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: Nov. 17, 2021 and Dec. 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 32.1 Reported by persons other than physicians 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:

An unannounced renewal inspection was conducted by the licensing inspector on December 7, 2021 from 10:45 a.m. to 12:50 p.m. A census of 29 residents was reported. A tour of the facility was conducted to include the observation of facility postings, resident rooms, buildings and grounds, lunch meal/menu, activities, medication pass, physician's orders/Medication Administration Records (MARs), and emergency food/water supply. Resident and staff interviews were also conducted. A sample of three resident records, three staff records, and other facility documentation was requested remotely on November 17, 2021 and reviewed prior to the on-site inspection. The violations cited are identified in this report. Please complete the "plan of correction" and "date to be corrected" for each 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 #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff record contained a current tuberculosis (TB) screening. Evidence: The record for Staff # 2 (date of hire: 2-20-2020) contained a TB screening last dated 3-8-2020.
Plan of Correction:	Revise the Employee TB Screening policy to modify the employee and manager notification process for non-compliance, to include an audit of completion by mid-month and additional notifications to staff. The Employee Health Nurse will audit screening records and verify current list of active employees with HR.
Standard #:	22VAC40-73-260-C
Description:	Based on observation of facility postings, the facility failed to post a listing of all staff who have current certification in first aid or CPR so that the information is readily available to all staff at all times. Evidence: The facility did not have a list posted of staff certified in first aid/CPR.
Plan of Correction:	A current listing of all staff certified in CPR and FA will be posted in the Assisted Living breakroom, where all staff have access. This list will be updated at least monthly and as needed by HR and the Unit Manager.
Standard #:	22VAC40-73-970-E
Description:	Based on a review of facility documentation, the facility failed to ensure that it documented the number of residents participating in fire and emergency evacuation drills. Evidence: The facility's Emergency Drill Reporting Forms (November 2020- October 2021) did not document the number of resident's participating in fire/evacuation drills and the facility's accompanying Disaster Drill/Training Attendance sign-in sheets only documented staff who participated.
Plan of Correction:	The emergency drill form will be updated to include resident participation numbers. Facility Services will maintain drill records