Every finding on record at Agape Hospice Care of Carrollton, LLC

Based on review of policy titled “Complaint/Grievance Process,” record reviews, staff and patient interviews, and complaint log, it was determined that the agency failed to protect and promote patient rights by failing to document complaint/grievance for one patient (P) (P#3) of four sampled patients. --- Findings include: Review of the agency’s policy titled “Complaint/Grievance Process,” revised 10/28/22 reveals the following:Purpose  To set forth guidelines for the resolution of patient concerns dissatisfaction or complaints and to protect patient and family rights.Procedure1.  The organization staff member receiving the complaint notify Area Vice President or designee immediately when possible or in any case within five (5) days of alleged grievance and document the grievance on the Customer Feedback Form. The Area Vice President or designee investigate the grievance within five days after receipt of such grievance and will make every effort to resolve the grievance to the patient’s satisfaction unless otherwise required by state law.  Response to the patient regarding the complaint will occur within five days of receipt unless otherwise required by state law.3. Complaints and any action taken will be documented on the Customer Feedback form9. All complaints will be logged, tracked and trended Review of clinical record documentation revealed P#1 was admitted to hospice services on 7/31/25. Review of the complaint log for the year of 2025 failed to reveal documentation of the complaint being investigated. During an interview at the agency on 11/24/25 at approximately 12:00 p.m., the Volunteer Coordinator stated that P#3 did verbalize a complaint to her regarding a volunteer overstepping her boundaries by asking the patient about her personal business such as the patient’s will. The Volunteer Coordinator reported that she was aware of the complaint but failed to document the complaint in the agency complaint log as required. During an interview with the Executive Director on 11/24/25 at approximately 12:15 pm, the Executive Director stated that she was aware of P#3 complaint regarding the volunteer crossing boundaries and did confirm that the Volunteer Coordinator failed to document the occurrence in the complaint log as required. During a telephone interview with P#3 on 11/24/25 at 2:00 pm, P#3 confirmed that the agency volunteer assigned to her came to her home was asking inappropriate questions which made her feel uncomfortable such as questions regarding her will. P#3 stated that she did make a complaint to the Volunteer Coordinator regarding the volunteer and her inappropriate behavior.

Based on review of policy titled" Volunteer Services," record reviews, staff and patient interviews, it was determined the agency failed to service the patient and family by not providing volunteer services for one patient (P) (P#3) of four sampled patients. --- Findings included: Review of the policy titled “Volunteer Services,” revised 6/12/2023 revealed the following:PolicySage family of companies will provide volunteer services under the direction of a volunteer coordinator and with the assistance of trained hospice volunteers. Review of records for P#3 revealed a coordination note titled “Client coordination note report,” dated 9/5/2025 revealing volunteer services were cancelled. Review of records failed to confirm documentation of further communication notes from the Volunteer Coordinator (VC). On 11/24/2025 at 2:45 p.m. a telephone interview was conducted with patient P#3 revealed that P#3 was not receiving volunteer services at the time, however, verbalized the desire to have volunteer services. Pt#3 explained that she was told by the volunteer coordinator not to tell anyone in the agency that she was unhappy with the volunteer that was previously assigned to her and that the volunteer was too involved with her personal life and was asking questions about her will. P#3 stated that the volunteer coordinator stated that she would take care of the issue with the volunteer. P#3 stated that the volunteer coordinator removed the volunteer and told her that the agency did not have enough volunteers at the time to provide her with volunteer services. P#3 states that she agreed to wait until another volunteer was available and that it would be great to have volunteer services restarted as she could use the services. On 11/24/2025 at 1:23 p.m., an in-office interview was conducted with the Director of Clinical Operation (DCO), who states she was vaguely aware of the complaint regarding P#3. She stated that the volunteer coordinator handles issues with the volunteers. An interview was conducted with the Volunteer Coordinator (VC) on 11/24/25 at 1:33 p.m. revealed volunteer was terminated, and volunteer services were cancelled.

