The Parc at Harbor View Senior Living

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 needs situation.
• The policy developed by the Residence does not specify what constitutes a prompt response and timely assistance to Residents. Residence management stated the maximum response time is seven (7) minutes.
• During the months of October 2024 and January 2025, there were 138 e-call response times over the seven (7) minute limit.

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

• AGE reviewed seven (7) Resident Records reviewing documentation from April 2024 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

AGE reviewed the Residence records of 16 Residents utilizing

• bed rails / U-bars or similar devices for the period of 2024 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 three (3) Residents noting that the Resident can independently navigate around a bed rail/ U-bar was missing.

C. 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 April 1, 2024, through the date of the Compliance Review.

Resident Safety Assurances

• Documentation of the review identifying a staff person for follow-up action was missing for 2024.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from April 1, 2024, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of the review identifying a target date for follow-up action was missing for the last quarter of 2024.
• Documentation of the review identifying a staff person for follow-up action was missing for the last three quarters of 2024.
• Documentation of the review stating clear outcomes was missing for the second and fourth quarters of 2024.

Medication administration observation

• AGE observed one (1) Personal Care (PC) staff and one (1) nurse providing medication assistance to six (6) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• AGE observed the PC staff leave unsecured medications in one (1) Resident's unit while the PC staff left the room to get a glass of water for the Resident.
• Medication Administration Record documentation was missing from one (1) Resident's medication storage container.

D. Reporting Resident-specific Emergencies- Incident Reports

• AGE reviewed the Residence records and incident reports from April 2024 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 19 incident reports greater than 24 hours after the occurrence of the incident or accident.

Personnel Record Requirements

• AGE reviewed the personnel records of seven (7) staff members to determine compliance with personnel record requirements.
• Two (2) personnel records were missing documentation of a signed job description.

Correspondence Log

• AGE reviewed the 90- Day correspondence log documentation maintained in one (1) SCR log and one (1) Traditional log to communicate necessary information to maintain the continuity of care for Residents.
• The Traditional log did not document communication every 24 hours.
• The SCR log did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

General Orientation

• AGE reviewed the personnel records of seven (7) staff members to determine compliance with orientation requirements.
• Documentation of General Orientation for two (2) staff records were missing.

Training Needs Assessment

• AGE reviewed the Residence records to determine compliance with annual training needs assessment requirements.
• Documentation of annual training needs assessments was missing for 2024.

Introductory Visit and Review

• AGE reviewed the records of seven (7) 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:
• Six (6) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours, at the time of move-in or at the time of change in the Resident's condition.

Supervision

• AGE reviewed the records of four (4) Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2024 through the date of the Compliance Review.
• Documentation confirming the completion of SAMM and skills evaluations every six months was missing from four (4) records for the 2024 calendar year reviewed.

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.
• B. Specific Corrective Actions.

Submit to AGE the following:

• Documentation confirming a completed and current assessment of all Residents using a bed rail or u-bar.
• Documentation confirming current Introductory Visits for all Residents have been completed by an ALR nurse for all PC staff.
• Documentation confirming current biannual SAMM and skills evaluations have been completed by a nurse for all PC staff.

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 April 17, 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

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