Caring for Our Children: Chapter 1 - Staffing Chapter 1: Staffing 1.1 CHILD:STAFF RATIO AND GROUP SIZE STANDARD 1.001 RATIOs for SMALL FAMILY CHILD CARE Homes The small family child care home provider child:staff ratios shall conform to the following table: If the small family child care home provider has no children under two years of age in care, then the small family child care home provider may have 1-6 children over two years of age in care If the small family child care home provider has 1 child under two years of age in care, then the small family child care home provider may have 1-3 children over two years of age in care If the small family child care home provider has 2 children under two years of age in care, then the small family child care home provider may have no children over two years of age in care The small family child care home provider's own children shall be included in the child:staff ratio. RATIONALE: Although child:staff ratios alone do not predict the quality of care, direct warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Care - givers must be recognized as performing a job for groups of children that parents of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes. Low child:staff ratios are most critical for infants and young toddlers (0 to 24 months) (1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower child:staff ratios (3). For 3- and 4-year old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow 3- to 5- year old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4). The National Fire Protection Association (NFPA) requires in the NFPA-101 Life Safety Code that small family child care homes serve no more than 2 clients incapable of self-preservation (6). COMMENTS: Some states are setting limits on the number of school-age children that are allowed to be cared for in small family child care homes, e.g., two school-age children in addition to the maximum number allowed for infants/preschool children. No data are available to support using a different ratio where school-age children are in family child care homes. Since school-age children require focused caregiver time and attention for supervision and adult-child interaction, this standard applies the same ratio to all children over two years of age. The family child care provider must be able to have a positive relationship and provide guidance for each child in care. Unscheduled inspections encourage compliance with this standard. For more information regarding brain development in children in child care, see STANDARD 1.010. TYPE OF FACILITY: Small Family Child Care Home STANDARD 1.002 RATIOS FOR LARGE FAMILY CHILD CARE HOMES AND CENTERS Child:staff ratios in centers and large family child care homes shall be maintained as follows during all hours of operation, including transport and nap times: Age Maximum Child:Staff Ratio Maximum Group Size Birth - 12 mos. 3:1 6 13 - 30 mos. 4:1 8 31 - 35 mos. 5:1 10 3-year-olds 7:1 14 4-year-olds 8:1 16 5-year-olds 8:1 16 6 - 8-year-olds 10:1 20 9 - 12-year-olds 12:1 24 During nap time, at least one adult shall be physically present in the same space as the children. Other adults who are included in the child:staff ratio need not be in the same space with the children when all the children are napping. However, in case of emergency, these adults shall be on the same floor and shall have no barrier to their coming to help immediately. The caregiver who is in the same space with the children shall be able to summon these adults without leaving the children. When there are mixed age groups in the same room, the child:staff ratio and group size shall be consistent with the age of most of the children when no infants or toddlers are in the mixed age group. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers shall be maintained. In large family child care homes with two or more care-givers caring for no more than 12 children, no more than three children younger than 2 years of age shall be in care. RATIONALE: These child:staff ratios are within the range of recommendations for each age group that the National Association for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recommends a range that assumes the director and staff are highly trained and, by virtue of the accreditation process, has determined a staffing pattern that enables effective staff function. The standard for child:staff ratios in this document uses a single desired ratio, rather than a range, for each age group. In some cases, these child:staff ratios and group sizes are the more stringent ratios and group sizes recommended in the National Research Council's report, Who Cares for America's Children? Child Care Policy for the 1990s (1). According to the National Research Council, child:staff ratios and group size are two of the four most important areas to be addressed in national standards. Children with special health care needs may require additional staff on-site, depending on their special need and extent of disability (1). Low child:staff ratios for non-ambulatory children are essential for fire safety. The National Fire Protection Association, in its NFPA-101 Life Safety Code , recommends that no more than three children younger than 2 years of age be cared for in large family child care homes where two staff members are caring for up to 12 children (6). Children benefit from social interactions with peers. However, larger groups are generally associated with less positive interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one interaction, intimate knowledge of individual children, and consistent caregiving (7). Although child:staff ratios alone do not predict the quality of care, direct warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers must be recognized as performing a job for groups of children that parents of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes. Low child:staff ratios are most critical for infants and young toddlers (0 to 24 months) (1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower ratios (3). For 3- and 4-year old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow 3- to 5- year old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4). In addition, the children's physical safety and sanitation routines require a staff that is not fragmented by excessive demands. Child:staff ratios in child care settings should be sufficiently low to keep staff stress below levels that might result in anger with children. Caring for too many young children, in particular, increases the possibility of stress to the caregiver, and may result in loss of self-control. Although observation of sleeping children does not require the physical presence of more than one caregiver, the staff needed for an emergency response or evacuation of the children must remain available for this purpose. Nap time may be the best option for regular staff conferences and staff training, but these activities should take place in an area next to the room where the children are sleeping so no barrier will prevent the staff from assisting if emergency evacuation becomes necessary. COMMENTS: The child:staff ratio indicates the maximum number of children permitted per caregiver (8). These ratios assume that caregivers do not have time-consuming bookkeeping and housekeeping duties, so they are free to provide direct care for children. The ratios do not include other personnel (such as bus drivers) necessary for specialized functions (such as driving a vehicle). Group size is the number of children assigned to a caregiver or team of caregivers occupying an individual classroom or well-defined space within a larger room (8).The "group" in child care represents the "homeroom" for school-age children. It is the psychological base with which the child identifies and from which the child gains continual guidance and support in various activities. This standard does not prohibit larger numbers of children from joining in collective activities as long as child:staff ratios and the concept of "home room" are maintained. Unscheduled inspections encourage compliance with this standard. These standards are based on what children need for quality nurturing care. Those who question whether these ratios are affordable must consider that our efforts to limit costs have resulted in overlooking the basic needs of children and creating a highly stressful work environment for caregivers. Community resources other than parent fees and a greater public investment in child care are critical to achieving the child:staff ratios and group sizes specified in this standard. For more information regarding brain development in children in child care, see STANDARD 1.010. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 1.003 RATIOS FOR FACILITIES SERVING CHILDREN WITH SPECIAL HEALTH NEEDS Facilities enrolling children with special needs shall determine, by an individual assessment of each child's needs, whether the facility requires a lower child:staff ratio. RATIONALE: The child:staff ratio must allow the needs of the children enrolled to be met. The facility should have sufficient direct care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be able to serve children who need fewer services, and the staffing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet the child's type and degree of special need. The facility should seek consultation with parents and other professionals regarding the appropriate child:staff ratio and may wish to increase the number of staff members if the child requires significant special assistance. COMMENTS: These ratios do not include personnel who have other duties that might preclude their involvement in needed supervision while they are performing those duties, such as cooks, maintenance workers, or bus drivers. TYPE OF FACILITY: Center; Large Family Child Care Home: Small Family Child Care Home STANDARD 1.004 RATIOS DURING TRANSPORTATION Child:staff ratios established for out-of-home child care shall be maintained on all transportation the facility provides or arranges. The driver shall not be included in the ratio. No child of any age shall be left unattended in a vehicle. RATIONALE: Children must continue to receive adequate supervision during transport. Placement of a child in a vehicle does not eliminate the need for supervision. Drivers must not be distracted from safe driving practices by being simultaneously responsible for the supervision of children. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.005 RATIOS FOR WADING AND SWIMMING The following child:staff ratios shall apply while children are wading or swimming: Developmental Levels Child:Staff Ratio Infants 1:1 Toddlers 1:1 Preschoolers 4:1 School-age Children 6:1 During any swimming/wading activity involving mixed developmental levels where either an infant or a toddler is present, the ratio shall always be 1 adult to 1 infant/toddler. The required ratio of adults to older children shall be met without including the adults who are required for supervision of infants and/or toddlers. An adult shall remain in direct physical contact with infants at all times during swimming or wading. RATIONALE: The circumstances surrounding drownings and water-related injuries of young children suggest that requirements and environmental modifications will reduce the risk for this type of injury. Essential elements are close continuous supervision (9), fences and self-locking gates around all swimming/wading pools, hot tubs, and spas, and special safety covers on pools when they are not in use (10). Infant swimming programs have led to water intoxication and seizures because infants may swallow excessive water when they are engaged in any submersion activities. COMMENTS: These ratios do not include personnel who have other duties that might preclude their involvement in supervision during swimming/wading activities while they are performing those duties. Thus, this ratio excludes cooks, maintenance workers, or lifeguards from being counted in the child:staff ratio if they are involved in these specialized duties at the same time. A lifeguard is not counted in the child:staff ratio unless he/she is assigned only to the children in that group. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 1.2 LICENSURE/CERTIFICATION OF QUALIFIED INDIVIDUALS STANDARD 1.006 CHILD CARE CREDENTIAL Any individual who will be primarily responsible for children in a separate classroom, a group of children, or a small family child care home shall hold an official child care credential as granted by the authorized state agency. RATIONALE: The supervision of children must be overseen by a person who has experience and education to properly care for them. The qualification of anyone who will be alone with children must be actively assured and not assumed. