Caring for Our Children: Chapter 8 - Administration Chapter 8: Administration 8.1 IDENTIFIABLE GOVERNING BODY/ACCOUNTABLE INDIVIDUAL STANDARD 8.001 Governing body of the facility The facility shall have an identifiable governing body or person with the responsibility for and authority over the operation of the center or program. The governing body shall appoint one person at the facility, or two in the case of co-directors, who is responsible for day-to-day management. The administrator for facilities licensed for more than 100 children shall have no other assigned duties. Responsibilities of the person responsible for the operation of the facility shall include, but shall not be limited to, the following: a) Ensuring stable and continuing compliance with all applicable rules, regulations, and facility policies and procedures; b) Developing and implementing policies that promote the achievement of quality child care; c) Ensuring that all written policies are updated and used, as described in this chapter; d) Hiring, firing, assigning roles, duties, and responsibility to, supervising, and evaluating personnel; e) Providing orientation of all new parents, employees, and volunteers to the physical structure, policies, and procedures of the facility. See Orientation Training, STANDARD 1.023 through STANDARD 1.025 f) Notifying all staff, volunteers, and parents of any changes in the facility's policies and procedures; g) Providing for continuous supervision of visitors and all non-facility personnel; h) When problems are identified, planning for corrective action, assigning and verifying that a specific person corrects the problem by a specified date; i) Arranging or providing repair, maintenance, supplemental education, or other services at the facility; j) Providing or arranging for inservice training for staff and volunteers, based on the needs of the facility and qualifications and skills of staff and volunteers. See Continuing Education, STANDARD 1.029 through STANDARD 1.036; k) Recommending an annual budget and managing the finances of the facility; l) Maintaining required records for staff, volunteers, and children at the facility; m) Providing for parent involvement, including parent education. See Parent Relationships, STANDARD 2.044 through STANDARD 2.057; n) Reporting to the governing or advisory board on a regular basis as to the status of the facility's operation; o) Providing oversight of research studies conducted at the facility and joint supervision of students using the facility for clinical practice. RATIONALE: Management principles of quality improvement in any human service require identification of goals and leadership to ensure that all those involved (those with authority and experience, and those affected) participate in working toward those goals. Problem-solving approaches that are effective in other settings also work in early childhood programs. This standard describes accepted personnel management practices. General administrative management starts with the principle of "unity of command" with role definitions clearly defined and communicated along with performance expectations, and implementation of routinely scheduled evaluation of staff performance. For any organization to function effectively, lines of responsibility must be clearly delineated, with an individual who is designated to have ultimate responsibility. COMMENTS: Management to ensure that policy is carried out includes providing staff and parents with written handbooks, training, supervising with frequent feedback, and monitoring with checklists. A national survey of model health and safety practices in facilities, a project through the American Public Health Association (APHA) and the American Academy of Pediatrics (AAP), found exemplary facilities that had effective surveillance procedures. For example, in one of these facilities, an observation checklist was developed covering every area of the facility from parking lot to classrooms. Two individuals were assigned to walk around the center noting whether all items on the checklist were in good order. The two individuals were a parent and a staff member, or the director and a staff member. When any deficiencies were found, the process included identifying a person responsible for correcting the problem and a date by which correction should occur. A comprehensive site observation checklist is available in the print version of Model Child Care Health Policies . Copies of this publication can be purchased from the National Association for the Education of Young Children (NAEYC) or from the American Academy of Pediatrics (AAP). Contact information for the NAEYC and the AAP can be found in Appendix BB. TYPE OF FACILITY: Center STANDARD 8.002 written delegation of administrative authority There shall be written delegation of administrative authority, designating the person in charge of the facility and the person(s) in charge of individual children, for all hours of operation. RATIONALE: Caregivers are responsible for the protection of the children in care at all times. In group care, each child must be assigned to an adult to ensure individual children are supervised and individual needs are addressed. Children should not be placed in the care of unauthorized family members or other individuals. TYPE OF FACILITY: Center STANDARD 8.003 access to facility records The designated person in charge shall have access to the records necessary to manage the facility and shall allow regulatory staff access to the facility and records. RATIONALE: Those with responsibility must have access to the information required to carry out their duties and make reasonable decisions. TYPE OF FACILITY: Center 8.2 MANAGEMENT AND HEALTH POLICIES AND STATEMENT OF SERVICES STANDARD 8.004 content of policies The facility shall have policies to specify how the caregiver addresses the developmental functioning and individual or special needs of children of different ages and abilities who can be served by the facility. These policies shall include, but not be limited to, the items described in STANDARD 8.005 and below: a) Admission and Enrollment; b) Supervision; c) Discipline; d) Care of Acutely Ill Children; e) Child Health Services; f) Use of Health Consultants g) Health Education h) Medications; i) Emergency Plan; j) Evacuation Plan, Drills, and Closings; k) Authorized Caregivers; l) Safety Surveillance; m) Transportation and Field Trips; n) Sanitation and Hygiene; o) Food Handling, Feeding, and Nutrition; p) Sleeping q) Evening and Night Care Plan; r) Smoking, Prohibited Substances, and Firearms; s) Staff Health, Training, Benefits, and Evaluation; t) Maintenance of the Facility and Equipment; u) Review and Revision of Policies, Plans, and Procedures, STANDARD 8.040 and STANDARD 8.041. The facility shall have specific strategies for implementing each policy. For centers, all of these items shall be written. RATIONALE: Facility policies should vary according to the ages and abilities of the children enrolled to accommodate individual or special needs. Program planning should precede, not follow, the enrollment and care of children at different developmental levels and with different abilities. Neither plans nor policies affect quality unless the program has devised a way to implement the plan or policy. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.005 initial provision of written information to parents and caregivers At enrollment, and before assumption of supervision of children by caregivers at the facility, the facility shall provide parents and caregivers with a statement of services, policies, and procedures that shall include at least the following information along with the policies listed in STANDARD 8.004: a) The licensed capacity, child:staff ratios, ages and number of children in care. If names of children and parents are made available, parental permission for any release to others shall be obtained; b) Services offered to children including daily activities, sleep positioning policies and arrangements, napping routines, guidance and discipline policies, diaper changing and toilet learning/training methods, child handwashing, oral health, and health education. Any special requirements for a child shall be clearly defined in writing before enrollment; c) Hours and days of operation; d) Admissions criteria, enrollment procedures, and daily sign-in/out policies, including forms that must be completed; e) Policies for termination and notice by the parent or the facility; f) Policies regarding payments of fees, deposits, and refunds; g) Planned methods and schedules for conferences or other methods of communication between parents and staff; h) Plan for Urgent and Emergency Medical Care or Threatening Incidents. See Emergency Procedures, STANDARD 3.048 through STANDARD 3.052; and Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023. i) Evacuation procedures and alternate shelter arrangements for fire, natural disasters, and building emergencies. See Evacuation Plan, Drills, and Closings, STANDARD 8.024 through STANDARD 8.027; j) Nutrition. Schedule of meals and snacks. See General Requirements, STANDARD 4.001 through STANDARD 4.010; Requirements for Special Groups or Ages of Children, STANDARD 4.011 through STANDARD 4.025 and Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; k) Policy for food brought from home. See Food Brought from Home, STANDARD 4.040 and STANDARD 4.041; l) Policy on infant feeding. See Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021 and Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; m) Policies for staffing including the use of volunteers, helpers, or substitute caregivers, child:staff ratios, deployment of staff for dif-ferent activities, authorized caregivers, me-thods used to ensure continuous supervision of children. See Child:Staff Ratio and Group Size, STANDARD 1.001 through STANDARD 1.005; n) Policies for sanitation and hygiene. See Hygiene and Sanitation, Disinfection, and Maintenance, STANDARD 3.012 through STANDARD 3.040; o) Non-emergency transportation policies. See Transportation, STANDARD 2.029 through STANDARD 2.038; p) Presence and care of any pets or any other animals on the premises. See Animals, STANDARD 3.042 through STANDARD 3.044; q) Policy on health assessments and immunizations. See Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002; Preventive Health Services, STANDARD 3.003 through STANDARD 3.004; and Immunizations, STANDARD 3.005 through STANDARD 3.007; r) Policy regarding care of acutely ill children, including exclusion or dismissal from the faci-lity. See Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068; Caring for Ill Children, STANDARD 3.070 through STANDARD 3.080; and Plan for the Care of Acutely Ill Children, STANDARD 8.011 and STANDARD 8.012; s) Policy on administration of medications. See Medications, STANDARD 3.081 through STANDARD 3.083; and Medication Policy, STANDARD 8.021; t) Policy on use of child care health consultants. See STANDARD 1.040 through STANDARD 1.044; u) Policy on health education. See STANDARD 2.060 through STANDARD 2.067. v) Policy on smoking, tobacco use, and prohibited substances. See Smoking and Prohibited Substances, STANDARD 3.041 and Policy on Smoking, Tobacco Use, Prohibited Substances, and Firearms, STANDARD 8.038 and STANDARD 8.039; w) Policy on confidentiality of records. See STANDARD 8.054. Parents and caregivers shall sign that they have reviewed and accepted this statement of services, policies and procedures. RATIONALE: The Model Child Care Health Policies has all of the necessary text to comply with this standard organized into a single document. Each policy has a place for the facility to fill in blanks to customize the policies for a specific site. The text of the policies can be edited to match individual program operations. Since the task of assembling all the items listed in this standard is formidable, starting with a template such as Model Child Care Health Policies can be helpful. COMMENTS: Parents are encouraged to interact with their own children and other children at drop-off and pick-up times and during visits at the center. Parents and caregivers, including volunteers, may have different approaches to routines than those followed by the facility. Review of written policies and procedures by all adults prior to contact with the children in care helps ensure consistent implementation of carefully considered decisions about how care should be provided at the facility. For large and small family child care homes, a written statement of services, policies and procedures is recommended but not required. If the statement is provided orally, parents should sign a statement attesting to their acceptance of the statement of services, policies and procedures presented orally to them. Model Child Care Health Policies can be adapted to these smaller settings. Copies of the current edition of Model Child Care Health Policies can be purchased from the National Association for the Education of Young Children (NAEYC) or from the American Academy of Pediatrics (AAP). Contact information for the NAEYC and the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home ADMISSION AND ENROLLMENT POLICY STANDARD 8.006 nondiscrimination policy The facility's written admission policy shall be nondiscriminatory in regard to race, culture, sex, religion, national origin, ancestry, or disability. A copy of the policy and definitions of eligibility shall be available for review on demand. RATIONALE: Nondiscriminatory policies advocate for quality child care services for all children regardless of the child's citizenship, residency status, financial resources, and language differences. COMMENTS: Facilities should be able to accommodate all children except those whose needs require extreme modifications beyond the capability of the facility's resources. However, facilities should not have blanket policies against admitting children with disabilities. Instead, a facility should make an individual assessment of a child's needs and the facility's ability to meet those needs. Federal laws do not permit discrimination based on disability (Americans with Disabilities Act). Inclusion of children with disabilities in all child care and early childhood educational programs is strongly encouraged. See Chapter 7, Children Who Are Eligible for Services Under the Individuals with Disabilities Education Act (IDEA), for more information on the Americans with Disabilities Act (ADA). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.007 exchange of information upon enrollment Arrangements for enrollment of children shall be made in person by the parents or legal guardians. The facility shall advise the parents/legal guardians of their responsibility to provide information to the facility regarding their children. RATIONALE: Parents or legal guardians must be fully informed about the facility's services before delegating responsibility for care of the child. The facility and parents must exchange information necessary for the safety and health of the child. