Fillable Commonwealth of Massachusetts ALR Complaint Form With Instructions

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Commonwealth of Massachusetts ALR Complaint Form With Instructions

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CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
ELIZABETH C. CHEN, PhD, MBA, MPH
Secretary
The Commonwealth of Massachusetts
Executive Office of Elder Affairs
One Ashburton Place, 5th Floor
Boston, Massachusetts 02108
Instructions for Filing an Assisted Living Residence Complaint
The Executive Office of Elder Affairs (EOEA) is the regulatory agency responsible for the
oversight and certification of Assisted Living Residences (ALRs) in Massachusetts. Please read
the following instructions before submitting your complaint.
You may use this form to submit a complaint regarding concerns for health, safety and welfare
of residents. Examples include, but are not limited to, issues with medication management and
assistance; abuse, neglect or financial exploitation; mistreatment of residents; failure to provide
services; concerns regarding insufficient staffing levels.
It is optimal to submit complaints as soon as possible and ideally while the Resident is still
residing at the ALR. EOEA is generally unable to investigate complaints regarding matters
which occurred more than 6-12 months ago. Due to the frequency of staff and management
turnover, it is difficult to investigation complaints regarding past issues or when the Resident no
longer resides in the ALR.
We encourage you to first address your concerns with the ALR management directly, prior to
submitting a formal complaint to EOEA. The ALR is required to have a process for addressing
grievances and ALR management staff should be able to direct you regarding this procedure.
EOEA will assume that the submission of a complaint indicates you have exhausted all of the
grievance procedures afforded by the ALR management.
Limitations
EOEA cannot address issues regarding customer service; billing and fee disputes; personality
conflicts; individual preferences; and quality of amenities. If you are a current resident of an
ALR, the Assisted Living Ombudsman is the best resource for advocacy regarding these matters.
The Assisted Living Ombudsman can be reached at phone number 1-800-AGE-INFO (243-
4636); or by calling the EOEA main number 617-727-7750.
Tel: (617) 727-7750
Fax: (617) 727-9368
TTY/TTD 1-800-872-0166
www.mass.gov/elder
EOEA cannot address issues regarding healthcare services received by outside healthcare
providers (such as hospice or VNA); care received at a rehabilitation center, Skilled Nursing
Facility (SNF), or hospital; or pharmacy services. These matters should be directed to the
Department of Public Health.
Please include as much information and detail—including specific dates, names and locations—
as possible when completing this form. Please attach additional pages if more space is needed. If
you wish to remain anonymous, you may leave the section requesting complainant contact
information blank; however, EOEA will not be able to contact you if additional information is
needed.
EOEA determines the most appropriate response to complaints based on severity and scope.
EOEA does not investigate all complaints, and the timing of investigations or contact is
determined in a discretionary manner based on immediate threat to health or safety.
Periodically, the ALR regulations are reviewed, during which time there is a period of time
afforded for public comment. If you would like to be notified of any upcoming EOEA public
forums regarding Assisted Living, please complete the complainant contact information section
and indicate your response.
The complaint form can be mailed Attention to: ALR Certification Unit, One Ashburton Place,
5
th
floor, Boston, MA 02108; or emailed to ALRHelp@MassMail.State.MA.US.
Next Steps
Upon receipt of the completed complaint form, EOEA will send a letter acknowledging the
submission of a complaint. The complaint will be reviewed by a staff member of the Assisted
Living Certification Unit to determine whether the complaint involves a possible violation of the
ALR regulations (651 CMR 12.00 et seq.).
EOEA may take any of the following actions, depending on circumstances and pervasive nature
of the complaint, including: reviewing related information at an upcoming scheduled
recertification visit; requesting information from the ALR for off-site review; monitoring the
ALR for additional complaints or concerning incidents; referring the complaint to another
agency; filing the complaint as part of public record; conducting a site visit. EOEA oversees
ALRs in accordance with the regulations and prioritizes systemic issues concerning the health,
safety and welfare of residents.
The Commonwealth of Massachusetts
Executive Office of Elder Affairs
One Ashburton Place, 5th Floor
Boston, Massachusetts 02108
Submit Completed Form:
1) By Mail to ALR Certification at address noted above
2) By Email to ALRHelp@MassMail.ma.us
Massachusetts Assisted Living Residence (ALR) Complaint Form
Person Filing Complaint
If you wish to remain anonymous, leave this section blank.
Name (First and Last):
Address:
City: State: Zip Code:
Email Address:
Primary Phone Number: Secondary Phone Number:
Date Complaint Being Submitted (m/d/yy):
Would you like to be notified of any upcoming EOEA public forums regarding Assisted Living?
Yes No
Assisted Living Residence (ALR)
ALR Name:
Address:
City:
Resident Information
Name (First and Last):
Self
Family Member
Friend
Legal Representative (HCP, POA, Guardian)
Other:
Healthcare Provider
Employee—Present Former
First Responder (EMTs, Paramedic)
Anonymous
Law Enforcement Agent
Tel: (617) 727-7750
Fax: (617) 727-9368
TTY/TTD 1-800-872-0166
www.mass.gov/elder
Page 1 of 3
Resident Currently Lives at ALR:
No
Complainant’s Relationship to Resident:
Yes
Massachusetts Assisted Living Residence (ALR) Complaint Form
Executive Office of Elder Affairs
Nature of the Complaint
Quality of Care
Medication Management/Errors
Drug Diversion/Theft
Theft
Alleged, Suspected or Confirmed Abuse, Neglect or Financial Exploitation
Billing/Fees
Environmental Safety
Staffing Levels
Unprofessional Practice
Discrimination
Other:
Have you notified ALR Staff of complaint? If yes, provide information below.
Date Notified (m/d/yy):
Name and Title of ALR Staff Notified:
Manner of Notification:
In
-person
Email
Phone
Written
Letter
ALR Response:
Did you report this complaint to any other agency?
ALR Ombudsman Law Enforcement
Protective Services Attorney General
Other:
Page 2 of 3
Massachusetts Assisted Living Residence (ALR) Complaint Form
Executive Office of Elder Affairs
Description of Complaint (Including Details, Dates, Locations, Names, Etc.) —Attach Additional
Pages if Needed:
Page 3 of 3
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Commonwealth of Massachusetts ALR Complaint Form With Instructions

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Completed 10 May 2020

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