Based on policies and procedures, record reviews and staff and family interviews, it was determined the governing body failed to assume responsibility for all hospice services and meeting patients’ needs. Specifically, the agency failed to provide volunteers and failed to follow up on complaints for one patient (P) (P#3) of four sampled patients. --- Findings included: Review of the policy titled “Governing Body,” revised 11/29/2023 revealed the following:PurposeTo outline the roles and responsibilities of the Governing body.PolicyThe Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations. Cross refer to L0650: SERVING THE HOSPICE PATIENT AND FAMILYCross refer to L0508: EXERCISE OF RIGHTS/RESPECT FOR PROPRTY/PERSON

Based on record review, staff interviews, and review of agency policies titled, ";Medication Administration Record", # MED-2 dated 6/2019, and ";Medication Administration" #PRCM-17 revised 6/22/2021, the agency failed to document a patient specific comprehensive assessment that includes all areas of hospice care needed for the palliation and management of the terminal illness for two patients (P) (P#1, P#2) of two sampled patients (P#1, P#2). In addition, the failure to assess and document medication needs resulted a delay in receiving medications that are needed to manage symptoms for one of two sampled patients (P#2). --- The findings include: Review of policy # MED-2 titled ";Medication Administration Record", dated 6/2019 (2.) reveals the following: Procedure: 2. During each patient visit, the hospice nurse will assess the patients medications for additions, changes or discontinuations and will document all pertinent information concerning medication changes. Review of policy #PRCM-17, titled ";Medication Administration", revised 6/22/2021 reveals the following: Procedure: · The nurse will document the following in the clinical record: § Medication education § Side effects § Administration § Date discontinued § Other related information as indicated. 1. Review of the ";nursing assessment" and ";nursing narrative record" for P#1 (certification period 2/17/2023 through 5/17/2023 and 5/18/2023 through 8/15/2023) revealed the records failed to contain documentation of medication reviews or discussion with family regarding medication regimen. 2. Review of nursing visit records dated 6/2/2023, 6/5/2023, 6/14/2023 for P#2 revealed no documentation of medication review. Review of agency on call log reveals a call to the on call staff from agency social worker (SW) on 6/14/2023 at 8:27 p.m. revealing P#2 short of breath, anxious and out of morphine (used to relieve moderate to severe pain). Interview at agency with RN AA on 6/27/2023 at 2:50 p.m. revealed nurse does not routinely check medications or discuss medications with family for P#2. Interview with RN BB Director of Clinical Care (DOCC) confirmed nurses are not documenting that they are checking medication needs at every visit.

Based on record reviews, staff interviews, and review of agency policy titled ";Interdisciplinary Group Plan of Care" with a date of April 5, 2023, it was determined the agency failed to develop and maintain a system of communication in accordance with hospices own policies and procedures for ensuring patients and patients families were informed of changes in plan of care (POC) as discussed during interdisciplinary group (IDG) meetings for one patient (P) (P#1) of two sampled patients (P#1, P#2). --- The findings include: Review of agency policy titled ";Interdisciplinary Group Plan of Care" dated April 5 2023, reveals the following: ";Sage Family of Companies personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." During record reviews surveyor reviewed nursing visit notes (certification period February 17, 2023 through May 17, 2023 and May 18, 2023 through August 15, 2023) which failed to include documentation of updates to P#1s legal representative (family member) by phone or in person. An interview conducted on June 27, 2023 at 2:00 pm with RN AA revealed P#1 had paid care givers and the legal representative (family member) was not present during most home visits. RN AA additionally revealed she rarely spoke to legal representative (family member) either by phone or in person and did not update legal representative (family member) during or after nursing visits were made.

Based on a review of clinical records, staff interviews, and a review of the agencys on-call reports, it was determined that the Hospice failed to effectively provide appropriate interventions for symptom management at the end of life for one patient (P#1) of three sampled patients (P#1, P#2, P#3). P#1 was found to have a low oxygen saturation and was not provided any interventions to achieve an acceptable saturation. --- Cross reference L0512 as it relates to Licensed Practical Nurse (LPN) AA not providing oxygen therapy to one patient (P#1) out of three sampled (P#1, P#2, P#3). P#1 was documented to have an oxygen saturation of 86% (normal oxygen saturation levels are 95% or higher). No interventions were documented to aid P#1 in achieving an acceptable oxygen saturation.