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home DISCIPLINE POLICY STANDARD 8.008 Content of Written discipline policy Each facility shall have and implement a written discipline policy that outlines positive methods of guidance (described in Discipline, STANDARD 2.039 through STANDARD 2.043) appropriate to the ages of the children enrolled. It shall explicitly describe positive, nonviolent, non-abusive methods for achieving discipline. These shall include the following: a) Redirection; b) Planning ahead to prevent problems; c) Encouragement of appropriate behavior; d) Consistent, clear rules; e) Children involved in solving problems. All caregivers shall sign an agreement to implement the facility's discipline policy. All facilities shall have written discipline policies. RATIONALE: Caregivers are more likely to avoid abusive practices if they are well-informed about effective, non-abusive methods for managing children's behaviors. Positive methods of discipline create a constructive and supportive social group and reduce incidents of aggression. COMMENTS: Examples of appropriate alternatives to corporal punishment for infants and toddlers include brief, verbal expressions of disapproval; for preschoolers, "time out" (such as an out-of-group activity) under adult supervision; for school-age children, denial of privileges. A helpful resource for discussion of staff-child interactions is the National Association for the Education of Young Children's (NAEYC) Guide to Accreditation. Contact information for the NAEYC is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home, Small Family Child Care Home STANDARD 8.009 implementation of discipline policy The caregiver shall implement a policy that promotes positive guidance and discipline techniques and prohibits corporal punishment, psychological abuse, humiliation, abusive language, binding or tying to restrict movement, and the withdrawal or forcing of food and other basic needs, as outlined in STANDARD 2.043. A policy explicitly stating the consequence for staff who exhibit these behaviors shall be determined and reviewed and signed by each staff member prior to hiring. RATIONALE: Corporal punishment may be physical abuse or may become abusive very easily. Emotional abuse can be extremely harmful to children, but, unlike physical or sexual abuse, it is not adequately defined in most state child abuse reporting laws. Corporal punishment is clearly prohibited in small family child care homes in 47 states, and is prohibited in centers in 50 states (1, 2). Research links corporal punishment with negative effects such as later criminal behavior and impairment of learning (3-5). Primary factors supporting the prohibition of certain methods of punishment include current child development theory and practice, legal aspects (namely that a caregiver is not acting in place of parents with regard to the child), and increasing liability suits. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.010 policy on childrens' acts of aggression The facility shall have policies for dealing with acts of aggression and fighting (such as biting and hitting) by children. These policies shall include: a) Separation of the children involved; b) Immediate attention to the individual child or caregiver who was bitten; c) Notification to parents of children involved in the incident, if an injury requires first aid or medical attention, as specified in Incidence Logs of Illness, Injury, and Other Situations That Require Documentation, STANDARD 8.061 through STANDARD 8.064; d) Review of the adequacy of the caregiver supervision and appropriateness of facility activities; e) Administrative policy for dealing with recurrences. RATIONALE: Aggressive acts, both intentional and unintentional, occur in out-of-home care settings (6, 7). Administrative guidelines are necessary for the management of recurrent acts of aggression and should be developed within the facility based on the resources and structure of the facility. Potential injuries and infections that may be incurred when caring for young children are health and safety hazards for caregivers. Training and educational materials should be provided to caregivers to help them understand how best to prevent and respond to these situations. COMMENTS: In general, reducing child:staff ratios and child group sizes, having training for caregivers, and using positive guidance and discipline techniques that care for the victim and avoid rewarding the aggressor with attention, will help to decrease acts of aggression (such as biting and hitting). For additional information on discipline policy, see also Discipline, STANDARD 2.039 through STANDARD 2.043. Biting and hitting are manifestations of different emotional feelings at different ages. Biting is a common behavior in the infant or toddler who is expressing a feeling. Hitting may be an immature behavior with no malicious intent. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PLAN FOR THE CARE OF ACUTELY ILL CHILDREN AND CAREGIVERS STANDARD 8.011 content and development of the plan for care of ill children and caregivers The facility's plan for the care of ill children and caregivers shall be developed in consultation with the facility's health consultant. See STANDARD 1.040 through STANDARD 1.044. This plan shall include: a) Policies and procedures for urgent and emergency care; b) Admission and inclusion/exclusion policies. Conditions that require that a child be excluded and sent home are specified in Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068; c) A description of illnesses common to children in child care, their management, and precautions to address the needs and behavior of the ill child as well as to protect the health of other children and caregivers. See Infectious Diseases, STANDARD 6.001 through STANDARD 6.039; d) A procedure to obtain and maintain updated individual emergency care plans for children with special health care needs; e) A procedure for documenting the name of person affected, date and time of illness, a description of symptoms, the response of the caregiver to these symptoms, who was notified (such as a parent, legal guardian, nurse, physician, health department), and the response; f) The standards described in Reporting Illness, STANDARD 3.087 and STANDARD 3.088; and Notification of Parents, STANDARD 3.084 and STANDARD 3.085. g) Medication Policy. See STANDARD 8.021. All child care facilities shall have written policies for the care of ill children and caregivers. RATIONALE: The policy for the management of ill children should be developed in consultation with health care providers to address current understanding of the technical issues of contagion and other health risks. In group care, the facility must address the well-being of all those affected by illness: the ill child, the staff, parents of the ill child, other children in the facility and their parents, and the community. Where compromises must be made, the priority of the policy should be to meet the needs of the ill child. The policy should address the circumstances under which separation of the ill child from the group is required; the circumstances under which the caregiver, parents, legal guardian, or other designated persons need to be informed; and the procedures to be followed in these cases. The policy should take into consideration: The physical facility; The number and the qualifications of the facility's personnel; The fact that children do become ill frequently and at unpredictable times; The fact that working parents often are not given leave for their children's illnesses (8). Infectious diseases are a major concern of parents and caregivers. Since children, especially those in group settings, can be a reservoir for many infectious agents, and since caregivers come into close and frequent contact with children, caregivers are at risk for developing a wide variety of infectious diseases. Following the infection control standards will help protect both children and caregivers from communicable disease. Recording the occurrence of illness in a facility and the response to the illness characterizes and defines the frequency of the illness, suggests whether an outbreak has occurred, may suggest an effective intervention, and provides documentation for administrative purposes. COMMENTS: Facilities may comply by adopting a model policy and using reference materials as authoritative resources. The Model Child Care Health Policies , the print or internet version available from NAEYC and the AAP, may be helpful; or see the Red Book or Preparing for Illness , a booklet which translates the recommendations of the Red Book for child care providers, available from the AAP. Check for other materials provided by the licensing agency, resource and referral agency, or health department. Training for staff on management of illness can be facilitated by using Part 6: Illness in Child Care , of the video series developed to illustrate how to comply with the standards in Caring for Children . The video series is available from the AAP and NAEYC. See the sample symptom record in Appendix F. The sample symptom record is also provided in Healthy Young Children produced by the NAEYC. See also a sample document for permission for medical condition treatment in Appendix W. Contact information for the National Association for the Education of Young Children (NAEYC) and the American Academy of Pediatrics (AAP) can be found in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.012 exclusion and alternative care for children At the discretion of the person authorized by the child care provider to make such decisions, children who are ill shall be excluded from the child care facility for the conditions defined in STANDARD 3.065 through STANDARD 3.068. When children are not permitted to receive care in their usual child care setting and cannot receive care from a parent or relative, they shall be permitted to receive care in one of the following arrangements, if the arrangement meets the applicable standards: a) Care in the child's usual facility in a special area for care of ill children; b) Care in a separate small family child care home or center that serves only children with illness or temporary disabilities; c) Care by a child care worker in the child's own home. RATIONALE: Young children who are developing trust, autonomy, and initiative require the support of familiar caregivers and environments during times of illness to recover physically and avoid emotional distress (9). Young children enrolled in group care experience a higher incidence of mild illness (such as upper respiratory infections or otitis media) and other temporary disabilities (such as exacerbation of asthma or eczema) than those who have less interaction with other children. Sometimes, these illnesses preclude their participation in the usual child care activities. Most state regulations require that children with certain conditions be excluded from their usual care arrangement (10). To accommodate situations where parents cannot provide care for their own ill children, several types of alternative care arrangements have been established. When children with possible communicable diseases are present in the alternative care arrangements, preventing the further spread of disease is a priority. Although most facilities claim to adhere to general principles of prevention and control of communicable disease, in a study of such practices, only one facility followed strict isolation procedures (11). In another study, a facility providing care for ill children demonstrated no additional transmission of communicable disease from the children served to the rest of the well children attending the usual child care facilities (12). COMMENTS: Working parents should be entitled to family sick leave days to care for their ill children. Professionals and the public generally agree that when a child is seriously ill, or when it is not yet clear that the illness is a mild one, the parent should be able to stay home with the child. When a child is recuperating from a mild illness that precludes participation in the child's usual child care setting, parents may need alternative arrangements. At a minimum, working parents should be able to use their own sick or personal days to care for their ill children. However, children are ill frequently; some parents need help in making alternative arrangements for the days when the child is not very ill and the parents need to be at work. Facilities unable to care for ill children should be supportive and helpful to parents, giving them ideas for alternative arrangements. However, the responsibility for care cannot be transferred from the parent to the child care provider unless the caregiver is willing to accept this responsibility. The decision to accept responsibility for the care of ill children should rest with a designated person at the child care facility, who must weigh staffing and programmatic considerations that affect this decision. Though considerations may vary from one instance to another, parents must know who will make the decision. Sometimes a child can be included in the facility's regular group of children, with modified activities. Sometimes a center can set up a "get well room" where ill children not able to participate with the regular group can receive care. Some centers have set up satellite small family child care homes for their enrolled children. Ideally, the children know the caregiver because the caregiver works at the center when no child is ill. Similarly, a child's regular small or large family child care home provider could include the child in the regular group if appropriate, or might have a "get well room," if adequate supervision can be provided. Other alternative care arrangements include a worker sent by a home health agency or from a pool of caregivers to the child's home, arrangements in a pediatric unit of a hospital, pediatric office, or other similar setting. Special facilities caring only for ill children should meet more specialized requirements. For more information regarding caring for ill children, see STANDARD 3.070 through STANDARD 3.080. