Suncrest Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing the plan of care. This standard was not met as evidenced by clinical record review and interview. In 9 of 19 (47%) clinical records reviewed, the agency did not ensure that the patients’ plans of care included clearly defined, patient-specific, and observable/measurable goals directly linked to an identified problem or risk. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/25/2025 with a terminal diagnosis of Alzheimer’s disease and secondary dysphagia. At the start of care visit on 06/25/2025, the Registered Nurse (RN) documented that the patient was alert and oriented only to self and had expressive aphasia. The patient had lost the ability to feed herself approximately six months prior, required a mechanical soft diet, and was at increased risk for aspiration. On 12/16/2025, the RN noted the patient had emesis on her shirt, and nausea medication was requested from facility staff. The patient had frequent episodes of diarrhea secondary to Irritable Bowel Syndrome (IBS) and intermittent nausea and vomiting. During the visit on 01/27/2026, the patient exhibited a “PAINAD” (Pain Assessment in Advanced Dementia) score of 2/10 with chronic daily pain in her contracted, arthritic hands. During the interdisciplinary group meeting (IDG) on 01/15/2026, the patient continued to have IBS-related loose stools; however, there were decreased vomiting episodes. During the 01/29/2026 IDG review, the patient continued to have IBS flare-ups with loose stools. A review of the plans of care for 09/23/2025 through 12/21/2025 and 12/22/2025 through 02/19/2026 revealed that nausea and vomiting were identified as problems; however, the only intervention noted was to assess the occurrence and characteristics of these symptoms, with the goal of decreasing nausea and vomiting. No measurable goals were identified for the patient’s ongoing diarrhea, nor was a specific, measurable pain goal documented on the plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/24/2025 with the terminal diagnosis of chronic obstructive pulmonary disease (COPD) and the comorbid condition of congestive heart failure (CHF). The Nurse Practitioner Face-to-Face Visit dated 11/28/2025 documented that the patient was NYHA (New York Heart Association) Class IV, dyspneic with minimal activity, during conversation, and at rest. The patient had required an increase in Prednisone to 40 mg daily with a 7-day taper to 10 mg daily for maintenance the prior month. He remained on 3 liters per minute (LPM) of oxygen (O2) continuously, with documented episodes requiring 3.5 LPM and increased nebulizer use up to six times daily. Additional findings included a high fall risk due to an unsteady gait and the hazard posed by oxygen tubing. Although the patient used a walker, he continued to ambulate unsafely. On 12/26/2025, the patient rated his shortness of breath (SOB) as 4/10 with a respiratory rate of 26 breaths per minute at rest while using 3.5 LPM of O2 via nasal cannula. During the IDG Meeting on 12/17/2025, nursing noted that the patient required Lorazepam during an episode of SOB associated with anxiety. A review of the patient’s plans of care for the periods 10/29/2025–12/27/2025 and 12/28/2025–02/25/2026 revealed that although COPD was appropriately identified as a problem, no fall risk was documented despite multiple indicators (unsteady gait, oxygen tubing creating environmental hazards, and documented unsafe ambulation). No fall-prevention goals or interventions were included, despite the patient’s significant documented fall-related risks and functional instability. The COPD goals included one patient-specific goal: “Remain at home.” The second goal, “Continue to receive great care and be comfortable,” was not measurable and did not define what “comfortable” meant for this patient—no dyspnea parameters, acceptable respiratory effort levels, anxiety indicators, or functional tolerances were established. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/22/2025 with the terminal diagnosis of carcinoma of the endocervix. During the RN start of care visit on 11/22/2025, the nurse documented the patient’s pain as 4/10, with the worst pain reaching 10/10 and a personal pain goal of 3/10, describing constant aching, cramping, and throbbing pain in the lower abdomen, pelvic region, and upper thigh. The patient expressed a desire to remain interactive with her four daughters. She requested to increase her Gabapentin from 200 mg three times daily to 300 mg at admission. On 12/10/2025, the IDG set a goal for the patient “to remain comfortable,” noting she was refusing MD-recommended changes. Then, on 12/24/2025, the patient was reported to be experiencing intermittent HPV (Human Papilloma Virus) outbreaks, and the IDG set goals to “continue effective pain management related to cervical cancer, decrease frequency and severity of HPV outbreak episodes, and maintain comfort and functional independence as tolerated.” On 12/31/2025, the patient experienced outbreak symptoms with blistering and soreness to the vaginal area and thighs, and was treated