VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Covenant Columns
510 Park Avenue
Richmond, VA 23223
(804) 222-5133

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: July 31, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

Technical Assistance:

Staff training is old license Healthcare oversight Fire drill times Discharge statement Full updates to staff and resident records with new licensee information Shower head Visiting Hours

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-31-2023, 8:45 a.m. ? 10:15 a.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: 7 Number of resident records reviewed: 5 Number of staff records reviewed:3 An exit meeting will be 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1 provided Staff #4?s tuberculosis exam that was dated 1-09-2019.
Plan of Correction:	Will be completed by mid October
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within 30 days preceding admission, a person had a physical examination with required information. Evidence: 1. Resident #1 admitted 12-20-2022. Resident #1 did not have a physical examination including: Any known allergies and description of the person's reactions; Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it; A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; and A statement that specifies whether the individual is or is not capable of self- administering medication. 2. Resident #4 admitted 6-01-2023 and did not have a physical examination on file. Staff #2 confirmed that there was no physical examination on file.
Plan of Correction:	Resident #1 Penicillin Resident breaks out in hives. Resident #1 TB assessment completed on 4-19-23 Resident #1 Physical examination was completed on 5/31/23 No prohibited conditions or care needs Resident is non ambulatory Resident is capable of self administering medications. Resident #4 has had a physical. Have contacted her Dr. on several occasions and still haven?t received it.
Standard #:	22VAC40-73-350-B
Description:	Based on record review and interview with staff, the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: Resident #1 admitted 12-20-2022. The Sex Offender screening provided by Staff #1 was dated 9-14-2023.
Plan of Correction:	Resident #1 sex offender was completed on 9-14-2023
Standard #:	22VAC40-73-440-B
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was signed by the administrator in addition to the assisted living facility staff person who has successfully completed the state-approved training on the UAI. Evidence: 1. The following three residents? UAIs were not signed by the administrator: a. Resident #1?s UAI dated 12-20-2022; b. Resident #2?s UAI dated 9-20-2022; and c. Resident #3?s UAI dated 2-08-2023. 2. Staff #1 confirmed during interview that the UAIs were only signed by Staff #2 and not additionally by the administrator as required.
Plan of Correction:	Administrator has signed all UAI?s
Standard #:	22VAC40-73-450-B
Description:	Based on interview with staff, the facility failed to ensure the licensee, administrator, or his designee who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession, shall develop a comprehensive ISP to meet the resident's service needs. Evidence: A review of four resident records documented that Staff #1 or Staff #2 completed all ISPs for residents; however, Staff #1 confirmed neither Staff #1 nor Staff #2 have completed the department-approved ISP training.
Plan of Correction:	Administrator and required staff will received ISP Training.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and dates identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: Resident #4 admitted 6-01-2023. The comprehensive ISP dated 6-01-2023 did not identify needs addressed on the UAI such as help with laundry, money management, transportation, shopping and home maintenance; as well as allergies to iodine, morphine, and codeine were not listed on the ISP but were on the resident?s UAI and attached physician?s orders.
Plan of Correction:	Resident #4?s ISP as well as allergies will be completed.
Standard #:	22VAC40-73-870-F
Description:	Based on observation and interview with staff, the facility failed to ensure all inside steps had nonslip surfaces. Evidence: The staircase in the back of the facility closest to the dining room area of the facility does not have nonslip surfaces. Photographic evidence was obtained. Staff#1 confirmed during interview.
Plan of Correction:	Stairs have been completed with non-slit surface
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure the fire and emergency evacuation drawing was posted in a conspicuous place on each floor of each building used by residents. Evidence: On the first floor, a posting titled for the previous licensee titled ?First Floor Fire Evacuation Plan? and on the second floor, titled ?2nd floor fire evacuation plan? with listed directions of how to exit were posted. There was no fire and emergency evacuation drawing observed posted in the facility.
Plan of Correction:	This was completed on 9-26-2023
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #2?s date of hire was during the previous license (11-03-2021); however, the criminal record check was not requested until 5-04-2023. 2. Staff #3?s date of hire was 6-09-2023. As of 7-31-2023, the criminal record check had not been requested.
Plan of Correction:	Staff #2 background was completed on 2-23 upon new administrator Staff #3 had a background check completed with the previous administrator. Will re submit the background check.