The Residence at Boylston Place

• Service and Service Coordination Requirements-

Self-administered Medication Management (SAMM) and Limited Medication Administration (LMA)

• EOEA reviewed eight (8) Resident Records to determine compliance with requirements for Self-administered Medication Management (SAMM).
• Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for two (2) Residents.
• General Requirements for an Assisted Living Residence (ALR)-
• EOEA reviewed five (5) Resident Records reviewing documentation from October 2022 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

• Four (4) records were missing documentation of a service plan reassessment required within 30 days after the commencement of residency.
• Four (4) records were missing signatures of the Resident or Legal Representative.

Service Plan Development and Requirements

• Four (4) records were missing documentation of a reassessment review being completed every six months.
• Documentation of individualized enrichment activities provided to the resident was missing in two (2) Special Care Residence (SCR) records.
• Four (4) records were missing signatures of the Resident or Legal Representative.
• 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 October 20, 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was conducted, the target date for follow up to findings and clear outcomes was missing for the 2023 calendar years reviewed.

Resident Safety Assurances

• Documentation of the staff person responsible for follow-up action was missing for the 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• EOEA reviewed the Residence's quarterly medication documentation audits from October 20, 2022 through the date of the Compliance Review to ensure compliance with SAMM and Residence policies.
• Documentation of a quarterly medication review was missing for the fourth quarter of the 2022 calendar year.

Medication administration observation

• EOEA observed two (2) Personal Care (PC) staff and one (1) nurse providing medication assistance to nine (9) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• EOEA observed unsecured medications in two (2) SAMM Resident's apartments.

LMA

• EOEA observed expired medications in one (1) Resident's medication storage container.
• EOEA observed medications without a pharmacy label stored in one (1) Resident's medication storage container. These medications were also not listed on the Resident's prescribed medication list.
• Reporting Resident-specific Emergencies- Incident Reports
• EOEA reviewed the Residence records and incident reports from October 2023 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.
• Controlled Substances
• EOEA reviewed the Controlled Substance (CS) procedure to provide safeguards to prevent theft from Residents who participate in SAMM / LMA.
• EOEA observed one Resident's Controlled Substance Log Book does not list the name of the controlled medications being monitored to prevent theft.
• Record Requirements- Correspondence Log
• EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents.
• The Traditional 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 quarterly staffing level assessments was missing for all quarters of 2023, and the first two quarters of 2024.
• Staffing Requirements- Health Screening Requirements
• EOEA reviewed the personnel records of eight (8) staff members to determine compliance with Health Screening requirements.
• Six (6) records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023/2024 flu season.
• Training Requirements-

General Orientation

• EOEA reviewed the personnel records of eight (8) staff members to determine compliance with orientation requirements.
• Documentation of General Orientation for two (2) staff records were missing.

Training Needs Assessment

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

Introductory Visit and Review

• EOEA reviewed the records of eight (8) Residents to determine compliance with the requirements that a nurse review 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:
• Five (5) 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.
• Resident Rights and Disclosures- Resident Disclosures
• EOEA reviewed eight (8) Resident records to determine compliance with record requirements.
• A Disclosure of Rights and Services was missing in four (4) records.
• The required notification of the right to bring a Representative prior to the first meeting were missing in four (4) records.
• Compliance Reviews of Assisted Living Residences- Compliance Review Requirements
• EOEA reviewed Resident records as required by 651 CMR 12.09.
• EOEA was not provided timely access to the requested Residence records. EOEA arrived onsite at 8:00 AM and requested that all documentation be provided no later than 11:00 AM to ensure a thorough audit. By 1:00PM the following requested Residence documentation and / or records had not been presented to EOEA:
• SCR Resident Safety Checks for the months of August and September 2024.
• Monthly documentation of SCR Safety Checks from the date of move-in to the date of the compliance review for the four (4) SCR Residents selected by EOEA.
• E-call response times for December 2022, June 2023 and September 2024.