the agency failed to implement the plan of care for the frequency of services provided for 4 (Patient #1, Patient #4, Patient #6, Patient #7) of 10 sampled patients reviewed for services provided per the plan of care.  Findings: --- Review of the agency’s The Plan of Care policy, revised on October 2015, revealed in part, the care provided to the patient must be in accordance with the plan of care.  Patient #1Review of Patient #1’s Recertification Order for the certification period of 09/22/2025 through 11/20/2025 revealed, in part, Patient #1 was to receive hospice aide services three times a week for eight weeks, then twice a week for one week effective 09/22/2025.  Review of Patient #1’s record for the certification period of 09/22/2025 through 11/20/2025, revealed, in part:The week of 09/21/2025 through 09/27/2025 the only hospice aide visits completed were dated 09/22/2025 and 09/24/2025;The week of 09/28/2025 through 10/04/2025 the only hospice aide visits completed were dated 09/29/2025 and 10/01/2025;The week of 10/12/2025 through 10/18/2025 the only hospice aide visits completed were dated 10/15/2025 and 10/17/2025;The week of 10/19/2025 through 10/25/2025 the only hospice aide visits documented was a missed visit refused by the patient on 10/20/2025; and,The week of 11/02/2025 through 11/08/2025 the only hospice aide visits completed were dated 11/05/2025 and 11/06/2025. Review of Patient #1’s Recertification Order for the certification period of 11/21/2025 through 01/19/2026 revealed, in part, Patient #1 was to receive hospice aide services once a week for the first week, then three times a week for eight weeks, then once a week for one week effective 11/21/2025.  Review of Patient #1’s record for the certification period of 11/21/2025 through 01/19/2026, revealed, in part:No hospice aide visit was completed the first week of the certification period of 11/21/2025 to 11/22/2025; The week of 11/23/2025 through 11/29/2025 the only hospice aide visit completed was dated 11/26/2025; and, The week of 11/30/2025 through 12/06/2025 the only hospice aide visit completed was dated 12/04/2025.  In an interview on 12/10/2025 at 1:21PM, S1Administrator indicated hospice aide visits were not completed per the ordered frequencies per the plan of care, and the agency had no further documentation to present to refute the above findings.  Patient #4Review of Patient #4’s Hospice Certification and Plan of Care for the certification period of 01/31/2025 through 04/30/2025 revealed, in part, Patient #4 was to receive hospice aide services twice a week for twelve weeks.  Review of Patient #4’s record for the certification period of 01/31/2025 through 03/05/2025 revealed, in part:The week of 02/16/2025 through 02/22/2025 the only hospice aide visit completed was dated 02/20/2025.  In an interview on 12/10/2025 at 1:23PM, S1Administrator indicated the agency had no documented evidence Patient #4 was offered and received two hospice aide visits the week of 02/16/2025 through 02/22/2025.  Patient #6Review of Patient #6’s Hospice Certification and Plan of Care for the certification period of 12/18/2024 through 03/17/2025 revealed, in part, Patient #6 was to receive skilled nursing services four times a week for one week and hospice aide services once a week for one week. Review of Patient #6’s record revealed, in part:The week of 12/15/2024 through 12/22/2024 the only skilled nurse visits completed were dated 12/18/2024, 12/20/2024, and 12/21/2024; and,The week of 12/15/2024 through 12/22/2024, no hospice aide visits were completed.  In an interview on 12/10/2025 at 1:47PM, S1Administrator indicated the agency did not ensure the skilled nurse and hospice aide services were completed per the frequency specified in Patient #6’s plan of care.  Patient #7Review of Patient #7’s physician order dated 01/09/2025 revealed, in part, the hospice aide would start providing services to Patient #7 three times a week, starting on 01/13/2025.  Review of Patient #7’s record revealed, in part:The week of 01/12/2025 through 01/18/2025 the only hospice aide visits completed were dated 01/15/2025 and 01/17/2025; and, The week of 01/19/2025 through 01/25/2025 the only hospice aide visits completed were dated 01/20/2025 and 01/24/2025.  In an interview on 12/10/2025 at 1:30PM, S1Administrator indicated the agency had no evidence Patient #7 received hospice aide services three times a week per Patient #7’s 01/09/2025 physician order, which was incorporated into the plan of care.

