CHAPTER 10:
Licensing and Community Action

10.1 Introduction

This chapter contains standards for the responsibilities of agencies, organizations, and society, not for the individual caregiver/teacher or child care facility. These standards provide the support systems for implementation of the standards in the preceding chapters. Although many of these standards are directed to state administrative activity, they define necessary actions to assure the health and safety of children in out-of-home settings. The chapter addresses standards for the licensing of child care facilities, a process by which states grant official permission to operate an activity which would otherwise be prohibited by law. Licensing can also be known as “permission,” “certification,” “registration,” or “approval.” For the purposes of simplicity, licensing will be used to convey these other terms in this chapter. The term “license” can also be known as “permit,” “certificate,” “registration,” or “approval” and will be used to convey these other terms.

10.2 Regulatory Policy

STANDARD 10.2.0.1: Regulation of All Out-of-Home Child Care

Every state should have a statute that identifies the licensing agency and mandates the licensing and regulation of all full-time and part-time out-of-home care of children, regardless of setting, except care provided by parents or legal guardians, grandparents, siblings, aunts, or uncles (sometimes called relative, friend, and neighbor care) or when a family engages an individual in the family’s home to care solely for their children (1,2).

RATIONALE: A state statute gives government the authority to protect children as vulnerable and dependent citizens and to protect families as consumers of child care service. Licensing must have a statutory basis, because it is unknown to the common law. The statute must address the administration and location of the responsibility. Fifty states have child care regulatory statutes. The laws of some states exempt part-day centers, school-age child care, care provided by religious organizations, drop-in care, summer camps, or care provided in small or large family child care homes (3). In some states the threshold for family child care homes being regulated leaves many children unprotected (4). These exclusions and gaps in coverage expose children to unacceptable risks.

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 1997. Licensing and public regulation of early childhood programs: A position statement. Washington, DC: NAEYC.

2. U.S. Department of Health and Human Services, Administration for Children and Families, National Child Care Information and Technical Assistance Center. 2010. Understanding and supporting family, friend, and neighbor child care. http://nccic.acf.hhs.gov/resource/understanding-and-supporting-family-friend-and-neighbor-child-care/.

3. Child Care and Early Education Research Connections. 2010. Child care licensing and regulation: A key topic resource list. 2nd ed. http://www.researchconnections.org/files/childcare/keytopics/licensing.pdf.

4. National Association of Child Care Resource and Referral Agencies (NACCRRA). 2010. Leaving children to chance: NACCRRA’s ranking of state standards and oversight of small family child care homes, 2010 update. Arlington, VA: NACCRRA. http://www.naccrra.org/publications/naccrra-publications/publications/854-0000_Lvng Children 2 Chance_rev_031510.pdf.

STANDARD 10.2.0.2: Adequacy of Staff and Funding for Regulatory Enforcement

All phases of regulatory administration should have authorization, funding, and enough qualified staff to monitor and enforce the law and regulations of the state.

RATIONALE: For regulations to be effective, the regulatory body must formulate, implement, and enforce licensing requirements and assure that licensing inspectors are both sufficient in numbers and capable of fairly and effectively developing and applying the regulations. Funds for all phases of the licensing process should be provided, or faulty administrative operations may result; such as inadequate protection of children, formulation of irresponsible standards, inadequate investigations, and insufficient and unfair enforcement (1).

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2009. Recommended best practices for human care licensing agencies. The NARA Vision Series Part I. Lexington, KY: NARA. http://www.naralicensing.org/associations/4734/files/Recommended Best Practices.pdf.

STANDARD 10.2.0.3: State Statute Support of Regulatory Enforcement

The state statute should authorize the suppression of illegal operations and enforcement of child care regulations and statutory provisions. Reports of unlicensed care should be promptly investigated and illegally operating providers either brought into the regulated system or forced to terminate offering care. Fines for continuing to provide unlicensed care should be substantial enough to serve as an effective deterrent.

RATIONALE: Without proper enforcement, especially the suppression of illegal operations, licensing could become a ritual and lose its safeguarding intent. Some state laws lack adequate provisions for enforcement. Without effective enforcement, licensing fails to meet its responsibility to protect children from harm (1).

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Suppressing illegal operations. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

10.3 Licensing Agency

10.3.1 The Regulation Setting Process

STANDARD 10.3.1.1: Operation Permits

The licensing agency should issue permits of operation to all facilities that comply with the state’s licensing regulations and rules.

RATIONALE: Every child has a right to protective care that meets the regulations and rules, regardless of the child care setting in which the child is enrolled. Public and private schools, nurseries, preschools, centers, child development programs, babysitting centers, early childhood observation centers, small and large family child care homes, drop-in care, and all other settings where young children receive care by individuals who are not close relatives should be regulated. Facilities have been able to circumvent rules and regulations in some states by claiming to be specialized facilities. Nothing in the educational philosophy, religious orientation, or setting of an early childhood program inherently protects children from health and safety risks or provides assurance of quality of child care.

Any exemptions for care provided outside the family may place children at risk. In addition to the basic protection afforded by stipulating requirements and inspecting for licensing, facilities should be required to be authorized for operation. Authorization for operation gives states a mechanism to identify facilities and individuals that are providing child care and authority to monitor compliance. These facilities and individuals may be identified as potential customers for training, technical assistance, and consultation services. Currently, many church run nurseries, nursery schools, group play centers, and home based programs operate incognito in the community because they are not required to notify any centralized agency that they care for children (2).

The lead agency for licensing of child care in most states is the human services agency. However, the state public health agency can be an appropriate licensing authority for safeguarding children in some states. The education system is increasingly involved in providing services to children in early childhood. The standards should be equally stringent no matter what agency assumes the responsibility for regulating child care.

In-home care, which is the care of a child in his/her own home by someone whom the parent has employed, not a family child care home, should not be licensed as a child care facility. The relationship between the parent and caregiver/teacher is that of employer and employee rather than that of purchaser and provider of care, thus licensing or certification of the individual who provides such care, rather than of the service itself, is desirable and recommended.

COMMENTS: A good resource on licensing, regulatory, and enforcement issues is the National Association for Regulatory Administration (NARA) at http://www.naralicensing.org, an international professional organization for licensors, dedicated to promoting excellence in human care regulation and licensing through leadership, education, collaboration, and services. In addition, the “Licensing and Public Regulation of Early Childhood Programs” document published by the National Association for the Education of Young Children (NAEYC) includes rationale for policy decisions related to licensing and regulation (1). In addition, the National Association for Child Care Resource and Referral Agencies (NACCRRA) publishes periodic reports comparing the licensing regulations of the states against standards formulated by NACCRRA; these reports are available at http://www.naccrra.org.

RELATED STANDARDS:

Appendix GG: Licensing and Public Regulation of Early Childhood Programs

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 1997. Licensing and public regulation of early childhood programs: A position statement. Revised ed. Washington, DC: NAEYC.

2. National Association for Regulatory Administration (NARA), National Child Care Association (NCCA). 2004. License exempt early care and education programs: Equal protection and quality education for every child. Joint position paper. http://nara.affiniscape.com/associations/4734/files/JointPP.pdf.

STANDARD 10.3.1.2: Rational Basis of Regulations

The state child care licensing agency should formulate, implement, and enforce regulations that reduce risks to children in out-of-home child care (1,2).

RATIONALE: Regulations describe the minimum performance required of a facility. Regulations must be:

1. Understandable to any reasonable citizen;
2. Specific enough that any person knows what is to be done and what is not to be done;
3. Enforceable, in that they are capable of measurement;
4. Consistent with new technical knowledge, current research findings and changes in public views to offer necessary protection and to avoid unacceptable risk;
5. Easily available in both print and electronic media.

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Formulation of rules. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

2. Class, N. E., J. English. 1983. Formulating operationally valid standards. The administrative regulation of community care facilities with special reference to child care. A compilation of papers by Norris E. Class, Professor Emeritus, School of Social Work, University of Southern California.

STANDARD 10.3.1.3: Community Participation in Development of Licensing Rules

State licensing rules should be developed with active community participation by all interested parties including parents/guardians, service providers, advocates, professionals in medical and child development fields, funding and training sources (1,2).

Regulations formulated through a representative citizen process should come before the public at well-publicized public hearings held at convenient times and places in different parts of the state. The licensing rules should be re-examined and revised at least every five years, to assure that the rules can be informed by new relevant research findings and significant social data. The regulatory development process should include many opportunities for public debate and discussion as well as the ability to provide written input.

RATIONALE: The legal principle of broad interest representation has long been applied to the formulation of regulations for child care. Changes in regulation can be implemented only with broad support from the different interests affected. State administrative laws and constitutional principles require public review. The interests of the child must take precedence over all other interests. The system should allow for more frequent changes when required to protect children’s health or safety, e.g., updates on Sudden Infant Death Syndrome (SIDS) risk reduction measures.

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Formulation of rules. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

2. Class, N. E., J. English. 1985. Formulating valid standards for licensing. J Am Public Welfare Assoc 43:32-35.

10.3.2 Advisory Groups

STANDARD 10.3.2.1: Child Care Licensing Advisory Board

States should have an official child care licensing advisory body for regulatory and related policy issues. A child care advisory board should:

1. Review proposed rules and regulations prior to adoption;
2. Recommend administrative policy;
3. Recommend changes in legislation; and
4. Guide enforcement, if granted this authority via the legislative process.

The advisory group should include representatives from the following agencies and groups:

1. State agencies with regulatory responsibility or an interest in child care (human services, public health, fire marshal, emergency medical services, education, human resources, attorney general, safety council);
2. Organizations with a child care emphasis;
3. Operators, directors, owners, and caregivers/teachers reflecting various types of child care programs including for-profit and non-profit;
4. Professionals with expertise related to the rules; may include pediatrics, physical activity, nutrition, mental health, oral health, injury prevention, resource and referral, early childhood education, and early childhood professional development;
5. Parents/guardians who reflect the diversity of the families that are consumers of licensed child care programs.