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HEALTH PLAN FOR CHILD HEALTH SERVICES STANDARD 8.013 written procedure for obtaining preventive health service information Each facility shall develop and follow a written procedure for obtaining necessary medical information including immunizations (see Recommended Childhood Immunization Schedule in Appendix G) and periodic preventive health assessments (see Recommendations for Preventive Pediatric Health Care in Appendix H) as recommended by the American Academy of Pediatrics (AAP) and the Health Care Financing Administration of the U.S. Department of Health and Human Services (13, 14). Facility staff shall encourage parents/legal guardians to schedule these preventive health services in a timely fashion. Documentation of an age-appropriate health assessment that includes an update of immunizations and screenings shall be filed in the child's record at the facility within 6 weeks of admission and following each subsequent routinely scheduled preventive health care visit. The staff of the facility shall review the admission and all subsequent reports of the child's health assessment visits that occur while the child is enrolled and shall offer a list of concerns for the parents to bring to upcoming check-up visits. Medical information shall include any information needed for the special medical care of the child. Questions raised by child care staff shall be directed to the family or, with parental permission, to the child's health care clinician for explanation and discussion of the implications for care. Centers shall have written procedures for the verification of compliance with recommended immunizations and periodic health assessments of children. Centers shall maintain confidential records of immunizations, periodic health assessments and any special medical considerations. RATIONALE: Health assessments are important to ensure prevention, early detection of remediable problems, and planning for adaptations needed so that all children can reach their potential. When age-appropriate health assessments and use of health insurance benefits are promoted by child care providers, children enrolled in child care will have increased access to immunizations and other preventive services (15). With the expansion of eligibility for medical assistance and the new federal subsidy of state child health insurance plans (Title XIX and Title XXI of the Social Security Act), the numbers of children who lack insurance for routine preventive health care should be limited to those in middle income families whose parents' employers do not provide coverage. Requirements for the documentation of preventive health care provides an important safety net for children of busy parents who may be unfamiliar with or lose track of the schedule their children should follow for routine care. At least one state audits a sample of child health records in every child care center and large family child care home for compliance with a licensing requirement for documentation that enrolled children are up-to-date with the AAP schedule. Over several years of audit, the aggregated data have been used to target pockets of need, leading to a steady improvement in services. In conversation with S.S. Aronson, MD (September 2000), compliance with immunization requirements was documented for over 90% of the children in 1999; screening tests were documented for up to two-thirds of the children, depending on the test. The facility must have accurate, current information regarding the medical status and treatment of each child so it will be able to determine and adjust its capability to provide needed services. COMMENTS: The facility should expect and encourage regular health assessments. Assistance for caregivers and low income parents can be obtained through the Medicaid Early Periodic Screening and Diagnostic Treatment (EPSDT) program (Title XIX) and the state's version of the federal Child Health Insurance Program (S-CHIP or Title XXI) (17). Most states require that child care providers document that the child's health records are up-to-date to protect the child and other children whom the under-immunized child would expose to increased risk of vaccine-preventable disease. State regulations regarding immunization requirements for children may differ, but the child care facility should strive to comply with the national, annually published, Recommended Childhood Immunization Schedule , from the American Academy of Pediatrics' (AAP), Centers for Disease Control and Prevention (CDC), and the Academy of Family Practice (AFP). See Appendix G. Contact information for the AAP, CDC, and AFP is located in Appendix BB. A child's entrance into the facility need not be delayed if an appointment for health supervision is scheduled. Often appointments for well-child care must be scheduled several weeks in advance. In such cases, the child care facility must obtain a medical history report from the parents and documentation of an appointment for routine health supervision, as a minimum requirement for the child to attend the facility on a routine basis. The child should receive immunizations as soon as practical to prevent an increased exposure to vaccine-preventable diseases. Local public health staff (such as the staff of immunization units, EPSDT programs) should provide assistance to caregivers in the form of record-keeping materials, educational materials, and on-site visits for education and help with surveillance activities. A copy of a form to use for documentation of routine health supervision services is available from the National Association for the Education of Young Children (NAEYC) or the AAP in the Model Child Care Health Policies. Contact information for the NAEYC and the AAP is located in Appendix BB. As more child care providers begin to use computers to reduce the complexity of record-keeping, they may want to use software for checking immunization status for age and documentation of the child's status for other services of routine preventive care. Such software for immunization checks is in common use nationally (18). Clinic Assessment Software Application (CASA) is a menu-driven relational database developed by the National Immunization Program of the Centers for Disease Control and Prevention (CDC) as an assessment tool for immunization clinics and health care providers. This application is used for the data entry and analysis of immunization status. It includes reminder and recall tracking capabilities as well as other special features. CASA produces reports from a menu and provides programmatic feedback on the up-to-date status of individual children and for a group of children in an age range set by the user. In conversation with S.S. Aronson (July 2001), customized, non-commercial software (called ECELSTRAK) that checks children's status for all routine health supervision services (screenings and immunizations) is being used for a statewide audit of child care health records in Pennsylvania's licensing of child care facilities. Commercial software that incorporates the decision rules for routine health supervision services is being developed and may be commercially available soon. Health professionals can photocopy, then update old reports with strike-outs, added dates, and initials over the course of several visits. Having to fill out the form brings up the issue of the child's use of child care as part of the check-up visit and fosters discussions related to the child's adjustment and the parent's satisfaction with the arrangements. For a sample Child Health Assessment that includes immunization and preventive health records, see Appendix Z. See STANDARD 8.053 for information on confidentiality and access to records. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.014 documentation of exemptions and exclusion of children who lack immunizations Exemptions from the requirement for up-to-date immunization made for religious or medical reasons shall be documented in the child's record. A child whose immunizations are not kept up-to-date shall be excluded after three written remin-ders to parents over a 3-month period. If more than one immunization is needed in a series, time shall be allowed for the immunizations to be obtained at the appropriate intervals. RATIONALE: National surveys document that child care has a positive influence on protection from vaccine-preventable illness (20). Immunizations should be required for all children in child care settings. Facilities must consider the consequences if they accept responsibility for exposing a child who cannot be fully immunized because of immaturity to a child who may bring disease to the facility because of refusal to be immunized. Although up to 6 weeks after the child starts to participate in child care may be allowed for the acquisition of immunizations for which the child is eligible, parents should maintain their child's immunization status according to the nationally recommended schedule to avoid potential exposure of other children in the facility to vaccine-preventable disease. COMMENTS: See Appendix G, for the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP). Check for the new schedule that is posted each January on the AAP ( www.aap.org ) and CDC ( www.cdc.gov ) websites. When a child who has a medical exemption from immunization is included in child care, reasonable accommodation of that child requires planning to exclude such a child in the event of an outbreak. For children who are incompletely immunized because of the parents' religious reasons, the facility may be at legal risk for allowing exposure of the child and other children in the facility to increased risk of vaccine-preventable infections. Prudent child care providers should discuss with an attorney, the liability risk for enrolling a child whose parents refuse to accept immunization of their child for non-medical reasons. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.015 identification of child's medical home and parental consent for information exchange As part of the enrollment of a child, the child care provider shall ask the family to identify the child's health care providers (medical home) and to provide written consent to enable the caregiver to establish communication with those providers. The family will always be informed prior to the use of the permission unless it is an emergency or a suspected abusive situation. The providers with whom the facility shall exchange information with parental consent shall include: a) Sources of regular medical and dental care (such as the child's health care provider, dentist, and medical facility); b) Source of emergency services, when required; c) Special clinics the child may attend, including sessions with medical specialists and registered dietitians; d) Special therapists for the child (such as occupational, physical, speech, nutrition). These special therapists shall provide written documentation of the services rendered; e) Counselors, therapists, or mental health service providers for parents (such as social workers, psychologists, or psychiatrists). RATIONALE: Primary health care providers are involved not only in the medical care of the child but in the ecological system in which the child exists. A major barrier to productive working relationships between child care and health care providers is inadequacy of communication channels (21, 22). Knowing who is treating the child and coordinating services with these sources of service is vital to the ability of the caregivers to offer appropriate care of the child. Every child should have a health care provider for primary care, and those with special needs will have therapists and consultants. COMMENTS: A source of health care may be a community clinic, a public health department, or a primary health care provider. Families should also know the location of the hospital emergency room nearest to their home. The emergency room is not an appropriate place for routine care, but may properly be used in an emergency. Education and information for caregivers about community resources is a good topic for staff training. For more information regarding communication between a child's care facility and that child's health care providers, see STANDARD 2.054. See STANDARD 8.053 through STANDARD 8.057, regarding confidentiality and access to records. For a sample Child Health Assessment that includes important health information, see Appendix Z See also a sample document for permission for medical condition treatment in Appendix W. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.016 information sharing on therapies and treatments needed The person at the child care facility who is responsible for planning care for the child shall seek information on therapies and treatments being provided to the child that are directly relevant to the health and safety of the child in the child care facility. The consent of the child's parents shall be obtained before this confidential information is sought. RATIONALE: The facility must have accurate, current information regarding the medical status and treatment of the child so it will be able to determine the facility's capability to provide needed services or to obtain them elsewhere. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.017 information sharing on family health Families shall be asked to share information about family health (such as chronic diseases) that might affect the child's health. RATIONALE: A family history of chronic disease helps child care providers understand family stress and experiences of the child within the family. COMMENTS: Information on family health can be gathered by simply asking parents to tell the caregiver about any chronic health problems that the child's parents, siblings, or household members have or by requesting that this information be supplied by the child's primary health care provider. Family management of chronic illness may require additional support services. