The Compass School of Ashburn
44128 Navajo Drive
Ashburn, VA 20147
Current Inspector: Karen Dickens (571) 423-6978
Inspection Date: Oct. 1, 2019
Complaint Related: No
- Areas Reviewed:
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)
63.2 Child Abuse & Neglect
63.2 Facilities & Programs.
- Technical Assistance:
Discussion was held on the topics of staff and children's records, medication and supervision.
An unannounced renewal inspection was conducted from approximately 9:10 am through 2:45 pm. During the inspection, 60 children were observed in direct care of 12 staff members. Ratios were in compliance. Children were observed during snack time, engaged in group activities, circle time, exercising, small motor activities, manipulatives, outdoor time and engaged with staff. Interactions were positive. The center was clean, organized and contained a varied supply of developmentally appropriate materials. A selection of 5 staff and 6 children's records were reviewed. The physical space, evacuation drills, attendance records, cribs, 15 injury reports, a sampling of medications, required posted documents, emergency supplies and the Emergency Preparedness Plan were reviewed. Areas of non-compliance are identified in the violation notice. If you have any questions regarding this inspection, please contact the Licensing Inspector, Maria Robles at firstname.lastname@example.org.
Standard #: 22VAC40-185-160-A Description: Based on record review, the center failed to ensure that each staff member submitted documentation of a negative tuberculosis screening no later than 21 days after employment.
1) Staff #5's record (start date 06/17/2019) did not contain documentation of a current Tb screening.
Plan of Correction: Staff will be asked to obtain a Tb screening.
Standard #: 22VAC40-185-40-I Description: Based on documentation review and , there was no written procedures for injury prevention.
1) Administrative staff were not able to locate written procedures for injury prevention.
Plan of Correction: We are working on a report for this quarter.
Standard #: 22VAC40-185-60-A Description: Based on record review, the center did not maintain a complete record for each child enrolled.
1) Child #4 and Child #5's records did not have documentation of the parent's work phone number.
2) Child #1's record did not have documentation of name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
3) Child #4 and Child #5's record did not have documentation of the name, address, and phone number of a second emergency contact to call if a parent cannot be reached.
4) Child #1, Child #2 and Child #3's records did not contain documentation of annual updates and confirmation of up-to-date information.
Plan of Correction: Files will be audited.
Standard #: 22VAC40-185-70-A Description: Based on record review, the center did not maintain a complete record for each staff member.
1) Staff #5's record did not contain documentation that two or more references were checked before employment.
Plan of Correction: We will contact the references and document it.
Standard #: 22VAC40-185-240-A Description: Based on record review, the center failed to document that all staff received mandatory training by the end of their first day of assuming job responsibilities.
1) Staff #1 and Staff #4's record did not contain documentation of having completed mandatory training by the end of their first day.
Plan of Correction: We will retrain staff in orientation procedures and documenting the training.
Standard #: 22VAC40-185-240-C Description: Based on record review, one staff member did not attend 16 annual hours of staff development activities.
1) Staff #3's (hire date 11/07/2016) record contains documentation of only 1 of the 16 required hours of annual training.
Plan of Correction: We will audit the files and create a spreadsheet for training hours.
Standard #: 22VAC40-185-260-A Description: Based on documents review, the center has not obtained an annual fire inspection report from the fire official.
1) The most recent fire inspection is dated 05/03/2018.
Plan of Correction: We will contact the fire department's office.
Standard #: 22VAC40-185-280-H Description: Based on observation, cosmetics, medications, or other harmful agents were stored in areas, purses or pockets that are accessible to children.
1) In the Navigators room (infants), two purses were observed stored in a cabinet with no lock or latch, making it accessible to children.
Plan of Correction: We will put a latch in the cabinet.
Standard #: 22VAC40-185-420-E-1 Description: Based on documentation review, time spent on stomach is not being documented daily for one infant required to have it recorded.
1) 0 of 11 daily records reviewed for Child #6, had documentation of time spent on stomach.
Plan of Correction: We will inform our teachers to make sure they record it on the form provided.
Standard #: 22VAC40-185-510-C Description: Based on review of medications and medication documentation, the center's procedures for administering medication, were not followed.
1) According to the medication log for Child #1, one long term over-the-counter medication was administered on 04/10/2019, after the authorization expired on 3/28/2019.
2) Child #3's medication authorization with only a parent's signature, exceeded the allowable 10 work days authorization period.
3) One long term prescription medication for Child #3 did not have a written authorization form signed by the physician.
Plan of Correction: We will do monthly audits and create documentation with expiration and authorization dates.
Standard #: 22VAC40-185-510-G Description: Based on medication and record review, the center failed to ensure that medication was maintained in the original, labeled container.
1) One medication for Child #2 was not in an original container with a prescription label attached.
Plan of Correction: We will ask the parents for the prescription label.
Standard #: 22VAC40-185-520-B Description: Based on observation, sunscreen was not stored inaccessible to children under five years of age.
1) In the Sound stage room (3-4 year olds), 8 containers of sunscreen were observed in an unlocked lower cabinet under the classroom sink.
Plan of Correction: Cabinet will be locked.
Standard #: 22VAC40-185-520-C Description: Based on observation, requirements for the use of diaper ointment were not followed.
1) In the Inventors Workshop room (2-3 year olds), 11 diaper cream containers were observed under the changing table. The door had a latch that was not being used during inspection.
Plan of Correction: Teacher locked it during inspection.
Standard #: 22VAC40-185-550-D Description: Based on document review, two shelter-in-place drills were not practiced per year.
1) One shelter-in-place was documented for the year of 2018 (05/2018).
Plan of Correction: Two drills will be conducted this year.
Standard #: 22VAC40-185-550-M Description: Based on record review, the center did not maintain complete written records of children's serious and minor injuries.
1) Out of 15 injury reports reviewed, 9 did not document the time at which parents were informed of the injury.
2) Out of 15 injury reports reviewed, 5 did not document the manner in which the parents were informed of the injury.
Plan of Correction: Staff will be retrained on filling the injury reports.
A compliance history is in no way a rating for a facility.
The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.
Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.