with Valacyclovir as well as topical agents, and Dexamethasone was also prescribed. At the 01/29/2026 IDG, the patient had experienced increased vaginal bleeding with clots, consistent with cervical cancer progression, and expressed anxiety and concern about the bleeding; she also reported bloating and facial rounding likely due to Dexamethasone. The two-week goal was to monitor vaginal bleeding and clot burden, continue pain management, assess need for further symptom interventions, and maintain comfort and functional independence as tolerated. The patient’s active medication regimen included Fentanyl 50 mcg/hour (pain), Gabapentin (neuropathic pain), Hydromorphone (as needed – PRN pain), Methadone (pain), Dexamethasone (inflammation), and Valacyclovir (HPV). A review of the plans of care for the benefit periods 11/22/2025 – 01/24/2026 and 01/25/2026 to 03/25/2026 included the identified problem of cancer with the goal that the IDG would “develop a plan to promote patient comfort and assist in the achievement of a comfortable, peaceful death,” along with goals for the patient to verbalize relief of outbreak sores and for the patient/caregiver to demonstrate appropriate medication use; however, these goals were broad, staff-focused, and not measurable, and the plan of care lacked objective clinical outcomes related to the patient’s cancer-related pain, outbreak symptoms, or comfort, such as target pain scores, frequency of breakthrough pain, functional tolerances, or measurable indicators for HPV outbreak control. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/18/2025 with the terminal diagnosis of cirrhosis of the liver. During the admission visit on 12/18/2025, the RN documented that the patient experienced daily, intermittent aching, stabbing, and shooting pain to the left hip rated 5/10 on admission, with the worst pain reaching 8/10 and an identified personal pain-relief goal of 3/10. The RN also documented cluttered pathways within the home, poor posture, and difficulty with transfers—all indicators of an increased fall risk. During the IDG meeting on 12/31/2025, the patient was reported to be alert and oriented but severely weak, requiring a two-person assist for toileting. On 01/23/2026, nursing documentation indicated that the patient complained of severe leg pain but refused pain medication. A facility medication aide reported that the patient frequently appeared to be in pain but would not request medication. During the 01/29/2026 IDG, the RN reported that it was suspected the patient was experiencing more severe pain than he verbalized, yet continued to decline analgesics. A review of the plan of care for the benefit period 12/18/2025–03/17/2026 showed that a problem of pain management had been identified; however, the associated goals were broad and non-measurable and included that the patient “will be free of pain or verbalize an acceptable level of pain with the current pain management regimen” and “demonstrate an understanding of the appropriate use of medications to manage pain”. To address the increased fall risk, the associated goals were similarly non-specific and stated that the patient would “demonstrate necessary behaviors to maintain good safety awareness and minimize falls” and would “verbalize an understanding of fall prevention and home safety measures”. These goals lacked objective, clinically measurable criteria, such as target pain scores, observable functional indicators, fall-risk mitigation measures, or defined timeframes to evaluate whether pain control or fall-prevention goals were met. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/10/2025 with the terminal diagnosis of congestive heart failure. An on-call communication note dated 01/26/2026 at 2132 (9:32 p.m.) documented that the patient’s sister found the patient without oxygen, with an oxygen saturation of 79% and a heart rate of 112 bpm (beats per minute); after the sister applied oxygen at 4 LPM via nasal cannula, the patient’s saturation rose to 97% and heart rate declined to 86 bpm, though the patient continued to experience shortness of breath with minimal movement. During a nursing visit on 01/27/2026, the RN documented that the patient became rapidly short of breath with activity, that oxygen saturation dropped to 82% after a shower, and obtained orders to increase hospice aide visits and to provide education regarding the need for rest after exertion. During the IDG on 12/17/2025, the patient was noted to have experienced chronic neuropathy pain rated 5/10, required Gabapentin and Hydrocodone four times daily, was oxygen dependent at 2.5 LPM, and short of breath at rest, with a two-week goal limited to establishing a care plan and confirming DNR (do not resuscitate) and funeral arrangements. Subsequent IDGs on 12/31/2025, 01/14/2026, and 01/28/2026 referenced confusion with scheduling, medication management needs, and adjustments to Metformin and Glipizide dosing, with two-week goals limited to establishing the care plan, monitoring medications, and fall prevention. Review of the plan of care for the benefit period 12/10/2025–03/09/2026 showed