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home DEPARTURE AND TRANSITION PROCESS STANDARD 8.018 PLANNING for child's transition to new services If a parent requests assistance with the transition process from the facility to a public school or another program, the designated care or service coordinator at the facility shall review the child's records, including needs, learning style, supports, progress, and recommendations and shall obtain written informed consent from the parent prior to sharing information at a transition meeting, in a written summary, or in some other verbal or written format. The process for the child's departure shall also involve sharing and exchange of progress reports with other care providers for the child and the parents or legal guardian of the child within the realm of confidentiality guidelines. The facility shall determine in what form and for how long archival records of transitioned children shall be maintained by the facility. RATIONALE: Families in transition benefit when support and advocacy are available from a facility representative who is aware of their needs and of the community's resources. This process is essential in planning the child's departure or transition to another program. Information regarding successful behavior strategies, motivational strategies, and similar information may be helpful to staff in the setting to which the child is transitioning. COMMENTS: Some families are capable of advocating effectively for themselves and their children; others require help negotiating the system outside of the facility. An interdisciplinary process is encouraged. Though coordinating and evaluating health and therapeutic services for children with special needs is primarily the responsibility of the school district or regional center, staff from the child care facility (one of many service providers) should participate, as staff members have had a unique opportunity to observe the child. In small and large family child care homes where an interdisciplinary team is not present, the caregivers should participate in the planning and preparation along with other care or treatment providers, with the parents written consent. It is important for all providers of care to coordinate their activities and referrals; otherwise the family may not be well informed. If records are shared electronically, providers should ensure that the records are encrypted for security and confidentiality. For more information on confidentiality, see Confidentiality and Access to Records, STANDARD 8.053 through STANDARD 8.057. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.019 FORMAT FOR THE TRANSITION PLAN Each service agency or caregiver shall have a format and timeline for the process of developing a transition plan to be followed when each child leaves the facility. The plan shall include the following components: a) Review and final preparation of the child's records; b) A child and family needs assessment; c) Identification of potential child care, educational, or programmatic arrangements. RATIONALE: Many factors contribute to the success or failure of a transition. These concerns can be monitored effectively when a written plan is developed and followed to ensure that all steps in a transition are included and are undertaken in a timely, responsive manner. COMMENTS: Though the child care provider can and should offer support in this process, child care is a free-market system where the parent is the consumer and decision-maker. It is best if the process of planning begins at least 3 months prior to the anticipated transition since finding the proper facility for a child can be a complex and time consuming process in some communities. Each agency can adapt the format to its own needs. However, consistent formats for planning and information exchange, requiring written parental consent, would be useful to both caregivers and families in both localities when children with special needs are involved. The use of outside consultants for small and large family child care homes is especially important in meeting this type of standard. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HEALTH CONSULTATION STANDARD 8.020 arrangements for use of health consultants Every facility shall seek the services of a health consultant. This health consultant will provide the facility with ongoing consultation to assist in the development of written policies relating to health and safety, as specified in Health Consultants, STANDARD 1.040 through STANDARD 1.044. RATIONALE: Caregivers rarely are trained health care professionals. Health consultants can help develop and implement written policies for prevention and management of injury and disease. Advance planning in this area can reduce stress for caregivers, parents, and health professionals. Use of health consultants for child care is becoming a reality. In 1998, 24 states and one city required regulated facilities to have a health consultant (23). Many states have been developing health consultation services due in part to a national program funded by the Maternal and Child Health Bureau, Health Resources and Services Administration (HRSA) to help every state implement the Healthy Child Care America Campaign. Training programs for health consultants have been developed by Early Childhood Education Linkage System (ECELS), American Public Health Association (APHA), and the National Training Institute for Child Care Health Consultants (NTI) at the University of North Carolina (UNC-CH). COMMENTS: Unless provided through a public health system, the health consultant's services are difficult to obtain particularly for small family child care homes. Caregivers should seek services from the public health resources, pay for consultation from community nursing services, seek the services of a health consultant through state and local professional organizations, such as the following resources: Local chapters of the American Academy of Pediatrics; American Nurses' Association; Visiting Nurse Association; American Academy of Family Physicians; National Association of Pediatric Nurse Practitioners; National Association for the Education of Young Children; National Association for Family Child Care; National Resource Center for Health and Safety in Child Care; National Training Institute for Child Care Health Consultants; State and local health departments (especially the public health nursing departments, the environmental health departments, and the state communicable disease specialist's or epidemiologist's office); State Injury Prevention Director. Caregivers should not overlook parents of children enrolled in their facilities who are health professionals capable of performing as child care health consultants. The specific policies for an individual facility depend on the resources available to that facility (23). To be effective, a health consultant should know what resources are available in the community and should involve caregivers and parents in setting policies. Setting policies in cooperation with both caregivers and parents will better ensure successful implementation (23). Licensing requirements for facilities increasingly require that facilities make specific arrangements with a health consultant to assist in the development of written policies for the prevention and control of disease. Child care facilities should offer health consultants some form of compensation for services to foster access and accountability. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home MEDICATION POLICY STANDARD 8.021 written policy on use of medications The facility shall have a written policy for the use of any prescription medication that has been prescribed to a particular child by that child's primary health care provider. The facility shall also have a written policy for the use of any nonprescription oral or topical medication that the facility keeps on hand to use with parental consent when the medication may be indicated. A medication record maintained on an ongoing basis by designated staff shall include the following: a) Specific, signed parental consent for the caregiver to administer medication; b) Prescription by a health care provider, if required; c) Administration log; d) Checklist information on medication, including possible side effects, brought to the facility by the parents. The facility shall consult with the State Board of Nursing or their health consultant about required training and documentation for medication administration and develop a plan regarding medication administration training. RATIONALE: Caregivers need to be aware of what medication the child is receiving and when, who prescribed the medicine, and what the known reactions or side effects may be in the event that a child has a negative reaction to the medicine (24). A child's reaction to medication may occasionally be extreme enough to initiate the protocol developed for emergencies. This medication record is especially important if medications are frequently prescribed or if long-term medications are being used. COMMENTS: A sample medication administration policy is provided in Model Child Care Health Policies , from the National Association the Education of Young Children (NAEYC) and the American Academy of Pediatrics (AAP). The medication record contents and format, as well as policies on handling medications, are provided in the AAP publication Health in Day Care: A Manual for Health Professionals . A sample medication administration log is provided in Healthy Young Children from the NAEYC. Contact information for the AAP and the NAEYC is located in Appendix BB For additional information on medications, see STANDARD 3.081 through STANDARD 3.083. See also a sample document for permission for medical condition treatment in Appendix W. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PLAN FOR URGENT MEDICAL CARE OR THREATENING INCIDENTS STANDARD 8.022 written plan and training for handling urgent medical care or threatening incidents The facility shall have a written plan for reporting and managing any incident or unusual occurrence that is threatening to the health, safety, or welfare of the children, staff, or volunteers. The facility shall also include procedures of staff training on this plan. The following incidents, at a minimum, shall be addressed in the plan: a) Lost or missing child; b) Suspected sexual, physical, or emotional abuse or neglect of a child (as mandated by state law); c) Injuries requiring medical or dental care; d) Serious illness requiring hospitalization, or the death of a child or caregiver, including deaths that occur outside of child care hours. The following procedures, at a minimum, shall be addressed in the plan: a) Provision for a caregiver to accompany a child to the source of urgent care and remain with the child until the parent or legal guardian assumes responsibility for the child; b) Provision for a backup caregiver or substitute (see Substitutes, STANDARD 1.037 through STANDARD 1.039) for large and small family child care homes to make this feasible. Child:staff ratios must be maintained at the facility during the emergency; c) The source of urgent medical and dental care (such as a hospital emergency room, medical or dental clinic, or other constantly staffed facility known to caregivers and acceptable to parents); d) Assurance that the first aid kits are resupplied following each first aid incident, and that required contents are maintained in a serviceable condition, by a periodic review of the contents; e) Policy for scheduled reviews of staff members' ability to perform first aid for averting the need for emergency medical services. RATIONALE: Emergency situations are not conducive to calm and composed thinking. Drafting a written plan provides the opportunity to prepare and to prevent poor judgements made under the stress of an emergency. An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, procedures, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of children. Routine restocking of first aid kits is necessary to ensure supplies are available at the time of an emergency. Management within the first hour or so following a dental injury may save a tooth. COMMENTS: Parents may also have on file their preferred dentists in case of emergency. Parents should be notified, if at all possible, before dental services are rendered, but emergency care should not be delayed because the child's own dentist is not immediately available. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.023 review of written plan for urgent care The facility's written plan for urgent medical care and threatening incidents shall be reviewed with each employee upon employment and yearly thereafter in the facility to ensure that policies and procedures are understood and followed in the event of such an occurrence. RATIONALE: Emergency situations are not conducive to calm and composed thinking. Drafting a written plan and reviewing it in preservice meetings with new employees and annually thereafter, provides the opportunity to prepare and to prevent poor judgements made under the stress of an emergency. An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, procedures, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of children. For additional information on emergency plans, see also Evacuation Plan, Drills, and Closings, STANDARD 8.024 through STANDARD 8.027; and Emergency Procedures, STANDARD 3.048 through STANDARD 3.052. See Appendix Y, for a sample Incident Report Form . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home EVACUATION PLAN, DRILLS, AND CLOSINGS STANDARD 8.024 written evacuation plan The facility shall have a written plan for reporting and evacuating in case of fire, flood, tornado, earthquake, hurricane, blizzard, power failure, bomb threat, or other disaster that could create structural damages to the facility or pose health and safety hazards to the children and staff. The facility shall also include procedures for staff training on this emergency plan. RATIONALE: Emergency situations are not conducive to calm and composed thinking. Drafting a written plan provides the opportunity to prepare and to prevent poor judgments made under the stress of an emergency. An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided children in child care. Such an approach requires written plans, policies, procedures, rehearsals, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of the children and staff. COMMENTS: Diagrammed evacuation procedures are easiest to follow in an emergency. Floor plan layouts that show two alternate exit routes are best. Plans should be clear enough that a visitor to the facility could easily follow the instructions. A sample emergency evacuation plan is provided in Healthy Young Children from the National Association for the Education of Young Children (NAEYC). Contact information for the NAEYC is located in Appendix BB. See Appendix Y, for a sample Incident Report Form . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.025 implementing evacuation drills Evacuation drills for natural disasters shall be practiced in areas where they occur: a) Tornadoes, on a monthly basis in tornado season; b) Floods, before the flood season; c) Earthquakes, every 6 months; d) Hurricanes, annually. RATIONALE: Regular evacuation drills constitute an important safety practice in areas where these natural disasters occur. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.026 use of daily roster during drills The center director or his/her designee shall use a daily class roster in checking the evacuation and return to a safe space for ongoing care of all children and staff members in attendance during an evacuation drill. Small and large family home child caregivers shall count to be sure that all children are safely evacuated and returned to a safe space for ongoing care during an evacuation drill. RATIONALE: Use of a roster ensures that all children are accounted for. Evacuation of the usual child care facility is only the first step. Children and staff must have a safe and appropriately supplied place of refuge where children can receive care until parents can arrive to provide care for their children. Parents should be informed in advance of the location of this alternate site so that in an emergency, they can go directly there instead of needing to search for their children during a crisis. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.027 approval and implementation of fire evacuation procedure A fire evacuation procedure shall be approved by a fire inspector for centers and by a local fire department representative for large and small family child care homes during an annual on-site visit when an evacuation drill is observed and the facility is inspected for fire safety hazards. The procedure shall be practiced at least monthly from all exit locations at varied times of the day and during varied activities, including nap time. RATIONALE: The extensive turnover of both staff and children, in addition to the changing developmental ability of children to participate in evacuation procedures in child care, necessitates frequent practice of the evacuation drill. Practicing fire evacuation procedures on a monthly basis helps make these procedures routine for everyone. Fires are responsible for the great majority of burn deaths (25). The routine practice of emergency evacuation plans fosters calm, competent use of the plans in an emergency. COMMENTS: Fire prevention programs for planning exit routes in the home are readily available. One such program is called "EDITH" ("Exit Drill In The Home"), which applies to one's own family. This, or a similar program, is available from some local fire departments. The facility should time the procedure and aim to evacuate all persons in a specific number of minutes recommended by the local fire department for that facility. See STANDARD 8.069, for information on evacuation drill records. See also Posting Documents, STANDARD 8.077. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home AUTHORIZED CAREGIVERS STANDARD 8.028 authorized persons to pick up child Names, addresses, and telephone numbers of persons authorized to take a child under care out of the facility shall be maintained. The facility shall establish a mechanism for identifying a person for whom the parents have given the facility prior written authorization to pick up their child. Also, policies shall address how the facility will handle the situation if a parent arrives who is intoxicated or otherwise incapable of bringing the child home safely, or if a non-custodial parent attempts to claim the child without the consent of the custodial parent. RATIONALE: Caregivers must not be unwitting accomplices in schemes to gain custody of children by accepting a telephone authorization provided falsely by a person claiming to be the child's custodial parent or claiming to be authorized by the parent to pick up the child. COMMENTS: When a parent wants to authorize additional persons to pick up their child, documentation of this request should be kept in the child's file. The facility can use photo identification, photographs supplied by the parents or taken with a camera by the facility, as a mechanism for verifying the identification of a new person to whom the parents have given written authorization to pick up their child. Child care providers should not attempt to handle on their own an unstable (for example, intoxicated) parent who wants to be admitted but whose behavior poses a risk to the children. Child care providers should consult local police or the local child protection agency about their recommendations for how staff can obtain support from law enforcement authorities to avoid incurring increased liability by releasing a child into an unsafe situation or by improperly refusing to release a child. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.029 POLICY on Actions to be Followed when no authorized person arrives to pick up a chilD Child care facilities shall have a written policy identifying actions to be taken when no authorized person arrives to pick up a child. The plan shall be developed in consultation with the child care health consultant and child protective services. In the event of emergency situations arising that may make it impossible for a parent to pick up a child as scheduled or to notify the authorized contact to do so, the facility shall attempt to reach each authorized contact, as listed in the facility's records. If these efforts fail, the facility shall immediately implement the written policy on actions to be followed when no authorized person arrives to pick up a child. RATIONALE: A natural disaster or tragic event such as a car crash or terrorist attack may lead to the parent being hurt or delayed due to transportation problems related to the event. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.030 documentation of drop off and pick up of child Caregiving adults (parents and staff) who bring the child to or remove the child from the facility shall sign a roster with the names of the children noting the time of arrival and departure, and use an established mechanism to ensure that the caregiver accepting or relinquishing the care of the child is aware that the child is being dropped off or picked up. RATIONALE: The keeping of accurate records of admission and release is of utmost importance to the caregiver in relation to establishing who is in the care of the facility at any one time. Accurate record keeping also aids in tracking the amount (and date) of service for reimbursement and for allows for documentation in the event of legal action involving the facility. COMMENTS: Time clocks and cards can serve as verification, but they should be signed by the adult who drops off and picks up the child each day. Some notification system must be used to alert the caregiver whenever the responsibility for the care of the child is being transferred to or from the caregiver to another person. TYPE OF FACILITY: Center; Large Family Child Care Home TRANSPORTATION AND FIELD TRIPS STANDARD 8.031 transportation policy for centers Written policies shall address the safe transport of children by vehicle to or from the facility, including on field trips, home pick-ups and deliveries, and special outings. The transportation policy shall include: a) Licensing of vehicles and drivers b) Operation and maintenance of vehicles. See Vehicles, STANDARD 5.235 through STANDARD 5.240; c) Driver selection, training, and supervision. See Qualifications of Drivers, STANDARD 2.030; d) Child:staff ratio during transport. See STANDARD 1.004; e) Permitted and prohibited activities during transport; f) Backup arrangements for emergencies; g) Seat belt and car seat use. STANDARD 2.033; h) Drop-off and pick-up plans. See STANDARD 2.032. RATIONALE: Motor vehicle crashes are the leading cause of death in the United States (26). Therefore, it is necessary for the safety of children to require that the caregiver comply with requirements governing the transportation of children in care, in the absence of the parent. COMMENTS: Maintenance should include an inspection checklist for every trip. Vehicle maintenance service should be performed according to the manufacturer's recommendations or at least every 3 months. TYPE OF FACILITY: Center STANDARD 8.032 transportation policy for homes Written policies shall address the safe transport of children by vehicle to and from the small or large family child care home for any reason, including field trips or special outings. The following shall be provided for: a) Child:staff ratio during transport; b) Backup arrangements for emergencies; c) Seat belt and car seat use; d) Licensing of vehicles and drivers; e) Maintenance of the vehicles; f) Safe use of air bags. RATIONALE: Motor vehicle crashes are the leading cause of death in the United States (26). Therefore, it is necessary for the safety of children to require that the caregiver comply with minimum requirements governing the transportation of children in care, in the absence of the parent. COMMENTS: For information on child:staff ratio during transport, see STANDARD 1.004. For information on seat belt and car seat use, see STANDARD 2.033. TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home MAINTENANCE AND USE OF THE FACILITY AND EQUIPMENT STANDARD 8.033 policy on use and maintenance of play areas Child care facilities shall have policies related to: a) Safety, purpose, and use of indoor and outdoor equipment for gross motor play; b) Supervision of indoor and outdoor play spaces; c) Staff training (to be addressed as employees receive training for other safety measures); d) Recommended inspections of the facility and equipment, as follows: 1) Inventory, once (at the time of purchase). Updated when changes to equipment are made in the playground; 2) Audits of the active (gross motor) play areas (indoors and outdoors) by an individual with specialized training in playground inspection, once a year; 3) Inspections, once a month; 4) Whenever injuries occur. For centers, the policies shall be written. RATIONALE: Properly laid out play spaces, properly designed and maintained equipment, installation of energy-absorbing surfaces, and adequate supervision of the play space by caregivers/parents help to reduce both the potential and the severity of injury (27). Written policies and procedures are essential for education of staff and may be useful in situations where liability is an issue. The technical issues associated with the selection, maintenance, and use of playground equipment and surfacing are so complex that specialized training is required to conduct annual inspections. Active play areas are associated with the most frequent and the most severe injuries in child care (19). COMMENTS: The increasing number of children in out-of-home care, as well as an increasing awareness and understanding of issues in child safety, combine to highlight the importance of developing and maintaining safe play spaces for children in child care settings. Parents expect that their child will be adequately supervised and will not be exposed to hazardous play environments, yet will have the opportunity for free, creative play. To obtain information on identifying a Certified Playground Safety Inspector (CPSI) to inspect a playground, contact the National Parks and Recreation Association (NPRA) on official company letterhead requesting a list of CPSI's in the appropriate state. They will fax a list within 2 weeks. Contact information for NPRA is located in Appendix BB. For additional information, see Playground and Equipment Records, STANDARD 8.071 and STANDARD 8.072. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PLAN FOR SANITATION AND HYGIENE STANDARD 8.034 sanitation policies and procedures The child care facility shall have written sanitation policies and procedures for the following items: a) Maintaining equipment used for handwashing, toilet use, and toilet learning/training in a sanitary condition, as specified in Toilet, Diapering, and Bath Areas, STANDARD 5.116 through STANDARD 5.135; Toileting and Diapering, STANDARD 3.012 through STANDARD 3.019; and Sanitation, Disinfection, and Maintenance of Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033; b) Maintaining diaper changing areas and equipment in a sanitized condition, as specified in Diaper Changing Areas, STANDARD 5.132; c) Maintaining toys in a sanitized condition in facilities, as specified in Selection, Sanitation, Disinfection, and Maintenance of Toys and Objects, STANDARD 3.036 through STANDARD 3.038; d) Managing pets or other animals in a safe and sanitary manner, as specified in Animals, STANDARD 3.042 through STANDARD 3.044; e) Proper handwashing procedures consistent with the method described in STANDARD 3.021 and STANDARD 3.022. The facility shall display handwashing instruction signs conspicuously; f) Personal hygiene of caregivers and children as specified in Handwashing, STANDARD 3.020 through STANDARD 3.023; g) Practicing environmental sanitation policies and procedures, as specified in Interior Maintenance, STANDARD 5.229 through STANDARD 5.234; h) Maintaining sanitation for food preparation and food service as specified in Kitchen Maintenance, STANDARD 4.055; Food Brought From Home, STANDARD 4.061 through STANDARD 4.065; Kitchen and Equipment, STANDARD 4.042 through STANDARD 4.049; Food Safety, STANDARD 4.050 through STANDARD 4.060; and Maintenance, STANDARD 4.061 through STANDARD 4.065. RATIONALE: Many communicable diseases can be prevented through appropriate hygiene and sanitation practices. Bacterial cultures of environmental surfaces in facilities, which are used to gauge the adequacy of sanitation and hygiene practices, have demonstrated evidence of fecal contamination. Contamination of hands, toys, and other equipment in the room has appeared to play a role in the transmission of diseases in child care settings (28). Regular and thorough cleaning of toys, equipment, and rooms helps to prevent transmission of illness (29). Animals, including pets, can be a source of illness for people, and people may be a source of illness for animals (29). The steps involved in effective handwashing (to reduce the amount of bacterial contamination) are easily forgotten. Posted signs provide frequent reminders to staff and orientation for new staff. Education of caregivers regarding handwashing, cleaning, and other sanitation procedures can reduce the occurrence of illness in the group of children with whom they work (30). Illnesses may be spread by way of: Human waste (such as urine and feces); Body fluids (such as saliva, nasal discharge, eye discharge, open skin sores, and blood); Direct skin-to-skin contact; Touching a contaminated object; The air, in droplets that result from sneezes and coughs. Since many infected people carry communicable diseases without symptoms, and many are contagious before they experience a symptom, caregivers need to protect themselves and the children they serve by carrying out, on a routine basis, universal precautions and sanitation procedures that approach every potential illness-spreading condition in the same way. Handling food in a safe and careful manner prevents the growth of bacteria and fungi. Outbreaks of foodborne illness have occurred in many settings, including child care facilities. COMMENTS: The ABC's of Safe and Healthy Child Care developed by the Centers for Disease Control (CDC) and distributed by the National Technical Information Service (NTIS) is a handbook that provides guidance for maintaining safe and healthy child care practices in all settings. Contact information for the NTIS is located in Appendix BB. Making Food Healthy and Safe for Children from the National Center for Education in Maternal and Child Health (NCEMCH) is a guide for meeting nutrition standards in child care settings. Contact information for the NCEMCH is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PLANS AND POLICIES FOR FOOD HANDLING, FEEDING, AND NUTRITION STANDARD 8.035 food and nutrition service policies and plans The facility shall have a food handling, feeding, and nutrition plan under the direction of the administration that addresses the following items and delegates responsibility for each: a) Kitchen layout; b) Food procurement, preparation, and service; c) Staffing; d) Nutrition education. A Child Care Nutrition Specialist and a food service expert shall provide input for and facilitate the development and implementation of a written nutrition plan for the child care center or programs. RATIONALE: Having a plan that clearly delegates responsibility and that encompasses the pertinent nutrition elements will promote the optimal health of children and staff in child care settings. COMMENTS: For more information on Child Care Nutrition Specialists, see STANDARD 4.026 and STANDARD 4.027 and Appendix C. For information on nutrition education, see STANDARD 4.069 and STANDARD 4.070. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.036 infant feeding policies Policies about infant feeding shall be developed with the input and approval of the child's health care provider and the Child Care Nutrition Specialist and shall include the following: a) Storage and handling of expressed human milk; b) Determination of the kind and amount of commercially prepared formula to be prepared for infants as appropriate; c) Preparation, storage, and handling of formula; d) Proper handwashing of the caregiver; e) Use and proper disinfection of feeding chairs and of mechanical food preparation and feeding devices, including blenders, feeding bottles, and food warmers; f) Whether formula or baby food shall be provided from home, and if so, how much food preparation and use of feeding devices, including blenders, feeding bottles, and food warmers, shall be the responsibility of the caregiver; g) A prohibition against bottle propping or prolonged feeding; h) Caregivers shall hold infants during bottle-feeding; i) Specification of the number of children who can be fed by one adult at one time; j) Handling of food intolerance or allergies (such as to cow's milk, peanuts, orange juice, eggs, or wheat); k) Responding to infants' need for food in a flexible fashion to allow demand feedings in a manner that is consistent with the developmental abilities of the child. Written policies for each infant about infant feeding shall be developed with each individual infant's parents. RATIONALE: Growth and development during infancy require that nourishing, wholesome, and developmentally appropriate food be provided, using safe approaches to feeding. Because individual needs must be accommodated and improper practices can have dire consequences for the child's health and safety, the policies for infant feeding should be developed with professional nutritionists and the child's parents. COMMENTS: For information on nutrition requirements for infants, see STANDARD 4.011 through STANDARD 4.021. For information on meal service, seating, and supervision, see STANDARD 4.028 through STANDARD 4.039. For information on food allergies, see STANDARD 4.007, STANDARD 4.009, and STANDARD 4.010. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home EVENING AND NIGHT CARE PLAN STANDARD 8.037 plans for evening and nighttime care Facilities that provide evening and nighttime care shall have plans for such care that include the supervision of sleeping children as specified in Supervision, STANDARD 2.028; the management and maintenance of sleep equipment as specified in Sleeping, STANDARD 5.142 through STANDARD 5.148; and Selection, Sanitation, Disinfection, and Maintenance of Bedding, as specified in STANDARD 3.039 and STANDARD 3.040. Centers shall have written plans for evening and nighttime care, including emergency plans. RATIONALE: Evening and nighttime child care routines are significantly different from those required for daytime and should be addressed in a comprehensive and predetermined manner. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home POLICY ON SMOKING, TOBACCO USE, PROHIBITED SUBSTANCES, AND FIREARMS STANDARD 8.038 policies prohibiting smoking, tobacco, alcohol, illegal drugs, and toxic substances Facilities shall have written policies specifying that smoking, use of chewing tobacco, use of alcohol, use or possession of illegal drugs, over-use or inappropriate use of prescribed drugs, or unauthorized potentially toxic substances are prohibited in the facility at all times (including outdoor play areas) and during all times when caregivers are responsible for the supervision of children, including times when children are transported and during field trips. The facility shall provide information to employees about available drug, alcohol, and tobacco counseling and rehabilitation and employee assistance programs. RATIONALE: The age, defenselessness, and lack of discretion of the child under care make this prohibition an absolute requirement. The hazards of second-hand smoke warrant the prohibition of smoking in proximity of child care areas at any time. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space. Smoking in outdoor areas when children are not present is acceptable. The use of alcoholic beverages in family homes while children are not in care is also permissible. COMMENTS: The policies related to smoking and use of prohibited substances should be discussed via handouts or pamphlets that are given to parents, especially those who have children in small family child care homes or school-age child care facilities, and staff, to inform them of the dangers of these prohibited substances and of services to prevent their use. For family child care home providers who smoke, provisions will need to be made to assure that children are not left unsupervised while the caregiver smokes. In addition, it is strongly urged that, whenever possible, the caregivers be non-tobacco users because of the role model effect of tobacco users on children. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.039 policy prohibiting firearms Firearms shall be prohibited in centers. If firearms are present in large or small family homes, they shall have child protective devices and be unloaded. They shall be kept under lock and key and be inaccessible to children. Ammunition shall be stored in locked storage, separate from firearms and inaccessible to children. Parents shall be notified that firearms are on the premises. RATIONALE: Children have a natural curiosity about firearms and have often seen their use glamorized on television. The potential for a tragic accident is great. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home REVIEW AND REVISION OF POLICIES, PLANS, AND PROCEDURES STANDARD 8.040 Availability of policies, plans, procedures At least annually or when changes are made, the facility shall make policies, plans, and procedures available to all persons affected (including parents and staff). When a child enters a facility, parents shall sign a statement that they have read and/or understand the content of the policies. Parents who are not able to read shall have the policies presented orally to them. Parents who are not able to understand the policies because of a language barrier shall have the policies presented to them in a language with which they are familiar. RATIONALE: State of the art information changes. A yearly review encourages child care administrators to keep information and policies current. Current information on health and safety practices that is shared and developed cooperatively among caregivers and parents invites more participation and compliance with health and safety practices. COMMENTS: This standard assumes that all disciplines that support and inform child care services such as health, public safety, emergency preparedness, and regulatory agencies have systems for disseminating current and accurate information that affects the health of all people in child care settings. TYPE OF FACILITY: Center; Large Family Child Care Home STANDARD 8.041 health consultant's review of health policies At least annually or when changes are made in the health policies, the facility shall obtain a review of the policies from a health consultant. RATIONALE: Changes in health information may require changes in the health policies of a child care facility. These changes are best known to health professionals who stay in touch with sources of updated information and can suggest how the new information applies to the operation of the child care program. For example, when the information on the importance of back-positioning for putting infants down to sleep became available, it needed to be added to child care policies. Frequent changes in recommended immunization schedules offer another example of the need for review and modification of health policies. COMMENTS: For information on Health Consultants, see STANDARD 1.040 through STANDARD 1.044. TYPE OF FACILITY: Center 8.3 PROGRAM OF ACTIVITIES STANDARD 8.042 plan for program activities The facility shall have a written comprehensive and coordinated planned program of daily activities based on a statement of principles for the facility that sets out the elements from which the daily plan is to be built. The program of activities shall: a) Address each developmental age group served, that is, infants, toddlers, preschoolers, school-age children, and children with special needs; b) Cover the elements of developmental activities specified in STANDARD 2.001 through STANDARD 2.028; c) Maintain the child:staff ratios described in Child:Staff Ratio and Group Size, STANDARD 1.001 through STANDARD 1.005; d) Provide for incorporation of specific health, development, and safety education activities into the curriculum on a daily basis throughout the year. Topics of health education shall include health promotion and disease prevention strategies, physical, oral/dental, mental, and social health, and nutrition; e) Offer a parent education plan about child health. Such a plan shall have been reviewed and approved by a licensed health professional, who may also serve as the facility's health consultant (see Health Consultants, STANDARD 1.040 through STANDARD 1.044). This plan shall primarily involve personal contacts with parents by knowledgeable caregivers. The parent education plan shall include topics identified in Health Education for Parents, STANDARD 2.065 through STANDARD 2.067, and cover the importance of developmentally appropriate activities. RATIONALE: Those who provide child care and early childhood education must themselves be clear about the components of their program. Child care is a "delivery of service" involving a contractual relationship between provider and consumer. A written plan helps to specify the components of the service and contributes to responsible operations that are conducive to sound child development and safety practices, and to positive consumer relations. The process of preparing plans promotes thinking about programming for children. Plans also allow for monitoring and for accountability. An increasing number of centers and homes are serving children with special needs. Early childhood specialists and pediatricians agree that cognitive, emotional/social, and physical development are inseparable. The child's health influences all areas of development. Continuity of responsive, affectionate care must be coupled with recognition by the caregiver of the child's developmental phase or stage to provide opportunities for the child to learn and mature through play (31, 32). Young children learn better by experiencing an activity and observing behavior than through didactic training (32). There is a "reciprocal relationship" between learning and play. Play experiences are closely related to learning (33). Parental behavior can be modified by education (33). Parents should be involved with the facility as much as possible. The concept of parent control and empowerment is key to successful parent education in the child care setting (33). Although research has not shown whether a child's eventual success in education or in society is related to parent education, support and education for parents lead to better parenting abilities (33). COMMENTS: Examples of parental health education activities include the following topics: Importance of having a primary health care provider (medical home) for each child; Verbal explanation of principles of personal hygiene; Discussions about the nutritional value of snacks; The importance of implementing effective child passenger and other safety practices; The value of exercise. Examples of child development activities include: Importance of talking and reading to children; Importance of creative play activities; Encouraging children to experience their natural environments. Parents and staff can experience mutual learning in an open, supportive setting. Suggestions for topics and methods of presentation are widely available. For example, the publication catalogs of the National Association for the Education of Young Children (NAEYC) and of the American Academy of Pediatrics (AAP) contain many materials for child, parent and staff education on child development, the importance of attachment and temperament, and other health issues. A certified health education specialist can also be a source of assistance. The American Association for Health Education (AAHE) and the National Commission for Health Education Credential ling, Inc. (NCHEC) provide information on this speciality. Contact information for the NAEYC, AAP, AAHE, and NCHEC is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.043 exchange of information at transitions Communication to facilitate transitions that occurs at times when children are being dropped off or picked up and other interactions with parents shall be the responsibility of the large or small family home child caregiver or the designated center or school-age child care provider on each shift. These caregivers shall be trained in health and development and shall observe each assigned child's physical condition, behavior, and personality factors on arrival and throughout the time when the child is in care. When several staff shifts are involved, information about the child shall be exchanged between caregivers assigned to each shift. RATIONALE: Personal contact on a daily basis between the child care staff and parents is essential to ensure the transfer of information required to provide for the child's needs. Information about the child's experiences and health during the interval when an adult other than the parent is in charge should be provided to parents because they may need such information to understand the child's later behavior. COMMENTS: This designated caregiver could be the health advocate. See Qualifications for Health Advocates, STANDARD 1.021. