Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on April 30, 2024, the state cited 5 findings at Youville House Assisted Living Residence, Inc.. 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
5 findings · 3 repeatEmergency call responseIn the month of March 2024 there were 40 e-call response times over the 10 minutes required by the Residence policy.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 to 2024 to determine compliance with Service Coordination requirements.
In the month of December 2022 there were 24 e-call response times over the 10 minutes required by the Residence policy.
In the month of June 2023 there were 14 e-call response times over the 10 minutes required by the Residence policy.
In the month of March 2024 there were 40 e-call response times over the 10 minutes required by the Residence policy.
This was also cited at the previous compliance review.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Reports filed with the stateUnsubmitted Annual Report▼
Paperwork the residence owes the state each year.
EOEA requires the Sponsor of the Residence to file a financial disclosure annually, within 90 days following the end of the fiscal year to assess the fiscal condition and ability to meet the needs of its Residents.
The Residence’s annual financial disclosure was not submitted to EOEA by the 2024 deadline.
Reports to EOEA: Annual Reports
651 CMR 12.04(13)
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 and 2023.
Documentation of a set target date for follow up action to the findings identified and person responsible for follow up were missing in all calendar years.
EOEA observed three PCA staff providing medication observation to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One Resident had one loose pill in the medication storage area.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(a)(c)
Emergency drills · Incident reportingThe Residence filed 15 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.Repeat finding▼
Emergency drills: Fire and elopement drills the residence must run and document on every shift.
Incident reporting: Telling the state, on time, when something happens to a resident.
The state cited these together under one finding.
EOEA reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.
Documentation of an evacuation drill conducted by the Residence for all shifts was missing for the 2023 calendar year.
EOEA reviewed the Residence records and submitted incident reports from July 26, 2022 through April 30, 2024 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 15 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR - Emergency Preparedness Plan and Reporting Requirements: Evacuation Drills Reporting Resident Specific Emergencies
651 CMR 12.04(11)(a)(4),(e)
Staff trainingMissing documentation of required LGBTQ training▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed eight personnel records, to determine compliance with training requirements.
Two records were missing documentation of the required LGBTQ training.
Corrective Actions.
Training Requirements: LGBTQ Training
M.G.L. c. 19A, § 43 651 CMR 12.04(1)(e)
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.