VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Guidepost Montessori at Ashburn Village
21711 Shellhorn Rd
Ashburn, VA 20147
(571) 210-7707

Current Inspector: Lisa Hudson (571) 389-2459

Inspection Date: Nov. 3, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Discussed the importance of accessibility of all records during inspections.

Comments:

An unannounced Monitoring inspection was conducted today. A total of 25 children with 8 staff were onsite. Observation of all 4 classrooms and playground and unoccupied classrooms was conducted. Administration was not onsite during the inspection which impacted the accessibility of recordation. Improvements noted with regards to the playground area regarding resilient surfacing in designated fall zones. A total of 4 staff records were partially reviewed due to some documentation that was not available. A total of 5 children's records were reviewed. This inspection occurred approximately between11am and 2:15pm. Please email me at:: lisa.hudson@doe.virginia.gov with any questions.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on staff record review, out of state background check searches were not completed. Evidence: Staff #3 resided in another state. Results of a Central Registry was not found and a Criminal Record search request was not made prior to hire as required. A Criminal Record search request has not been made to date for this staff.
Plan of Correction:	Provided documentation to licenser on 11.10.22 showing the out of state background check was completed prior to hiring as required. In the event both admins are out, we will ensure that the person filling in is knowledgeable of Bamboo HR to access the staff electronic files. Additionally, we will also ensure that all staff are aware of where the paper files are located. Additional support will also be provided the Guidepost central compliance team.
Standard #:	8VAC20-770-60-C-2
Description:	Based on staff record review, a Virginia Central Registry search was not received within 30 days of hire. Evidence: Staff #2 was hired on 06/30/2022. The Central Registry search was not requested until 08/08/2022. The result is dated 11/08/2022.
Plan of Correction:	Provided documentation to licenser on 11.10.22 showing the out of state background check was completed prior to hiring as required. In the event both admins are out, we will ensure that the person filling in is knowledgeable of Bamboo HR to access the staff electronic files. Additionally, we will also ensure that all staff are aware of where the paper files are located. Additional support will also be provided the Guidepost central compliance team.
Standard #:	8VAC20-780-40-E
Description:	Based on review of medication, the center failed to follow their own policy and procedures on medication administration. Evidence: 1.The medication authorization for Child # 1 did not include timeframes or duration. 2.The medication authorization for Tylenol in the Children?s House classroom was an authorization for a public school and not for the Center. 3.A medication authorization for acetaminophen in the Nido 1 classroom was not renewed after 10 working days.
Plan of Correction:	Will update Tylenol procedures to reflect child?s specific directions from the physician. Medication was returned home
Standard #:	8VAC20-780-60-A-8
Description:	Based on review of food allergies, one allergy action plan was not found. Evidence: Child #1 has a diagnosed food allergy. An allergy action care plan was not found.
Plan of Correction:	Allergy action plan has been updated and placed in students file along with physical medication
Standard #:	8VAC20-780-240-B
Description:	Based on staff record review, staff did not receive the required orientation training within 7 days of their documented hire date. Evidence: Staff # 2 and #3?s orientation training was not completed within the first 7 days of hire.
Plan of Correction:	Ensure orientation certificates have the correct date and uploaded into the online Bamboo HR virtual file, along with the VA pre-service.
Standard #:	8VAC20-780-240-C
Description:	Based on review of documented training, training did not include all required topics. Evidence: The orientation training for Staff #2 and #3 did not include the following topics: Safe sleep practices, SIDS, Shaken Baby and Abusive Head Trauma and Emergencies due to allergic reactions.
Plan of Correction:	The topics mentioned are covered in the pre-service training that staff take within the first seven days of employment and the certificate is in employee?s file.
Standard #:	8VAC20-780-245-J-1
Description:	Based on review of medication administration logs, a medication was administered to a child by a staff who has not completed the Medication Administration Training course. Evidence: Staff #4 administered a medication to Child # 2 on 10/06/2022. Staff #4 is not trained to administer medication.