This advisory board should be linked to the State Early Childhood Advisory Council (see Standard 10.3.2.2) as required by the Head Start Act of 2007 (1).

RATIONALE: The advisory group should actively seek citizen participation in the development of child care policy, including parents/guardians, child care administrators, and caregivers/teachers. The licensing advisory board should report directly to the agency having administrative authority over licensing.

RELATED STANDARDS:

Standard 10.3.2.2: State Early Childhood Advisory Council

REFERENCES:

1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Act/.

STANDARD 10.3.2.2: State Early Childhood Advisory Council

Each state should establish a state early childhood advisory council or charge an existing commission with the responsibility for developing a early childhood plan and facilitating cooperation among government public health, human service, and education departments; institutions of higher education; early childhood professional development systems; early childhood professional organizations; as well as community-based human services agencies. Schools, employers, parents/guardians, and caregivers/teachers should also be involved to ensure that the health, safety, and child development needs of children are met by the child care services provided in the state. The council should be mandated by law, and should report to the legislature and to the governor at least annually. Larger communities should have a network of local councils to advise the state council. The state child care licensing advisory board (see Standard 10.3.2.1) should have representation on the council.

RATIONALE: Coordination among public and private sources of health, social service, and education services is essential, especially when young children are in care. Some states have separate groups that advise the health agency, the social service agency, the education agency, the licensing agency, the governor, and the legislature (1). Other states have some, but not all, of these advisory bodies; each of which has some relevance to child care, but often with a different focus. National initiatives such as the Early Childhood Comprehensive Systems (ECCS) Initiative and the Healthy Child Care America (HCCA) program have done much to encourage effective collaboration among agencies and organizations with the ability to impact child care within states (2).

Time limited task forces could be created for specific purposes, but there is a need for one standing council that addresses early childhood as its primary responsibility. Mandating the council by law will reduce the likelihood that the council will be rendered ineffective by changes in political leadership or dissolved when its recommendations are not in agreement with a current administration.

Large municipalities with a similarly diverse group of agencies, authorities, and public and private resources should also have a council to coordinate early childhood activity. Participation of parent/guardian representatives in planning and implementing early childhood initiatives at the state and local levels promotes effective partnerships between parents/guardians and caregivers/teachers (1).

RELATED STANDARDS:

Standard 10.3.2.1: Child Care Licensing Advisory Board

REFERENCES:

1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc
.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Act/.

2. Healthy Child Care America (HCCA). 2010. About us. American Academy of Pediatrics. http://www.healthychildcare.org/about.html.

STANDARD 10.3.2.3: Collaborative Development of Child Care Requirements and Guidelines for Children Who Are Ill

Local and state health departments, child care licensing agencies, education and health professionals, attorneys, caregivers/teachers, parents/guardians, and representatives of the business community, including employers, should work together to develop child care licensing requirements and guidelines for children who are ill.

RATIONALE: Local and state health departments have the legal responsibility to control infectious diseases in their jurisdictions (1). To meet this responsibility, health departments generally have the expertise to provide leadership and technical assistance to licensing authorities, caregivers/teachers, parents/guardians, and health professionals in the development of licensing requirements and guidelines for the management of children who are ill. The heavy reliance on the expertise of local and state health departments in the establishment of facilities to care for children who are ill has fostered a partnership in many states among health departments, licensing authorities, caregivers/teachers, and parents/guardians for the adequate care of children who are ill in child care settings. Early care and education professionals can provide the information required to ensure child care settings support children’s social-emotional, language and cognitive development. In addition, the business community has a vested interest in assuring that parents/guardians have facilities that provide quality care for children who are ill so parents/guardians can be productive in the workplace. This vested interest is likely to produce meaningful contributions from the business community to creative solutions and innovative ideas about how to approach the regulation of facilities for children who are ill. All stakeholders in the care of children who are ill should be involved for the solutions that are developed in regulations to be most successful.

RELATED STANDARDS:

Standards 3.6.2.1-3.6.2.10: Caring for Children Who Are Ill

REFERENCES:

1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: American Public Health Association.

STANDARD 10.3.2.4: Public-Private Collaboration on Care of Children Who Are Ill

State and regional agencies should collaborate with employers to facilitate arrangements for the care of children who are ill in the following settings:

1. The child’s own home, under the supervision of an adult known to the parents/guardians and the child;
2. A separate area in the child’s own facility or in a specialized center, where both the caregiver/teacher and the facility are familiar to the child;
3. A child’s own small family child care home;
4. A space within the small family child care home network’s central place that serves children from participating small family child care homes, where both the caregiver and the facility are familiar to the child.

RATIONALE: The most appropriate care of a child who is ill is at the child’s own home by a parent/guardian. This is in the best interests of the child, family, and community. Businesses should be encouraged to allow the use of paid sick leave for this purpose. However, when parent care puts the family income or parent employment at risk, the child should receive care that is appropriate for the child. Often, when faced with the pressures of the workplace, parents/guardians take children who are ill to work, leave them in places where either or both the caregiver/teacher and place are unfamiliar, or leave them alone. Under the stress of illness, children need familiar caregivers/teachers and familiar places where their illnesses and their emotional needs can be managed competently.

RELATED STANDARDS:

Standards 3.6.2.1-3.6.2.10: Caring for Children Who Are Ill

10.3.3 Licensing Role with Staff Credentials, Child Abuse Prevention, and ADA Compliance

STANDARD 10.3.3.1: Credentialing of Individual Child Care Providers

The state licensing agency or a credentialing body recognized by the state child care regulatory agency should credential or license all persons who provide child care or who may be responsible for children or who may be alone with children in a facility. The credential should be granted to individuals who meet age, education, and experience qualifications, whose health status facilitates providing safe and nurturing care, and who have no record of conviction for criminal offenses against persons, especially children, or confirmed act of child abuse. The state should establish qualifications for differentiated roles in child care and a procedure for verifying that the individual who is authorized to perform a specified role meets the qualifications and is credentialed for that role.

RATIONALE: Individual credentialing will enhance child health and development and protect children by ensuring that the staff who care for children are healthy and are qualified for their roles. The current system, in which the details of staff qualifications and ongoing training are checked as part of facility inspection, is cumbersome for child care administrators and licensing inspectors alike. If staff qualifications were established as part of a separate, more central process, the licensing agency staff could check center records of character references and whether staff members have licenses for the roles for which they are employed.

Centralizing individual credentialing, qualifying, or licensing (whichever term is consistent with the state’s approach to authorizing legal professional activity) will improve control over quality, encourage a career ladder with increasing qualifications, and reduce the risk of abuse. It will help consumers know that individuals who are caring for their children have met basic requirements for consumer protection. Such a process is analogous to that provided for other education professionals (teachers), and even those service providers with less potential for harm than is involved in caring for children (such as beauticians, barbers, taxi drivers).

The cost of individual certification, credentialing, or licensure will be offset by the benefits to consumers of reliable and consistent qualifications of child care personnel. Program administrators, licensors, and child care personnel, who do not have to undertake the tedious process of verification of each portion of an individual’s credentials during all site visits, when sites are licensed, or when individuals change jobs, will experience cost savings and assurance of compliance. Public and private policymakers should use financial and other incentives to help caregivers/teachers meet credentialing requirements. They should encourage community colleges to offer courses appropriate for provider training at times convenient for child care workers to attend and for other agencies to offer online courses available to providers from their homes or places of employment.

Periodic renewal of the credential should be required, and should be related to requirements for continuing education and the absence of founded claims of child abuse or criminal convictions. The requirement for renewable certification is likely to deter people from applying for work in child care as a way of gaining access to children for sexual purposes since the process would include a background screening that includes a check of the sex offender registry and child abuse registry (1).

COMMENTS: In a centralized individual credentialing system, successful completion of education should be verified by requiring the individual to submit evidence of completion of credit-bearing courses that have been previously approved as meeting the state’s requirements to a central verification office where this transcript should be continually updated. Background screening records should be checked by state licensing agency staff for evidence of behavior that would disqualify an individual for work in specified child care roles. Evidence of a recent health examination indicating ability to care for children can be submitted at the same time. The center director then knows whether job applicants who have been working in the field previously are qualified at the time they apply for the job, without lengthy waiting for background checks of a prospective employee and without having to hire before background checks have been completed. By this means, children are not exposed to health and safety risks from understaffing, or to care by unqualified or even dangerous individuals employed provisionally because the results of a check are not yet available to the director.

RELATED STANDARDS:

Section 1.3: Pre-service Qualifications

REFERENCES:

1. Finkelhor, D., L. M. William, N. Burns. 1988. Nursery crimes: Sexual abuse in day care. Beverly Hills, CA: Sage Publications.

STANDARD 10.3.3.2: Background Screening

Every state should have a statute which mandates the licensing agency or other authority to obtain a background screening that includes a criminal records check, a sex offender registry check, and a child abuse registry check on every prospective child care staff person, volunteer, or on a family child care home provider’s family member who is over ten years of age and who comes in contact with children. The expense of background screenings should be a public responsibility. No staff (paid or volunteer) or family member should be unsupervised with the children until all background screenings have been completed and found to be acceptable.

RATIONALE: Some states do not regulate family child care providers who care for just a few children. Caregivers/teachers who care for more children are required to comply with legal requirements in most states. In nearly all States, regulations require background screenings for all child care center staff. This screening requirement may protect children from abuse and reduce liability risks (1). Some local governments regulate family child care caregivers/teachers who are not covered by State regulations or have regulations that exceed the state requirements.

COMMENTS: The cost of background screenings, where they have been implemented, has become an additional financial burden on programs, which are forced to pass on the expense to parents/guardians or staff. Placing the burden on potential new staff, volunteers, and substitute caregivers/teachers themselves proves to be another disincentive to enter this field of work. A solution to this problem should be sought in addressing the overall need to support development of a well educated and competent early education workforce. For workers who enter the field as a first work experience, previous child abuse histories may be unknown. In many cases juvenile records are sealed and cannot be used for the purposes of background screenings. Juvenile offender records begin at age ten. Most state regulations are not clear on whether sex offender registries are to be checked (2).

