VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Father's House Christian Home
15261 Jubilee Road
Culpeper, VA 22701-4501
(540) 727-8292

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 12, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency and Preparedness Mixed Population

Comments:

Date of Inspection: May 12 and 13, 2022 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 20 Number of records reviewed and interviews conducted- 4 resident records and 2 staff records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during lunch and activities. The Licensing Inspector reviewed the following documents during the inspection: fire drills, pharmacy review, health care oversight, menus, activity calendars and emergency drills. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on direct observation by the Licensing Inspector, it was determined that the facility staff failed to follow the facility policies for infection control practices. Evidence: The medication aide that was administering medications to residents failed to wash the hands between the different residents as required.
Plan of Correction:	The medication aide was re-educated at the time of inspection. All staff administering medications will follow the facility policies for hand hygiene.
Standard #:	22VAC40-73-680-H
Description:	Based on direct observation by the Licensing Inspector, a staff member failed to document medications administered as required. Evidence: The medication aide was observed during a medication administration pass. The medication aide failed to document the medication administered at the time it was administered.
Plan of Correction:	The medication aide was re-educated at the time of inspection. All staff administering medications to residents will document the medication given at the time of administration.