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 1.3 PRESERVICE QUALIFICATIONS AND SPECIAL TRAINING GENERAL QUALIFICATIONS FOR ALL CAREGIVERS, INCLUDING DIRECTORS, OF ALL TYPES OF FACILITIES STANDARD 1.007 STAFF RECRUITMENT Staff recruitment shall be based on a policy of non-discrimination with regard to gender, race, ethnicity, disability, or religion, as required by the Equal Employment Opportunity Act. The policy of non-discrimination shall extend also to sexual orientation. Staff recruitment policies shall adhere to requirements of the Americans with Disabilities Act as it applies to employment. The tasks required for each position shall be defined in writing and the suitability of an applicant shall be measured with regard to the applicant's qualifications and abilities with the tasks required in the role. RATIONALE: Child care providers must adhere to federal law. In addition, child care providers should model diversity and non-discrimination in their employment practices to enhance the quality of the program and to teach children and parents about diversity and tolerance for individuals on the staff who are competent caregivers with different background and orientation in their private lives. The goal of the Americans with Disabilities Act (ADA) in employment is to reasonably accommodate applicants and employees with disabilities to provide them equal employment opportunity and to integrate them into the program's staff to the extent feasible, given the individual's limitations. Under the ADA, employers are expected to make reasonable accommodations for persons with disabilities. Some disabilities may be accommodated, whereas others may not allow the person to do essential tasks. The fairest way to address this evaluation is to define the tasks and measure the abilities of applicants to perform them. COMMENTS: Reasons to deny employment include the following: The applicant or employee is not qualified or is unable to perform the essential functions of the job with or without reasonable accommodations; Accommodation is unreasonable or will result in undue hardship to the program; The applicant's or employee's condition will pose a significant threat to the health or safety of that individual or of other staff members or children. Accommodations and undue hardship are defined and based on each individual situation. Caregivers can obtain copies of the Equal Employment Opportunity Act and the American with Disabilities Act from their local public library (11, 12). Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers will be routed to the appropriate region. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.008 REFERENCES AND BACKGROUND CHECKS Directors of centers and caregivers in large and small family child care homes shall check references and examine employment history and criminal and other appropriate court records (including fingerprinting and checks with state child abuse registries) before employing any staff member (including substitutes), even in states where licensing has not been instituted. Background checks shall be required for all child care providers. When checking references, prospective employers shall specifically ask about previous convictions with child abuse or child sexual abuse. Failure of the prospective employee to disclose previous convictions of child abuse or child sexual abuse is grounds for dismissal. Persons who acknowledge being sexually attracted to children or who acknowledge having physically or sexually abused children, or who are known to have committed such acts shall not be hired or allowed to work in the child care facility. RATIONALE: To ensure their safety and physical and mental health, children must be protected from any risk of abuse. Although few persons will acknowledge past child abuse to another person, the obvious attention directed to the question by the licensing agency or caregiver may discourage some potentially abusive individuals from seeking employment in child care. In addition, the measure is very inexpensive. COMMENTS: Records of substantiated child abuse are usually kept in state social services departments. In the State of California, a state supported service for facilitating background checks has been successful in identifying people applying for child care jobs who have a history of previous offenses against children. Child care centers with multiple caregivers are more likely to protect children from abuse than child care sites where there is only one caregiver. Therefore, this standard must be applied to caregivers who work in isolation. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.009 PRESERVICE AND ONGOING STAFF TRAINING In addition to the credentials listed in STANDARD 1.014, prior to employment, a director of a center or a small family child care home network enrolling 30 or more children shall provide documentation of at least 26 clock hours of training in health, psychosocial, and safety issues for out-of-home child care facilities. Small family child care home providers shall provide documentation of at least 12 hours of training in child development and health management for out-of-home child care facilities prior to initiating operation. All directors and caregivers shall document receipt of training that revisits the following topics every 3 years: a) Child development knowledge and best practice, including knowledge about the developmental stages of each child in care; b) Child care as a support to parents; c) Parent relations; d) Ways that communicable diseases are spread; e) Procedures for preventing the spread of communicable disease, including handwashing, sanitation, diaper changing, food handling, health department notification of reportable diseases, equipment, toy selection and proper washing, sanitizing to reduce the risk for disease and injury, and health issues related to having pets in the facility; f) Immunization requirements for children and staff, as defined in STANDARD 1.045; g) Common childhood illnesses and their management, including child care exclusion policies; h) Organization of the facility to reduce the risks for illness and injury; i) Teaching child care staff and children about infection control and injury prevention; j) Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations; k) Emergency procedures, as defined in STANDARD 3.048 through STANDARD 3.052; l) Promotion of health in the child care setting, through compliance with STANDARD 3.001 through STANDARD 3.089; m) Management of a blocked airway, rescue breathing, and other first aid procedures, as required in SSTANDARD 1.026; n) Recognition and reporting of child abuse in compliance with state laws; o) Nutrition; p) Knowledge of medication administration policies and practices; q) Caring for children with special needs in compliance with the Americans with Disabilities Act (ADA); r) Behavior management. RATIONALE: The director of a center or large family child care home or the small family child care home provider is the person accountable for all policies. Basic entry-level knowledge of health and safety is essential to administer the facility. Caregivers must be knowledgeable about infectious disease because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community. Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training is important because the director or small family child care home provider is fully responsible for all aspects of the health of the children in care. COMMENTS: The American Academy of Pediatrics (AAP) and the National Association for the Education of Young Children (NAEYC) published a set of videos, based on the first edition of Caring for Our Children, that illustrates how to meet the standards in centers and family child care homes. This six-part video series is accompanied by a set of reproducible handouts for training. Other training materials, including videos, workshop curricula, and print materials suitable for training of caregivers, are also available from the AAP and NAEYC. Contact information for the AAP and the NAEYC is located in Appendix BB. Training in infectious disease control and injury prevention is strongly recommended. This type of training may be obtained from qualified personnel of children's and community hospitals, managed care companies, health agencies, public health departments, pediatric emergency room physicians, or other health professionals in the community. For more information about training opportunities, contact the AAP, Healthy Child Care America Project, the National Resource Center for Health and Safety in Child Care, or the National Training Institute for Child Care Health Consultants (at the University of North Carolina). Contact information is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.010 ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING CHILDREN BIRTH TO 35 MONTHS OF AGE Caregivers shall be prepared to work with infants and toddlers and, when asked, shall be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers: a) Diapering; b) Bathing; c) Feeding; d) Holding; e) Comforting; f) Putting babies down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome (SIDS); g) Providing responsive and continuous interpersonal relationships and opportunities for child-initiated activities. To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional. RATIONALE: The brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers and children during daily routines. Children need to be allowed to pursue their interests and encouraged to reach for new skills (13). COMMENTS: For additional qualifications and responsibilities of teachers for centers and homes serving children from birth to 35 months, see also General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.010; and Training, STANDARD 1.023 through STANDARD 1.036. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.011 ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING CHILDREN 3 TO 5 YEARS OF AGE Caregivers shall demonstrate the ability to apply their knowledge and understanding of the following, to children within the program setting: a) Typical and atypical development of 3- to 5-year-old children; b) Social and emotional development of children, including children's development of independence and their ability to adapt to their environment and cope with stress; c) Cognitive, language, early literacy, and mathematics development of children through activities in the classroom; d) Cultural backgrounds of the children in the facility's care by demonstrating cultural competence through interactions with children and families and through program activities. To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional. RATIONALE: Three- and 4-year-old children continue to depend on the affection, physical care, intellectual guidance, and emotional support of their teachers (4, 13). A supportive, nurturing setting that supports a demonstration of feelings and accepts regression as part of development continues to be vital for preschool children. Preschool children need help building a positive self-image, a sense of self as a person of value from a family and a culture of which they are proud. Children should be enabled to view themselves as coping, problem-solving, passionate, expressive individuals. COMMENTS: For additional qualifications and responsibilities of teachers for centers and homes serving children between 3 and 5 years old, see also General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.011; and Training, STANDARD 1.023 through STANDARD 1.036. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.012 ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING SCHOOL-AGE CHILDREN Caregivers shall demonstrate knowledge about and competence with the social and emotional needs and developmental tasks of 5- to 12-year old children, be able to recognize and appropriately manage difficult behaviors, and know how to implement a socially and cognitively enriching program that has been developed with input from parents. To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional. RATIONALE: A school-age child develops a strong, secure sense of identity through positive experiences with adults and peers (14, 15). An informal, enriching environment that encourages self-paced cultivation of interests and relationships promotes the self-worth of school-age children. When children display behaviors that are unusual or difficult to manage, caregivers should work with parents to seek a remedy that allows the child to succeed in the child care setting, if possible. COMMENTS: The first resource for addressing behavior problems is the child's source of routine health care. Support from a mental health professional may be needed. If the child's health provider cannot help or obtain help from a mental health professional, the child care provider and the family may need a mental health consultant to advise about appropriate management of the child. Local mental health agencies or pediatric departments of medical schools may offer help from child psychiatrists, psychologists, other mental health professionals skilled in the issues of early childhood, and pediatricians who have a subspecialty in developmental and behavioral pediatrics. For additional qualifications and responsibilities of teachers for centers serving school-age children, see also General Qualifications for All Caregivers, STANDARD 1.007through STANDARD 1.012; and Training, STANDARD 1.023 through STANDARD 1.036. