Compass on the Bay

Service and Service Coordination Requirements- Emergency Response

• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• The policy developed by the Residence does not specify the amount time the staff is expected to respond to an e-call in a timely manner". Management stated the maximum response time is eight minutes.
• The Residence has chosen to document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulation to provide timely assistance to a Resident in the event of an emergency needs situation.
• Documentation of hourly safety checks from March 1, 2025 through the date of the compliance review for five SCR Residents had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00 p.m. and 7:00 a.m.

B. Service and Service Coordination- Special Care

• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
• Documentation to support the required SCR operations review was incomplete for the first half of the 2024 calendar year reviewed.
• Age identified deficiencies with operational safeguards related to the risk of potential hazards in the physical environment:
• Cleaning chemicals were unsecured in the kitchenette and accessible by Residents.

C. General Requirements for an Assisted Living Residence (ALR)-

• AGE reviewed the documentation of five Resident Records from March 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Screening and Assessment / Service Plan Development and Requirements

• Two records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for four records.

D. Quality Assurance and Performance Improvement

• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from March 24, 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was completed was missing for the 2023 and 2024 calendar years reviewed.
• Documentation of a target date for follow up action to findings was missing for 2024 calendar year reviewed.

Resident Safety Assurances

• Documentation of the date the audit was completed was missing for the 2023 and 2024 calendar years reviewed.
• Documentation of a target date for follow up action to findings was missing for 2024 calendar year reviewed.
• Documentation of the staff person responsible for follow-up action to findings was missing for the 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from March 24, 2023, through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation of the person responsible for conducting the audit was missing for the first quarter of the 2024 calendar year reviewed.
• Documentation of specific findings was missing for the second quarter of 2023 and the fourth quarter of the 2024 calendar years reviewed.
• Documentation of the target date for follow up action and staff person responsible for follow-up was missing for the fourth quarter of 2023, the first three quarters of 2024 and the first quarter of 2025.
• Documentation of a specific outcome was missing for the third quarter of the 2023 calendar year reviewed.

Medication administration observation

• AGE observed two Personal Care (PC) staff providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM.

SAMM

• AGE observed one Resident's expired medication stored in a cabinet outside the resident's unit waiting for disposal.

E. Reporting Resident-specific Emergencies- Incident Reports

• AGE reviewed the Residence records and incident reports from March 24, 2023, through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 29 incident reports greater than 24 hours after the occurrence of the incident or accident.

A specific plan of what will be or has been done to correct each of the cited in Section II above;

• Provide a description of what will be done to prevent the recurrence of each of the issue(s) identified in Section II to ensure the problem does not recur;

Identify the designation of the individual(s) who will be responsible for monitoring the correction; and,

• The date by which each correction will be achieved.

V. NEXT STEPS:

• In accordance with 651 CMR 12.09(4)(g), you are required to respond in writing to AGE within ten (10) days after receiving this notice indicating your agreement or disagreement with the findings. If you agree with the findings, please submit in writing to AGE all required information/corrections by June 5, 2025.
• If you disagree with the findings, you may request an informal review pursuant to 651 CMR 12.10(1) by submitting your request using certified mail, return receipt requested, together with a detailed written rebuttal of the findings within ten (10) days of your receipt of this letter.

If you have any questions regarding this matter, please contact me at

• 617-573-1792 or by email at thomas.j.thompson@mass.gov .