VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Northeast Stars Montessori Preschool
697 N. Washington Street
Alexandria, VA 22314
(703) 945-0408

Current Inspector: Mahrukh Aziz (571) 835-4718

Inspection Date: Jan. 16, 2025

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. 20 Access to minor's records 22.1 Background Checks Code, Carbon Monoxide 54.1 Provider must be MAT certified to administer prescription medication. 63.2 Child abuse and neglect

Technical Assistance:

Medications, staffing, medication administration training.

Comments:

An unannounced, on-site monitoring inspection was conducted on 1/16/25 from 9:04 am to 10:45am. The inspector reviewed compliance in the areas listed above. There were 28 children present and 4 staff. The inspector reviewed 4 children?s records and 4 staff records on-site. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program. Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 1/29/25. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	8VAC20-780-245-J-3
Description:	Any child for whom emergency medications have been prescribed shall always be in the care of a staff member who meets the requirements in subdivision 1 of 8VAC20-780-245 J. Child #2 has an emergency medication on supply that the center has agreed to administer if needed, but none of the staff on site have completed the training required to administer the emergency medication.
Plan of Correction:	Child#2 uses an Auvi-Q, which is an epinephrine auto-injector. Staff members at the center are MAT-certified to administer epinephrine auto-injector, which includes training.on the administration on EpiPen Jr. However, staff were unaware that separate training is required specifically for the use of Auvi-Q devices as it is also an epinephrine auto-injector. NES has decided not to accept Auvi-Q devices or any device that has not been covered under MAT training. Instead, the center will continue to administer standard epinephrine auto-injectors (EpiPen or EpiPen Jr. as part of policy. The parent handbook has been updated to clearly state that Auvi-Q devices and any other devices not covered in the MAT training will not be accepted for administration at the center.
Standard #:	8VAC20-780-350-B-3
Description:	The staff to children ratio for 2 year old children should be maintained at 1 staff to 8 children. 1. At 9:04 am, there were a total of twenty-six children present with three staff members. Two of the twenty-six children were two years old. 2. Between 9:04 am to 9:35 am, the children were observed as one large group, handwashing and eating morning snack in the large room. 3. At 9:35 am, the group was divided, and 8 children including the two year old children were taken into another room by Staff # 1.The center did not meet the ratio requirement for 31 minutes.
Plan of Correction:	During the visit, (2) 2.5 year olds from a separate group of 8 briefly joined the two groups of 3 years and older as we transitioned to handwashing and snack time. The situation was self corrected during the visit when the 2.5 year olds returned to their respective group. Staff were reminded to keep groups separate.
Standard #:	8VAC20-780-510-E
Description:	The center's medication administration procedures shall include methods to prevent use of outdated medication. The center's medication administration policy did not include procedures to ensure that outdated medication is not used.
Plan of Correction:	NES has a policy to return expired medication to parents. However, this policy was not previously included in the Parent Handbook. On 1/16/2025, the policy was formally added to the handbook to ensure clarity and transparency for all families. In addition, NES has developed a new Medication Expiration and Disposal Form to enhance accountability and support compliance with medication management procedures.
Standard #:	8VAC20-780-510-P
Description:	When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days are to be disposed of by the center. 1. Child #1's medication authorization expired over four months ago, and the medication also expired over four months ago. 2. Child #2's medication authorization expired over 16 months ago, and the medication expired over 13 months ago. 3. The staff present were not aware that the authorizations and medications had expired. Child # 1 and Child # 2's parents were not notified; and the center did not dispose of the medications after 14 days of authorization expiration.
Plan of Correction:	Child #1's parent was previously notified to bring in a new medication and updated form. However, the expired medication was inadvertently stored in the back of the cabinet instead of being returned to the parent or properly discarded. On 1/16/2025, following an inspection, the parent was contacted again and reminded that a new medication and the form was required. The expired medication was sent home. Child 2's parent was informed that their child's medication had expired, however,the parent did not confirm whether a replacement would be provided. The expired medication was mistakenly stored in the back of the cabinet rather than returned or discarded. On 1/16/2025, following the inspection, the parent was contacted to inform them that the expired medication would be sent home. The parent was also advised that if they wished for their child to have medication available on-site, they would need to provide an unexpired EpiPen along with updated form. As a corrective action, staff were retrained on the proper procedures for handling and disposing of medications. Additionally, a new Medication Expiration and Disposal Form was created to enhance accountability and ensure compliance.