Some states have established definitions for regular volunteers (for whom criminal record and child abuse registry checks should be required) and for short-term visitors, such as entertainers and others, who will not be unsupervised with the children.

REFERENCES:

1. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Career guide to industries, 2010-11 edition: Child day care services. http://www.bls.gov/oco/cg/cgs032.htm.

2. National Association of Child Care Resource and Referral Agencies. 2009. Comprehensive background checks. http://www.naccrra.org/policy/docs/Background-Checks-Sept22.pdf.

STANDARD 10.3.3.3: Licensing Agency Role in Communicating the Importance of Reporting Suspected Child Abuse

Licensing agencies should consistently make known the requirements for reporting and methods of reporting suspected child abuse.

RATIONALE: Child care staff and parents/guardians should be aware of the reporting requirements and the procedures for handling reports of child abuse (1,2). State requirements may differ, but those for whom reporting suspected abuse is mandatory usually include child care personnel. Information on how to call and how to report should be posted in licensed facilities so it is readily available to parents/guardians and staff. 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. State licensing agencies need to report suspected abuse or neglect which they become aware of to the State Child Protective Agency for appropriate follow-up.

Procedures for evaluating allegations of physical and emotional abuse may or may not be the purview of the licensing agency. This responsibility may fall to another agency to which the licensing agency refers child abuse allegations.

RELATED STANDARDS:

Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect

REFERENCES:

1. Child Welfare Information Gateway. Reporting. http://www
.childwelfare.gov/responding/reporting.cfm.

2. Child Help. Prevention and treatment of child abuse. http://www
.childhelp.org.

STANDARD 10.3.3.4: Licensing Agency Provision of Child Abuse Prevention Materials

The licensing agency should be a resource for or have knowledge of sources of child abuse prevention materials for child care facilities and parents/guardians. Guidance and technical assistance should also be provided related to their state’s child abuse/neglect statute and procedures including the facility’s responsibilities of reporting suspected child abuse and neglect.

RATIONALE: Centers and small and large family child care homes are good locations to distribute materials for the prevention of abuse and host community training events (1).

COMMENTS: State Child Welfare Agencies are a good source of information and materials and resources on prevention and may have designated staff who provide training in the community, including to early care and education program staff and parents/guardians.

Additional resources for licensing agencies can be found at: http://www.childwelfare.gov/preventing/ and http://www.childwelfare.gov/pubs/res_packet_2008/.

REFERENCES:

1. Center for the Study of Social Policy. Strengthening families. http://www.strengtheningfamilies.net.

STANDARD 10.3.3.5: Licensing Agency Role in Communicating the Importance of Compliance with Americans with Disabilities Act

Licensing agencies should consistently make known the requirements under the Americans with Disabilities Act that child care programs must follow.

RATIONALE: Child care programs must comply with the requirements of the Americans with Disabilities Act.

COMMENTS: Procedures for evaluating allegations of physical and emotional abuse may or may not be the purview of the licensing agency. This responsibility may fall to another agency to which the licensing agency refers child abuse allegations.

10.3.4 Technical Assistance from the Licensing Agency

STANDARD 10.3.4.1: Sources of Technical Assistance to Support Quality of Child Care

Public authorities (such as licensing agencies) and private agencies (such as resource and referral agencies), should develop systems for technical assistance to states, localities, child care agencies, and caregivers/teachers that address the following:

1. Meeting licensing requirements;
2. Establishing programs that meet the developmental needs of children;
3. Educating parents/guardians on specific health and safety issues through the production and distribution of related material.

RATIONALE: The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

1. Licensing agencies (on ways to meet the regulations);
2. Health departments (on health related matters);
3. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
4. Child care health, education, mental health consultant networks; American Academy of Pediatrics (AAP) state chapters and child care contacts; and state Early Childhood Comprehensive Systems (ECCS) grants are examples of partners providing technical assistance on health and related child care matters.

The state agency has a continuing responsibility to assist an applicant in qualifying for a license and to help licensees improve and maintain the quality of their facility. Regulations should be available to parents/guardians and interested citizens upon request and should be translated if needed. Licensing inspectors throughout the state should be required to offer assistance and consultation as a regular part of their duties and to coordinate consultation with other technical assistance providers as this is an integral part of the licensing process.

The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) and the Office of Child Care (OCC) of the Administration for Children and Families (ACF) continue to develop initiatives that provide funding to support technical assistance to early care and education. States should check with their State Child Care Administrators, Maternal and Child Health Directors, and Head Start State Collaboration Directors, for more information.

Providing centers and networks of small or large family child care homes with guidelines and information on establishing a program of care is intended to promote appropriate programs of activities. Child care staff is rarely trained health professionals. Since staff and time are often limited, caregivers/teachers should have access to consultation on available resources in a variety of fields (such as physical and mental health care; nutrition; safety, including fire safety; oral health care; developmental disabilities; and cultural sensitivity) (1,2).

The public agencies can facilitate access to children and their families by providing useful materials to child care providers.

RELATED STANDARDS:

Standards 2.4.3.1-2.4.3.2: Health Education for Parents/Guardians

Standard 10.3.3.1: Credentialing of Individual Health Care Providers

Standard 10.4.1.3: Licensing Agency Procedures Prior to Issuing a License

REFERENCES:

1. American Academy of Pediatrics. 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

2. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.

STANDARD 10.3.4.2: Licensing Agency Provision of Written Agreements for Parents/Guardians and Caregivers/Teachers

The licensing agency or a resource and referral agency should provide guidance, technical assistance, and training to support caregivers/teachers in developing written agreements between the child care facility and parents/guardians, as required by licensing regulations. The written agreement should be available at the time of an inspection visit.

RATIONALE: The licensing agency and the resource and referral agency can develop sample agreement forms or be a resource to parents/guardians and caregivers/teachers in locating the appropriate materials and tools.

STANDARD 10.3.4.3: Support for Consultants to Provide Technical Assistance to Facilities

State agencies should encourage the arrangement and coordination of and the fiscal support for consultants from the local community to provide technical assistance for program development and maintenance. Consultants should have training and experience in early childhood education, early childhood growth and development, issues of health and safety in child care settings, business practices, ability to establish collegial relationships with child care providers, adult learning techniques, and ability to help establish links between facilities and community resources. There should be collaboration among all parts of the early care and education community to provide technical assistance and consultation to improve the quality of care. The licensing agency should be an integral part of the quality rating and improvement system (QRIS) in the state; all parts of the system must collaborate to assure the most effective and efficient use of resources to encourage quality improvement. See Glossary for definition of QRIS.

The state regulatory agency with the Title V or State Child Care Resource and Referral Agency should provide or arrange for other public agencies, private organizations or technical assistance agencies (such as a resource and referral agency) to make the following consultants available to the community of child care providers of all types:

1. Program consultant, to provide technical assistance for program development and maintenance and business practices. Consultants should be chosen on the basis of training and experience in early childhood education and ability to help establish links between the facility and community resources;
2. Child care health consultant (CCHC), who has knowledge and expertise in child health and child development, is knowledgeable about the special needs of children in out-of-home care settings, and knows the child care licensing requirements and available health resources. A regional plan to make consultants accessible to facilities for ongoing relationships should be developed;
3. Nutritionist/registered dietitian, who also has the knowledge of infant and child development, food service, nutrition and nutrition education methods, to be responsible for the development of policies and procedures and for the implementation of nutrition standards to provide high quality meals, nutrition education programs and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors;
4. Early childhood education consultant, to assist centers, large family child care homes, and networks of small family child care homes in partnering with families in meeting the individual development and learning needs of children, including any special developmental and educational needs that a child may have. Early Childhood Education Consultants can assist providers n early detection and referral for identifying and addressing special learning needs, especially infants and toddlers;
5. Early childhood mental health consultant (ECMHC), to assist centers, large family child care homes, and networks of small family child care homes in meeting the emotional needs of children and families. The state mental health agency should promote funding through community mental health agencies and child guidance clinics for these services. At the least, such consultants should be available when caregivers/teachers identify children whose behaviors are more difficult to manage than typically developing children;
6. Dental health consultant, to assist centers, large family child care homes and networks small family child care homes in meeting the oral health needs of children. The dental health consultant should have knowledge of pediatric oral health and be able to help with policy and procedure development in this area;
7. Physical activity consultant, who has knowledge in infant and child motor development (developmental biomechanics), locomotion, ballistic, and manipulative skills, sensory-perceptual development, social, psychosocial, and cultural constraints in motor development, and development of cardio-respiratory endurance, strength and flexibility, and body composition, to be responsible for the development of policies and procedures for the implementation of age and developmentally appropriate physical activity standards to provide children with the movement experiences needed for optimal growth and development, physical education/movement programs, and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors.

A plan should be in place that supports the interdisciplinary collaboration of consultant support to programs to ensure coordinated support, avoid duplication and stress on programs and families, and promote efficient use of consultant resources.

Additionally, a plan should be in place that outlines how the state identifies, trains, and supports consultants who, in turn, support programs. Minimum qualifications required of consultants may be specified in state regulations. There are resources for training consultants, e.g., The National Training Institute for Child Care Health Consultants (NTI) that can be integrated into state plans for supporting health and other early childhood consultants. States will ideally take advantage of opportunities to partner with Head Start, child welfare, Part C and Part B, and others to maintain an ongoing system of supporting consultants and fostering partnerships that support children, families and programs and help improve the overall quality of services provided in the community.

RATIONALE: Securing expertise is acceptable by whatever method is most workable at the state or local level (for example, consultation could be provided from a resource and referral agency). Providers, not the regulatory agency, are responsible for securing the type of consultation that is required by their individual facilities. Ongoing relationships with CCHCs, nutritionists/registered dietitians, and ECMHCs are effective in promoting healthy and safe environments (3-5).

