Bridges by EPOCH at Lexington

• Service and Service Coordination Requirements - Emergency Response
• EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 through 2024 to determine compliance with Service Coordination requirements.
• In the month of April 2023 there were 23 e-call response times over the 10 minutes required by the Residence policy.
• In the month of March 2024 there were 19 e-call response times over the 10 minutes required by the Residence policy.
• Optional Services - Limited Medication Management (LMA)
• EOEA reviewed the records of five Residents to determine compliance with requirements with LMA documentation.
• Two records were intermittently missing staff signature documentation of the nurse administering medications.
• General Requirements for an Assisted Living Residence
• EOEA reviewed the records of five Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.

Screening and Assessment

• Two records were missing documentation of a reassessment review being completed every six months.

Service Plan Requirements

• Three SCR service plan records were missing documentation of individualized enrichment activities provided to the residents.

Bed Rail Assessments

• EOEA reviewed the Residence records of 22 Residents utilizing bed rails/ U-bars or similar devices for the period of 2022 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Documentation of an assessment confirming that the Resident can independently navigate around the bed rail/ U-bar were missing for seven Residents for the calendar year 2023.
• LMA, Resident Rights, and Quality Assurance and Performance Improvement
• LMA and Resident Rights.
• EOEA observed two Personal Care (PC) staff providing medication assistance to four Residents, and one nurse providing medication administration to two residents, to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA. [...]

In its April 15, 2024 communication to EOEA, the Residence noted the following (in pertinent part):

• The nurse administered medications in a safe and secure manner, followed standard nursing practice procedurally through identifying resident, reconciling medications prior to administration, maintaining control of said medications, and following standard infection control practices.
• Our Special Care residents view all areas of our households as their home... Several residents who receive LMA prefer to have their medications administered around mealtime and not in their apartments...
• 5. The residents receiving said medication assistance have agreed upon service plans signed by their legal representative authorizing us to administer medications in a common area...
• 651 CMR 12.02 requires Limited Medication Administration (LMA) be performed "from an original, pharmacy-filled and pharmacy-labeled container," completed in accordance with documentation requirements, and "all medication must be kept in the Resident's Unit and stored in such a manner that the nurse can adequately verify the integrity of the medication." The regulations do not include explicit [...]

651 CMR 12.08 (Resident Rights and Required Disclosures) establishes the right of ALR residents to:

• "Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy" (651 CMR 12.08(1)(b));
• "Privacy within the Resident's Unit subject to rules of the Assisted Living Residence reasonably designed to promote the health, safety and welfare of Residents" (651 CMR 12.08(1)(c));
• "Privacy during medical treatment or other rendering of services within the capacity of the Assisted Living Residence" (651 CMR 12.08(1)(p)); and
• "Informed consent to the extent provided by law" (651 CMR 12.08(1)(q)).
• Regarding the Residence's statement (2.) above, while ALR Residents have the right to access and use common areas within the ALR, common areas do not provide the same level of privacy as a Resident's Special Care Unit.1 As Residents retain the right of privacy during the provision of services and the right to give informed consent to receive such services, an ALR providing LMA to a Resident [...]
• Regarding the Residence's statement (5.) above, concerning Resident consent to receive LMA in a common area, EOEA reviewed two documents submitted by the Residence: a "Clinical Update Summary" and an "Agreement Service Plan." Under the "medications" heading in the "med management" section of the "Clinical Update Summary," the language states: "Staff able to assist with medications in a common [...]
• 1 "Special Care Unit: A portion of a Special Care Residence designed for and occupied pursuant to a Residency Agreement by one or two individuals as the private living quarters of such individuals." (651 CMR 12.02) (emphasis added). lines for the Residence's Wellness Director, the resident/responsible party, the legal representative, and the legal guardian (if applicable) to sign. [...]
• The "Agreement Service Plan" includes a section referencing LMA and the signature section includes language indicating that the parties agree to the services to be provided, but the form does not specify that LMA will be provided in a common area.
• Consequently, the two documents are insufficient to support that a Resident, Resident Representative, or legal guardian has provided informed consent for the administration of medication in a common area.
• LMA Policy and Quality Assurance and Performance Improvement.
• The Residence is required to maintain a medication management policy. 651 CMR 12.08(2)(a)(13) requires an ALR's Residency Agreement to include "a copy of the Residence's medication management policy including Limited Medication Administration, if applicable," and 651 CMR 12.08(3)(e) requires an ALR's Disclosure of Rights and Services statement to include a copy of the Residence's medication [...]

In addition, 651 CMR 12.00 requires the following:

• 651 CMR 12.04(10)(c) (Medication Quality Plan) requires the Residence to "develop and implement systems that support and promote safe SAMM, and if applicable, LMA programs," including the requirement to conduct a semi-annual evaluation of each PC worker's awareness of regulations and policies related to SAMM and LMA.
• 651 CMR 12.04(7) requires the Residence nurse and Service Coordinator to develop "an individualized Service Plan for each Resident" in accordance with the findings of the initial screening described in 651 CMR 12.04(6)." The Residence shall document its assessment findings regarding "medications (including dosage, method of administration and frequency)."
• 651 CMR 12.04(8)(a) requires that each service plan be based on a current assessment of the Resident, and 12.04(8)(a)(2)(b) requires the plan to indicate "the types of assistance with medications that the Residence shall provide, if any... "
• 651 CMR 12.05(1)(f) requires documentation of all aspects of LMA, including "a proper written medication order from an authorized prescriber, documentation of the name, dose, route of administration, and time the medication is administered. The nurse who administers the medication shall sign or initial the documentation... "
• As noted above, in its April 15, 2024 communication to EOEA, the Residence indicated that "[t]he nurse administered medications in a safe and secure manner, followed standard nursing practice procedurally ... " However, the Residence's LMA policy does not reference any procedures for providing LMA in a common area.
• Reporting Resident-specific Emergencies - Incident Reports
• EOEA reviewed the Residence's Records and submitted Incident Reports from May 2, 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident's health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.
• The Residence filed 25 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.