Every finding on record at Ultra Star Hospice, Inc.

Upon patient record review, 2 of 14 (Patient #4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #4-The plan of care dated 10/08/25 contains an order for LVN 1xwk and RN 1x for symptom follow up. The RN has made 2 visits. #5-The plan of care dated 10/01/25 contains an order for LVN 1xwk and RN 1x for symptom follow up. The RN has made 3 visits.

Upon patient record review, 2 of 5 (Patient #2, #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The social work comprehensive assessment noted "will continue to make monthly follow up visits to resume the counseling interventions and to monitor patient/family psychosocial status." The plan of care included psychosocial problems, goals and interventions although the social worker was not ordered to make ongoing visits. Patient #5: The admitting diagnosis was end stage Parkinson's however, the plan of care did not contain problems/interventions/goals for neurological.

Upon personnel record review, 1 of 1 applicable (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role Personnel #2: There was not evidence of signed job description for alternate administrator and alternate DPCS. [corrected on site]

Upon inpatient contract review, 1 of 1 (SNF contract Drier) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. [corrected on site]