Based on interview and record reviews, the agency failed to ensure the registered nurse provided written patient care instructions to the hospice aide prior to the hospice aide providing services for 1 (Patient #7) of 6 patients reviewed for hospice aide services.  Findings: --- Review of Patient #7’s physician order dated 01/09/2025 revealed, in part, the hospice aide would start providing services to Patient #7 three times a week, starting on 01/13/2025.  Review of Patient #7’s Aide Care Plan Report, which included Patient #7’s written care instructions, revealed the effective date of hospice care plan by the registered nurse was completed on 01/20/2025.  Review of Patient #7’s Client Schedule Report revealed, in part, Patient #7 received hospice aide services on 01/15/2025 and 01/17/2025.  In an interview on 12/10/2025 at 1:30PM, S1Administrator indicated the hospice aide care plan was developed by the registered nurse on 01/20/2025 which included the written patient care instructions; however, the hospice aide started providing services to Patient #7 on 01/15/2025 prior to the hospice aide care plan being developed.

Based on interviews and record reviews, the agency failed to ensure accurate documentation was completed for services provided for 4 (Patient #6, Patient #7, Patient #9, Patient #10) of 10 sampled patients reviewed for documentation of services provided. Findings: --- Review of the American Nurses Association’s Principles for Nursing Documentation, revised 2010, revealed, in part, documentation that is incomplete, inaccurate, or that is false and misleading can lead to a number of undesirable outcomes. Review of the agency’s Entries into the Clinical Record policy, revised October 2015, revealed in part, documentation in the clinical record would be accurate, and reflect the care or services provided. Patient #6Review of Patient #6’s Hospice Certification and Plan of Care for the certification period of 12/18/2024 through 03/17/2025 revealed, in part, Patient #6 was to receive hospice aide services once a week for one week. Review of Patient #6’s record revealed no evidence Patient #6 received hospice aide services from admission on 12/18/2024 through 12/23/2024 when Patient #6 expired. Review of Patient #6’s Registered Nurse Hospice Visit Note Report dated 12/23/2024 revealed, in part, supervisory functions were completed on the hospice aide.   In an interview on 12/10/2025 at 1:47PM, S1Administrator indicated the hospice aide supervisory visit was documented in error, as Patient #6 did not receive hospice aide services from admission to discharge. Patient #7Review of Patient #7’s physician order dated 01/09/2025 revealed, in part, the hospice aide would start providing services to Patient #7 three times a week, starting on 01/13/2025.  Review of Patient #7’s record revealed Patient #7 had a hospice aide supervisory visit completed on 01/14/2025; however, Patient #7 had not started receiving hospice aide services until 01/15/2025.  In an interview on 12/10/2025 at 1:30PM, S1Administrator indicated the hospice aide supervisory visit completed on 01/14/2025 was documented in error as Patient #7 had not received hospice aide services until 01/15/2025.  Patient #9Review of Patient #9’s Hospice Certification and Plan of Care for the certification period of 12/20/2024 through 03/19/2025 revealed, in part, Patient #9 was to receive hospice aide services three times a week effective 12/22/2024. Review of Patient #9’s Registered Nurse Hospice Visit Note Report dated 12/23/2024 revealed, in part, supervisory functions were completed on the hospice aide.   Review of Patient #9’s record revealed the only hospice aide visit completed was dated 12/26/2024. In an interview on 12/10/2025 at 1:35PM, S1Administrator indicated Patient #9’s hospice aide supervisory visit was documented in error on 12/23/2024, as Patient #9 did not receive hospice aide services until 12/26/2024. Patient #10Review of Patient #10’s Hospice Certification and Plan of Care for the certification period of 04/10/2025 through 05/16/2025 revealed, in part, no evidence Patient #10 had an order for hospice aide services. Review of Patient #10’s physician orders for the certification period of 04/10/2025 through 05/16/2025 revealed no evidence of an order for hospice aide services. Review of Patient #10’s record revealed no evidence Patient #10 received hospice aide services from 04/10/2025 through 05/16/2025. Review of Patient #10’s Registered Nurse Hospice Visit Notes for the certification period of 04/10/2025 through 05/16/2025 revealed the registered nurse documented supervising the hospice aide on the following dates, in part, 04/15/2025, 04/17/2025, 04/22/2025, 04/29/2025, 05/01/2025, 05/06/2025, 05/08/2025, 05/13/2025, and 05/14/2025.   In an interview on 12/09/2025 at 2:16PM, S4Registered Nurse indicated Patient #10 never received hospice aide services, and was unable to give a reason as to why hospice aide visits were being documented as having been performed. In an interview on 12/10/2025 at 1:37PM, S1Administrator indicated the above mentioned hospice aide supervisory visits were documented in error, as Patient #10 had not received hospice aide services.