Plan of Correction:	Staff member is reaching out to MAT trainer to obtain the second part of the training. In the event both admins are out, we will ensure that the person filling in is knowledgeable of Bamboo HR to access the staff electronic files. Additionally, we will also ensure that all staff are aware of where the paper files are located. Additional support will also be provided the Guidepost central compliance team.
Standard #:	8VAC20-780-245-J-3
Description:	Based on review of emergency medications, one child was in care of staff who do not meet the requirements for medication administration training. Evidence: An Auvi Q epinephrine was found onsite. No staff present have completed the additional Auvi Q medication administration training.
Plan of Correction:	Allergy action plan has been updated and placed in students file along with physical medication. Enrolling appropriate staff members in Auvi Q.
Standard #:	8VAC20-780-270-A
Description:	Based on observation of the center, one area was not maintained in an operable condition. Evidence: The toilet paper holder in the Toddler 1 classroom was broken and missing a bracke
Plan of Correction:	Ticket has been placed to facilities to install.
Standard #:	8VAC20-780-280-B
Description:	Based on observation of the Children?s House classroom, a hazardous substance was unlocked. Evidence: A spray bottle of bleach was found unlocked on the counter top.
Plan of Correction:	Ensure the staff are always returning the bleach bottles to the locked cabinets in the bathroom and classroom sink areas.
Standard #:	8VAC20-780-280-B
Description:	Based on observation of the Children?s House classroom, a hazardous substance was unlocked. Evidence: A spray bottle of bleach was found unlocked on the counter top.
Plan of Correction:	Ensure the staff are always returning the bleach bottles to the locked cabinets in the bathroom and classroom sink areas.
Standard #:	8VAC20-780-280-H
Description:	Based on observation of the Children?s House classroom, a purse was stored in an area accessible to children. Evidence: A staff purse was found in the lower area of a cabinet which was accessible to children
Plan of Correction:	Cabinet has a lock. We will ensure that cabinet is locked when purses are in it.
Standard #:	8VAC20-780-280-H
Description:	Based on observation of the Children?s House classroom, a purse was stored in an area accessible to children. Evidence: A staff purse was found in the lower area of a cabinet which was accessible to children
Plan of Correction:	Cabinet has a lock. We will ensure that cabinet is locked when purses are in it.
Standard #:	8VAC20-780-320-B
Description:	Based on observation of one bathroom, toilet paper was not maintained. Evidence: Toilet paper was not found in the bathroom in the Toddler Classroom.
Plan of Correction:	Ticket has been placed to facilities to install.
Standard #:	8VAC20-780-510-I
Description:	Based on review of medications, one prescribed medication found did not have a pharmacy label. Evidence: An Auvi-Q medication in the Children?s House classroom was not maintained in the original labeled container.
Plan of Correction:	We will make sure the forms are updated and more staff have their Auvi-Q will attend the training.
Standard #:	8VAC20-780-510-I
Description:	Based on review of medications, one prescribed medication found did not have a pharmacy label. Evidence: An Auvi-Q medication in the Children?s House classroom was not maintained in the original labeled container.
Plan of Correction:	Ensure staff are always locking the cabinet where medications are stored.
Standard #:	8VAC20-780-510-L
Description:	Based on observation of the center, medications were found unlocked. Evidence: Medication was found unlocked in a cabinet in the Children?s House classroom.
Plan of Correction:	Ensure staff are always locking the cabinet where medications are stored.
Standard #:	8VAC20-780-510-P
Description:	Based on review of medications, medication was not returned or disposed. Evidence: 1.A medication authorization expired on 09/11/2022 in the Nido 1 classroom. The medication has not been returned to the parent or disposed of. 2.A medication authorization expired on 08/07/2022 in the Nido 2 classroom. The medication has not been returned to the parent or disposed of.
Plan of Correction:	Medications that were not needed were retuned. Medication authorization was updated.
Standard #:	8VAC20-780-520-A
Description:	Based on review of topical ointments, one topical ointment was expired. Evidence: A topical ointment for Child #4 expired in August 2022.
Plan of Correction:	Expired ointment was retuned.