Agape Hospice Care of Carrollton, LLC

“Based on review of the agency policy titled, “Patient Discharge,” clinical record review, and staff interviews, it was determined that the hospice failed to properly notify a patient of an agency discharge instead of transfer and failed to ensure notice of discharge was provided to the patient prior to discharge for one of three patients(P) (P3) of three sampled discharge charts reviewed. Findings include: Review of an undated policy titled, “Patient Discharge,” revealed the following:PurposeTo establish guidelines and processes by which patients are discharged or recommended for discharge from the hospice program.ProcedureIII. If the patient is determined to no longer be medically eligible:B. The Hospice will assist in coordinating continued care when a patient is discharged from hospice IV. The Hospice will provide the Notice of Medicare Non-Coverage (NOMNOC) to the Medicare patient no later than two calendar days before the date their Medicare coverage will be ending or the second to last day of service if care is not being provided daily. 1. Review of the clinical record revealed P3 was admitted to hospice on 03/07/2025 and was discharged on 07/23/2026. Further review of the patient’s revealed a Request for Health Information Form from another agency dated 07/24/2026, however, the record lacks documentation that the request for health information was sent to the other agency. The record also lacked documentation of the NOMNOC form to indicate the patient was aware of being discharged from the agency and not being transferred to another agency. The patient was discharged from the agency on 07/23/2026, without documentation of follow up for community resources and support.On 9/22/2026, at 10:14 AM, during an office interview, the Administrator reported she spoke with P3 at length regarding a transfer to a different agency as P3 had voiced the desire to transfer to another agency. The Administrator revealed the agency received a request for release of information on 07/23/2026, however the clinical record did not indicate the records were sent to the requesting agency. The Administrator indicated that the team lead who was overseeing this case left the agency a month ago and did not scan the faxed coversheet into the record to show the records were sent, therefore the agency was unable to show proof that they had sent the requested documents to the agency to initiate the transfer. The transfer did not take place and P3 was discharged on 07/23/2026. The Administrator confirmed P3 did not sign a notice of discharge from the agency. The Administrator also revealed the agency provided a 10-day supply of medications at discharge and allowed oxygen to remain in the home. The Administrator insisted that the patient was transferred rather than discharged but did acknowledge the record lacked a completed transfer form and lacked documentation that requested records were sent to the requesting agency to initiate the transfer.On 09/22/2026, at 1:37 PM, during an office interview, the Team Manager reported that the prior team lead who was overseeing the case thought she had received a transfer form from the receiving agency, however it was a release of information form and not a transfer form. It was confirmed the agency did not complete a transfer form to initiate the transfer to another agency.”

“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”