Based on interview and record reviews, the agency failed to ensure criminal background checks were completed for all states licensed personnel who lived or worked in the past three years for 4 (S2Nurse Practitioner, S3Medical Director, S4Registered Nurse, S6Medical Social Worker) of 7 sampled licensed personnel records reviewed for criminal background checks.  Findings: --- Review of S2Nurse Practitioner’s personnel file revealed a hire date of 10/25/2024. Further review of S2Nurse Practitioner’s personnel file revealed S2Nurse Practitioner’s criminal background check dated 10/18/2024 was only completed for S2Nurse Practitioner’s domiciled parish (the parish which the employee lived) and not for the state of Louisiana.  Review of S3Medical Director’s personnel file revealed a hire date of 07/05/2021. Further review of S3Medical Director’s personnel file revealed S3Medical Director’s criminal background check dated 01/12/2023 was only completed for S3Medical Director’s domiciled parish and not for the state of Louisiana.  Review of S4Registered Nurse’s personnel file revealed a hire date of 05/20/2024. Further review of S4Registered Nurse’s personnel file revealed S4Registered Nurse’s criminal background check dated 05/16/2024 was only completed for S4Registered Nurse’s domiciled parish and not for the state of Louisiana.  Review of S6Medical Social Worker’s personnel file revealed a hire date of 02/28/2024.  Further review of S6Medical Social Worker’s personnel file revealed S6Medical Social Worker’s criminal background check dated 02/27/2024 was only completed for S6Medical Social Worker’s domiciled parish and not for the state of Louisiana.  In an interview on 12/10/2025 at 11:02AM, S1Administrator indicated he was not aware the criminal background checks for licensed personnel were completed by the licensed personnel’s domiciled county/parish, and not for the entire state, as required.

Based on record review and interview the agency failed to track and trend infections for 2 of 2 sampled patients (Patient #1 and Patient #2) reviewed for infection control in a total sample of 11 patients. Findings: --- Review of Patient #1s record revealed Patient #1 was prescribed Levofloxacin (medication used to treat infections) 500 milligrams (mg) one tablet daily for urinary tract infection (UTI) with a start date of 11/11/2022. Review of Patient #2s record revealed Patient #2 was prescribed Macrobid (medication used to treat infections) 100mg one tablet twice a day for UTI with a start date of 12/23/2022. Review of the agencys QAPI (Quality Assurance and Performance Improvement) Infection Reports for the fourth quarter (infections for 10/01/2022 thru 12/31/2022) revealed no documented evidence and the agency presented no documented evidence of Patient #1s Levofloxacin prescribed on 11/11/2022 and Patient #2s Macrobid prescribed on 12/23/2022 having been captured and tracked and trended for patterns of infections. In an interview on 01/11/2023 at 4:34 p.m., S1Interim Director of Nursing (DON)/Administrator confirmed neither Patient #1s Levofloxacin for an UTI nor Patient #2s Macrobid for an UTI were captured on the QAPI Infection Control Reports and therefore were not tracked and trended for patterns of infections.