activity and safety measures such as walker use, fall precautions, and oxygen precautions, as well as DME (durable medical equipment) including an oxygen concentrator, oxygen tank, walker, and shower chair; however, the patient’s increased fall risk was not addressed as a clinical problem, blood sugar management was not incorporated despite repeated medication adjustments, no measurable pain goals were included, and shortness of breath, one of the patient’s most significant symptoms, was not identified as a problem. The problem of heart failure included only a vague goal stating that the patient’s symptoms would be “consistent with the stage of disease process and problems managed as well as disease process will allow,” without measurable outcomes. Although interventions included pain management, oxygen therapy, and CHF education, no measurable or patient-specific criteria, such as dyspnea levels, pain score targets, or glucose parameters, were specified. CLINICAL RECORD 11: The patient elected the hospice benefit with the terminal diagnosis of COPD and an ongoing comorbid condition of lung cancer and neoplasm-related pain. During the start of care visit by the RN on 02/22/2024, the nurse documented the patient’s pain score as 4/10 with the worst pain experienced as 8/10 with a pain goal of 2, patient having chronic pain in left chest and abdomen requiring higher doses of narcotics over the past 3 months; “Patient’s goals are to manage shortness of breath, pain...” On 11/28/2025 the RN noted during a visit “pain 7; pain goal 6; pain abdomen, joints, back; aching, chronic, constant”. The RN, on 12/29/2025, noted during the visit, “pain 7; goal 6; patient reports pain unchanged at 7/10 in back shoulder and joints.” The patient’s active medication profile included Robaxin (muscle pain), Morphine 15mg every 4 hours (as needed for pain), and MS Contin 60mg (scheduled every 8 hours for pain). During the IDG on 12/18/2025 the nurse reported that the patient’s pain was progressively worsening, but the patient was resistant to change the pain regimen. Then on 01/29/2026 during IDG, the patient was agreeable to to switch from his previous Fentanyl patch to the MS Contin 60mg. The plan of care for the benefit periods from 10/14/2025 to 12/12/2025, and 12/13/2025 to 02/10/2026 were reviewed and revealed the identified the problem of COPD for which an intervention to assess the patient’s pain level, frequency, location and quality of pain was documented. The pain goal identified was for the patient to “verbalize/demonstrate measures to relieve pain. No clinically objective measurable pain goals were included such as acceptable pain scores, functional tolerance levels, or frequency of breakthrough pain dosing. CLINICAL RECORD 17: During the admission visit on 10/19/2025, the RN documented that the “…Pt and Son are Spanish-speaking only. Use of translator line used for all parts of assessment and admission…” The RN also noted that the patient had multiple dressings to the right arm and one to the left elbow, which the son reported were from bruising due to a recent fall. Despite significant generalized weakness, the patient made several attempts to stand from the wheelchair during the visit. The patient’s medication list at admission included Eliquis 2.5 mg twice daily. During the nursing assessment on 12/16/2025, the patient was noted to have scattered ecchymosis on both upper extremities and resolving ecchymosis to the chin/jaw area from a fall sustained the week prior. On 12/17/2026, during a follow-up visit, the RN contacted the hospice physician to report the patient’s recent falls and increased bleeding risk. At that time, an order was obtained to discontinue Eliquis. Review of the patient’s plan of care (POC) for the benefit period 10/19/2025–01/06/2026 confirmed that the patient’s fall risk and risk for injury were identified; however there were no interventions or goals addressing the patient’s increased bleeding risk while receiving anticoagulation therapy, despite documented bruising, repeated falls, and escalating safety concerns. The plan of care did not identify a communication problem, nor did it include interventions to address language barriers or ensure access to translation services for hospice staff who did not speak Spanish. CLINICAL RECORD 18: The patient elected the hospice benefit on 07/05/2025 with the terminal diagnosis of malignant neoplasm of the pancreas. The RN Start of Care assessment on 07/05/2025, the patient was documented to have generalized, chronic, constant aching pain. The patient’s medication profile included Morphine 20mg/mL Oral Concentrate, 0.5 mL (10 mg) every hour PRN for pain, and a Fentanyl 12 mcg/hour transdermal patch applied every 72 hours. IDG documentation dated 08/28/2025 and 09/11/2025 identified a two-week goal stating only that the “patient will be comfortable and have no falls.” At the 09/25/2025 IDG, documentation noted that the patient was receiving Fentanyl patches with reported improvement in pain; however, no measurable outcomes or patient-specific indicators of pain control were established. Review of the