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.013 GENERAL QUALIFICATIONS FOR ALL PERSONNEL OF CENTERS Staff members shall reflect the cultural, language, and ethnic backgrounds of children enrolled in the program. Centers shall have a plan of action for recruiting and hiring a diverse staff that is representative of the children in the facilities' care. RATIONALE: Young children's identities cannot be separated from family, culture, and their home language. Children need to see successful role models from their own ethnic and cultural groups and to develop the ability to relate to people who are different from themselves. COMMENTS: In staff recruiting, the hiring pool should extend beyond the immediate neighborhood of the child's residence or location of the facility, to reflect the diversity of people with whom the child can be expected to have contact as a part of life experience. TYPE OF FACILITY: Center QUALIFICATIONS OF DIRECTORS OF CENTERS STANDARD 1.014 GENERAL QUALIFICATIONS OF DIRECTORS The director of a center enrolling fewer than 60 children shall be at least 21 years old and shall have the following qualifications: a) A Bachelor's degree in early childhood education, child development, social work, nursing, or other child related field OR a combination of college coursework and experience, including: 1) A minimum of four courses in child development and early childhood education; 2) Two years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children enrolled in the center where the individual will act as the director; 3) A course in business administration or early childhood administration, or at least 6 months of on the job training in an administrative position; c) A valid certificate in pediatric first aid, including management of a blocked airway, and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028; d) Knowledge of community resources available to children with special needs and the ability to use these resources to make referrals or achieve interagency coordination; e) Administrative and management skills in facility operations; f) Capability in curriculum design; g) Oral and written communication skills; h) Demonstrated life experience skills in working with children in more than one setting. The director of a center enrolling more than 60 children shall have the above and at least 3 years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least 6 months experience in administration. RATIONALE: The director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (3, 16, 17). The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships. The well-being of the children, the confidence of the parents of children in the facility's care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice. Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides. A skilled director should know how to use community resources and to identify specialized personnel to enrich the staff's understanding of behavior and curriculum content. Past experience working in an early childhood setting is essential to running a facility. Life experience may include experience rearing one's own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings. COMMENTS: The profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the Guidelines for Preparation of Early Childhood Professionals (18). Additional information on the early childhood education profession is available from Wheelock College Institute for Leadership and Career Initiatives. The National Child Care Association (NCCA) has developed a 40-hour curriculum based on administrator competencies (19). Contact information for the NAEYC, the Wheelock College Institute for Leadership and Career Initiatives, and the NCCA is located in Appendix BB. The qualifications stipulated in the AAP/APHA standards, as well as state and local regulations for administrators of child care facilities that serve typically developing children, may require supplementation because of the special requirements of the populations of children with special needs. The center is one component in a network of services for children with special needs in most communities. Every state participating in Part C of IDEA is required to have a directory of services. Having a directory of services available is useful and could fulfill part of the requirement. Many communities have agencies, such as local resource and referral agencies, that gather information about services available to children with special needs. For additional information on qualifications for directors of centers, see General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.013; and Training, STANDARD 1.023 through STANDARD 1.036. TYPE OF FACILITY: Center STANDARD 1.015 mixed director/teacher role Centers enrolling 30 or more children shall employ a non-teaching director. Centers with fewer than 30 children may employ a director who teaches as well. RATIONALE: The duties of a director of a facility with more than 30 children do not allow the director to be involved in the classroom in a meaningful way. COMMENTS: This standard does not prohibit the director from occasional substitute teaching, as long as the substitute teaching is not a regular and significant duty. Occasional substitute teaching may keep the director in touch with the teachers' issues. TYPE OF FACILITY: Center STANDARD 1.016 DIFFERENTIATED ROLES Centers shall employ a teaching/caregiving staff for direct work with children in a progression of roles, as listed in descending order of responsibility: 1 Education Coordinators; 2 Lead Teachers; 3 Teachers; 4 Associate Teachers; 5 Assistant Teachers; 6 Aides. Each role with increased responsibility shall require increased educational qualifications and experience, as well as increased salary. RATIONALE: A progression of roles enables centers to offer career ladders rather than dead-end jobs. It promotes a mix of college-trained staff with other members of a child's own community who might have entered at the aide level and moved into higher roles through college or on-the-job training. Professional education and pre-professional inservice training programs provide an opportunity for career progression and can lead to job and pay upgrades and fewer turnovers. Turnover rates in child care positions in 1997 averaged 30% (20). COMMENTS: Early childhood professional knowledge must be required whether programs are in private centers, public schools, or other settings. The National Association for the Education of Young Children's (NAEYC) National Academy of Early Childhood Programs recommends a multi-level training program that addresses pre-employment educational requirements and continuing education requirements for entry-level assistants, teachers, and administrators. It also establishes a table of qualifications for accredited programs (5). The NAEYC requirements include development of an employee compensation plan to increase salaries and benefits to ensure recruitment and retention of qualified staff and continuity of relationships (18). The NAEYC's recommendations should be consulted in conjunction with the standards in this document. TYPE OF FACILITY: Center STANDARD 1.017 QUALIFICATIONS OF EDUCATION COORDINATORS, LEAD TEACHERS, AND TEACHERS Education coordinators, lead teachers, and teachers shall be at least 21 years of age and shall have at least the following education, experience, and skills: a) A Bachelor's degree in early childhood education, child development, social work, nursing, or other child-related field, or a combination of experience and relevant college coursework; b) One year or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care; c) On-the-job training to provide a nurturing environment and to meet the child's out-of-home needs; d) A valid certificate in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028; e) Knowledge of normal child development and early childhood education, as well as knowledge of children who are not developing typically; f) The ability to respond appropriately to children's needs; g) The ability to recognize signs of illness and safety hazards; h) Oral and written communication skills. Every center, regardless of setting, shall have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care. Additionally, facilities serving children with special needs associated with developmental delay shall have one licensed/certified teacher who is certified in special education. RATIONALE: Child care that promotes healthy deve-lopment is based on the developmental needs of infants, toddlers, and preschool children. Caregivers are chosen for their knowledge of, and ability to respond appropriately to, the needs of children of this age generally and the unique characteristics of individual children (2, 7, 12, 18). Both early childhood and special educational experience are useful in a center. COMMENTS: The profession of early childhood education is being informed by new research on child development practices related to child outcomes. For additional information on qualifications for child care staff, refer to the Guidelines for Preparation of Early Childhood Professional from the National Association for the Education of Young Children (NAEYC) (18). Additional information on the early childhood education profession is available from Wheelock College Institute for Leadership and Career Initiatives and the Center for the Child Care Workforce (CCW). Contact information is located in Appendix BB. TYPE OF FACILITY: Center STANDARD 1.018 QUALIFICATIONS FOR ASSOCIATE TEACHERS, ASSISTANT TEACHERS, AIDES, AND VOLUNTEERS Associate teachers shall be at least 18 years of age and shall have an Associate's degree in early childhood education or child development, and 6 or more months' of experience in child care. Assistant teachers shall be at least 18 years of age, have a high school diploma or GED, and participate in on-the-job training, including a structured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. Aides and volunteers shall be at least 16 years of age and shall participate in on-the-job training, including a structured orientation to the developmental needs of young children. Aides and volunteers shall not be counted in the child:staff ratio and shall work only under the continual supervision of qualified staff. Any driver who transports children for a child care program shall be at least 21 years of age. All associate teachers, assistant teachers, aides, drivers, and volunteers shall possess: a) The ability to carry out assigned tasks competently under the supervision of another staff member; b) An understanding of and the ability to respond appropriately to children's needs; c) Sound judgement; d) Emotional maturity. RATIONALE: While volunteers and students can be as young as 16, age 18 is the earliest age of legal consent. Mature leadership is clearly preferable. Age 21 allows for the maturity necessary to meet the responsibilities of managing a center or independently caring for a group of children who are not one's own. Child care that promotes healthy development is based on the developmental needs of infants, toddlers, and preschool children. Caregivers are chosen for their knowledge of, and ability to respond appropriately to, the general needs of children of this age and the unique characteristics of individual children (2, 7, 12, 18). Staff training in child development and/or early childhood education is related to positive outcomes for children (10). This training enables the staff to provide children with a variety of learning and social experiences appropriate to the age of the child. Everyone providing service to, or interacting with, children in a center contributes to the child's total experience. Adequate compensation for skilled workers will not be given priority until the skills required are recognized and valued. Caregiving requires skills to promote development and learning by children whose needs and abilities change at a rapid rate. COMMENTS: Experience and qualifications used by the Child Development Associate (CDA) program and the National Child Care Association credentialing program (NCCA) and included in degree programs with field placement are valued above didactic teaching alone. Early childhood professional knowledge must be required whether programs are in private centers, public schools, or other settings. The National Association for the Education of Young Children's (NAEYC) National Academy of Early Childhood Programs has established a table of qualifications for accredited programs (5). Caregivers who lack educational qualifications may be employed as continuously supervised personnel while they acquire the necessary educational qualifications if they have personal characteristics, experience, and skills in working with parents and children, and the potential for development on the job or in a training program. TYPE OF FACILITY: Center; Large Family Child Care Home QUALIFICATIONS FOR CAREGIVERS OF LARGE AND SMALL FAMILY CHILD CARE HOMES STANDARD 1.019 GENERAL QUALIFICATIONS OF FAMILY CHILD CARE CAREGIVERS Caregivers in large and small family child care homes shall be at least 21 years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in STANDARD 1.007 through STANDARD 1.012, based on ages of the children served, and shall have the following education, experience, and skills; a) Current accreditation by the National Association for Family Child Care (including entry-level qualifications and participation in required training) and have a college certificate representing a minimum of 3 credit hours of family child care leadership or master caregiver training or hold an Associate's degree in early childhood education or child development; b) A valid certificate in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028; c) Preservice training in health management in child care, including the ability to recognize signs of illness and safety hazards; d) Knowledge of normal child development, as well as knowledge of children who are not developing typically; e) The ability to respond appropriately to children's needs; f) Oral and written communication skills. Additionally, large family child care home care - givers shall have at least 1 year of experience, under qualified supervision, serving the ages and developmental abilities of the children in their large family child care home. Assistants, aides, and volunteers employed by a large family child care home shall meet the qualifications specified in STANDARD 1.018. RATIONALE: In both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care. Small family child care home providers often work alone and are solely responsible for the health and safety of small numbers of children in care. Age 18 is the earliest age of legal consent. Mature leadership is clearly preferable. Age 21 is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one's own. The National Association for Family Child Care (NAFCC) has established an accreditation process to enhance the level of quality and professionalism in small family child care (35). Contact information for