1 Report
Inspection Report — Aug 8, 2024
Routine
Date: Aug 8, 2024
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on August 8, 2024.
Findings
The state cited 6 findings, including 4 repeat findings, matching the state median of 6. The action taken was Plan of correction required.
Citations (6)
Incident reporting: The Residence filed 10 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed (repeat finding).
Emergency call response: In the months of December 2022, May 2023, and July 2024 there were 45 e-call response times over the ten minutes required by the Residence policy, and documentation of hourly safety checks in the Specialized Care Residence neighborhood for July 2024 had multiple missing entries (repeat finding).
Quality assurance program: Documentation of audit completion dates, target dates for follow-up, and responsible staff were missing for 2022 and 2023 calendar years, and some medication cassettes lacked resident name labels while some medications were left unsecured (repeat finding).
Resident screening and assessment · Resident care plans: Three records were missing documentation of the Legal Representative and scope of authority, and three records lacked documentation of a Service Plan reassessment within 30 days after residency commencement (repeat finding).
Resident records: The Residence did not use the Correspondence Log to communicate all significant information necessary to maintain continuity of care and did not consistently document each 24-hour period in the logs.
Staff training: One record was missing signature documentation supporting that Introductory Visits were conducted with all applicable staff prior to or within 48 hours after Personal Care services, and one record lacked documentation of Introductory Visits after a change of condition.
Report Facts
Findings: 6
Repeat findings: 4
State median findings: 6
Emergency call responses over ten-minute limit: 45
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