COMMENTS: Several states now have mental health consultants specifically serving the child care community. There are different models of mental health consultation. Some models are programmatic and only include the staff, others work with individual children with behavioral and emotional problems and the third model integrates both approaches. MHCs are usually social workers or professionals with a child development or psychology background who are trained to work in child care settings (2). There is no formal or standardized training for ECMHCs nationally. Developmental and behavioral pediatricians, child and adolescent psychiatrists, and child psychologists are resources for the behavioral and mental health needs of young children (1). Some, but not all, adolescent and child psychiatrists and psychologists, social workers and child counselors have the necessary skills to work with behavior problems of this youngest age group. To find such specialists, contact the Department of Pediatrics at academic centers or the State Department of Mental Health. The faculty at such centers can usually refer child care facilities to individuals with the necessary skills in their area.

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

1. AAP Chapter Child Care Contact (contact information can be found at http://www.healthychildcare.org);
2. Licensing agencies (on ways to meet the regulations and make quality improvements);
3. Health departments (on health related matters);
4. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
5. Community action programs or non-profit organizations (on health related matters including physical education, for health education and/or quality improvement issues);
6. Local university kinesiology departments (on early childhood motor development and physical activity issues);
7. Small business administration (on financial issues related to program operations);
8. Subsidy agencies may fund a variety of consultants to programs through the Child Care and Development Fund (CCDF) quality dollars;
9. Education departments often administer the food program dollars and may have technical assistance related to the Individuals with Disabilities Education Act (IDEA).

REFERENCES:

1. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

2. Healthy Child Care America. 2006. The influence of child care health consultants in promoting children’s health and well-being: A status report. Rockville, MD: Maternal and Child Health Bureau.

3. Crowley, A. A., J. M. Kulikowich. Impact of training on child care health consultant knowledge and practice. Ped Nurs 35:93-100.

4. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.

5. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.

STANDARD 10.3.4.4: Development of List of Providers of Services to Facilities

The local regulatory agency or resource and referral agency should assist centers and small and large family child care homes to formulate and maintain a list of community professionals and agencies available to provide needed health, dental, and social services to families.

RATIONALE: Families depend on their child care facilities to provide information about obtaining health and dental care and other community services. A number of communities have Family Resource Centers, which are central points for information. It is important that regulatory agencies and resource and referral agencies have knowledge of family resource centers or can provide a directory of community services to child care facilities.

Partnerships among health care professionals and community agencies are necessary to provide a medical home for all children. The American Academy of Pediatrics (AAP) defines the medical home as care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. The medical home is not a building, house, or hospital, but an approach to providing health care services in a high-quality and cost-effective manner (1,2). Health care professionals and other community service agencies are beginning to recognize that child care facilities are a logical opportunity to provide information or referral of children to a medical home. Child care programs also provide opportunities for education in health promotion and disease prevention for children and families (3).

REFERENCES:

1. Kempe, A., B. Beaty, B. P. Englund, R. J. Roark, N. Hester, J. F. Steiner. 2000. Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children. Pediatrics 105:1020-28.

2. American Academy of Pediatrics. 2008. Policy statement: The medical home. Pediatrics 122:450.

3. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505.

STANDARD 10.3.4.5: Resources for Parents/Guardians of Children with Special Health Care Needs

The state agency or council of agencies responsible for child care services for children with special health care needs should aid parents/guardians in their assessment of facilities for care of children with special health care needs. Agencies should provide printed and audiovisual information about assessment of specialized health care to the parents/guardians.

In addition, the regulatory agency should refer parents/guardians of children with special health care needs to a medical home for assistance in development and formulation of a written care plan to be used within a child care program.

RATIONALE: Parents/guardians of children with special health care needs require support to enable their identification and evaluation of facilities where their children can receive quality child care.

Parents/guardians should participate in the facility evaluation, both formally and informally. Unless the Interagency Coordinating Council (ICC) or some similar body provides information to parents/guardians, they are unlikely to be able to find and evaluate options for child care for children with special health care needs. While the professionals involved with the family may do this on behalf of the family, the parents/guardians should have every opportunity to play a significant role in the process.

The state licensing agency as well as the state agencies responsible for implementation of the Individuals with Disabilities Education Act (IDEA) should assist child care caregivers/teachers to recognize the opportunity they have to participate in the child’s overall care planning and to obtain training on effective inclusion in order to provide care to the children (1).

RELATED STANDARDS:

Section 1.6: Consultants

REFERENCES:

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. State Title V contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.

STANDARD 10.3.4.6: Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

The agency (or a council of such agencies) within the state responsible for overseeing child care for children with special health care or educational needs should assure that the Individualized Family Service Plan (IFSP) or the Individualized Education Program (IEP) includes compensation for the hours of time spent by members of the multidisciplinary team and the staff from the child care program in developing the assessment defined in Standards 8.7.0.1-8.7.0.3.

RATIONALE: Unless there is a source of compensation for the time spent in planning and completing assessments, these requirements cannot be implemented.

Funding under Individuals with Disabilities Education Act (IDEA) makes it possible for the resources and funding for service to follow the child. Traditionally, these funds have paid for individual therapists only, and not for others who participate in formulating the IFSP or IEP. This tradition of restrained spending inhibits effective service delivery for children and families (1).

COMMENTS: For more information and resources, contact the State Children with Special Health Care Needs Program Director. Contact information for each state can be found at: https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.

RELATED STANDARDS:

Standards 8.7.0.1-8.7.0.3: Assessment of Facilities for Children with Special Needs

REFERENCES:

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. State Title V contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.

STANDARD 10.3.4.7: Technical Assistance to Facilities to Address Diversity in the Community

Technical assistance and incentives should be provided by state, municipal, public, and private agencies to encourage facilities to address within their programs, the cultural and socioeconomic diversity in the broader community, not just in the neighborhood where the child care facility is located.

RATIONALE: Children who are exposed to cultural and socioeconomic diversity in early childhood are more likely to value and accept differences between their own backgrounds and those of others as they move through life (1,2). This attitude results in improved self-esteem and mental health in children from all backgrounds. Facilities may be able to attract participants from different income and cultural groups by paying attention to the location of the facility and available subsidies for low income families.

REFERENCES:

1. National Childcare Accreditation Council. 2005. Diversity in programming: Family day care quality assurance - Factsheet #4. http://www.ncac.gov.au/factsheets/factsheet4.pdf.

2. Biles, B. Activities that promote racial and cultural awareness. http://www.pbs.org/kcts/preciouschildren/diversity/read_activities.html.

10.3.5 Licensing Staff Training

STANDARD 10.3.5.1: Education, Experience and Training of Licensing Inspectors

Licensing inspectors, and others in licensing positions, should be pre-qualified by education and experience to be knowledgeable about the form of child care they are assigned to inspect. Prior to employment or within the first six months of employment, licensing inspectors should receive training in regulatory administration based on the concepts and principles found in the National Association for Regulatory Administration (NARA) Licensing Curriculum through onsite platform training or online coursework (1). In addition, they should receive no less than forty clock hours of orientation training upon employment (1). In addition, they should receive no less than twenty-four clock hours of continuing education each year (1), covering the following topics and other such topics as necessary based on competency needs:

1. The licensing statutes and rules for child care;
2. Other applicable state and federal statutes and regulations;
3. The historical, conceptual, and theoretical basis for licensing, investigation, and enforcement;
4. Technical skills related to the person’s duties and responsibilities, such as investigative techniques, interviewing, rule-writing, due process, and data management;
5. Child development, early childhood education principles, child care programming, scheduling, and design of space;
6. Law enforcement and the rights of licensees;
7. Center and large or small family child care home management;
8. Child and staff health in child care;
9. Detection, prevention, and management of child abuse;
10. Practical techniques and ADA requirements for inclusion of children with special needs;
11. Exclusion/inclusion of children who are ill;
12. Health, safety, physical activity, and nutrition;
13. Recognition of hazards.

RATIONALE: Licensing inspectors are a point of contact and linkage for caregivers/teachers and sources of technical information needed to improve the quality of child care. This is particularly true for areas not usually within the network of early childhood professionals, such as health and safety expertise. Unless the licensing inspector is competent and able to recognize areas where facilities need to improve their health and safety provisions (for example prevention of infectious disease), the opportunity for such linkages will be lost. To effectively carry out their responsibilities to license and monitor child care facilities, it is critical that licensing inspectors have appropriate, conceptually based professional development in the principles, concepts and practices of child care licensing as well as in the principles and practices of the form or child care to which they are assigned. When developed, it will be important for licensing inspectors to secure NARA Licensing Credentials.

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

STANDARD 10.3.5.2: Performance Monitoring of Licensing Inspectors

Licensing inspectors should receive initial and periodic competency-based training on the principles and practices of conducting licensing and monitoring inspections for compliance with licensing standards. Competency should be initially and periodically assessed by simultaneous, independent monitoring by a skilled licensing inspector until the trainee attains the necessary skills. Consistency in interpretation of licensing rules is essential for effective and equitable enforcement of the rules. Achieving consistency across inspectors throughout the state is difficult to achieve and maintain. Examples of effective techniques to achieve consistency are: development of interpretive guidelines which are designed to provide the intent of each rule, the means to achieve compliance, and the criteria to be used to measure compliance.

RATIONALE: Objective assessment of compliance is a learned skill that can be fostered by classroom and self teaching methods but should be mastered through direct practice and apprenticeship. To ensure consistent protection of children, licensing inspectors should undergo periodic retraining and reevaluation to assess their ability to recognize sound and unsound practices. In addition, all staff involved in licensing such as agency directors, attorneys, policy staff, managers, clerical/support personnel, and information system staff need periodic training updates. Training for licensors/inspectors should include best practice programming, child development theory, and law enforcement. The National Association for Regulatory Administration (NARA) professional development system is the primary source for training in the principles and practices of child care licensing (1).

