Sunrise of Plymouth Beach

• Service and Service Coordination Requirements- Emergency Response
• EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
• In the months of November 2022, August 2023 and April 2024 there were over 476 e-call response times over the ten (10) minutes required by Residence policy.
• The Residence is not demonstrating a effective means of monitoring and ensuring reasonable staff response times to Resident requests for assistance during November 2022 and August 2023.
• The Residence has chosen to manually 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 for April 2024 through the date of compliance review 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.
• Documentation of hourly safety checks for three (3) SCR Residents reviewed by EOEA from the date of move-in through the date of compliance review 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.
• Service and Service Coordination- Special Care
• EOEA reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is being administered with all the required safeguards.
• EOEA identified secured SCR entry and exit doors, with a 15-second delayed opening, not releasing when triggered.
• General Requirements for an Assisted Living Residence (ALR)- Bed Rail Assessments
• EOEA reviewed the Residence records of three (3) 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 conducted by a physical/occupational therapist every six months for one (1) Resident noting that the Resident can independently navigate around a bed rail/ U-bar for the calendar years reviewed.
• Quality Assurance and Performance Improvement
• EOEA 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 August 30, 2022, through the date of the Compliance Review.

Service Planning

• Documentation of the target date and the staff person responsible for follow-up action and clear outcomes was missing for the 2023 calendar year reviewed.

Resident Safety Assurances

• Documentation of the staff person conducting the audit, the target date and the staff person responsible for follow-up action and clear outcomes was missing for the 2022 calendar year reviewed.

Medication Quality Plan

• EOEA reviewed the Residence's quarterly medication documentation audits from August 30, 2022 through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of a target date for follow-up, the staff person responsible for follow-up, and clear outcomes was missing in last quarter of the 2022 calendar year reviewed.
• Medication Quality Plan reviews were insufficient in documenting and addressing three (3) reported medication errors in the first quarter of 2023, one (1) reported medication error in the third quarter of 2023 and four (4) reported medication errors in the first quarter of 2024.
• Reporting Resident-specific Emergencies- Incident Reports
• EOEA reviewed the Residence records and incident reports from August 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.
• The Residence filed 58 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Record Requirements- Correspondence Log
• EOEA reviewed the documentation maintained in a 90-day correspondence log to communicate information necessary to maintain the continuity of care for Residents in the Residence.
• The log did not consistently document for each 24-hour period in the Correspondence Log.
• The log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Staffing Requirements- Staffing Levels
• EOEA reviewed the Residence records to determine compliance with Staffing Level requirements.
• Documentation to confirm the Residence conducted timely quarterly staffing level assessments was missing for all four quarters of 2023 and the first quarter of 2024.
• Staffing Requirements- Health Screening Requirements
• EOEA reviewed the personnel records of five (5) staff members to determine compliance with Health Screening requirements.
• Five (5) records were missing documentation to confirm seasonal influenza vaccinations or declination statements.
• Training Requirements-

General Orientation

• EOEA reviewed the personnel records of five (5) staff members to determine compliance with orientation requirements.
• Documentation for five (5) employees having received a general orientation, consisting of all required topics and time requirements, was missing.

Training Needs Assessment

• EOEA reviewed the Residence records to determine compliance with annual training needs assessment requirements.
• Documentation of annual training needs assessments for the 2022 and 2023 calendar years reviewed missing.

Personal Care Services Provider Training Requirements and Exemptions

• EOEA reviewed the personnel records of three (3) personal care staff members to determine compliance with training requirements and exemptions.
• Documentation for two (2) employees having received 54- hours of training prior to providing services unless exempt as set forth by 651 CMR 12.07(9), was missing.

Supervision

• EOEA reviewed the records of three Personal Care (PC) staff to determine compliance with Personal Care evaluation requirements in the calendar year 2022 through the date of the Compliance Review.
• Documentation confirming the completion of Personal Care (PC) skills evaluations every six months was missing from three (3) records.