Based on a review of clinical records, staff interviews, and a review of the agencys on-call reports, it was determined that the Hospice failed to effectively provide appropriate interventions for symptom management at the end of life for one patient (P#1) of three sampled patients (P#1, P#2, P#3). P#1 was found to have a low oxygen saturation and was not provided any interventions to achieve an acceptable saturation. --- A review of the P#1clinical record revealed, P#1 was admitted on 9/18/20 with a diagnosis of other frontal temporal neurocognitive disorder (damage to the brain that causes issues with communication, behavior, and movement). A review of the agencys on-call log revealed, on 12/21/22 at 7:00 p.m., P#1s assisted living facility (ALF) called the hospice agency to alert the hospice staff that P#1 had a change in condition. P#1was not eating or drinking and was spitting out medications. A visit note dated 12/21/22 at 7:06p.m, written by Licensed Practical Nurse (LPN) AA, on-call nurse, documented P#1 was received lying in bed with eyes closed but was responsive to verbal and tactile stimuli. No signs and symptoms of pain or discomfort were documented. RN AA was unable to obtain a blood pressure. P#1s oxygen saturation was monitored at 86% (normal oxygen saturation levels are 95% or higher). P#1 clinical record failed to document interventions made by LPN AA to increase P#1 oxygen saturation. An interview was conducted on 1/9/23 at 11:00 a.m. with the Director of Clinical Operations (DCO). DCO confirmed LPN AA should have initiated an order from the physician to ensure P#1 had oxygen readily available. A phone interview was conducted on 1/10/23 at 11:09 a.m., with LPN AA from the agency headquarters. LPN AA acknowledged visiting P#1 on 12/21/22. LPN AA acknowledged P#1s oxygen saturation was 86% during the visit. LPN AA confirmed that if a patients oxygen saturation was that low, he would get a physician's order to administer oxygen. Review of policy titled, ";Ongoing Assessment" Policy #: PRCM-21 dated March 2013, was reviewed, and revealed; Procedure: · During each home visit, the registered nurse care manager, designee or other disciplines will evaluate the patient according to the problems identified during the initial assessment. · The nurse will assess each patient on each visit for the following: Pain secondary symptoms related to the terminal illness vital signs breath sounds skin integrity bowel sounds mental status appetite/diet functional status safety patient and family support progress towards goals compliance with treatment and medication the need for an alternative setting or level of care · Ongoing comprehensive assessments should focus on: Patients response to care Change in patient condition Change in patient diagnosis/prognosis · Based on the findings of the assessment, written/verbal orders will be generated and forwarded to the physician as needed · The physician will be notified to verify any changes in mediations, including over the counter medications and treatments/interventions that require physician approval. Review of policy titled, ";Care of the Dying Patient" Policy #: TER-1 dated July 5, 2019, was reviewed, and revealed; Procedure: · 1. The nurse will monitor the following: a. Vital sings, cardio-pulmonary status general comfort level b. Medication compliance/reactions c. Nutrition/hydration d. Elimination e. Skin condition f. Anticipate future medical needs, i.e., medications in alternate delivery forms, DME and supplies · 7. Provide ordered pain medication as needed. Review of policy titled, ";Pain Management" Policy #: TER-2 dated July 5, 2019, was reviewed, and revealed; Procedure: 4. Anticipate need for analgesics or additional methods of pain relief Review of policy titled, ";Medical Provisions" Policy #: PRCM-15 dated March 2013, was reviewed, and revealed; Policy: Agency will provide medical supplies and appliances, durable medical equipment (DME) and drugs and biologicals while the patient is under hospice care. Review of policy titled, ";Oxygen Administration" Policy #:RES-2 dated July 3, 2019, was reviewed, and revealed; Policy: Oxygen is administered to patients as necessary per physicians order. Review of policy titled, ";Medication Review and Profile" Policy #: PRCM-18 dated March 2013, was reviewed, and revealed; Policy: Patients receiving medications administered by the organization will have a current and accurate medication profile created by the registered nurse during the initial nurse case manager. Procedure: · A drug regimen review will be performed at the time of initial and comprehensive assessment to identify: o Effectiveness o Changes in the patients condition The agency failed to ensure P#1 received interventions to manage pain and symptoms in a timely manner causing undue pain and suffering at the end of life.