patient’s POC for the benefit period 07/05/2025–10/02/2025 identified a problem of pain management with the following goal: “Patient/Caregiver will verbalize understanding and demonstrate compliance and independence of the medication regimen and signs and symptoms of adverse reactions to report.” This goal focused solely on caregiver education and did not specify an expected patient outcome related to pain relief, such as acceptable pain levels, reduction in pain frequency, or improved comfort. Under the problem of Cancer, the POC listed the goal: “IDT will develop a plan to promote patient comfort and assist in the achievement of a comfortable, peaceful death.” This goal was broad, non-measurable, and staff-focused, and failed to establish objective criteria to determine whether the patient’s comfort or pain control had been achieved. CLINICAL RECORD 19: Clinical documentation showed that during the RN start of care visit on 07/11/2025, the nurse noted that the “…patient has behaviors, soft approach initiated…” On 07/15/2025, the Social Worker documented that facility staff reported the patient frequently had behavioral episodes during personal care and would attempt to hit staff when agitated. During the nursing visit on 07/17/2025, the RN recorded that the “…pt has been agitated this morning… Seroquel 100mg early today at 8 am… Pt still with agitation at 9:30 am…” An order for Seroquel 25mg every 4 hours PRN was subsequently obtained. The patient’s medication regimen included multiple agents for agitation, depression, and anxiety, including Haloperidol, Mirtazapine, and scheduled and PRN Seroquel. Review of the patient’s plan of care for the benefit period 07/05/2025–10/02/2025 revealed nursing interventions addressing education on symptom management, comfort measures, environmental modifications, and assessment for behavioral disturbances such as anxiety, agitation, and restlessness. The stated goal was for the patient’s anxiety/agitation to be “controlled” throughout hospice care; however, the plan of care did not include parameters, benchmarks, or objective criteria defining what constituted “controlled” anxiety or agitation. A joint clinical record review and an interview with the Senior Director of Clinical Quality (SDCQ) on 02/05/2026 confirmed that the patients’ plans of care presented as evidence did not include measurable, patient-specific goals. The SDCQ noted that clinicians had difficulty taking the additional step beyond selecting the electronic medical record’s (EMR) pre-formulated goals.”

“It is required that the Interdisciplinary Group (IDG), in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the patients’ plans of care were updated to incorporate new assessment findings into an individualized plan of care with associated interventions and goals. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/25/2025 with a terminal diagnosis of Alzheimer’s disease and secondary dysphagia. At the start of care visit on 06/25/2025, the Registered Nurse (RN) documented that the patient had lost the ability to feed herself and was at increased risk for aspiration. The physician’s certification of terminal illness (CTI) for the benefit period 09/23/2025–12/21/2025 referenced the patient’s dysphagia, and need for a mechanical soft diet, with coughing and up to one hour required to finish meals. The physician additionally noted intermittent rash requiring Hydrocortisone cream and Atarax. During IDG reviews on 11/12/2025 and 11/26/2025, nursing staff documented increased nausea, vomiting, and diarrhea attributed to IBS (Irritable Bowel Syndrome), and education was provided to the patient’s sister regarding aspiration risks and avoiding overfeeding. Two-week goals were established to decrease skin irritation and reduce nausea and vomiting. On 12/16/2025, the RN noted the patient had emesis on her shirt and nausea medication was requested from facility staff. Skin integrity concerns were documented due to the patient’s IBS, frequent diarrhea impacting skin, The RN documented superficial scratches noted to her forearms and buttocks with ongoing skin-picking behaviors. Education was provided to facility staff regarding the use of Geri sleeves to prevent further injury, and reinforcement was given to maintain a rolled washcloth in the patient’s hand throughout the day to protect contracted palms. The medication profile reflects ongoing management of itching and rash with Hydrocortisone 1% Topical Cream three times daily as needed and Atarax 50mg at bedtime. During IDG on 01/15/2026, the patient continued to have IBS-related loose stools, however with decreased vomiting episodes. Ongoing reinforcement was given regarding avoidance of overfeeding due to repeated reports of emesis, including an episode where the patient was found with vomit on her clothing. Facility staff reported additional vomiting episodes and expressed concern that the patient’s sister might be overfeeding her. During the 01/29/2026 IDG review, the patient continued to have IBS flare-ups with loose stools. The RN noted a left-hand contracture requiring cleaning and placement of a rolled towel