Interpretive guidelines (also known as indicator manuals or field guides) assist staff in consistent interpretation and also assist providers to better understand the intent of the rules and how to achieve compliance. States are beginning to put interpretive guidelines on their Websites for ready use by providers. Licensing staff must be trained on the interpretive guidelines and treat it as a living document which is frequently reviewed and revised as interpretation is refined. Another practice used by some states is to hold periodic case reviews by a licensing office with one individual presenting the case(s) which are critiqued by others. Procedure manuals, consisting of well developed and currendly used procedures to be used in the enforcement of licensing rules and regulatinos are also effective in achieving consistency when there is frequent training and revision as needed. Documents used by the agency for achieving consistency should be conveniently accessible to caregivers/teachers (1).

REFERENCES:

1. Stevens, C. 2008. Achieving the vision: A workbook for human care regulatory agencies. Lexington, KY: National Association for Regulatory Administration.

STANDARD 10.3.5.3: Training of Licensing Agency Personnel about Child Abuse

Staff and administrators in licensing agencies and state supported resource and referral agencies should receive sixteen hours of training about child abuse with an emphasis on how child abuse occurs in child care.

RATIONALE: Licensing and resource and referral persons should be at least as well informed about child abuse issues as caregivers/teachers. States should establish procedures to ensure compliance of the training requirement by agency personnel.

10.4 Facility Licensing

10.4.1 Initial Considerations for Licensing

STANDARD 10.4.1.1: Uniform Categories and Definitions

Each state should adopt uniform categories and definitions for its own licensing requirements. Every state should have individual standards that are applied to the following types of facilities:

1. Family child care home: A facility providing care and education of children, including the caregiver/teacher’s own children in the home of the caregiver/teacher:
   1. Small family child care home – one to six children;
   2. Large family child care home – seven to twelve children, with one or more qualified adult assistants to meet child: staff ratio requirements;
2. Center: A facility providing care and education of any number of children in a nonresidential setting, or thirteen or more children in any setting if the facility is open on a regular basis (for instance, if it is not a drop-in facility);
3. Drop-in facility: A child care program where children are cared for over short periods of time on a one-time, intermittent, unscheduled and/or occasional basis. Drop-in care is often operated in connection with a business (e.g., health club, hotel, shopping center, or recreation centers);
4. School-age child care facility: A facility offering activities to school-age children before and after school, during vacations, and non-school days set aside for such activities as caregivers’/teachers’ in-service programs;
5. Facility for children who are mildly ill: A facility providing care of one or more children who are mildly ill, children who are temporarily excluded from care in their regular child care setting;
6. Integrated or small group care for children who are mildly ill: A facility that has been approved by the licensing agency to care for well children and to include up to six children who are mildly ill;
7. Special facility for children who are mildly ill: A facility that cares only for children who are mildly ill, or a facility that cares for more than six children who are mildly ill at a time.

RATIONALE: Lack of standard terminology hampers the ability of citizens and professionals to compare rules from state to state or to apply national guidance material to upgrade the quality of care (1). For example, child care for seven to twelve children in the residence of the caregiver/teacher may be referred to as family day care, a group day care home, or a mini-center in different states. While it is not essential that each state use the same terms and some variability in definitions of types of care may occur, terminology should be consistent within the state and as consistent as possible from state to state in the way different types of settings are classified. Child care facilities should be differentiated from community facilities that primarily care for those with developmental disabilities, the elderly, and other adults and teenagers who need supervised care (2).

RELATED STANDARDS:

Standards 3.6.2.1-3.6.2.10: Caring for Children Who Are Ill

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 1997. Licensing and public regulation of early childhood programs: A position statement. Washington, DC: NAEYC.

2. Newacheck, P. W., B. Strickland, J. P. Shonkoff, et al. 1998. An epidemiologic profile of children with special health care needs. Pediatrics 102:117-23.

STANDARD 10.4.1.2: Quality Rating and Improvement Systems

States should develop a quality rating and improvement system (QRIS) to provide incentives to improve the quality of child care based on or using the licensing system as its foundation.

RATIONALE: A highly functioning licensing system has to be the foundation for a quality rating and improvement system in order to work properly (3). It is important to recognize the relevance of health and safety in the quality criteria (1,2).

COMMENTS: Quality rating and improvement systems (QRIS) are initiatives in states to provide incentives for improved child care in licensed child care centers and small and large family child care homes. It is important for the QRIS system to work closely with all parts of the early care and education system and the health care system. Examples include ensuring health and safety measures are part of the ratings and access to a child care health consultant is required.

REFERENCES:

1. Friedman, D. E. 2007. Quality rating systems: The experiences of center directors. Child Care Exchange 173:6-12.

2. U.S. Department of Health and Human Services, Administration for Children and Families, National Child Care Information and Technical Assistance Center. Quality improvement systems. http://nccic.acf.hhs.gov/topics/quality-improvement-systems.

3. Mitchell, A. W. 2005. Stair steps to quality: A guide for states and communities developing quality rating systems for early care and education. Alexandria, VA: United Way of America, Success By 6.

STANDARD 10.4.1.3: Licensing Agency Procedures Prior to Issuing a License

Before granting a license to a facility, the licensing agency should check as specified below for a record of a physical examination and for educational qualifications, and should check background screening records for all adults who are permitted to be alone with children in a facility. The licensing agency should also check background screening records for all persons over ten years of age who live in a small or large family child care home where child care is provided.

1. Staff health appraisals, as specified in Standard 1.7.0.1;
2. Educational requirements, as specified in Sections 1.3 and 1.4;
3. Criminal record files, for crimes of violence against persons, especially children, within the state of residence, and for personnel who have moved into the state within the past five years, federal or out of state criminal records of the other state(s) where the individual has resided in the past five years;
4. The child abuse registry, for a known history of child abuse or neglect in the state of residence and for personnel who have moved into the state within the past five years, the other state(s) where the individual has resided in the past five years (1);
5. The sex offender registry, for a known history of sex-related crimes in the state of residence and for personnel who have moved into the state within the past five years, the other state(s) where the individual has resided in the past five years.

RATIONALE: Requiring a check of both criminal records and the sex offender registry provides additional protection against individuals avoiding detection by using other names or files not being forwarded to the applicable agencies.

COMMENTS: In many cases juvenile records are sealed and cannot be used for the purposes of background checks. To determine the policy in your state or local jurisdiction contact the State Attorney General’s Office or the local County Prosecutor.

RELATED STANDARDS:

Section 1.3: Pre-service Qualifications

Section 1.4: Professional Development/Training

Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

STANDARD 10.4.1.4: Alternative Means of Compliance

Alternative means of compliance should be granted from state licensing requirements when the intent of the requirement is being met by equivalent means and does not compromise the health, safety or protection of children (1).

RATIONALE: The ability to grant alternative means of compliance recognizes the variety of settings and services that can effectively and safely meet children’s needs. Flexibility in applying licensing regulations should be permitted to the extent that children’s need for protection is met.

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

10.4.2 Facility Inspections and Monitoring

STANDARD 10.4.2.1: Frequency of Inspections for Child Care Centers, Large Family Child Care Homes, and Small Family Child Care Homes

The licensing inspector should make an onsite inspection to measure compliance with licensing rules prior to issuing an initial license and at least two inspections each year to each center and large and small family child care home thereafter. At least one of the inspections should be unannounced and more if needed for the facility to achieve satisfactory compliance or is closed at any time (1). Sufficient numbers of licensing inspectors should be hired to provide adequate time visiting and inspecting facilities to insure compliance with regulations

The number of inspections should not include those inspections conducted for the purpose of investigating complaints. Complaints should be investigated promptly, based on severity of the complaint. States are encouraged to post the results of licensing inspections, including complaints, on the Internet for parent and public review. Parents/guardians should be provided easy access to the licensing rules and made aware of how to report complaints to the licensing agency.

RATIONALE: Licensing inspections are important to assist facilities to achieve and maintain full compliance with licensing rules. Supervision and monitoring of child care facilities are critical to facilitate continued compliance with the rules in order to prevent or correct problems before they become serious (2). Technical assistance and consultation provided by licensing inspectors on an on-going basis are essential to help programs achieve compliance with the rules and go beyond the basic level of quality. These positive strategies are most effective when they are coupled with the non-regulatory methods used by other parts of the early care and education community to promote quality (such as professional development, quality and improvement rating systems, accreditation, peer support, and consumer education) (3). All of these methods are most effective when they work together within a coordinated early care and education system. Research has demonstrated that posting of licensing information on the Internet has a positive effect on compliance with licensing rules (3).

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2010. Strong licensing: The foundation for a quality early care and education system: NARA’s call to action. http://www.naralicensing.org/associations/4734/files/NARA_Call_to_Action.pdf.

2. National Association for Regulatory Administration (NARA). 1999. Licensing workload assessment. Technical assistance bulletin #99-01. Lexington, KY: NARA.

3. Witte, A. D., M. Queralt. 2004. What happens when child care inspections and complaints are made available on the internet? Faculty Working Paper 10227, Wellesley College Department of Economics and National Bureau of Economic Research, Wellesley Child Care Research Partnership.

3. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

STANDARD 10.4.2.2: Statutory Authorization of On-Site Inspections

The state statute should authorize the state regulatory agency to conduct on-site inspections of child care/early care and education facilities.

RATIONALE: The National Association for the Education of Young Children (NAEYC) Position Statement says, “Effective enforcement requires periodic on-site inspections on both an announced and unannounced basis with meaningful sanctions for noncompliance” (1). When unannounced inspections are used, they should be conducted at any hour the facility is in operation, i.e., evenings and nights included if the facility operates at those times (2). NAEYC recommends that all centers and large and small family child care homes receive at least one site visit per year. Unannounced inspections have been shown to be especially effective when targeted to providers with a history of low compliance (1).

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 1997. Licensing and public regulation of early childhood programs: A position statement. Washington, DC: NAEYC.

