Bridges by EPOCH at Hingham

EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 through 2024 to determine compliance with Service Coordination requirements.

In the month of March 2024 there were 20 e-call response times over the 10 minutes required by the Residence policy.

EOEA reviewed the records of five Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.

Three records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

Two records were missing documentation of a reassessment review 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 2022 and 2023.

Resident Safety Assurances

Documentation of a set target date for follow up action to the findings identified and person responsible for follow up was missing in the calendar year 2022.

Documentation of a set target date for follow up action to the findings identified and person responsible for follow up was missing in the first two quarters of calendar year 2023.

EOEA observed two Personal Care (PC) staff providing medication assistance to four Residents and one nurse providing medication administration to three residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

One Resident was missing their name and picture on their medication storage unit.

One Resident had one loose pill in the medication storage unit.

One Resident had one medication without a pharmacy label in their medication storage unit.

EOEA reviewed the Residence’s Records and submitted Incident Reports from September 29, 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.

The Residence filed eight incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.

EOEA reviewed the Controlled Substance (CS) policy and procedure to prevent the theft or diversion of controlled substances prescribed to Residents who participate in SAMM / LMA.

Residence staff is not consistently documenting the CS declining count after assisting Residents with CS medication administration.

EOEA reviewed the three current ninety (90)-day Correspondence Logs, for the Special Care Residences, required to communicate information necessary to maintain the continuity of care for all Residents.

The Residence did not consistently document for each 24-hour period in the Shipyard Correspondence Log.

EOEA reviewed the records of five Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers.

Two records were missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services, at the time of move-in.

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 required to document the timely assistance to a Resident in the event of an emergency needs situation were not all available for review for the months of December 2022 and June 2023.

Corrective Actions.