Astra Health Care Inc

The agency failed to provide care as ordered by the physician and coordinate care with the physician for 2 of 6 patients receiving intravenous (IV) care.

The agency failed to ensure each patient received home health services in accordance with the written plan of care established and periodically reviewed by a physician for 1 of 6 patients reviewed who received skilled nursing (SN) for intravenous (IV) care (Patient #7).

The agency failed to coordinate care with the physician in order to meet the needs of the patient for 2 of 6 patients reviewed who received skilled nursing (SN) for intravenous (IV) care (Patients #6 and #7).

The agency failed to coordinate care delivery with the patient and involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 2 of 6 patients reviewed who received skilled nursing (SN) for intravenous (IV) care (Patients #6…

The agency failed to have evidence of communication with the physician for orders and delays in providing services to 2 of 5 patients who required nursing services (Patients #1 and #7).

The agency failed to involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 2 of 3 patients who were accepted for services but not admitted to the agency (Patient's A and C).

Specifically, the agency failed to ensure plans of care were followed as ordered by the physicians, ensured physicians who were responsible for the care of the patients were promptly alerted with change of conditions and/or a change to the plan of care; and ensured the plans of care were accurate…

The agency failed to implement a quality assessment and performance improvement (QAPI) which evaluated all agency services and complied with the requirements and standards set forth in CFR 484.65. The failure created the potential for the agency to overlook trends which affected the quality of…

Agency staff consistently pulled old and prior clinical notes in the electronic medical record (EMR), added current information, but failed to edit out non-current, non-relevant, and outdated patient information before submitting them as new clinical notes.

The agency failed to ensure services and treatments were provided in conformance with physician's orders for 5 of 10 current patients reviewed (Patients #3, #4, #5, #10 and #13).

The agency failed to ensure nursing staff complied with professional standards and principles pertaining to appropriate infection control during the provision of care for 1 of 1 patients reviewed who required wound care (Patient #10).

The agency failed to ensure each patient's Plan of Care covered all pertinent treatments, medications and frequency of visits for 1 of 4 diabetic patient records reviewed (Patients #9).

The agency failed to provide services and treatments only as ordered by the physician for 1 of 4 diabetic patients' records reviewed (Patients #9).

The agency failed to ensure professional staff promptly alerted the physician of a change to the plan of care in 2 of 4 patients' record reviewed who received diabetic care (Patient #4 and #5).

The agency failed to ensure the plan of care contained patient's accurate current information of pertinent goals based on updated comprehensive assessment of the patients for 2 of 10 active patient records reviewed (Patients #9 and #10).

The agency failed to ensure clinical records contained accurate documentation of patient's clinical notes and plans of care for 5 of 10 active patient records reviewed (Patients #4, #5, #8, #9, and #10).

The agency failed to ensure all nursing interventions, treatments and services provided to patients were accurately and completely documented and included within the clinical record for 3 of 10 active patients (Patients #3, #5, and #10) and 1 of 4 discharged (Patient #13) patient records reviewed…