2. U.S. Department of Health, Education, and Welfare (DHEW), Office of Child Development (OCD). 1973. Guides for day care licensing. DHEW Publication no. OCD 73-1053. Washington, DC: DHEW, OCD.

STANDARD 10.4.2.3: Monitoring Strategies

The licensing agency should adopt monitoring strategies that ensure compliance with licensing requirements. These strategies should include the provision of technical assistance, advice and guidance to help providers achieve and maintain compliance with licensing requirements and consultation, advice and guidance to encourage upgrading the quality of care to exceed licensing requirements (1). When these strategies do not include a total annual review of all licensing requirements, the agency should review selected policies and performance indicators and/or conduct a random sampling of licensing requirements at least annually. The licensing agency should have procedures and staffing in place to increase the level of compliance monitoring for any facility found in significant noncompliance.

RATIONALE: Due to an insufficient number of inspectors in licensing agencies across the country, it is important to use various methods in the licensing process to insure quality (2). Monitoring with a focus on teaching, encouraging, upgrading and safeguarding, can be very successful in assisting programs and providers to achieve and maintain compliance with licensing requirements (2).

REFERENCES:

1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

STANDARD 10.4.2.4: Agency Collaboration to Safeguard Children in Child Care

The child care licensing, building, fire safety, and health authorities, as well as any other regulators (e.g., environmental, sanitation, and food safety), should work together as a team to safeguard children in child care. The team should eliminate duplication of inspections to create more efficient regulatory efforts. Examples of activities to be coordinated include:

1. Inspection of child care facility;
2. Reporting and surveillance systems;
3. Guidance in managing outbreaks of infectious diseases;
4. Preventing exposure of children to hazards;
5. Reporting child abuse;
6. Training and technical consultation;
7. Disaster preparedness and response planning (1).

Regulatory agents should collaborate to educate caregivers/teachers, parents/guardians, health care providers, public health workers, licensors, and employers about their roles in ensuring health and safety in child care settings.

RATIONALE: Frequently, caregivers/teachers are burdened by complicated procedures and conflicting requirements to obtain clearance from various authorities to operate. To use limited resources, agencies must avoid contradictions in regulatory codes, simplify inspection procedures, and reduce bureaucratic disincentives to the provision of safe and healthy care for children. When regulatory authorities work as a team, collaboration should focus on establishing the role of each agency in ensuring that necessary services and systems exist to prevent and control health and safety problems in facilities. Each member of the team gains opportunities to learn about the responsibilities of other team members so that close working relationships can be established, conflicts can be resolved, and decisions can be reached. In small states, a state level task force may be sufficient. In larger or more populous states, local task forces may be needed to promote effective use of resources.

COMMENTS: The licensing agency can facilitate communication and collaboration between the child care facility and the state health department, Emergency Medical Services (EMS) agencies, other regulatory agencies, funding agencies, child protection agencies, law enforcement agencies, community service agencies, school districts and school personnel, including school nurses, and local government to safeguard children in child care.

RELATED STANDARDS:

Standard 3.4.4.1: Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation

Standard 6.2.5.1: Inspection of Indoor and Outdoor Play Areas and Equipment

Chapter 7: Infectious Disease

Standards 9.2.4.1-9.2.4.10: Emergency/Security Policies and Plans

REFERENCES:

1. American Academy of Pediatrics. Children and disasters. http://www.aap.org/disasters/.

10.4.3 Procedures for Complaints, Reporting, and Data Collecting

STANDARD 10.4.3.1: Procedure for Receiving Complaints

Each licensing agency should have a procedure for receiving complaints regarding violation of the regulations. Such complaints should be recorded, investigated, and appropriate action, if indicated, should be taken.

RATIONALE: The telephone number, email address, or other contact method for filing complaints should be listed on material about licensing that is given to parents/guardians by the state licensing agency and the resource and referral agency. At a minimum, the licensing agency has responsibility for consumer protection. Complaints serve as an early warning before more serious adverse events occur. A fair and equitable process for handling complaints is essential to protect both the person complaining and the target of the complaint from harassment. In most cases complaint investigation should include an unannounced inspection.

STANDARD 10.4.3.2: Whistle-Blower Protection under State Law

State law should ensure that caregivers/teachers and child care staff who report violation of licensing requirements in the settings where they work are immune from discharge, retaliation, or other disciplinary action for that reason alone, unless it is proven that the report was malicious.

RATIONALE: Staff in child care facilities are in an excellent position to note areas of noncompliance with licensing requirements in the setting where they work. However, so that they feel safe about reporting these deficiencies, they must be assured immunity from retaliation by the child care facility unless the report is malicious. This immunity is best provided when a state statute mandates it. Individuals who report problems in their own workplace may be known as “whistle-blowers” (1).

Retaliatory complaints against a caregiver/teacher by disgruntled staff or parents/guardians at times serve only to harass the provider and expend valuable licensing resources or unnecessary work. States should recognize and develop a system to deal with these nuisance complaints.

REFERENCES:

1. U.S. Department of Labor, Northern Hudson Valley Job Services Employer Committee. 2010. Whistleblower protection laws. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/operations/Management and Administration/Human Resources/Personnel Policies/WhistleblowerPro.htm.

STANDARD 10.4.3.3: Collection of Data on Illness or Harm to Children in Facilities

The state regulatory agency should have access to an information system for collecting data relative to the incidence of illness and injuries, confirmed child abuse and neglect, and death of children in facilities. This data should be shared with appropriate agencies and the child care health consultant for analysis.

RATIONALE: Sound public policy planning in respect to health and safety in facilities starts with the collection of epidemiological data. When outbreaks or emergencies occur, quick identification of, and appropriate response to, an unusual circumstance is critical. Conducting daily health checks and keeping symptom records is a good way to identify the potential for an infectious disease emergency or outbreak. When children in a group seem to have similar symptoms that suggest a contagious disease is spreading, the program should consult with its child care health consultant or medical advisor (1). Licensing agencies can make appropriate and preventive changes to licensing regulations and program monitoring if they have accurate data on which to base those changes (2).

RELATED STANDARDS:

Standard 3.1.1.1: Conduct of Daily Health Check

Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect

Standard 3.6.4.5: Death

REFERENCES:

1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

10.5 Health Department Responsibilities and Role

STANDARD 10.5.0.1: State and Local Health Department Role

State and local health departments should play an important role in the identification, prevention and control of injuries, injury risk, and infectious disease in child care settings as well as in using the child care setting to promote health and safety. This role includes the following activities to be conducted in collaboration with the child care licensing agency:

1. Assisting in the planning of a comprehensive health and safety program for children and child care providers, including promoting and ensuring maintenance of a system of child care health consultation;
2. Monitoring the occurrence of serious injury events and outbreaks involving children or providers;
3. Alerting the responsible child care administrators about identified or potential injury hazards and infectious disease risks in the child care setting;
4. Controlling outbreaks, identifying and reporting infectious diseases in child care settings including:
   1. Methods for notifying parents/guardians, caregivers/teachers, and health care providers of the problem;
   2. Providing appropriate actions for the child care provider to take;
   3. Providing policies for exclusion or isolation of infected children;
   4. Arranging a source and method for the administration of needed medication;
   5. Providing a list of reportable diseases, including descriptions of these diseases. The list should specify where diseases are to be reported and what information is to be provided by the child care provider to the health department and to parents/guardians;
   6. Requiring that all facilities, regardless of licensure status, and all health care providers report certain infectious diseases to the responsible local or state public health authority. The child care licensing authority should require such reporting under its regulatory jurisdiction and should collaborate fully with the health department when the latter is engaged in an enforcement action with a licensed facility;
   7. Determining whether a disease represents a potential health risk to children in out-of-home child care;
   8. Conducting the epidemiological investigation necessary to initiate public health and safety interventions;
   9. Recommending a disease prevention or control strategy that is based on sound public health and clinical practices (such as the use of vaccine, immunoglobulin, or antibiotics taken to prevent an infection);
   10. Verifying reports of infectious diseases received from facilities with the assessment and diagnosis of the disease made by a health care provider and, or the local or state health department;
5. Designing systems and forms for use by facilities for the care of children who are ill to document the surveillance of cared for illnesses and problems that arise in the care of children in such child care settings;
6. Assisting in the development of orientation and annual training programs for caregivers/teachers. Such training should include specialized education for staff of facilities that include child who are ill, as well as those in special facilities that serve only children who are ill. Specialized training for staff who care for children who are ill should focus on the recognition and management of childhood illnesses, as well as the care of children with infectious diseases;
7. Assisting the licensing authority in the periodic review of facility performance related to caring for children who are ill by:
   1. Reviewing written policies developed by facilities regarding inclusion, exclusion, dismissal criteria and plans for health care, urgent and emergency care, and reporting and managing children with infectious disease;
   2. Assisting with periodic compliance reviews for those rules relating to inclusion, exclusion, dismissal, daily health care, urgent and emergency care, and reporting and management of children with infectious disease;
8. Collaborating in the planning and implementation of appropriate training and educational programs related to health and safety in child care facilities. Such training should include education of parents/guardians, primary care providers, public health and safety workers, licensing inspectors, and employers about how to prevent injury and disease as well as promote health and safety of children and their caregivers/teachers;
9. Promoting that health care personnel, such as qualified public health nurses, pediatric and family nurse practitioners, and pediatricians serve as child care health consultants;
10. Ensuring child care programs are included and represented in local and state disaster preparedness and pandemic flu planning.

RATIONALE: A number of studies have described the incidence of injuries in the child care setting (7-10). Although the injuries described have not been serious, these occur frequently, and may require medical or emergency attention. Child care programs need the assistance of local and state health agencies in planning of the safety program that will minimize the risk for serious injury (11). This would include planning for such significant emergencies as fire, flood, tornado, or earthquake (11-13). A community health agency can collect information that can promptly identify an injury risk or hazard and provide an early notice about the risk or hazard (14). An example is the recent identification of un-powered scooters as a significant injury risk for preschool children (15). Once the injury risk is identified, appropriate channels of communication are required to alert the child care administrators and to provide training and educational activities.

