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: June 23, 2020

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:

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 June 18, 2020 and concluded on June 19, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 38. 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 (MARs), and other facility documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and the violation was documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1140-B
Description:	Based on a review of staff records, the facility failed to ensure that within four months of the starting date of employment in the safe,secure unit, direct care staff attended at least 10 hours of training in cognitive impairment. Evidence: -The Relias training transcript for Staff # 1 (hire date:11-7-19) and Staff # 2 (hire date: 2-14-19), who both work on the facility's memory care unit, did not indicate at least 10 hours of training in cognitive impairment training within four months of each staff member's starting date of employment.
Plan of Correction:	Dementia Training assigned to the two staff identified on June 19, 2020. Audit completed of all other employees assigned to the unit. No other regular staff identified. All current PRN staff will be assigned 10-hour training,regardless of their current regular schedule, on June 22,2020. All future PRN staff hired will be assigned training to be completed within first 4-months of employment. All new hires to Memory Support and all staff with a PAR department code change/transfer to the Memory Support unit will be assigned the hours to be completed within 4 months of the date of hire/transfer.Human Resources implementing, completing and monitoring.