Based on a review of clinical records, staff interviews, and a review of the agencys on-call reports, it was determined the Hospice failed to ensure medications were readily available to effectively manage pain and symptoms at the end of life for one patient (P#1) of three sampled patients (P#1, P#2, P#3) causing undue pain and suffering at the end of life. --- Cross references L0546 as it relates to P#1

Based on a review of clinical records, staff interviews, and a review of the agencys on-call reports, it was determined the Hospice failed to ensure medications were readily available to effectively manage pain and symptoms at the end of life for one patient (P#1) of three sampled (P#1, P#2, P#3) causing undue pain and suffering at the end of life. Findings include: --- A review of the P#1clinical record revealed, P#1 was admitted on 9/18/20 with a diagnosis of other frontal temporal neurocognitive disorder (damage to the brain that causes issues with communication, behavior, and movement). A review of patient record note dated 12/20/22, (no time documented) revealed an update note from ALF that patient spitting out medications, decrease weight, but continues to walk in the ALF. A review of patient record dated now 12/23/22, (no time documented) revealed RN Case Manager CC called ALF to get an update of P#1. The ALF reported P#1 is resting comfortably without pain or respiratory distress at that time. RN CC documented she educated the ALF to call with any changes or concerns with P#1. RN instructed ALF to continue to monitor. She wrote, ALF verbalized understanding. A visit note dated 12/24/22 (no time documented) by Registered Nurse (RN) BB documented a PRN (as needed) visit was made to the patient on 12/24/22 after receiving a call from P#1s and P#1s Assisted Living Facility (ALF) at 9:27 a.m., stating P#1 was transitioning and in severe pain and distress. RN arrived at approximately 10:30 a.m. A visit note dated 12/24/22 (no time documented) further revealed, RN BB further documented on visit note dated 12/24/22, that P#1 was received lying in bed with eyes wide open, a frightened expression on face, respiration rate was 40 breaths per minute (normal respiration rate should be 12 to 16 breaths per minute) and shallow, fists clenched, moans with slightest touch or movement, oxygen saturation 70% on room air (breathing without supplemental oxygen), and non-verbal pain score of 7 on a scale of 1-10 was noted on the visit note. A visit note on 12/24/22 (no time documented) by RN BB further documented a plan to administer Roxanol (liquid short acting pain and shortness of breath relief medication) and oxygen via nasal cannula for comfort/relief and hypoxic (low oxygen saturation) distress. A visit note dated 12/24/22 (no time documented) further revealed RN BB documented P#1 did not have access to an emergency kit. STAT (immediate) medications (Roxanol and oxygen) were ordered at 11:00 a.m. P#1s medications did not arrive until 4:46 p.m. (approximately 4 1/2 hours after STAT order). P#1 was pronounced dead at 6:42 p.m. A review of an Incident report dated 12/24/22 (no time documented) revealed the pharmacy staff did not see that the (E-BOX)/COMFORT KIT was a STAT delivery at 11am, which held up the medication delivery. The medication was delivered after 4pm. A review of a customer feedback document dated 1/5/23 (no time documented), submitted to Agape Hospice by family of P#1, revealed the pt became active over the weekend. There was a breakdown of communication and delivery of equipment and medication. The pharmacy was not notified properly or there was a misunderstanding re: STAT for E-Kit. An interview was conducted on 1/9/23 at 11:00 a.m. with the Director of Clinical Operations (DCO). DCO confirmed the agency staff failed to ensure P#1 had an emergency kit readily available to administer. DCO also revealed that the agency staff saw P#1 several times throughout the week due to the P#1s decline in health. DCO confirmed agency staff did not ensure P#1 had the necessary medications and equipment on hand to assist the patient should the patient need anything to help ease pain and suffering at the time of death. P#1 failed to have an emergency kit available on site (emergency kit contains medications to assist with pain and suffering; Roxanol (pain medication) 20mg/ml- used for pain and shortness of breath, Levsin (stomach pain medication) 0.125mg tablets-used to decrease oral secretions, Dulcolax (stool softener)10mg suppositories-used for constipation, Ativan (antianxiety medication) 1mg tablets-used for anxiety, Phenergan (anti-vomiting and sedative medication ) 25mg-used for nausea/vomiting, Tylenol (Pain medication) 650mg tablets-used for fever headache, Haldol (medication to assist with agitation) 1mg tablets-used for agitation, Zofran (antinausea medication) 4mg tablets-used for nausea and vomiting. P#1 did not have access to pain medications to administer or oxygen concentrator (a medical device used to increase the availability of breathable oxygen) to initiate oxygen therapy. Review of policy titled, ";Emergency Medications (E-BOX)/COMFORT KIT with date of revision 4/2018, revealed: As part of your admission to hospice, the RN Case Manager has assessed the need for an E-BOX/COMFORT KIT. This box contains medications to assist in management of potential or anticipated symptoms, such as nausea, vomiting, pain or shortness of breath. These medications should not be utilized without specific instructions given by the hospice nurse. Keep this box in a designated area, out of the reach of children. Review of policy titled, ";Plan of Care" (POC)with date of revision March 2013, revealed: · The POC will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: o Interventions to manage pain and symptoms o Equipment and supply needs o Interventions to manage pain and symptoms o Drugs and treatment necessary to meet the needs of the patient The agency failed to ensure P#1 received interventions to manage pain and symptoms in a timely manner causing undue pain and suffering at the end of life.