Effective control and prevention of infectious diseases in child care settings depends on affirmative relationships among parents/guardians, caregivers/teachers, public health authorities, regulatory agencies, and primary health care providers. The major barriers to productive working relationships between caregivers/teachers and health care providers are inadequate channels of communication and uncertainty of role definition (4). Public health authorities can play a major role in improving the relationship between caregivers/teachers and primary care providers by disseminating information regarding disease reporting laws, prescribed measures for control and prevention of diseases and injuries, and resources that are available for these activities (11). Child care health consultant networks have proven to be effective in improving the health and safety of children in child care settings (16-18).

State and local health departments are legally required to control certain infectious diseases within their jurisdictions (20). All states have laws that grant extraordinary powers to public health departments during outbreaks of infectious diseases (1,11,12). Since infectious disease is likely to occur in child care settings, a plan for the control of infectious diseases in these settings is essential and often legally required. Early recognition and prompt intervention will reduce the spread of infection. Outbreaks of infectious disease in child care settings can have great implications for the general community (2). Programs administered by local health departments have been more successful in controlling outbreaks of hepatitis A than those that rely primarily on private physicians. Programs coordinated by the local health department also provide reassurance to caregivers/teachers, staff, and parents/guardians, and thereby promote cooperation with other disease control policies (3). Infectious diseases in child care settings pose new epidemiological considerations. Only in recent decades has it been so common for very young children to spend most of their days together in groups. Public health authorities should expand their role in studying this situation and designing new preventive health measures (4,5).

Collaboration is necessary to use limited resources most effectively. In small states, a state level task force that includes the Department of Health might be sufficient. In larger or more populous states, local task forces in addition to coordination at the state level may be needed. The collaboration should focus on establishing the role of each agency in ensuring that necessary services and systems exist to prevent and control injuries and infectious diseases in facilities (6,19).

Health departments generally have or should develop the expertise to provide leadership and technical assistance to licensing authorities, caregivers/teachers, parents/guardians, and primary care providers in the development of licensing requirements and guidelines for the management of children who are ill. The heavy reliance on the expertise of local and state health departments in the establishment of facilities to care for children who are ill has fostered a partnership in many states among health departments, licensing authorities, caregivers/teachers, and parents/guardians for the adequate care of children who are ill in child care settings (16-18).

RELATED STANDARDS:

Section 1.6: Consultants

Standard 3.6.2.5: Caregiver Qualifications for Facilities that Care for Children Who Are Ill

Standard 3.6.2.7: Child Care Health Consultants for Facilities that Care for Children Who Are Ill

Standards 3.6.4.3-3.6.4.4: Reporting Policies

REFERENCES:

1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: American Public Health Association.

2. Brady, M. T. 2005. Infectious disease in pediatric out-of-home child care. Am J Infect Control 33:276-85.

3. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association.

4. Ginter, P. M., Wingate, M. S., A. C. Rucks, R. D. Vasconez, L. C. McCormick, S. Baldwin, C. A. Fargason. 2006. Creating a regional pediatric medical disaster preparedness network: Imperative and issues. Maternal Child Health J 10:391-96.

5. Buttross, S. 2006. Caring for children of caretakers during a disaster. Pediatrics 117: S446-47.

6. Wilson, S. A., B. J. Temple, M. E. Milliron, C. Vazquez, M. D. Packard, B. S. Rudy. 2008. The lack of disaster preparedness by the public and it’s affect on communities. Internet J Rescue Disaster Med 7 (2): 1.

7. Murray, J. S. 2009. Disaster care: Public health emergencies and children. Am J Nursing 109: 28-29, 31.

8. Vollman, D., R. Witsaman, D. R. Comstock, G. A. Smith. 2009. Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005. Clinical Pediatrics 48:66-71.

9. Gordon, R. A., R. Kaestner, S. Korenman. 2007. The effects of maternal employment on child injuries and infectious disease. Demography 44:307-33.

10. Jansson, B., A. P. De Leon, N. Ahmed, V. Jansson. 2006. Why does Sweden have the lowest childhood mortality in the world? The role of architecture and public pre-school services. J Public Health Policy 27:146-65.

11. Gaines, S. K., J. M. Leary. 2004. Public health emergency preparedness in the setting of child care. Family and Comm Health 27:260-65.

12. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. 2006. Policy statement: The pediatrician and disaster preparedness. Pediatrics 117:560-65.

13. National Association of Child Care Resource and Referral Agencies. Helping families and children cope with trauma in the aftermath of disaster. http://www.naccrra.org/for_parents/coping/trauma.php.

14. Samet, J. M. 2004. Risk assessment and child health. Pediatrics 113:952-56.

15. Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta Paediatrics 92:50-54.

16. Crowley, A. A. and Kulikowich, J. M. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.

17. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.

18. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.

19. Garrett, A. L., R. Grant, P. Madrid, A. Brito, D. Abramson, I. Redlener. 2007. Children and megadisasters: Lessons learned in the new millennium. Advances Pediatrics 54:189-214.

20. National Child Care Information and Technical Assistance Center. State and territory emergency preparedness plans. http://nccic.acf.hhs.gov/poptopics/disasterprep.html.

STANDARD 10.5.0.2: Written Plans for the Health Department Role

The health department’s role defined in Standard 10.5.0.1 should be described in written plans that assign the responsibilities of community agencies and organizations involved in the prevention and control of injury, injury risk, and infectious disease in facilities. The plan should identify child care related risks and diseases as well as provide guidance for risk reduction, disease prevention and control. The health department should develop these written plans in collaboration with the licensing agency (if other than the health department), health care providers, caregivers/teachers, and parents/guardians to ensure the availability of sufficient community resources for successful implementation. In addition, the health department should provide assistance to the licensing agency (if other than the health department) for the promulgation and enforcement of child care facility standards. These services should be in addition to the health agency’s assigned responsibilities for enforcement of the state’s immunization and other health laws and regulations.

In addition to Caring for Our Children (CFOC) and Stepping Stones, the following resources should be consulted in the development of the health department plan:

1. Guidelines from the American Academy of Pediatrics (AAP), including current editions of Red Book, Managing Infectious Diseases in Child Care and Schools, Managing Chronic Health Needs in Child Care and Schools, and the many other relevant technical manuals on such topics as environment and nutrition;
2. Guidelines from the American Public Health Association (APHA), including Control of Communicable Diseases Manual;
3. Guidelines provided by the Centers for Disease Control and Prevention (CDC);
4. Guidelines from the U.S. Public Health Service’s Advisory Committee on Immunization Practices, as reported periodically in Morbidity and Mortality Weekly Report (MMWR);
5. State and local regulations and guidelines regarding infectious diseases in facilities;
6. Bright Futures - Guidelines for Health Supervision of Infants, Children, and Adolescents;
7. Current early childhood nutrition guidelines such as Preventing Childhood Obesity and Making Food Healthy and Safe for Children.
8. Current early childhood physical activity resources, such as Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition; Moving with a Purpose: Developing Programs for Preschoolers of All Abilities; and Purposeful Play: Early Childhood Movement Activities on a Budget.

RATIONALE: Written plans help define delegation and accountability, providing the continuity of purpose that helps to institutionalize performance.

RELATED STANDARDS:

Standard 10.5.0.4: Use of Fact Sheets on Common Illnesses Associated with Child Care

STANDARD 10.5.0.3: Requirements for Facilities to Report to Health Department

The child care licensing authority should require all facilities under its regulatory jurisdiction to report outbreaks to the health department and comply with state and local rules and regulations intended to prevent infectious disease that apply to child care facilities.

RATIONALE: State and local health departments are legally required to control certain infectious diseases within their jurisdictions. All states have laws that grant extraordinary powers to public health departments during outbreaks or epidemics of infectious disease or bioterrorism attacks. Since infectious disease is likely to occur in child care settings, a plan for the control of infectious diseases in these settings is essential and often legally required. Early recognition and prompt intervention will reduce the spread of infection.

Outbreaks of infectious disease in child care settings can have great implications for the general community (1,4). Programs administered by local health departments have been more successful in controlling outbreaks of hepatitis A than those that rely primarily on private physicians. Programs coordinated by the local health department also provide reassurance to caregivers/teachers, staff, and parents/guardians, and thereby promote cooperation with other disease and safety control policies (2). Infectious diseases in child care settings pose epidemiological considerations. Public health authorities should expand their role in studying this situation and designing new preventive health and safety measures (3).

REFERENCES:

1. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child-care centers. Infect Dis Clin North Am 11:347-65.

2. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association.

3. Reves, R. R., L. K. Pickering. 1992. Impact of child day care on infectious diseases in adults. Infect Dis Clin North Am 6:239-50.

4. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 10.5.0.4: Use of Fact Sheets on Common Illnesses Associated with Child Care

Health departments should help child care providers use prepared prototype parent and staff fact sheets on common illnesses associated with child care. These fact sheets should:

1. Be provided to parents/guardians when their child is first admitted to the facility, to staff at the time of employment and to both parents/guardians and staff when infectious disease notification is recommended;
2. Contain the following information:
3. Disease (case or outbreak) to which the child was exposed;
4. Signs and symptoms of the disease that the parents/guardians and caregivers/teachers should watch for in the child;
5. Mode of transmission of the disease;
6. Period of communicability;
7. Disease prevention measures recommended by the public health department (if appropriate);
8. Emphasize modes of transmission of respiratory disease and infections of the intestines (often with diarrhea) and liver, common methods of infection control (such as hand hygiene).

