VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Covenant Woods
7090 Covenant Woods Drive
Mechanicsville, VA 23111
(804) 569-8000

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: April 1, 2021 and April 7, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on April 1, 2021 and concluded on April 7, 2021 with a virtual tour of the facility. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 30. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, physician's orders, Medication Administration Records, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and a violation was documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on a review of staff records, the facility failed to ensure that the orientation and training required in subsections B and C of this section occurred within the first seven working days of employment. Evidence: The Record of Initial ALF Staff Training form for Staff # 1 (date of hire: 8-4-2020) was dated 8-20-2020 for section 120.C.9 regarding training on methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another. The Licensing Inspector also noted that the Record of Initial ALF Staff Training form was not signed or dated by Staff # 1 and did not contain the trainer's initials.
Plan of Correction:	Employee completed training. The initial orientation document has been updated with the topic in 120.C.9 to be used with all future new hires on the first day of hire. This same form and all forms used to document training have been updated to include the formal signature by the staff receiving training and the trainer's initials. Old forms have been removed from circulation to avoid use in the future. Human resources maintains the training form templates.