Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on November 13, 2024, the state cited 7 findings at Brigham House. 3 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6.
This page covers one review, not a history, and it is not a score or a ranking. A finding means the state identified something the residence has to correct; it does not on its own mean a resident was harmed. The state does not publish what happened after this review, so a finding listed here may since have been fixed.
Facility details
What the state found
7 findings · 3 repeatEmergency call response · Food and dietary servicesIn the month of August 2024 there were 90 e-call response times over the eight minutes required by the Residence policy.▼
Emergency call response: How quickly staff answer a resident's emergency call button.
Food and dietary services: Meals, dietary review and how the kitchen is run.
The state cited these together under one finding.
EOEA reviewed response times and tests of the emergency response system from the calendar years 2023 to 2024 to determine compliance with Service Coordination requirements.
In the month of January 2023 there were 31 e-call response times over the eight minutes required by the Residence policy
In the month of June 2023 there were 29 e-call response times over the eight minutes required by the Residence policy.
In the month of August 2024 there were 90 e-call response times over the eight minutes required by the Residence policy.
EOEA reviewed the Residence’s dietary plan reviews from 2023 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.
Menus lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
EOEA reviewed the records of six Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
EOEA reviewed the Residence records of 18 Resident utilizing bed rails / U-bars or similar devices for the period of 2023 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 determining that the Resident can independently navigate around the bed rail / assistive device was missing for two Residents.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response Dietary Reviews
651 CMR 12.04(2)(b) (3)(b),(4)
Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans.▼
The written plan describing the care each resident is assessed to need.
General Requirements for an ALR: Service Plan Requirements
651 CMR 12.04(6) 651 CMR 12.04(8)(a)(3)(c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.Repeat finding▼
The residence's own program for auditing and improving the care it gives.
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, 2023 and 2024.
Resident Safety Assurances
Documentation of management evaluating the effectiveness of the Evidence Informed Falls Prevention Program was missing for calendar year 2023.
Documentation of a set target date for follow-up action was missing the first three quarters of calendar year 2023.
EOEA observed two PCA staff providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:
One PCA staff left the Resident’s unit without observing the Resident take their 8AM dose of medication.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(b)(c)
Incident reportingThe Residence filed 17 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence’s Records and submitted Incident Reports from November 3, 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 17 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
EOEA reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.
Documentation of a missing person drill conducted by the Residence for third shift was missing for the 2023 calendar year.
General Requirements for an ALR - Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies Elopement Drills
651 CMR 12.04(11)(a)(4),(e)
Staff health screeningMissing documentation of employee Health Screening Requirements.Repeat finding▼
Health checks the residence must document for the people it employs.
EOEA reviewed six personnel records to determine compliance with Health Screening requirements.
Three records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
This was also cited at the previous compliance review.
Staffing Requirements: Health Screening Requirements
651 CMR 12.06(8)(e)(1)
Staff trainingMissing documentation of required LGBTQ trainingRepeat finding▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed six personnel records, to determine compliance with training requirements.
Two records were missing documentation of the required LGBTQ training.
Resident Rights and Disclosures- Resident Disclosures
EOEA reviewed six Resident records to determine compliance with record requirements.
Documentation that a Disclosure of Rights and Services was received by the Resident or Representative at the first meeting missing in five records.
Corrective Actions.
This was also cited at the previous compliance review.
Training Requirements: LGBTQ Training
M.G.L. c. 19A, § 43 651 CMR 12.04(1)(e)
Information given to residentsMissing Full Disclosure of Rights and Services.▼
What the residence must tell residents in writing about services, costs and rights.
Resident Rights and Disclosures: Resident Disclosures
651 CMR 12.08
Glossary
Abbreviations the state uses without explaining themWhat the residence must doThe residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.▼
The residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.