NAFCC is found in Appendix BB. COMMENTS: A large family child care home provider caring for more than six children and employing one or more assistants functions as a facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees. For more information on assessing the work environment of family child care employees, see Creating Better Family Child Care Jobs: Model Work Standards , a publication by the Center for the Child Care Workforce (CCW) (21). Contact information for the CCW is located in Appendix BB. TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home STANDARD 1.020 Support networks for family child care Large and small family child care home providers shall have active membership in local or state family child care associations (if such associations exist) or in the National Association for Family Child Care (NAFCC), or belong to a network of family child care home providers that offers ongoing training and information on how to provide quality child care. RATIONALE: Membership in peer professional organizations shows a commitment to quality child care and also provides a conduit for information to otherwise isolated caregivers. Membership in a family child care association and attendance at meetings indicate the desire to gain new knowledge about how to work with children. COMMENTS: For more information about family child care associations, contact the National Association for Family Child Care (NAFCC). Contact information is located in Appendix BB. For additional qualifications and responsibilities of large and small family child care home providers, see General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.012; and Training, STANDARD 1.023 through STANDARD 1.036. TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home STANDARD 1.021 QUALIFICATIONS FOR HEALTh aDVOCATES Each facility shall designate a person as health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents. The health advocate shall be the primary parent contact for health concerns, including health-related parent/staff observations, health-related information, and the provision of resources. The health advocate shall also identify children who have no regular source of health care and refer them to a health care provider who offers competent routine child health services. For centers, the health advocate shall be licensed/certified/credentialed as a director, lead teacher, teacher, or associate teacher, or shall be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly). The health advocate shall have documented training in the following topics that include: a) Sudden Infant Death Syndrome (SIDS), for facilities caring for infants; b) Control of infectious diseases, including Standard/Universal Precautions; c) How to recognize and handle an emergency; d) Recognition and handling of seizures; e) Recognition of safety, hazards, and injury prevention interventions; f) How to help parents, caregivers, and children cope with death, severe injury, and natural or man-made catastrophes; g) Recognition of child abuse and neglect and knowledge of when to contact a consultant; h) Organization and implementation of a plan to meet the emergency needs of children with special health needs. RATIONALE: The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (22). A designated caregiver with health training is effective in developing an ongoing relationship with the parents and a personal interest in the child (8, 23). Caregivers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans. COMMENTS: The director should assign the health advocate role to a staff member who seems to have an interest, aptitude and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (22). A health advocate is a regular member of the staff of a center or large or small family child care home network, and is not the same as the health consultant recommended in Health Consultants, STANDARD 1.040 through STANDARD 1.044. For small family child care homes, the health advocate will usually be the caregiver. If the health advocate is not the child's caregiver, the health advocate should work with the child's caregiver. The person who is most familiar with the child and the child's family will recognize atypical behavior in the child and support effective communication with parents. A plan for personal contact with parents should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers and families on health-related matters. For additional qualifications and responsibilities of health advocates, see Training, STANDARD 1.023 through STANDARD 1.036; and Direct Care and Provisional Staff, STANDARD 1.009 through STANDARD 1.013. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.022 staff who check immunization records At least one caregiver shall have knowledge of childhood immunization requirements and shall be responsible for periodically reviewing the children's immunization records to ensure that they are current. The caregiver shall have sufficient knowledge of childhood immunization requirements to be able to review immunization records and determine which immunizations are needed and when they should be given. This person shall be responsible for reviewing each child's immunization records at least quarterly and for identifying and referring, to their usual source of health care, children in need of additional immunizations. RATIONALE: Children require frequent immunizations in early childhood. Although children may be current with required immunizations when they enroll, they sometimes miss scheduled immunizations thereafter. Because the risk of vaccine-preventable disease increases in group settings, assuring appropriate immunizations is an essential responsibility in child care. COMMENTS: For more information on immunizations, see STANDARD 3.005 and STANDARD 3.006. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 1.4 TRAINING ORIENTATION TRAINING STANDARD 1.023 initial orientation of all staff All new full-time and part-time staff shall be oriented to, and demonstrate knowledge of, the items listed below. The director of any center or large family child care home shall provide this training to all newly hired caregivers before they begin to care for children. For centers, the director shall document, for each new staff member, the topics covered and the dates of orientation training. Staff members shall not be expected to take responsibility for any aspect of care for which their orientation and training have not prepared them. Small family child care home providers shall avail themselves of orientation training offered by the licensing agency, a resource and referral agency, or other such agency. This training shall include evaluation that involves demonstration of the knowledge and skills covered in the training lesson. The orientation shall address, at a minimum: a) Regulatory requirements; b) The goals and philosophy of the facility; c) The names and ages of the children for whom the caregiver will be responsible, and their specific developmental needs; d) Any special adaptation(s) of the facility required for a child with special needs for whom the staff member might be responsible at any time; e) Any special health or nutrition need(s) of the children assigned to the caregiver; f) The planned program of activities at the facility. See Program of Developmental Activities, STANDARD 2.001 through STANDARD 2.027; g) Routines and transitions; h) Acceptable methods of discipline. See Discipline, STANDARD 2.039 through STANDARD 2.043; and Discipline Policy, STANDARD 8.008 through STANDARD 8.010; i) Policies and practices of the facility about relating to parents. See Parent Relationships, STANDARD 2.044 through STANDARD 2.057; j) Meal patterns and food handling policies and practices of the facility. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; Food Service Records, STANDARD 8.074; Nutrition and Food Service, STANDARD 4.001 through STANDARD 4.070; k) Occupational health hazards for caregivers, including attention to the physical health and emotional demands of the job and special considerations for pregnant caregivers. See Occupational Hazards, STANDARD 1.048; and Major Occupational Health Hazards , Appendix B; l) Emergency health and safety procedures. See Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023; and Emergency Procedures, STANDARD 3.048 through STANDARD 3.052; m) General health and safety policies and procedures, including but not limited to the following: 1) Handwashing techniques and indications for handwashing. See Handwashing, STANDARD 3.020 through STANDARD 3.024; 2) Diapering technique and toilet use, if care is provided to children in diapers and/or children needing help with toilet use, including appropriate diaper disposal and diaper-changing techniques. See Toilet, Diapering, and Bath Areas, STANDARD 5.116 through STANDARD 5.125; Toilet Use, Diapering, and Toilet Learning/Training, STANDARD 3.012 through STANDARD 3.019; Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033; 3) Identifying hazards and injury prevention; 4) Correct food preparation, serving, and storage techniques if employee prepares food. See Food Safety, STANDARD 4.042 through STANDARD 4.060; 5) Knowledge of when to exclude children due to illness and the means of illness transmission; 6) Formula preparation, if formula is handled. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; and Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021; 7) Standard precautions and other measures to prevent exposure to blood and other body fluids, as well as program policies and procedures in the event of exposure to blood/body fluid. See Prevention of Exposure to Body Fluids, STANDARD 3.026; n) Recognizing symptoms of illness. See Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002; o) Teaching health promotion concepts to children and parents as part of the daily care provided to children. See Health Education for Children, STANDARD 2.060 through STANDARD 2.063; p) Child abuse detection, prevention, and reporting. See Child Abuse and Neglect, STANDARD 3.053 through STANDARD 3.059; q) Medication administration policies and practices; r) Putting infants down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome (SIDS). Caregivers shall also receive continuing education each year, as specified in Continuing Education, STANDARD 1.029 through STANDARD 1.036. RATIONALE: Upon employment, staff members should be able to perform basic sanitizing and emergency procedures. Orientation ensures that all staff members receive specific and basic training for the work they will be doing and become acquainted with their new responsibilities. Orientation programs for new employees should be specific to an individual facility since facilities and the children enrolled vary(30). Because of frequent staff turnover, directors are obligated to institute orientation programs that protect the health and safety of children and new staff members. Orientation and ongoing training are especially important for aides and assistant teachers, for whom preservice educational requirements are limited. Entry into the field at the level of aide or assistant teacher should be attractive and easy for members of the families and cultural groups of the children in care to enter the field. Training ensures that staff members are challenged and stimulated, have access to current knowledge, and have access to education that will qualify them for new roles. Offering a career ladder will attract individuals into the child care field, where labor is in short supply. Ongoing training in one role can become preservice training to qualify for another role. Health training for child care staff not only protects the children in care, infectious disease control in child care helps to prevent spread of infectious disease in the community. Young children in child care have been shown to be associated with community outbreaks. COMMENTS: Many states have preservice education and experience qualifications for caregivers by role and function. States are including ongoing health training in their licensing requirements; the broader skills have proved important and necessary to teachers in part-day and full-day programs alike. Both full-day and part-day programs require competence in all facets of child development, not just the learning components. Child care staff members are important figures in the lives of the young children in their care and in the wellbeing of families and the community. In the future, all training for child care staff should include more attention to health issues. Training in conflict resolution is encouraged. Child abuse includes also children's abuse of their peers. Staff should learn how to handle conflict resolution among the children and among themselves, as well as modeling examples of conflict resolution from which children can learn. Colleges and accrediting bodies should examine teacher preparation guidelines and substantially increase the health content of early childhood professional preparation. For definitions of Standard precautions, Transmission-based precautions, Universal precautions, see Glossary. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.024 orientation for care of children with special health needs When a child care facility enrolls a child with special needs, the facility shall ensure that staff members have been oriented in understanding that child's special needs and ways of working with that child in a group setting. Caregivers in small family child care homes, who care for a child with special needs, shall meet with the parents and a health care worker involved with the child (if the parent has provided prior, informed, written consent) about the child's special needs and how these needs may affect his/her developmental progression or play with other children. In addition to Orientation Training, STANDARD 1.023, the staff in child care facilities shall have orientation training based on the special needs of children in their care. This training may include, but is not limited to, the following topics: a) Positioning for feeding and handling techniques of children with physical disabilities; b) Proper use and care of the individual child's adaptive equipment, including how to recognize defective equipment and to notify parents that repairs are needed; c) How different disabilities affect the child's ability to participate in group activities; d) Methods of helping the child with special needs to participate in the facility's programs; e) Role modeling, peer socialization, and interaction; f) Behavior modification techniques, positive rewards for children, promotion of self-esteem, and other techniques for managing difficult behavior; g) Grouping of children by skill levels, taking into account the child's age and developmental level; h) Intervention for children with special health care problems; i) Communication needs. RATIONALE: A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities. Staff members need information about how to help children use adaptive equipment properly. Staff members need to understand how and why various items are used and how to check for malfunctions. If a problem occurs with adaptive equipment, the staff must recognize the problem and inform the parent so that the parent can notify the health care or equipment provider of the problem and request that it be remedied. While the parent is responsible for arranging for correction of equipment problems, child care staff must be able to observe and report the problem to the parent. COMMENTS: These training topics are generally applicable to all personnel serving children with special needs and apply to these facilities. The curriculum may vary depending on the type of facility, classifications of disabilities of the children in the facility, and ages of the children. The staff is assumed to have the training described in Orientation Training, STANDARD 1.023, including child growth and development. These additional topics will extend their basic knowledge and skills to help them work more effectively with children who have special needs and their families. Caregivers should have a basic knowledge of special needs, supplemented by specialized training for children with special needs. The types of children with special needs served should influence the selection of the specialized training. The number of hours offered in any inservice training program should be determined by the staff's experience and professional background. Service plans in small family child care homes may require a modified implementation plan. The option of child care in small family child care homes for children with special needs must include special requirements. Training and other technical assistance can be obtained from the following: The state-designated lead agency responsible for implementing IDEA; American Academy of Pediatrics (AAP); American Nurses' Association (ANA); State and community nursing associations; National therapy associations; Local resource and referral agencies; Federally funded, University Centers for Excellence in Developmental Disabilities Education, Research, and Service programs for individuals with developmental disabilities; Other colleges and universities with expertise in training others to work with children who have special needs; Community-based organizations serving people with disabilities (Easter Seals, American Diabetes Association, American Lung Association, etc.). The parent is responsible for solving equipment problems unless the parent requests that the child care facility remedy the problem directly and the staff agrees to do it. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.025 orientation during initial employment During the first 3 months of employment, the director of a center or the caregiver in a large family home shall document, for all full-time and part-time staff members, additional orientation in, and the employees' satisfactory knowledge of, the following topics: a) Recognition of symptoms of illness and correct documentation procedures for recording symptoms of illness. This shall include the ability to perform a daily health assessment of children to determine whether any are ill and, if so, whether a child who is ill should be excluded from the facility; b) Exclusion and readmission procedures and policies; c) Cleaning and sanitation procedures and policies; d) Procedures for administering medication to children and for documenting medication administered to children; e) Procedures for notifying parents or legal guardians of a communicable disease occurring in children or staff within the facility; f) Procedures and policies for notifying public health officials about an outbreak of disease or the occurrence of a reportable disease. Before being assigned to tasks that involve identifying and responding to illness, staff members shall receive orientation training on these topics. Small family child care home providers shall not commence operation before receiving orientation on these topics. RATIONALE: Children are ill frequently. Staff members responsible for child care must be able to recognize illness, carry out the measures required to prevent the spread of communicable diseases, and handle ill children appropriately. COMMENTS: See also Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home FIRST AID AND CPR STANDARD 1.026 first aid training for staff The director of a center and a large family child care home and the caregiver in a small family child care home shall ensure that all staff members involved in providing direct care have training in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in STANDARD 1.027. At least one staff person who has successfully completed training in pediatric first aid, as specified in STANDARD 1.027, shall be in attendance at all times and in all places where children are in care. Instances in which at least one staff member shall be certified in CPR include when children are involved in swimming and wading and when at least one child is known to have a specific special health need as determined by that child's physician (such as cardiac arrhythmia) that makes the child more likely than a typical child to require cardiac resuscitation. In each case of a child with a special health need, the child care provider shall ask the child's physician whether caregivers with skills in the management of a blocked airway and rescue breathing will suffice, or whether caregivers require skills in cardiac resuscitation to meet the particular health needs of the child. Records of successful completion of training in pediatric first aid, as specified in STANDARD 1.027, shall be maintained in the files of the facility. RATIONALE: To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including management of a blocked airway and rescue breathing, coupled with a facility that has been designed or modified to ensure the safety of children, can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions. Knowledge of pediatric first aid, including management of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important to the outcome of an emergency situation. The need for cardiac resuscitation is rare. Children who have specific cardiac problems, such as cardiac arrhythmia, or children who are drowning in cold water, require cardiac resuscitation. Except in these two instances, cessation of cardiac function does not occur until respiratory failure causes irreversible and devastating brain damage. Therefore, except in these two instances, caregivers require respiratory resuscitation skills, not CPR skills. Small family child care home providers often work alone and are solely responsible for the health and safety of children in care. They must have the necessary skills to manage any emergency while caring for all the children in the group. In a study of incidence of injuries in centers, first aid was sufficient treatment for the majority of incidents (25). In a survey of over 2,000 child care programs in North Carolina, 16% had used first aid for choking, 2.3% had used rescue breathing, and only 1% had used CPR during the preceding 36 months of the survey. The authors of this report felt that maintaining CPR training and certification was difficult and probably not cost-effective (37). Minor injuries are common. For emergency situations that require attention from a health professional, first aid procedures can be taken to control the situation until a medical professional can provide definitive care. Documentation of current certification in the facility assists in implementing and in monitoring for proof of compliance. COMMENTS: Preparation of the first edition of this document included an extensive discussion of whether the staff should have cardiac resuscitation skills for children. Many people use the term "CPR" as shorthand for resuscitation and rescue skills. In discussions with the American Academy of Pediatrics' liaison to the American Heart Association pediatric resuscitation committee, this issue was discussed again during the preparation of this edition of the Standards, with the same conclusion related to limited circumstances where CPR training should be required. Ongoing education about the difference between training in pediatric first aid that includes management of a blocked airway and rescue breathing and training in CPR will be necessary because of the public's familiarity with and use of the term "CPR." CPR training for cardiac resuscitation involves specific courses focused on pulmonary and cardiac resuscitation, not first aid for other, more common injuries. Evaluations of retention of the techniques taught in CPR courses reportedly reveals poor recall within months after completion. The time and other resources required to provide pediatric CPR training could be better spent on learning first aid, including management of a blocked airway and rescue breathing, and other types of training. CPR training for management of adult cardiac emergencies is valuable and appropriate as a staff and community health goal, but as described above, such training is not a standard of practice for routine child care. For each child with a special health need, the child care health form should have a check-off box or a request for notification about whether caregivers with skills in management of a blocked airway and rescue breathing will suffice, or does the child have a greater risk than a typical child to require cardiac resuscitation. This proactive approach will alert the child's clinician to consider the need for caregivers to acquire cardiac resuscitation skills on a case-by-case basis. If the child's clinician indicates that the child's condition might require that caregivers provide cardiac resuscitation, CPR training should be required for staff who care for the child. Instead of CPR training for all staff in child care, this focused approach is more likely to insure the safety of the few children for whom CPR might be required. For additional information on first aid and CPR, see STANDARD 2.027, on pediatric first aid training requirements; STANDARD 1.028, which requires staff to have CPR training for activities involving swimming or wading; and RECOMMENDATION 9.038 through RECOMMENDATION 9.040, on state and local training and technical assistance. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.027 topics covered in first aid training Management of a blocked airway and rescue breathing comprise two of the core elements of pediatric first aid training. In addition, the course must present an overview of the Emergency Medical Services (EMS), accessing EMS, safety at the scene, and isolation of body substances, and the first aid instruction that is offered shall include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations: a) Abrasions and lacerations; b) Bleeding, including nosebleeds; c) Burns; d) Fainting; e) Poisoning, including swallowed, contact, and inhaled; f) Puncture wounds, including splinters; g) Injuries, including insect, animal, and human bites; h) Shock; i) Convulsions or nonconvulsive seizures; j) Musculoskeletal injury (such as sprains, fractures); k) Dental and mouth injuries; l) Head injuries; m) Allergic reactions, including information about when auto-injected epinephrine might be required; n) Eye injuries; o) Loss of consciousness; p) Electric shock; q) Drowning; r) Heat-related injuries, including heat exhaustion/heat stroke; s) Cold injuries; t) Moving and positioning injured/ill persons; u) Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner; v) Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature of 105 degrees F or higher, or looking/acting severely ill); w) Standard Precautions; x) Organizing and implementing a plan to meet an emergency for any child with a special health care need; y) Addressing the needs of the other children in the group while managing emergencies in a child care setting. RATIONALE: First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including management of a blocked airway and rescue breathing, coupled with a facility that has been designed or modified to ensure the safety of children, can reduce the potential for death and disability. Knowledge of pediatric first aid, including management of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important to the outcome of an emergency situation. Small family child care home providers often work alone and are solely responsible for the health and safety of children in care. Such providers must have pediatric first aid competence. COMMENTS: Usually, other children will have to be supervised while the injury is managed. Parental notification and communication with emergency medical services must be carefully planned. First aid information can be obtained from the American Academy of Pediatrics (AAP) and the American Heart Association (AHA). Contact information for the AAP and the AHA is located in Appendix BB. For discussion of the need for training in CPR, see STANDARD 1.026. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.028 cpr training for swimming and wading Facilities that have a swimming pool or use a water-filled wading pool shall require that at least one staff member with current documentation of successful completion of training in infant and child (pediatric) CPR (Cardiopulmonary Resuscitation) shall be on duty at all times during business hours. At least one of the caregivers, volunteers, or other adults who is counted in the child:staff ratio for wading and swimming shall have documentation of successful completion of training in basic water safety and infant and child CPR according to the criteria of the American Red Cross or the American Heart Association. For small family child care homes, the person trained in water safety and CPR shall be the caregiver. Written verification of successful completion of CPR and lifesaving training, water safety instructions, and emergency procedures shall be kept on file. RATIONALE: Drowning involves cessation of breathing and rarely requires cardiac resuscitation of salvageable victims. Nevertheless, because of the increased risk for cardiopulmonary arrest related to wading and swimming, the facility should have personnel trained to provide CPR and to deal promptly with a life-threatening drowning emergency. During drowning, cold exposure provides the possibility of protection of the brain from irreversible damage associated with respiratory and cardiac arrest. Children drown in as little as 2 inches of water. The difference between a life and death situation is the submersion time. Thirty seconds can make a difference. The timely administration of resuscitation efforts by a care-giver trained in water safety and CPR is critical. Studies have shown that prompt rescue and the presence of a trained resuscitator at the site can save about 30% of the victims without significant neurological consequences. COMMENTS: See also Safety Rules for Swimming/Wading Pools, STANDARD 5.215; and Water Safety, STANDARD 3.045 through STANDARD 3.047. For information on the child:staff ratio for wading and swimming, see STANDARD 1.005. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home CONTINUING EDUCATION STANDARD 1.029 continuing education for directors and caregivers in centers and large family child care homes All directors and caregivers of centers and large family child care homes shall successfully complete at least 30 clock hours per year of continuing education in the first year of employment, 16 clock hours of which shall be in child development programming and 14 of which shall be in child health, safety, and staff health. In the second and each of the following years of employment at a facility, all directors and caregivers shall successfully complete at least 24 clock hours of continuing education based on individual competency needs and any special needs of the children in their care, 16 hours of which shall be in child development programming and 8 hours of which shall be in child health, safety, and staff health. The effectiveness of training shall be assessed by change in performance following participation in training. RATIONALE: Because of the nature of their caregiving tasks, caregivers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the staff member(s) involved. Too often, staff members make training choices based on what they like to learn about (their "wants") and not the areas in which their performance should be improved (their "needs"). Participation in training does not ensure that the participant will master the information and skills offered in the training experience. Therefore, successful completion, not just participation, must be assessed. In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver, the training/education of caregivers is a specific indicator of child care quality (20). Most skilled roles require training related to the functions and responsibilities the role requires. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers on child development, health, and safety. The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the preservice qualifications of staff. Training should address the following areas: Health and safety; Child growth and development; Nutrition; Planning learning activities; Guidance and discipline techniques; Linkages with community services; Communication and relations with families; Detection of child abuse; Advocacy for early childhood programs; Professional issues (18). There are few illnesses for which children should be excluded from child care. Decisions about management of ill children are facilitated by skill in assessing the extent to which the behavior suggesting illness requires special management (30). Continuing education on managing communicable diseases helps prepare caregivers to make these decisions. All caregivers should be trained to prevent, assess, and treat injuries common in child care settings and to comfort an injured child. COMMENTS: Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC) and the National Child Care Association (NCCA). Contact information is located in Appendix BB. Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job. Resources for training on health issues include: State and local health departments (especially the public health nursing department); Resource and referral agencies; State and local chapters of: - American Academy of Pediatrics (AAP); - American Academy of Family Physicians (AAFP); - American Nurses' Association (ANA); - Visiting Nurse Association (VNA); - National Association of Pediatric Nurse Practitioners (NAPNAP); - National Association for the Education of Young Children (NAEYC); - National Association for Family Child Care (NAFCC); - National Training Institute for Child Health Consultants; - Emergency Medical Services for Children (EMSC) National Resource Center. For nutrition training, facilities should check to be sure that the nutritionist, who provides advice, has experience with, and knowledge of, food service issues in the child care setting. Most state maternal and child health departments have a Nutrition Specialist on staff. If this Nutrition Specialist has knowledge and experience in child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility. Many resources are available for nutrition specialists who can provide training in food service and nutrition. See Appendix C, for qualifications of nutrition specialists. Some resources to contact include: Local, county, and state health departments; State university and college nutrition departments; Home economists at utility companies; State affiliates of the American Dietetic Association; State and regional affiliates of the American Public Health Association; The American Association of Family and Consumer Services; National Resource Center for Health and Safety in Child Care; Registered dietitian at a hospital; High school home economics teachers; The Dairy Council; The local American Heart Association affiliate; The local Cancer Society; The Society for Nutrition Education; The local Cooperative Extension office. Nutrition education resources may be obtained from the Food and Nutrition Information Center. Contact information is located in Appendix BB. The staff's continuing education in nutrition may be supplemented by periodic newsletters and/or literature or audiovisual materials prepared or recommended by the Nutrition Specialist. See Appendix C, for information on qualifications for nutrition specialists. Caregivers should have a basic knowledge of special needs, supplemented by specialized training for children with special needs. The type of special needs of the children in care should influence the selection of the training topics. The number of hours offered in any inservice training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism. Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. Home study, video courses, workshops, training newsletters, telecommunications, and lectures can be used to meet the training hours requirement, as can training conducted on site at the child care facility. Completion of training may be documented by self-declaration or by submitting self-tests. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location. See also Technical Assistance and Consultation to Caregivers and Families, RECOMMENDATION 9.030 and RECOMMENDATION 9.036; and Training, RECOMMENDATION 9.038 through RECOMMENDATION 9.040. See STANDARD 1.052 and STANDARD 1.055, on performance evaluation related to continuing education. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 1.030 continuing education for small family child care home providers Small family child care home providers shall have at least 24 clock hours of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer. RATIONALE: In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver, the training/education of caregivers is a specific indicator of child care quality (20). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers who are better trained are better able to prevent, recognize, and correct health and safety problems. Because of the nature of their caregiving tasks, caregivers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the child care provider. Too often, caregivers make training choices based on what they like to learn about (their "wants") and not the areas in which their performance should be improved (their "needs"). Small family child care home providers often work alone and are solely responsible for the health and safety of small numbers of children in care. Peer review is part of the process for accreditation of family child care. Self-evaluation may not identify training needs or focus on areas in which the caregiver is particularly interested and may be skilled already. COMMENTS: The content of continuing education for small family child care home providers may include the following topics: Child growth and development; Infant care; Recognizing and managing minor illness; Managing the care of children who require the special procedures listed in Standard 3.063; Business aspects of the small family child care home; Planning developmentally appropriate activities in mixed age groupings; Nutrition for children in the context of preparing nutritious meals for the family; Acceptable methods of discipline; Organizing the home for child care; Preventing unintentional injuries in the home; Available community services; Detecting, preventing, and reporting child abuse; Advocacy skills; Pediatric first aid, including management of a blocked airway and rescue breathing. See STANDARD 1.026 and STANDARD 1.027; CPR (if the caregiver takes care of children with special needs or has a swimming/wading pool). See STANDARD 1.028; Methods of effective communication with children and parents; Mental health; Evacuation drill procedures, as specified in Evacuation Plan, Drills, and Closings, STANDARD 8.024 through 8.027; Occupational health hazards. See Occupational Hazards, STANDARD 1.048; and Major Occupational Health Hazards , Appendix B; Death, dying, and the grief cycle; SIDS risk-reduction practices. In-home training alternatives to group training for small family child care home providers are available, such as distance courses on the Internet, listening to audiotapes or viewing videotapes with self-checklists. These training alternatives provide more flexibility for providers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home providers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking. TYPE OF FACILITY: Small Family Child Care Home STANDARD 1.031 training of staff who handle food All staff members with food handling responsibilities shall obtain training in food service. The director of a center or a large family child care home or the designated supervisor for food service shall obtain certification equivalent to the Food Service Manager's Protection (Sanitation) certificate. RATIONALE: Outbreaks of foodborne illness have occurred in many settings, including child care facilities. Some of these outbreaks have led to fatalities and severe disabilities. Young children are particularly susceptible to foodborne illness. Because large centers serve more meals daily than many restaurants do, the supervisors of food handlers in these settings should have successfully completed food service certification, and the food handlers in these settings should have successfully completed courses on appropriate food handling. COMMENTS: Sponsors of the Child and Adult Care Food Program provide this training for some small family child care home providers. For training in food handling, contact the regional office of the Food and Drug Administration, health departments, or the delegate agencies that handle nutrition and environmental health inspection programs. Contact information is located in located in Appendix BB. Other sources are US Department of Agriculture (USDA) publications, family child care associations, resource and referrals, and licensing agencies. