Agape Hospice Care of Cherokee County, LLC

“Based on review of agency policy titled “On Call for Patient Care-Addendum,” “Plan of Care Process, “ review of on call log, clinical record reviews, and staff and family interviews, it was determined the hospice failed to protect and promote the exercise of patient’s rights by not providing effective pain management and symptom control for one patient (P) (P3) of five patients reviewed. Findings include: Cross reference to L0512 relating to facility failure to provide effective pain management and symptom control for conditions related to the terminal illness and at the end of life for P3.”

“Based on review of agency policies, clinical record reviews, personnel record reviews and staff interviews, it was determined the agency’s governing body failed to ensure the nursing services were made available within one hour of notification during afterhours (time when agency office is closed) and during regular business hours to meet patients’ needs for five patients (P) (P1, P2 , P3, P4, P5) of five sampled patients from agency on-call report.It was determined the agency’s governing body failed to provide all persons providing hands-on care directly to patients had a current certification in basic cardiac life support (BCLS) or cardiopulmonary resuscitation (CPR) certification. Specifically, the hospice failed to ensure that two clinical employees, certified nurse aide (CNA) AA, licensed practical nurse (LPN) BB, of eight clinical employees sampled maintained current BCLS or CPR certifications.It was determined the governing body failed to ensure patient’s rights were maintained by effectively managing pain and controlling symptoms for conditions related to the terminal illness and at the end of life for one patient (P3) of five sampled patients. Findings included: Findings include:Cross reference to L0651 relating to nursing services made available within one hour of notification; persons providing hands-on care had a current certification in basic cardiac life support (BCLS) or cardiopulmonary resuscitation (CPR) certification Cross reference to L0512 relating to effectively managing pain and controlling symptoms for conditions related to the terminal illness and at the end of life.”

“Based on policy titled “On Call of Patient Care-Addendum,” clinical record reviews, on-call log, and staff interview, it was determined the agency failed to comply with the nursing services one- hour response time of a patient experiencing a crisis situation or change in condition for five patients (P) (P1, P2, P3, P4, P5) of five patients sampled from the agency’s on-call report. Findings included: Review of policy titled “On Call of Patient Care-Addendum” dated 12/27/2023, revealed the following:“PROCEDUREB. On-site nursing services available within one hour of notification where the terminally ill and the patient with an advanced and progressive disease who has contracted for nursing services experiences a symptom-management crisis situation.” 1. Review of on call log for P1 revealed that agency was called on 03/01/2026 at 5:07 AM, and the nurse arrived at patient’s home at 6:31 AM. 2. Review of on call log for P2 revealed that on 03/01/2026, the agency was called at 6:09 PM and the nurse arrived at patient’s home at 7:16 PM. 3. Review of on- call log for P3 revealed that on 02/08/2026 the agency was called at 2:49 PM and at 5:10 PM. There is no documentation of a nursing visit made on 02/08/2026. On 02/09/2026 at 3:38 AM the agency was called again and the nurse arrived on 02/09/2026 at 5:08 PM. 4. Review of on- call log for P4 revealed that on 02/08/2026 the agency was called at 11:53 AM and the nurse arrived at 1:07 PM. 5. Review of on call log for P5 revealed that on 03/01/2026 at 6:19 PM the agency was called and the nurse arrived at 7:55 PM. On 03/10/2026 at 2:00 PM, during an office interview, the Director of Clinical Operations (DCO) confirmed P1, P2, P3, P4, P5, had a delay in nursing services during agency after hours. DCO acknowledged the problem with not meeting the one-hour window for arrival at patient’s homes after on call received and was identified as a problem in December 2025. On 03/10/2026 at 3:30 PM, during an office interview, the agency the agency Assistant Vice President (AVP) confirmed the agency had a problem with not meeting the one-hour window for arrival at patient’s homes after on call received and was identified as a problem in December 2025. He also confirmed the agency had been operating in this manner for years.”

“Based on review of agency policy titled “Plan of Care Process, “policy titled “On Call of Patient Care-Addendum,” review of on call log, clinical record reviews, and staff and family interviews, it was determined the hospice agency failed to provide effective pain management and symptom control for conditions related to the terminal illness and at the end of life for one Patient (P) (P3) of five patients reviewed. Findings included: Review of agency policy titled “On Call of Patient Care-Addendum,” dated 12/27/2023, revealed the following:“Procedure B:On-site nursing services are available within one hour of notification where the terminally ill and the patient with an advanced and progressive disease who has contracted nursing services experiences a symptom-management crisis situation.” Review of agency policy titled “Plan of Care Process,” dated 9/1/2021, revealed the following:“V1. The POC includes, but is not limited to:A. Interventions to manage pain and symptoms and identified issues/problems.D. Drugs and treatments necessary to meet the needs of the patient.” Review of on call log for P3 revealed that on 02/08/2026 at 1:51 PM, the agency received a call from the Assisted Living Facility (ALF) where P3 resides, stating that P3 is not doing well. Review of on call log for P3 revealed that on 02/08/2026 at 5:10 PM, the facility called again stating that “Ekit (Emergency medication kit) needs to be sent to [Name]”. Review of on call log for P3 revealed that on 02/09/2026 at 3:17 PM, the facility called the agency stating, Patient (P3) ceased breathing. Review of care coordination note dated 02/08/2026, ALF requesting Comfort Kit medications (same as E-Kit). On 02/09/2026 at 3:17 AM, agency was called to report P3 had ceased breathing. Review of the death visit note, the nurse arrived on 02/09/2026 at 5:08 AM. Review of death visit note revealed P3 expired on 02/09/2026 at 5:27 AM. Review of the document titled “pharmacy patient dispense history” revealed Comfort Kt for P3 arrived on 02/10/2026, the day after P3 expired. On 03/10/2026 at 2:00 PM , an office interview was conducted with Director of Clinical Operations (DOCO) who confirmed that P3 had a delay in nursing services during (after business hours). DOCO also confirmed that P3’s records failed to reveal that the nurse made a visit on 02/08/2026. On 3/12/2026 at 1:58 PM, during a phone interview, the family of P3 stated” P3 never received a Comfort Kit before she died, and the hospice never notified me that P3 had a change in condition.””