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 8.4 PERSONNEL POLICIES STANDARD 8.044 written personnel policies The facility shall have and implement written personnel policies. All written policies shall be reviewed and signed by the employee affected by them upon hiring and annually thereafter. Small family child care home providers shall develop policies for themselves, which are reviewed and revised annually. These policies shall address the following items: a) A wage scale with merit increases; b) Scheduled increases of small family child care home fees; c) Sick leave; d) Vacation leave; e) Family, parental, medical leave; f) Personal leave; g) Educational benefits; h) Health insurance and coverage for occupational health services; i) Social security or other retirement plan; j) Holidays; k) Workers' compensation or a disability plan as required by the number of staff; l) Minimally, breaks totaling 30 minutes within an 8-hour period of work, or as required by state labor laws; m) Maternity benefits; n) Overtime/compensatory time policy; o) Grievance procedures; p) Probation period; q) Grounds for termination; r) Training of new caregivers and substitute staff. See Training, STANDARD 1.023 through STANDARD 1.034; and Substitutes, STANDARD 1.037 through STANDARD 1.039; s) Personal/bereavement leave; t) Disciplinary action; u) Periodic review of performance. See Performance Evaluation, STANDARD 1.051 through STANDARD 1.057; v) Exclusion policies pertaining to staff illness. See Staff Exclusion, STANDARD 3.069; w) Staff health appraisal. See STANDARD 1.045 and STANDARD 1.046; x) Professional development leave. Centers and large family child care homes shall have written policies that address all of these items. Small family child care homes shall have written policies that address items f, j, l, m, o, p, s, v. RATIONALE: Written personnel policies provide a means of staff orientation and evaluation essential to the operation of any organization. Caregivers who are responsible for compliance with policies must have reviewed them. The quality and continuity of the caregiving workforce is the main determiner of the quality of care. Nurturing the nurturers is essential to prevent burnout and promote retention. Fair labor practices should apply to child care as well as other work settings. Child care workers should be considered as worthy of benefits as workers in other career areas. Medical coverage should include the cost of the health appraisals and immunizations required of child care workers, and care for the increased incidence of communicable disease and stress-related conditions in this work setting. Sick leave is important to minimize the spread of communicable diseases and maintain the health of staff members. Sick leave may promote recovery from illness and thereby decreases the further spread or recurrence of illness. Other benefits contribute to higher morale and less staff turnover, thus promoting quality child care. Lack of benefits is a major reason reported for high turnover of child care staff (34). The potential for acquiring injuries and infections when caring for young children is a health and safety risk for child care workers. Information abounds about the incidence of infectious disease for children in child care settings. Staff members come into close and frequent contact with children and their excretions and secretions and are vulnerable to these illnesses as well, as children are reservoirs for many infectious agents. In addition, many child care workers are women who are planning a pregnancy or who are pregnant, and they may be vulnerable to the potentially serious effects of infection on the outcome of pregnancy. COMMENTS: Staff benefits may be appropriately addressed in center personnel policies and in state and federal labor standards. Not all the material in such policies is necessarily appropriate for state child care licensing requirements. Although the business plan of the caregiver will determine the scope of benefits the caregiver can offer, this standard outlines the types of benefits that must be considered to control staff turnover and reduce stress, which decreases caregiver performance. Some benefits may be beyond the reach of a small family child care home provider's capability. The Center for the Child Care Workforce (CCW) has developed model work standards for both center-based staff and family child care home providers with specific recommendations for these elements of personnel policies. Model Work Standards serve as a tool to help programs assess the quality of the work environment and set goals to make improvements. For more information, contact the CCW. Contact information is located in Appendix BB. A policy of encouraging sick leave, even without pay, or of permitting a flexible schedule will allow the caregiver to take time off when needed for illness. An acknowledgment that the facility does not provide paid leave but does give time off will begin to address workers' rights to these benefits and improve quality of care. There may be other nontraditional ways to achieve these benefits. The subsidy costs of staff benefits will need to be addressed for child care to be affordable to parents. Staff benefits may be appropriately addressed in center personnel policies and in state and federal labor standards. Not all the material that has to be addressed in these policies is appropriate for state child care licensing requirements. Having facilities acknowledge which benefits they do provide will help to enhance the general awareness of staff benefits among child care workers and other concerned parties. Currently, this standard is difficult for many facilities to achieve, but new federal programs and shared access to small business benefit packages will help. Many options are available for providing leave benefits and education reimbursements, ranging from partial to full employer contribution, based on time employed with the facility. Providers should be encouraged to have health insurance. Health benefits can include full coverage, partial coverage (at least 75% employer paid), or merely access to group rates. Some local or state child care associations offer reduced group rates for health insurance for child care facilities and individual providers. For more information, see Creating Better Child Care Jobs: Model Work Standards for Teaching Staff of Center-Based Child Care and Creating Better Family Child Care Jobs: Model Work Standards from the Center for the Child Care Workforce (CCW). Contact information for the CCW is located in Appendix BB. TYPE OF FACILITY: Centers; Large Family Child Care Home; Small Family Child Care Home 8.5 WRITTEN STATEMENT OF SERVICES STANDARD 8.045 written statement of services The facility shall provide parents with a written statement of services that contains the items specified in Management and Health Policy and Statement of Services, STANDARD 8.004 through STANDARD 8.041. Parents shall sign this statement of services. RATIONALE: Parents will need a written statement of services to refer to from time to time. Having the parent sign the statement of services helps to emphasize the contractual relationship between the parent and the child care facility and prevent later, stressful disputes about whether the parent was informed about the content of the statement. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 8.6 SPECIAL NEEDS PLAN For information on planning for the care of children with special needs who have an IFSP/IEP, see Chapter 7, Children Receiving Services Under IDEA. 8.7 RECORDS CHILD RECORDS STANDARD 8.046 contents of child records The facility shall maintain a file for each child in one central location within the facility. This file shall be kept in a confidential manner (see Confidentiality and Access to Records, STANDARD 8.053 through STANDARD 8.057) but shall be immediately available to the child's caregivers (who shall have parental consent for access to records), parents or legal guardian, and the licensing authority upon request. The file for each child shall include the following: a) Pre-admission enrollment information; b) Health report and immunization record, completed and signed by the child's health care provider, preferably prior to enrollment or no later than 6 weeks after admission. This record shall document the most recent assessment based on the standard age-related schedule of the American Academy of Pediatrics (AAP); c) Admission agreement signed by the parent at enrollment; d) Health history, completed by the parent at admission, preferably with staff involvement; e) Medication record, maintained on an ongoing basis by designated staff. RATIONALE: The health and safety of individual children requires that information regarding each child in care be kept and made available on a need-to-know basis. Prior informed, written consent of the parent/guardian is required for the release of records/information (verbal and written) to other service providers, including process for secondary release of records. Consent forms should be in the native language of the parents, whenever possible, and communicated to them in their normal mode of communication. Foreign language interpreters should be used whenever possible to inform parents about their confidentiality rights. COMMENTS: See STANDARD 8.053 for information on confidentiality and access to records. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.047 pre-admission enrollment information for each child The file for each child shall include the following pre-admission enrollment information: a) The child's name, address, sex, and date of birth; b) The full names of the child's parents or legal guardians, and their home and work addresses and telephone numbers. Telephone contact numbers shall be confirmed by a call placed to the contact number during the facility `s hours of operation. Names, addresses, and telephone numbers shall be updated at least quarterly; c) The names, addresses, and telephone numbers of at least two additional persons to be notified in the event that the parents or legal guardians cannot be located. Telephone information shall be confirmed and updated as specified in item b above; d) The names and telephone numbers of the child's primary sources of medical care, emergency medical care, and dental care; e) The child's health payment resource; f) Written instructions of the parent, legal guardian, and the child's health care provider for any special dietary needs or special needs due to a health condition; or any other special instructions from the parent; g) Scheduled days and hours of attendance; h) In the event that one parent is the sole legal guardian of the child, legal documentation evidencing his/her authority; i) Enrollment date, reason for entry in child care, and fee arrangements; j) Signed permission to act on parent's behalf for emergency treatment and for use of syrup of ipecac, if medically indicated. See STANDARD 3.050; k) Authorization to release child to anyone other than the custodial parent. See Authorized Caregivers, STANDARD 8.028 through STANDARD 8.030. The emergency information in items a through e above shall be obtained in duplicate with original parent/legal guardian signatures on both copies. One copy shall be in the child's confidential record and one copy shall be easily accessible at all times. This information shall be updated quarterly and as necessary. A copy of the emergency information must accompany the child to all offsite excursions. RATIONALE: These records and reports are necessary to protect the health and safety of children in care. An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided for children in child care. Such an approach requires written plans, policies, procedures, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of children. Emergency information is the key to obtaining needed care in emergency situations (35). Caregivers must have written parental permission to allow them access to information they and Emergency Medical Services personnel may need to care for the child in an emergency (35). Contact information must be verified for accuracy. See Appendix X, for the Emergency Information Form for Children with Special Needs , developed by the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP) and the Emergency Medical Services for Children National Resource Center (EMSC). Contact information for the AAP, ACEP and EMSC is located in Appendix BB. Health payment resource information is usually required before any non-life-threatening emergency care is provided. COMMENTS: Duplicate records are easily made using multiple-copy forms, carbon paper, or photocopying. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.048 contents of child's health report The file for each child shall include a health report of an age-appropriate health assessment completed and signed by the child's health care provider. Preferably, this report shall be submitted prior to enrollment, but it shall be submitted no later than 6 weeks after admission. The health report shall include the following medical and developmental information: a) Records of the child's immunizations; b) A description of any disability, sensory impairment, developmental variation, seizure disorder, or emotional or behavioral disturbance that may affect adaptation to child care (including previous surgery, serious illness, history of prematurity, if relevant); c) An assessment of the child's growth based on the percentile for height, weight, and, if the child is younger than 24 months, head circumference; d) A description of health problems or findings from an examination or screening that needs follow-up; e) Results of screenings-vision, hearing, dental, nutrition, developmental, tuberculosis, hematocrit or hemoglobin, urine, lead, blood pressure and so forth; f) Dates of significant communicable diseases (such as chickenpox); g) Prescribed medication(s), including information on recognizing, documenting, reporting, and responding to potential side effects; h) A description of current acute or chronic health problems and a special care plan that defines routine and emergency management that might be required by the child while in child care. The care plan for the child with acute or chronic health problems shall include specific instructions for caregiver observations, program activities or services that differ from those required by typically developing children. Such instructions shall include specific teaching and return demonstration of the ability of caregivers to provide medications, procedures, or implement modifications required by children with asthma, severe allergic reactions, diabetes, medically-indicated special feedings, seizures, hearing impairments, vision problems or any other condition that requires accommodation in child care; i) A description of serious injuries sustained by the child in the past that required medical attention or hospitalization; j) Other special instructions for the caregiver. The health report shall include space for additional comments about the management of health problems and for additional health-related data offered by the health care provider or required from the facility. The health report shall be updated at each age-appropriate health assessment by supplemental notes dated and signed by the child's health provider on a copy of the previous health report or by submission of a new report and whenever the child's health status changes. RATIONALE: The requirement of a health report for each child reflecting completion of health assessments and immunizations is a valid way to ensure timely preventive care for children who might not otherwise receive it and can be used in decision-making at the time of admission and during ongoing care (35). This requirement encourages families to have a primary health care provider (medical home) for each child where timely and periodic well-child evaluations are done. The objective of timely and periodic evaluations is to permit detection and counseling for improved oral, physical, mental, and emotional/social health (14). The reports of such evaluations provide a conduit for communication of information that helps the health professional and the child care provider determine appropriate services for the child. When the parent carries the request for the report to the health professional, concerns of the child care provider can be delivered by the parent to the child's health professional and consent for communication is thereby given. The parent can give written consent for direct communication between the health care provider and the caregiver so that the forms can be faxed or mailed. Quality child care requires information about the child's health status and need for accommodations in child care (35). COMMENTS: The purpose of a health report is to: Give information about a child's health history, special needs, and current health status to allow the caregiver to provide a safe setting and healthful experience for each child; Promote individual and collective health by fostering compliance with approved standards for health care assessments and immunizations; Document compliance with licensing standards; Serve as a means to ensure early detection of health problems and a guide to steps for remediation; Serve as a means to facilitate and encourage communication and learning about the child's needs among caregivers, health care providers, and parents. If the child's medical record is not available at the time the child is enrolled in a program, child care providers can offer a 6-week grace period when the parent can arrange to obtain the medical record, but written permission should be obtained from the child's parent or guardian to contact the child's primary health care provider in case of an emergency. The child care provider should also ask whether or not there are any health problems (such as allergies, asthma, or developmental irregularities) that might affect the child's participation in the program. The requirement for updated health reports does not mean that the child should have a special examination for entry into child care or at intervals related to duration of participation in child care. The evaluations by the child's health professional should occur according to the national schedule for routine preventive care. The medical reports should confirm that the child has received all the age appropriate services outlined in the guidelines for assessments of the American Academy of Pediatrics (AAP), Bright Futures, or Medicaid's Early Periodic Screening and Diagnostic Treatment (EPSDT) program (14, 37, 41). The report submitted upon enrollment can document a previous age-appropriate examination if the child is not due for the next check-up visit. Updates of the report should address new immunizations, contagious diseases, new or changed medications, and new or changed special concerns. Busy clinicians appreciate having the parent and child care provider complete as much information on the medical report as possible, so that they know what information the child care provider already has on hand and what information needs to be added. Filling in the child's and child care provider's identifying information, and previously provided immunization dates are evidence to the clinician of an interest in sharing information and the paperwork burden. Health data should be presented in a form usable by caregivers to identify any special needs for care. Local Early Periodic Screening and Diagnostic Treatment (EPSDT) program contractor, if available, should be called upon to help with liaison and education activities. In some situations, screenings may be performed at the facilities. When clinicians do not fill out forms completely enough to assist the caregiver in understanding the significance of health assessment findings or the unique characteristics of a child, the caregiver should obtain parental consent to contact the child's clinician to explain why the information is needed and to request clarification. Samples of a health care provider's exam form and special care plans for children with chronic illness are provided in Model Child Care Health Policies from the National Association for the Education of Young Children (NAEYC) or the American Academy of Pediatrics (AAP). Contact information for the NAEYC and the AAP is located in Appendix BB. The AAP recommends vision and hearing screenings at every health supervision visit, with objective vision screening and measurement of visual acuity by 4 years of age, and objective hearing screening (audiometry) by 5 years of age. The AAP recommends that all children have their first dental exam, by an oral health professional, at 3 years of age. A primary health care provider could examine the mouth of a child up to 3 years of age. After 3 years, the child should visit a dentist for examinations at intervals prescribed by the dentist. Children with suspected oral problems should see a dentist immediately, regardless of age or interval. These guidelines are described in "A Guide to Children's Dental Health," a brochure published by the AAP. Bright Futures recommends the first dental exam, by an oral health professional, at 12 months of age. Contact information for the AAP is located in Appendix BB. See Appendix H, for Recommendations for Preventive Pediatric Health Care . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.049 contents of admission agreement The file for each child shall include an admission agreement signed by the parent at enrollment. The agreement shall include the following: a) Admission agreement or contract stating the rule prohibiting corporal punishment and verbal abuse. See Discipline Policy, STANDARD 8.008 through STANDARD 8.010; b) Admission agreement or contract stating that all parents may visit the site at any time when their child is there, and that they will be admitted immediately. See STANDARD 2.046; c) Documentation of written consent signed and dated by the parent or legal guardian for: 1) Emergency transportation; 2) All other transportation provided by the facility. See STANDARD 1.004; and Transportation, STANDARD 2.029 through STANDARD 2.038; 3) Planned or unplanned activities off-premises. Such consent shall give specific information about where, when, and how such activities shall take place, including specific information about walking to and from activities away from the facility; 4) Telephone authorizations for release of the child. See Authorized Caregivers, STANDARD 8.028 through STANDARD 8.030; 5) Swimming/wading, if the child will be participating. See STANDARD 1.005, on child:staff ratio; Water Safety, STANDARD 3.045 through STANDARD 3.047; and Swimming, Wading, and Water, STANDARD 5.198 through STANDARD 5.218; 6) Any health service obtained for the child by the facility on behalf of the parent. Such consent shall be specific for the type of care provided to meet the tests for "informed consent" to cover on-site screenings or other services provided; 7) Release of any information to agencies, schools, or providers of services. See Confidentiality and Access to Records, STANDARD 8.053 through STANDARD 8.057; 8) Authorization to release the child to anyone other than the custodial parent; 9) Emergency treatment; 10) Administration of medications (standing orders and short-term). See Medication Policy, STANDARD 8.021; d) Statement that parent has received and discussed a copy of the state child abuse reporting requirements. RATIONALE: Positive guidance and discipline is more effective than corporal punishment, which may become abusive very easily. The open-door policy may be the single most important method of preventing the abuse of children in child care (35). When access is restricted, areas observable by the parent may not reflect the care the children actually receive. These records and reports are necessary to protect the health and safety of children in care. These consents are needed by the person delivering the medical care. Advance consent for emergency medical or surgical service is not legally valid, since the nature and extent of injury, proposed medical treatment, risks, and benefits cannot be known until after the injury occurs. The parent/child care partnership is vital. Participation of parents in decisions concerning children is a primary goal of Head Start (31). COMMENTS: See also a sample document for permission for medical condition treatment in Appendix W. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.050 contents of child care program's health history The file for each child shall include a health history completed by the parent at admission, preferably with staff involvement. This history shall include the following: a) Identification of the child's pediatric primary care clinician or designated "medical home"; b) Developmental variations, sensory impairment, or disabilities that may need consideration in the child care setting; c) Description of current physical, social, and language developmental levels; d) Current medications. See Medication Policy, STANDARD 8.021; and Medications, STANDARD 3.081 through STANDARD 3.083; e) Special concerns (such as allergies, chronic illness, pediatric first aid information needs); f) Specific diet restrictions, if the child is on a special diet; g) Individual characteristics or personality factors relevant to child care; h) Special family considerations; i) Dates of communicable diseases. RATIONALE: A health history is the basis for meeting the child's needs in health, mental and social areas in the child care setting and should be thoroughly understood by the significant child care provider at the time of registration or upon its receipt. COMMENTS: A sample developmental health history is provided in Healthy Young Children from the National Association for the Education of Young Children (NAEYC). Contact information for the NAEYC is located in Appendix BB. For a sample Child Health Assessment , see Appendix Z. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.051 contents of medication record The file for each child shall include a medication record maintained on an ongoing basis by designated staff. The medication record shall include the following: a) Specific signed parent consent for the caregiver to administer medication; b) Prescription by a health care provider, if required; c) Administration log; d) Checklist information on medication brought to the facility by the parents. RATIONALE: Caregivers should not administer medication based solely on a parent's request. Before assuming responsibility for administration of medicine, facilities must have written confirmation of a physician or nurse practitioner's orders to include clear, accurate instruction and medical confirmation of the child's need for medication while in the facility. COMMENTS: The medication record contents and format, as well as policies on handling of medications, are provided in Model Child Care Health Policies, 3rd edition, from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. A sample medication administration log is provided in Healthy Young Children from the National Association for the Education of Young Children (NAEYC). Contact information for the NAEYC is located in Appendix BB. For additional information, see Medications, STANDARD 3.081 through STANDARD 3.083; and Medication Policy, STANDARD 8.021. See also a sample document for permission for medical condition treatment in Appendix W. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 8.052 contents of facility health record for each child The file for each child shall include a facility health record maintained on an ongoing basis by designated staff. The facility health record shall include: a) Staff and parent observations of the child's health status and physical condition; b) Response to any treatment provided while the child is in child care, and any observable side effects; c) Notations of health-related referrals and follow-up action; d) Notations of health-related communications with parents or the child's health care providers; e) Staff observations of the child's learning and social activity; f) Documentation of planned communication with parents and a list of participants involved. See Regular Communication, STANDARD 2.047 and STANDARD 2.048; g) Documentation of parent participation in health education. See Health Education for Parents, STANDARD 2.065 through STANDARD 2.067. RATIONALE: A facility health record maintained by caregivers can document caregivers' observations and concerns that may lead to intervention decisions. COMMENTS: The facility health record is a confidential, chronologically-oriented location for the recording of staff observations, patterns of illness, and parent concerns, can be followed and can become guidelines for intervention, if needed. Facility observation records provide useful information over time on each child's unique characteristics. Parents and caregivers can use these records in planning for the child's needs. On occasion, the child's health care provider can use them as an aid in diagnosing health conditions. "Hands-on" opportunities for parents to work with their own child or others in the company of caregivers should be encouraged and documented. Staff notations on communication with parents can be in a "parent log" separate from the child's health record. See a sample symptom record, Appendix F. See also a sample document for permission for medical condition treatment in Appendix W.