Blaire House of Tewksbury

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 month of March 2024 there were 73 e-call response times over the seven (7) minutes required by Residence policy.

EOEA reviewed the Residence’s dietary plan reviews from 2023 through the date of compliance review to confirm consistency with the most recent edition of Dietary Guidelines.

Current Resident menus were missing designations of which selections meet the daily recommend allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the of the National Research Council of the National Academy of Sciences.

EOEA reviewed five (5) Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Two (2) records were without documentation to confirm the initial assessment was conducted by a nurse.

Five (5) records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

Five (5) records were missing documentation of a reassessment being completed every six months.

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2023 through the date of the Compliance Review.

Resident Safety Assurances

Documentation identifying staff members responsible for follow action and clear outcomes was missing for the 2023 calendar year reviewed.

Documentation of a bi-annual review of the Evidenced Informed Falls Prevention Program, required per Residence policy, was missing in the 2023 calendar year reviewed.

EOEA reviewed the Residence’s quarterly medication documentation audits for the calendar year 2023 through the date of Compliance Review to ensure compliance with SAMM protocols and Residence policies.

Documentation of a target date and staff person responsible for follow up action was missing for the first and fourth quarters of the 2023 calendar year reviewed.

EOEA reviewed the Residence records and incident reports from March 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 twelve (12) incident reports greater than 24 hours after the incident or accident.

EOEA requires the Sponsor of the Residence to file a financial disclosure form, annually, within 90 days following the end of the ALRs fiscal year or if extended in response to a waiver request within 30-days after the end of the ALRs fiscal year.

The Residence’s annual financial disclosure form was not submitted to EOEA by the March 31, 2024, deadline.

EOEA reviewed five (5) Resident records to determine compliance with record requirements.

A Disclosure of Rights and Services was missing in two (2) Resident records.

EOEA reviewed the personnel records of five (5) staff members to determine compliance with orientation requirements.

Orientation documentation for Five (5) records lacked sufficient information to determine if:

All regulatory topics were covered.

Required topics met the minimum number of hours,

Orientations were facilitated or unfacilitated.

Requirements of additional topics and hours for Special Care Residence staff were met.

EOEA reviewed the records of five (5) 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 after the provision of Personal Care (PC) services, at the time of move-in or at the time of change in the Resident’s condition.

Resident Rights and Required Disclosures – Required Disclosures

EOEA reviewed five (5) Resident records to confirm compliance with the Disclosure of Rights and Services requirements.

The required Disclosure notification of the right to bring a Representative prior to the first meeting, was missing in four (4) records.

EOEA reviewed the Residence’s records including all documents that should be maintained in relation to the operations of the Residence.

The Residence’s records to document providing timely assistance to a Resident in the event of an emergency needs situation for June 2023 were not all available for review.