“Based on review of agency policies, clinical record reviews and staff interviews, it was determined that the agency governing body failed to ensure the nursing services were made available within one hour of notification during afterhours (time when agency office is closed) and during regular business hours to meet patients’ needs for five patients (P) (P1 P2 P3 P4 P5) of five sampled patients from agency on-call report, failed to provide all persons providing hands-on care directly to patients had a current certification in basic cardiac life support (BCLS) or cardiopulmonary resuscitation (CPR) certification. Specifically, the hospice failed to ensure that two clinical employees, certified nurse aide (CNA) AA, licensed practical nurse (LPN) BB, of eight clinical employees sampled maintained current BCLS or CPR certifications. The agency’s governing body failed to guarantee all patients’ rights were maintained by effectively controlling pain and managing symptoms related to terminal illnesses for one patient (P3) of five sampled patients. Findings included: 1. Review of agency policy titled “On Call of Patient Care-Addendum” dated 12/27/2023 revealed the following:“ProcedureB. On-site nursing services available within one hour of notification where the terminally ill and the patient with an advanced and progressive disease who has contracted for nursing services experiences a symptom-management crisis situation;” Review of the on-call log for P1 revealed that agency was called on 03/01/2026 at 5:07 AM, and the nurse arrived at patient’s home at 6:31 AM. Review of the on-call log for P2 revealed that on 03/01/2026, the agency was called at 6:09 PM and the nurse arrived at patient’s home at 7:16 PM. Review of the on-call log for P3 revealed that on 02/08/2026 the agency was called at 2:49 PM and again the agency was called at 5:10 PM. On 02/09/2026 at 3:38 AM the nurse arrived on 02/09/26 at 5:08 AMReview of the on-call log for P4 revealed that on 020/8/2026 the agency was called at 11:53 AM and the nurse arrived at 1:07 PM. Review of the on-call log for P5 revealed that on 03/01/2026 at 6:19 PM the agency was called and the nurse arrived at 7:55 PM. On 03/10/2026 at 2:00 PM during an office interview the Director of Clinical Operations (DCO) confirmed P1 P2 P3 P4 P5 had a delay in nursing services during agency after hours. DCO admitted the problem with not meeting the one-hour window for arrival at patients’ homes after on call received and was identified as a problem in December 2025. On 03/10/2026 at 3:30 PM during an office interview the agency the agency Assistant Vice President (AVP) admitted the agency had a problem with not meeting the one-hour window for arrival at patients’ homes after on call received and was identified as a problem in December 2025. He also confirmed the agency had been operating in this manner for years. 2. Review of policy titled “Administrative Policy Manual Personnel Records,” dated 05/01/2025, revealed the following:“PROCEDURE:V. Personnel record contents for Hospice employees may include but not be limited to:N. Copy of CPR certification, if required.” The HR file for CNA AA, with a hire date of 12/04/2023, failed to reveal a current BCLS or CPR certification. The HR file for LPN BB, with a hire date of 10/20/2020, failed to reveal a current BCLS or CPR certification. Surveyors informed the Director of Clinical Operations (DCO) of the missing current BCLS or CPR documentation for the above-mentioned employees on 03/10/2026, 03/11/2026, and 03/12/2026, and surveyors requested evidence of current BCLS or CPR certifications from the DCO on 03/10/2026, 03/11/2026, 03/12/2026, and the documents were not provided as of 03/12/2026 at 5:06 PM. According to review of the employees’ schedules, CNA AA and LPN BB were still seeing patients as of 03/12/2026. During an in-office interview on 03/12/2026 at 5:06 PM, the DCO revealed that no further documentation was available for CNA AA and LPN BB. The DCO confirmed the HR files lack required documentation. Cross reference L0512- patient’s rights”

“Based on clinical record review, review of policy titled “Professional Boundaries,” and staff and family interviews, it was determined the agency failed to obtain consent from family member of patient prior to taking patient out of facility for one patient (P) (P#1) of three sampled patients. The findings include: Review of policy titled “Professional Boundaries,” effective March 2013, reveals the following:Policy: Employees of (facility) work very closely with patients and their families during end-of-life care. Facility employees will maintain professionalism. Review of chaplains’ note dated 5/6/2025 at 8:09 AM reveals that chaplain (CH) AA failed to obtain consent from P#1’s family before he took the patient out for a car ride. On 5/12/25 at 2:00 p.m., an interview was conducted with CH AA. The CH AA said it was a mistake that he did not obtain consent from the P#1’s family before he took P#1 out. On 5/13/25 at 12:45 p.m., an interview was conducted with Director of Clinical Operation (DCO) BB, who said that the staff of the memory care where the patient was living, called her and reported what the CH AA did. The DCO BB called the CH AA and investigated the incident. The DCO BB said that she called the P#1’s family, and they were terribly upset, because the CH AA did not get permission from them before he took the P#1 out for a car ride. On 5/13/25 at 6:00 p.m., an interview was conducted with the P#1’s family member. She verbalized her concern that the CH AA took her mother out for a car ride without their consent. She also said that her brother was upset and immediately removed their mother from their agency and placed her in another hospice agency.”