Glen at Grove Manor

A. General Requirements for an Assisted Living Residence (ALR)

• AGE reviewed four Resident Records reviewing documentation 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.

Service Plan Development and Requirements

• Three records were missing documentation of a service plan review required within 30 days after the commencement of residency.

B. 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 2023, through the date of the Compliance Review.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from March 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of the audit was missing for the 2023 and 2024 calendar years.

Medication administration observation

• AGE observed one PC staff providing medication assistance to two Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• AGE observed two loose pills in two Resident's medication storage units.

C. Controlled Substances

• AGE reviewed the Controlled Substance policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM.
• The Residence policy does not include steps regarding the safeguards for storage and disposal of controlled substances.

D. Record Requirements- Personnel Record Requirements

• AGE reviewed the personnel records of four staff members to determine compliance with personnel record requirements.
• Two records were missing documentation of a signed job description.

E. Record Requirements - Correspondence Log

• AGE reviewed the current Correspondence Log for the Residence required to communicate information necessary to maintain the continuity of care for all Residents.
• The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.

F. Staffing Requirements- Health Screening Requirements

• AGE reviewed the personnel records of four staff members to determine compliance with Health Screening requirements.
• Two records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.

G. Training Requirements - Introductory Visit and Review

• AGE reviewed the records of four Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:
• Four records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.

H. Resident Rights and Required Disclosures - Additional Disclosures

• AGE reviewed four Resident records to confirm compliance with the Additional Disclosure requirements.
• The informational cover sheet required by AGE for each Residency Agreement was missing in two records.

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.

Submit to AGE the following:

• Documentation of completion of a Quarterly Medication Quality Audit.
• Documentation of completion of a revised Controlled Substance policy and procedure to provide safeguards for storage and disposal of controlled substances.
• Documentation of completion of all Personnel Record requirements for all personnel.
• Documentation to support that Introductory Visits were consistently conducted with all applicable staff.
• Documentation confirming the completion of AGE required informational cover sheets for all Residents.

V. NEXT STEPS:

• In accordance with 651 CMR 12.09(4)(g), you are required to respond in writing to AGE within 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 1, 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 10 days of your receipt of this letter.
• If you have any questions regarding this matter, please contact me at 617-222-7411 or by email at Christopher.mundy2@mass.gov