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: March 7, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-7-23 from 10:20 a.m.- 3:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food and water supplies, medication pass, physician?s orders, and medication administration records (MARs). An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation and an interview with the administrator, the facility failed to ensure the semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. Evidence: The facility was unable to provide documentation of the semi-annual review of the emergency preparedness and response plan with residents, staff, and volunteers. The administrator stated that the facility would ensure that reviews of the facility?s plan would be conducted and documented semi-annually.
Plan of Correction:	A review of the plan was shared with residents on 3.10.2023 and proper signatures were collected. A revised schedule was created to ensure resident, staff and volunteer reviews. Evidence of review(s) will be audited by the AL Manager and submitted to the Administrator.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation and an interview with the administrator the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: The facility was unable to provide documentation of an exercise in which a resident emergency was practiced. The administrator stated that the facility had conducted a recent practice exercise for a weather-related emergency, but not a resident emergency practice exercise.
Plan of Correction:	A revised training schedule was created to specify resident emergencies. Evidence of training will be audited by the AL Manager and submitted to the Administrator.