for support and skin protection, with staff educated to maintain contracture care to reduce skin breakdown. Two-week goals were to reinforce safe feeding practices with caregivers, monitor hand contractures, and assess skin breakdown. Review of the plans of care dated 09/23/2025–12/21/2025 and 12/22/2025–02/19/2026 evidenced no updated plan of care goals to address the patient’s dysphagia and ongoing education needs for the patient’s sister about safe feeding interventions and goals. Additionally, there were no skin integrity goals addressing itching, rashes, repetitive skin-picking, or risk of breakdown, despite clear ongoing symptoms and repeated documentation. CLINICAL RECORD 18: The patient elected the hospice benefit on 07/05/2025. On 08/22/2025, the RN documented the onset of a Stage 1 pressure ulcer located at the medial buttocks/gluteal fold, measuring 3.5 cm x 2 cm. On the same date, a physician order was obtained to apply a skin barrier cream with brief changes and during incontinence episodes daily until resolved. Further documentation on 09/15/2025 indicated that the buttocks area was red, excoriated, and macerated. On 09/21/2025, a nursing on-call visit documented a skin tear to the left elbow resulting from a fall. On 09/22/2025, an RN documented cleansing the left elbow skin tear with wound cleanser and applying antibiotic ointment. Review of Interdisciplinary Group Meeting (IDG) documentation revealed that on 08/28/2025 and again on 09/11/2025, the team discussed that over the prior two weeks the patient had a new superficial open area to the buttocks being treated with skin barrier cream. The sole documented two-week goal identified at both meetings was for the patient “to be comfortable and have no falls.” At the 09/25/2025 IDG, documentation noted a superficial open area to the coccyx, treated with Calmoseptine, described as improved and currently Stage 1. A review of the clinical record, comprehensive assessments, IDG documentation and the plan of care for the benefit period from 07/05/2025 to 10/02/2025 revealed no evidence that the interdisciplinary plan of care was updated to reflect ongoing skin integrity risks, individualized wound care goals and prevention strategies. The patient died on hospice services on 09/28/2025. A joint clinical record review and interview with the Senior Director of Clinical Quality (SDCQ) on 02/05/2026 confirmed that the patients’ plans of care presented as evidence were not updated to reflect new assessment findings (e.g., changes in symptoms, risks, or medication needs).”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During the review of Volunteer Program documents and interviews with the Volunteer Coordinator (VC - Personnel Record 4) on 02/03/2026 and the Administrator (Personnel Record 2) on 02/04/2026, it was determined that the agency did not meet the requirement that volunteer services account for at least 5% of the total patient care hours. Specifically, year-end 2025 data showed that volunteer hours averaged 3.2% of the total patient care hours provided by all paid hospice employees and contract staff, which is below the required 5%. Review of QAPI records further revealed that a prior volunteer PIP, implemented from 07/13/2021 through 07/30/2025, did not achieve or sustain compliance with the 5% volunteer hour requirement. Despite these efforts, the Volunteer Program has not kept pace with agency growth. Census data indicated that the agency’s average daily census (ADC) increased from an average of 220 in 2024 to 270 in 2025. Correspondingly, total monthly patient care hours increased from 4,511 hours in January 2025 to 7,265 hours in December 2025, further contributing to the inability of the volunteer program to meet the required 5% threshold. Documented volunteer recruitment strategies include posting flyers, outreach to college and university students requiring volunteer hours, utilization of an online volunteer matching platform, engagement with local community groups, and participation in marketing events. Retention activities include monthly volunteer meetings; ongoing communication through phone calls and text messages; recognition through birthday and holiday cards; hosting a volunteer appreciation event during Volunteer Appreciation Month; and individual, off-site meetings such as coffee gatherings. This deficiency was acknowledged by the agency and resulted in the initiation/revision of a QAPI Performance Improvement Project (PIP) on 01/21/2026. During the review of Volunteer Program documents and interviews with the Volunteer Coordinator (VC) (Personnel Record 4) on 02/03/2026 and the Administrator (Personnel Record 2) on 02/04/2026, it was determined that the agency did not meet the requirement that volunteer services account for at least 5% of the total patient care hours. Specifically, year-end 2025 data showed that volunteer hours averaged 3.2% of the total patient care hours provided by all paid hospice employees and contract staff, which is below the required 5%. This deficiency was acknowledged by the agency and resulted in the initiation/revision of a QAPI Performance