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.032 child abuse education Caregivers shall use child abuse prevention education materials provided by the licensing agency, state and national organizations, or from other community agencies such as local branches of the National Committee to Prevent Child Abuse, to educate and establish child abuse prevention and recognition measures for the children, caregivers, and parents. The education and prevention shall address physical, sexual, and psychological or emotional abuse, injury prevention, the dangers of shaking infants and toddlers, as well as signs and symptoms of sexually transmitted diseases. Child care directors and head teachers shall participate in training to recognize visible signs of child abuse, including pattern marks, bruises in unusual locations, pattern or immersion burns, shaken baby syndrome, and behaviors suggesting sexual abuse. They shall know how to refer children with vaginal, penile, or rectal discharge or bleeding to their health provider. A child care provider shall refer the child to the local child protection agency for any reasonable suspicion of child abuse or neglect. Caregivers shall be trained in compliance with their state's child abuse reporting laws. RATIONALE: Centers and large and small family child care homes are strategic locations in which to distribute materials for the prevention of abuse and also for indicators of sexually transmitted diseases. The medical diagnosis of child physical and sexual abuse is complex. However, education about the physical manifestations of abuse can increase the number of appropriate referrals to physicians and child protection agencies. COMMENTS: All caregivers should learn about the mandated reporting requirements for caregivers, the process for follow-up after making a report, and the protection and exposure of mandated reporters under the state's child abuse law. States and child care providers will select appropriate material from the many available media that can be used in child abuse prevention activities. Child abuse materials designed for medical audiences may not be suitable for child care training because the photographs in them contain shocking images. Selective use of photographs that help caregivers recognize signs of physical abuse, however, is appropriate. Resources are available from the American Academy of Pediatrics, the National Clearinghouse on Child Abuse and Neglect Information, and the National Committee for Prevention of Child Abuse. Contact information is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.033 training on occupational risk related to handling body fluids The director of a center or a large family child care home caregiver shall ensure that all staff members who are at risk of occupational exposure to blood or other blood-containing body fluids will be offered hepatitis B immunizations and will receive annual training in Standard Precautions. Training shall be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA Standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens") and local occupational health requirements and shall include, but not be limited to: a) Modes of transmission of bloodborne pathogens; b) Standard Precautions; c) Hepatitis B vaccine, pre-exposure, or post-exposure within 24 hours; d) Program policies and procedures regarding exposure to blood/body fluid; e) Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs. RATIONALE: Providing first aid in situations where blood is present is an intrinsic part of a caregiver's job. Split lips, scraped knees and other minor injuries associated with bleeding are common in child care. Regarding the applicability of the OSHA standard to child care, Patricia K. Clark, Director of the Directorate of Compliance Assistance stated: "One of the central provisions of the OSHA standard on bloodborne pathogens is that employers are responsible for determining which job classifications or specific tasks and procedures are reasonably anticipated to result in worker contact with blood or other potentially infectious materials (OPIM). The standard relates coverage to occupational exposure, regardless of where that exposure may occur, since the risk of infection with bloodborne pathogens is dependent on the likelihood of exposure to blood or OPIM regardless of the particular job title or place of employment. If it is determined that a child care worker has occupational exposure, as defined by the standard, then that employee is covered by all sections of the standard including training, vaccination, personal protective equipment, and so forth." Child care workers who are designated as responsible for rendering first aid or medical assistance as part of their job duties are covered by the scope of this standard. COMMENTS: OSHA has model exposure control plan materials for use by child care facilities. Using the model exposure control plan materials, child care providers can prepare a plan to comply with the OSHA requirements. The model plan materials are available from regional offices of OSHA. Contact information for OSHA is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 1.034 training record The director of a center or a large family child care home shall provide and maintain documentation of training received by, or provided for, staff. For centers, the date of the training, the number of hours, the names of staff participants, the name(s) and qualification(s) of the trainer(s), and the content of the training (both orientation and continuing education) shall be recorded in each staff person's file or in a separate training file. Small family child care home providers shall keep a written record of training acquired. RATIONALE: The training record shall be used to assess each employee's need for additional training and to provide regulators with a tool to monitor compliance. Continuing education with course credit shall be recorded and the records made available to staff members to document their applications for licenses/certificates or for license upgrading (26). In many states, small family child care home providers are required to keep records of training. COMMENTS: Colleges issue transcripts, workshops can issue certificates, and facility administrators can maintain individual training logs. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.035 RELEASED TIME AND EDUCATIONAL LEAVE A center, large family child care home or a support agency for a network of small family child care homes shall make provisions for paid, released time for staff to participate in required training during work hours, or reimburse staff for time spent attending training outside of regular work hours. Any hours worked in excess of 40 hours in a week shall be paid at time and a half. RATIONALE: Most caregivers work long hours and most are poorly paid (20). Using personal time for education required as a condition of employment is an unfair expectation until compensation for work done in child care is much more equitable. Many child care workers also work at other jobs to make a living wage and would miss income from their other jobs, or would incur stress in their family life if they had to take time outside of child care hours to participate in work-related training. COMMENTS: Education in child care often takes place when the participant is not released from other work-related duties, such as answering phones or caring for children. Providing substitutes and released time during work hours for such training is likely to enhance the effectiveness of training. Large family child care homes employ staff in the same way as centers, except for size and location in a residence. For small family child care home providers, released time and compensation while engaged in training can be arranged only if the small family child care home provider is part of a support network that makes such arrangements. This standard does not apply to small family child care home providers independent of networks. The Fair Labor Standard Act mandates payment of time and a half for all hours worked in excess of 40 hours in a week. TYPE OF FACILITY: Center, Large Family Child Care Homes, Small Family Child Care Homes STANDARD 1.036 payment for continuing education Directors of centers and large family child care homes shall arrange for continuing education that is paid for by the government, by charitable organizations, or by the facility, rather than by the employee. Small family child care home providers shall avail themselves of training opportunities offered in their communities. RATIONALE: Caregivers often make low wages and may not be able to pay for mandated training. A majority of child care workers earn close to or less than the minimum wage (20). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 1.5 SUBSTITUTES STANDARD 1.037 employment of substitutes Substitutes shall be employed to ensure that child:staff ratios (as specified in Child:Staff Ratio and Group Size, STANDARD 1.001 through STANDARD 1.005) are maintained at all times. Substitutes and volunteers must meet the requirements specified in General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.013. Those without licenses/certificates shall work under direct supervision and shall not be alone with a group of children. A substitute shall have the same clearances as the provider including criminal record check, child abuse history, and medical assessment. RATIONALE: The risk to children from care by unqualified caregivers is the same whether the caregiver is a paid substitute or a volunteer. Substitutes should be free from communicable diseases. COMMENTS: Substitutes are difficult to find, especially at the last minute. Planning for a competent substitute pool is essential for child care operation. Requiring substitutes for small family child care homes to have first aid certification, which includes management of a blocked airway and rescue breathing, forces these caregivers to close during the times they cannot cover with a competent substitute. Since closing a child care home has a negative impact on the families and children they serve, systems should be developed to provide qualified alternative homes or substitutes for family child care home providers. The lack of back-up for family child care home providers is an inherent liability in this type of care. The problem is somewhat ameliorated when family child care home providers who do not operate at full capacity every day can provide back-up care for children enrolled with other family child care home providers. Parents and children should be familiar with these alternative arrangements. Few family child care home providers are comfortable with having a stranger, even a qualified substitute, come into their home to provide alternative care in the setting most familiar to the child. Parents who use family child care must be sure they have suitable alternative care for situations in which the child's usual caregiver cannot provide the service. See also Qualifications of Large and Small Family Child Care Home Providers, STANDARD 1.019 and STANDARD 1.020; Staff Health, STANDARD 1.045; and Licensure/Certification of Qualified Individuals, STANDARD 1.006. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 1.038 orientation of substitutes for centers and large family child care homes The director of any center or large family child care home shall provide orientation training to newly hired substitutes. This training shall include the opportunity for an evaluation and a repeat demonstration of the training lesson. In centers, this orientation training shall be documented. All substitutes shall be oriented to, and demonstrate competence in, the tasks for which they will be responsible. All substitute caregivers, during the first week of employment, shall be oriented to, and shall demonstrate competence in at least the following items: a) The names of the children for whom the caregiver will be responsible, and their specific developmental needs; b) Any special health or nutrition need(s) of the children assigned to the caregiver; c) The planned program of activities at the facility. See Program of Activities, STANDARD 8.042 and STANDARD 8.043; and Program of Developmental Activities, STANDARD 2.001 through STANDARD 2.027; d) Routines and transitions; e) Acceptable methods of discipline. See Discipline, STANDARD 2.039 through STANDARD 2.043; f) Meal patterns and food handling policies of the facility. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036, Food Service Records, STANDARD 8.074, and Nutrition and Food Service, STANDARD 4.001 through STANDARD 4.070; g) Emergency health and safety procedures. See Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023; and Emergency Procedures, STANDARD 3.048 through STANDARD 3.052; h) General health policies and procedures as appropriate for the ages of the children cared for, including but not limited to the following: 1) Handwashing techniques, including indications for handwashing. See Handwashing, STANDARD 3.020 through STANDARD 3.023; 2) Diapering technique, if care is provided to children in diapers, including appropriate diaper disposal and diaper changing techniques. See Toilet, Diapering, and Bath Areas, STANDARD 5.116 through STANDARD 5.125; Toileting, Diapering, and Toilet Learning/Training, STANDARD 3.012 through STANDARD 3.019; Sanitation, Disinfection, and Maintenance of Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033; 3) The practice of putting infants down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome, as well as general nap time routines for all ages. See STANDARD 3.008 and STANDARD 5.144 through STANDARD 5.146; 4) Correct food preparation and storage techniques, if employee prepares food. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036 and Food Safety, STANDARD 4.050 through STANDARD 4.059; 5) Formula preparation if formula is handled. See Nutrition for Infants, STANDARD 4.016 through STANDARD 4.019; 6) Proper use of gloves in compliance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. See STANDARD 3.026 and Appendix D, on proper gloving procedures; 7) Injury Prevention and Safety. RATIONALE: Upon employment, staff members shall be able to carry out the duties assigned to them. Because facilities and the children enrolled in them vary, orientation programs for new employees that address the health and safety of the children enrolled as well as employees' health and safety concerns specific to the site, can be most productive (24). Because of frequent staff turnover, centers and large family child care homes must institute orientation programs as needed that protect the health and safety of children and new staff. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 1.039 orientation for substitutes for small family child care homes A short-term substitute caregiver in a small family child care home shall be oriented on the first day of employment to emergency response practices, including how to call for emergency medical assistance, how to reach parents or emergency contacts, how to arrange for transfer to medical care, and the evacuation plan. RATIONALE: Upon employment, staff members should be able to carry out the duties assigned to them. Because facilities and the children enrolled in them vary, orientation programs for new employees that address the health and safety of the children enrolled as well as employees' health and safety concerns specific to the site, can be most productive (24). COMMENTS: Substitute caregivers must possess current CPR if the small family-child-care home has a swimming/wading pool and first aid certification which includes management of a blocked airway and rescue breathing. See First Aid and CPR, STANDARD 1.026 through STANDARD 1.028. For more information on emergencies, see Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023; and Evacuation Plan, Drills, and Closings, STANDARD 8.024 through STANDARD 8.027. TYPE OF FACILITY: Small Family Child Care Home 1.6 HEALTH CONSULTANTS STANDARD 1.040 Use of child care health consultants Each center, large family child care home, and small family child care home network shall use the services of a health consultant qualified to provide advice for child care as defined in STANDARD 1.041. Centers and large and small family child care home providers shall avail themselves of community resources established for health consultation to child care. RATIONALE: Few child care staff are trained as health professionals and few health professionals have training about the community child care programs. When physical, mental, social, or health concerns are raised for the child or for the family, they should be addressed appropriately, often through consultation with or referral to resources available in the community. Caregivers need to use health consultants in a variety of fields (such as physical and mental health care, nutrition, environmental safety and injury prevention, oral health care, and developmental disabilities). Health consultants should have specific training in the child care setting (31). Such training is more widely available through efforts such as state programs implementing the Healthy Child Care America Campaign, and national support funded by the Maternal and Child Health Bureau, Health Resources and Services Administration, including the National Resource Center for Health and Safety in Child Care, the national staff of the Healthy Child Care America Campaign at the American Academy of Pediatrics and the National Training Institute for Child Care Health Consultants. Contact information is located in Appendix BB. In states where health consultation is mandatory, compliance is nearly universal (32). COMMENTS: A health consultant should be a health professional who has an interest in and experience with children, has knowledge of resources and regulations, and is comfortable linking health resources with facilities that provide primarily education and social services. State regulatory agencies should maintain or contract for the maintenance of a registry of health consultant resources in the community. For example, in Pennsylvania, the PA Chapter of the American Academy of Pediatrics (AAP) maintains and provides training and support for health professionals in such a registry under contracts with the child care regulatory agency and the state department of health. Additional registries are being developed by the National Resource Center for Health and Safety in Child Care, Healthy Child Care America Campaign from the Maternal and Child Health Bureau, Health Resources and Services Administration, and the National Training Institute for Child Care Health Consultants. Child care health consultants may be employed by public or non-profit agencies such as health departments or resource and referral agencies, other health institutions, or may work as independent health consultants. Caregivers also should not overlook health professionals with pediatric and health consultant experience who are parents of children enrolled in their facility. However, involving parents as health consultants requires caution to avoid crossing boundaries of confidentiality and conflict of interest. To foster access to and accountability of health consultants, some form of compensation should be offered. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.041 Knowledge and skills of child care health consultants A facility shall have a health consultant who is a health professional with training and experience as a child care health consultant. Graduate students in a discipline related to child health shall be acceptable as child care health consultants supervised by faculty knowledgeable in child care. A child care health consultant shall either have the full knowledge base and skills required for this role, or arrange to partner with other health professionals who can provide the necessary knowledge and skills. The knowledge base of the child care health consultant (personally or by involving other health professionals) shall include: a) National health and safety standards for out-of-home child care; b) How child care facilities conduct their day-to-day operations; c) Child care licensing requirements; d) Disease reporting requirements for child care providers; e) Immunizations for children; f) Immunizations for child care providers; g) Injury prevention for children; h) Staff health, including occupational health risks for child care providers; i) Oral health for children; j) Nutrition for children; k) Inclusion of children with special health needs in child care; l) Recognition and reporting requirements for child abuse and neglect; m) Community health and mental health resources for child and parent health. The skills of the child care health consultant shall include the ability to perform or arrange for performance of the following activities: a) Teaching child care providers about health and safety issues; b) Teaching parents about health and safety issues; c) Assessing child care providers' needs for health and safety training; d) Assessing parents' needs for health and safety training; e) Meeting on-site with child care providers about health and safety; f) Providing telephone advice to child care providers about health and safety; g) Providing referrals to community services; h) Developing or updating policies and procedures for child care facilities; i) Reviewing health records of children; j) Reviewing health records of child care providers; k) Helping to manage the care of children with special health care needs; l) Consulting with a child's health professional about medication; m) Interpreting standards or regulations and providing technical advice, separate and apart from the enforcement role of a regulation inspector. Although the child care health consultant may have a dual role, such as providing direct care to some of the children or serving as a regulation inspector, these roles shall not be mixed with the child care health consultation role. The child care health consultant shall have contact with the facility's administrative authority, the staff, and the parents in the facility. The administrative authority shall review, respond to, and implement the child care health consultant's recommendations. The child care health consultant shall review and approve the written health policies used by center-based facilities. Programs with a significant number of non-English-speaking families shall seek a child care health consultant who is culturally sensitive and knowledgeable about community health resources for the parents' native culture and languages. RATIONALE: The specific health and safety consultation needs for an individual facility depend on the characteristics of that facility (31). All facilities should have an overall child care health consultation. The special circumstances of group care may not be part of the health professional's usual education. Therefore, child care providers should seek health consultants who have the necessary specialized training or experience. Such training is more readily available now as described in the previous standard. To be effective, a child care health consultant should know the available resources in the community and should engage in a partnership with the administrative authority for the facility, the staff, and parents in the consultative and policy-setting process. Setting health and safety policies in cooperation with the staff, parents, health professionals, and public health authorities will help ensure successful implementation of a quality program (30). Health professionals who serve as child care health consultants do not always have a public health perspective or the full range of knowledge and skills required. Therefore, public health professionals and other health professionals with appropriate training and skills should serve as a resource to inform those who work in the private sector or whose health professional expertise is specialized and lacking in broader knowledge and skills that may be required. For example, while a sanitarian may provide excellent health consultation on hygiene and infectious disease control, another health professional may need to be consulted about medication administration or playground safety. A Certified Playground Safety Inspector would be able to provide consultation about gross motor play hazards, and would not likely be able to provide sound advice about food safety and nutrition. COMMENTS: The policies and procedures reviewed for approval by child care health consultants should include, but not be limited to, the following: Admission and readmission after illness, including inclusion/exclusion criteria; Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child's attendance; Plans for health care and management of children with communicable diseases; Plans for surveillance and management of illnesses, injuries, and problems that arise in the care of children; Plans for caregiver training and for communication with parents and health care providers; Policies regarding nutrition, nutrition education, and oral health; Plans for the inclusion of children with special health needs; Emergency plans; Safety assessment of facility playground; Policies regarding staff health and safety; Policies for administration of medication. See Identifiable Governing Body/Accountable Individual, STANDARD 8.001 through STANDARD 8.003, for additional information regarding administrative authority. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.042 specialized consultation for facilities serving children with disabilities When children at the facility include those with developmental delay or disabilities, the staff or documented consultants shall include any of the following, with prior informed, written parental consent and as appropriate to each child's needs: a) A physician; b) A registered dietitian; c) A registered nurse or pediatric nurse practitioner; d) A psychologist; e) A physical therapist; f) An occupational therapist; g) A speech pathologist; h) A respiratory therapist; i) A social worker; j) A parent of a child with special needs; k) The child care provider. RATIONALE: The range of professionals needed may vary with the facility, but the listed professionals should be available as consultants when needed. These professionals need not be on staff at the facility, but may simply be available when needed through a variety of arrangements, including contracts, agreements, and affiliations. The parent's participation and written consent in the native language of the parent, including Braille/sign language, is required to include outside consultants. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 1.043 frequency of child care health consultation visits The health consultant shall visit each facility as needed to review and give advice on the facility's health component. Center-based facilities that serve any child younger than 2 years of age shall be visited at least once a month by a health professional with general knowledge and skills in child health and safety. Center-based facilities that are not open at least 5 days a week or that serve only children 2 years of age or older shall be visited at least quarterly, on a schedule that meets the needs of the composite group of children. Small and large family child care homes shall be visited at least annually. Written documentation of health consultant visits shall be maintained at the facility. RATIONALE: Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children it serves (29). Infants are particularly vulnerable to injuries, infections, and psychological harm. Their rapid changes in behavior make regular and frequent visits by the health consultant extremely important. In facilities where health and safety problems or a high turnover of staff occurs, more frequent visits by the health consultant should be arranged.