Based on review of personnel files and staff interview, it was determined that the Hospice failed to ensure that a Registered Nurse completed an annual and initial competency evaluation for two (2) of three (3) employees (#1 and #2) sampled hospice aides. The findings include: 1. The personnel record for employee #1 reflected a hire date 8/23/19. Initial competency evaluation was completed by a Registered Nurse (RN) on 8/23/19, but lacked documented proof or evidence that a RN completed an annual competency evaluation of the aide's skills for 2020. 2. The personnel record for employee #2 reflected a hire date 4/1/13. Initial competency evaluation was completed by a RN on 4/1/13, but lacked documented proof or evidence a RN completed an annual competency evaluation of the aide's skills for 2020, 2021, and 2022. 3. In an interview on 4/27/22, at 1:00 p.m., the Human Resources (HR) Manager confirmed that a Registered Nurse did not complete initial and annual competency evaluations for the two aides.

Based on observation, clinical record review, and staff interviews, it was determined that the Agency failed to order patients' medication: Seroquel 50milligrams (MG), one tablet oral at bedtime; drugs must be made routinely available on 24 hours basis 7 days a week for all patients. The hospice agency failed to comply with the regulation for one (1) of sixteen (16) sampled patients (P#1). The finding include: During a home visit observation conducted on 4/26/22, at approximately 9:20 a.m., with Registered Nurse (RN) AA for (P#1), it was revealed that the patient was admitted on 2/10/22, with a diagnosis of Senile degeneration of brain, Alzheimer's disease, and dementia. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile. A discrepancy was found. P#1 was taking Seroquel 50mg (antipsychotic) one tablet oral at bedtime; the medication was missing because it was not ordered by (RN) AA. On 4/26/22, at 10:00 a.m., an interview was conducted with (RN) AA, who confirmed that Seroquel 50mg one tablet oral at bedtime, was not available.

Based on personnel file review and interview with the staff, it was determined that the Hospice failed to ensure that staff members obtained Cardiopulmonary Resuscitation (CPR) training for one (1) of three (3) Certified Nurse Aide (CNA) sampled employees (employee#1). The findings include: The personnel files of hospice employee #2 lacked documentation of Cardiopulmonary resuscitation (CPR). During the interview on 4/27/22, at 1:00 p.m., the Human Resources (HR) Manager failed to present verification of CPR cards for employee #1, and verified that the surveyor had been given all documentation regarding personnel medical records. On 4/27/22. at 2:45 p.m., an interview was conducted with Administrator who stated employee #2 was hired on 4/1/13; but she was not available for interview. Administrator also stated she was not aware that employee #2's CPR had expired on 12/31/20.