Improvement Project (PIP) on 01/21/2026. Review of QAPI records further revealed that a prior volunteer PIP, implemented from 07/13/2021 through 07/30/2025, did not achieve or sustain compliance with the 5% volunteer hour requirement. According to the current PIP, the Administrator and the VC are scheduled to meet monthly to monitor progress toward achieving the 5% benchmark and to evaluate which documented recruitment strategies are most effective in increasing the percentage of volunteer hours. Additionally, the VC participates in meetings with organization-wide Volunteer Coordinators to review volunteer programs and share recruitment and retention practices. Documented volunteer recruitment strategies include posting flyers, outreach to college and university students requiring volunteer hours, utilization of an online volunteer matching platform, engagement with local community groups, and participation in marketing events. Retention activities include monthly volunteer meetings; ongoing communication through phone calls and text messages; recognition through birthday and holiday cards; hosting a volunteer appreciation event during Volunteer Appreciation Month; and individual, off-site meetings such as coffee gatherings. Despite these efforts, the Volunteer Program has not kept pace with agency growth. Census data indicated that the agency’s average daily census (ADC) increased from an average of 220 in 2024 to 270 in 2025. Correspondingly, total monthly patient care hours increased from 4,511 hours in January 2025 to 7,265 hours in December 2025, further contributing to the inability of the volunteer program to meet the required 5% threshold.”

“Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care in that skilled nurse or hospice aide visits were not conducted for 3 of 5 patients (Patient #1, #3 and #4) for which records were reviewed. Failure to provide services as ordered may have caused harm and a delay in effective care of these clients. Review of the clinical record for Patient #1 revealed a start of care date of 11/30/2023 and discharge date of 02/05/2024. Review of the plan of care for the period 11/30/2023 – 02/05/2024 included orders: SN: 1d1 (once on day one), 1-2 WK12WK (1-2 times per week for 12 weeks) + 10 prn (as needed). Review of SN visit notes revealed no visit was conducted during the week of 12/24/2023-12/30/2023. There was no documentation in the record of a missed visit or MD notification of a missed visit. Review of the clinical record for Patient #3 revealed a start of care date of 11/01/2023 and discharge date of 12/28/2023. MD orders dated 11/18/2023 were: HHA 2WK11WK (2 times per week for 11 weeks). Review of the record revealed HHA visits were conducted 1 time per week during the weeks of 11/19/2023-11/25/2023 and 12/17/2023-12/23/2023. There was no documentation in the record of missed visits. Review of the clinical record for Patient #4 revealed a start of care date of 05/27/2023. Review of the plan of care for the period 11/23/2023-01/20/2024 included orders: SN: 2WK9 (2 times per week for 9 weeks) + 8 prn. Review of SN visit notes revealed visits were conducted 1 time per week during the weeks of 11/26/2023-12/02/2023, 12/03/2023-12/09/2023, 12/10/2023-12/16/2023, 12/17/2023-12/23/2023, 12/24/2023-12/30/2023, 12/31/2023-01/06/2024, and 01/07/2024-01/13/2024. There was no documentation in the record of missed visits. Surveyor conducted an interview on 02/12/2024 with AA/ASN at 10:51 a.m. Clinical records for Pt #1, #3 & #4 were reviewed. Surveyor requested for review any additional visit or missed visit notes. Pt #1- (11/30/23-2/5/24): AA/ASN confirmed SN visit orders were 1-2 times per week + 10 prn, and no visit was conducted during the week of 12/24/2023-12/30/2024. Surveyor asked why the failure to provide care occurred. AA/ASN stated she didnt know but would research it. Pt #3- (11/1/23-12/28/23): HHA orders were (11/18/23): 2 times per week. Review of the record revealed only 1 visit was conducted during the week of 12/17/2023-12/23/2024. AA/ASN confirmed the finding and stated she didnt know why 2 HHA visits were not conducted that week. Pt #4- (11/23/23-1/20/24): Orders were SN 2 times per week + 8 prn. SN visits were provided 1 time per week each week. AA/ASN stated usually the order is 1-2 times per week depending on the patients needs. This may have caused the failure to provide care as ordered in the plan of care. Surveyor conducted a telephone interview on 02/12/2024 at 2:40 p.m. with RNCM. The clinical records for Patients #1 and #4 were discussed. SN visit frequency in the plan of care was confirmed. Surveyor discussed missed visits for Patients #1 and #4. RNCM stated she was not sure why the visit was missed for Patient #1 and acknowledged a missed visit note was not placed in the record. RNCM stated, “;Normally orders are 1-2 visits per week. I forgot to change the order.” Review of the agencys policy and procedure manual included a policy titled, “;The Plan of Care, Policy No. 9-017, Revised June 2022”, which read “;The care provided to the patient must be in accordance with the plan of care.””