Based on record review and interview the agency failed to coordinate care to ensure patients were assessed after falls for injuries for 2 of 2 sampled patients (Patient #1 and Patient #3) reviewed for care coordination in a total sample of 11. Findings: --- Patient #1 Review of Patient #1s Client Coordination Note dated 11/12/2022 at 3:06 a.m., revealed Patient #1 had a fall and was unable to get back up and back to bed. Further review revealed Patient #1s caregiver advised to call emergency medical services for lift assistance. Review of Patient #1s Client Coordination Note dated 11/12/2022 at 3:36 a.m. revealed emergency medical services called the on-call nurse due to Patient #1s blood pressure recorded as 70/40 mmHg (milligrams of mercury) and then 92/58mmHg (normal blood pressure was 120/80mmHg). Review of Patient #1s record revealed no documented evidence and the provider presented no documented evidence of the agency having sent a nurse to assess Patient #1 post fall until 11/14/2022. In an interview on 01/12/2023 at 9:17 a.m., S1Interim Director of Nursing (DON)/Administrator stated the agency had no documented evidence of the agency staff having seen and assessed Patient #1 post fall of 11/12/2022 until 11/14/2022. Patient #3 Review of Patient #3s Client Coordination Note dated 12/04/2022 at 9:51 a.m. revealed Patient #3s caregiver called to report Patient #3 had a fall during the night and now had knee pain and could not walk well. Review of Patient #3s Visit Note Report dated 12/04/2022 revealed no documented evidence of S6Licensed Practical Nurse (LPN) having assessed Patient #3s knee post fall. In an interview on 01/12/2023 at 9:30 a.m., S1Interim DON/Administrator stated the agency had no documented evidence of S6LPN having assessed Patient #3s knee post fall. S1Interim DON/Administrator stated S6LPN was notified on 12/04/2022 to see Patient #3 for a routine visit and was not notified of the fall, or to assess Patient #3s knee. S1Interim DON/Administrator further stated S6LPN did not document any coordination of care on 12/04/2022 with the registered nurse.

Based on record review and interview the agency failed to ensure a patient had the necessary medication for symptom control immediately after admit for 1 of 11 sampled patients (Patient #6) reviewed. Findings: --- Review of Patient #6s Registered Nurse (RN) Start of Care Visit Note Report dated 09/03/2022 revealed, in part, Patient #6 had an oxygen saturation level (level of oxygen in the blood) of 86% (normal limits was 94% or higher), Patient #6 was assessed as short of breath with need for opioids and other medication. Review revealed Patient #6 had multiple emergency room visits in the last six months due to shortness of breath. Further review revealed education was provided on medications for pain and discomfort, Morphine and Lorazepam. Review of Patient #6s On-Call Coordination Note dated 09/03/2022 at 11:09 p.m. revealed Patient #6s caregiver called due to pain and shortness of breath and Patient #6 did not have any medication in the home. Review of Patient #6s Visit Note Report dated 09/03/2022 revealed S5Licensed Practical Nurse (LPN) assessed Patient #6s tailbone pain and shortness of breath. Further review revealed the only medication mentioned was Tylenol (over the counter medication for pain) for symptom control. Review of Patient #6s Pharmacy Delivery Invoice revealed the first time any medication was delivered after hospice admit was 09/04/2022. Further review revealed the following medications, in part, were delivered: Lorazepam (medication used for anxiety and shortness of breath) 2 milligram/milliliter (mg/ml) and Morphine Sulfate (narcotic pain medication) 100mg/5ml. In an interview on 01/12/2023 at 10:23 a.m., S1Interim Director of Nursing (DON)/Administrator stated the medications for pain and shortness of breath symptom control should have been present for admit.