RATIONALE: Education is a primary method for providing information to primary care providers and parents/guardians about the incidence of infectious diseases in child care settings (1). Education of child care staff and parents/guardians on the recognition and transmission of various infectious diseases is important to any infection control policy (1). Training of child care staff has improved the quality of their health related behaviors and practices. Training should be available to all parties involved, including caregivers/teachers, public health workers, health care providers, parents/guardians, and children. Good quality training, with imaginative and accessible methods of presentation supported by well-designed materials, will facilitate learning. The number of studies evaluating the importance of education of child care staff in the prevention of disease is limited. However, data from numerous studies in hospitals illustrate the important role of continuing education in preventing and minimizing the transmission of infectious disease (1). The provision of fact sheets on infectious childhood diseases at the time their child is admitted to a facility helps educate parents/guardians as to the early signs and symptoms of these illnesses and the need to inform caregivers/teachers of their existence. Illness information sheets can be assembled in a convenient booklet for this purpose. Health departments may consult or use nationally accepted fact sheets on common illnesses available from such agencies as the American Academy of Pediatrics (AAP) in its Managing Infectious Diseases in Child Care and Schools, 2nd ed. and the Centers for Disease Control and Prevention (CDC).

RELATED STANDARDS:

Standards 3.2.1.1-3.2.3.4: Hygiene

Chapter 7: Infectious Disease

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

10.6 Caregiver/Teacher Support

10.6.1 Caregiver/Teacher Training

STANDARD 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

The licensing agency should promote participation in a variety of caregiver/teacher and consumer training and support services as an integral component of its mission to reduce risks to children in out-of-home child care. Such training should emphasize the importance of conducting regular safety checks and providing direct supervision of children at all times. Training plans should include mechanisms for training of prospective child care staff prior to their assuming responsibility for the care of children and for ongoing/continuing education. The higher education institutions providing early education degree programs should be coordinated with training provided at the community level to encourage continuing education and availability of appropriate content in the coursework provide by these institutions of higher education.

Persons wanting to enter the child care field should be able to learn from the regulatory agency about training opportunities offered by public and private agencies. Discussions of these trainings can emphasize critical child care health and safety messages. Some training can be provided online to reinforce classroom education.

Training programs should address the following:

1. Child growth and development including social-emotional, cognitive, language, and physical development;
2. Child care programming and activities;
3. Discipline and behavior management;
4. Mandated child abuse and neglect reporting;
5. Health and safety practices including injury prevention, basic first aid and CPR, reporting, preventing and controlling infectious diseases, children’s environmental health and health promotion, and reducing the risk of SIDS and use of safe sleep practices;
6. Cultural diversity;
7. Nutrition and eating habits including the importance of breastfeeding and the prevention of obesity and related chronic diseases;
8. Parent/guardian education;
9. Design, use and safe cleaning of physical space;
10. Care and education of children with special health care needs;
11. Oral health care;
12. Reporting requirements for infectious disease outbreaks;
13. Caregiver/teacher health;
14. Age-appropriate physical activity.

RATIONALE: Training enhances staff competence (1,2,4). In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1,2). Most states require limited training for child care staff depending on their functions and responsibilities. Some states do not require completion of a high school degree or GED for various levels of teacher positions (5). Staff members who are better trained are more able to prevent, recognize, and correct health and safety problems. Decisions about management of illness are facilitated by the caregiver’s/teacher’s increased skill in assessing a child’s behavior that suggests illness (2,3). Training should promote increased opportunity in the field and openings to advance through further degree-credentialed education.

RELATED STANDARDS:

Standards 1.4.2.1-1.4.2.3: Orientation Training

Standard 10.6.2.1: Development of Child Care Provider Organizations and Networks

REFERENCES:

1. U.S. General Accounting Office (USGAO); Health, Education, and Human Services Division. 1994. Child care: Promoting quality in family child care. Report to the chairman, subcommittee on regulation, business opportunities, and technology, committee on small business, House of Representatives. Publication no. GAO-HEHS-95-36. Washington, DC: USGAO.

2. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute.

19. Aronson, S. S., L. S. Aiken. 1980. Compliance of child care programs with health and safety standards: Impact of program evaluation and advocate training. Pediatrics 65:318-25.

3. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. Pediatrics 94:1108-10.

4. Moon, R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.

5. National Child Care Information and Technical Assistance Center, National Association for Regulatory Administration (NARA). 2010. The 2008 child care licensing study: Final report. Lexington, KY: NARA. http://www.naralicensing.org/associations/4734/files/1005_2008_Child Care Licensing Study_Full_Report.pdf.

STANDARD 10.6.1.2: Provision of Training to Facilities by Health Agencies

Public health departments, other state departments charged with professional development for out of home child care providers, and Emergency Medical Services (EMS) agencies should provide training, written information, consultation in at least the following subject areas or referral to other community resources (e.g., child care health consultants, licensing personnel, health care professionals, including school nurses) who can provide such training in:

1. Immunization;
2. Reporting, preventing, and managing of infectious diseases;
3. Techniques for the prevention and control of infectious diseases;
4. Exclusion and inclusion guidelines and care of children who are acutely ill;
5. General hygiene and sanitation;
6. Food service, nutrition, and infant and child-feeding;
7. Care of children with special health care needs (chronic illnesses, physical and developmental disabilities, and behavior problems);
8. Prevention and management of injury;
9. Managing emergencies;
10. Oral health;
11. Environmental health;
12. Health promotion, including routine health supervision and the importance of a medical or health home for children and adults;
13. Health insurance, including Medicaid and the Children’s Health Insurance Program (CHIP);
14. Strategies for preparing for and responding to infectious disease outbreaks, such as a pandemic influenza;
15. Age-appropriate physical activity;
16. Sudden Infant Death Syndrome (SIDS) and Shaken Baby Syndrome/Abusive Head Trauma.

RATIONALE: Training of child care staff has improved the quality of their health related behaviors and practices. Training should be available to all parties involved, including caregivers/teachers, public health workers, health care providers, parents/guardians, and children. Good quality training, with imaginative and accessible methods of presentation supported by well-designed materials, will facilitate learning.

RELATED STANDARDS:

Standards 1.4.4.1-1.4.6.2: Continuing Education

Standard 10.5.0.1: State and Local Health Department Role

10.6.2 Caregiver/Teacher Networking and Collaboration

STANDARD 10.6.2.1: Development of Child Care Provider Organizations and Networks

State-level agencies and resource and referral agencies should encourage the development of child care provider organizations or networks, to attract, train, support, and encourage participation in facility quality ratings and accreditation, for those caregivers/teachers who would like to be part of an organization or system. National professional organizations should encourage the development of local child care provider organizations and networks.

When possible, these networks should include a central facility for enrichment activities for groups of children and support in-service programs for caregivers/teachers.

RATIONALE: To enhance staff qualifications and a nurturing environment, child care providers need support (1,3). This especially applies to family child care home providers who tend to be more isolated than those employed in centers. In studies of the quality of care in family child care homes, the caregivers/teachers who provided better care were those who viewed their role as a profession and acted accordingly, participating in continuous improvement activities (2).

COMMENTS: Professional networking organizations offer professional encouragement, support, and training to promote rigorous professional standards (3). This should include the promotion of quality ratings, accreditation, credentialing, and other quality improvement initiatives that are based on implementing best practices in early childhood education.

RELATED STANDARDS:

Standard 10.3.3.1: Credentialing of Individual Child Care Providers

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute.

3. Bromer, J. 2009. The Family Child Care Network impact study: Promising strategies for improving family child care quality. http://www.erikson.edu/hrc/researchdetail.aspx?c=1296.

STANDARD 10.6.2.2: Fostering Collaboration to Establish Programs for School-Age Children

Public and private agencies should foster collaboration among the schools, child care facilities, and resource and referral agencies to establish programs for school-age children, ages five to twelve and older. Such care should be designed to meet the social and developmental needs of children who receive care in any setting.

RATIONALE: More than fifteen million children in the United States are left alone after school each day (1). School-age children who are under-supervised (“latchkey children”) are exposed to considerable health and safety risks. Bringing these children into supervised, quality child care is a societal responsibility. In addition to providing protection for children, these programs can offer homework assistance, tutoring and other support for school achievement.

REFERENCES:

1. Afterschool Alliance. Facts and research: America after 3pm. http://www.afterschoolalliance.org/AA3PM.cfm.

10.7 Public Policy Issues and Resource Development

STANDARD 10.7.0.1: Development of Resource and Referral Agencies

States should encourage the use of public and private resources in local communities to develop resource and referral agencies. The functions of these agencies should include the following:

1. Helping parents/guardians find developmentally appropriate child care that protects the health and safety of children;
2. Giving parents/guardians consumer information to enable them to know about, evaluate, and choose among available child care options;
3. Helping parents/guardians maintain a dialogue with their caregivers/teachers;
4. Recruiting new potential caregivers/teachers;
5. Providing training, technical assistance, and consultation, including health and safety, to new facilities and to all caregivers/teachers;
6. Compiling data on supply and demand to identify community needs for child care;
7. Providing information to employers on options for their involvement in meeting community child care needs;
8. Participating in and/or supporting the state’s Quality Rating Improvement System (QRIS) and/or similar quality improvements;
9. Assisting programs in achieving accreditation and providers in achieving credentials.

RATIONALE: Resource and referral agencies provide a locus in the community to assist parents/guardians in fulfilling their childrearing responsibilities, a mechanism to coordinate and provide the resources and services that supplement and facilitate the functions of the family, and a mechanism for the coordination of services that helps keep children safe and healthy (1).

REFERENCES:

1. National Association of Child Care Resource and Referral Agencies (NACCRRA). 2008. Covering the map: Child care resource and referral agencies providing vital services to parents throughout the United States. Arlington, VA: NACCRRA. http://www.naccrra.org/publications/naccrra-publications/publications/Parent Svc Report_MECH_screen.pdf.

STANDARD 10.7.0.2: Coordination of Public and Private Resources to Ensure Families’ Access to Quality Child Care

National and state agencies should coordinate public and private resources to ensure that all families have access to affordable, safe, and healthy child care for their children. To the extent possible, communities should coordinate multiple funding streams to support child care. Strengthening the child care workforce through professional development opportunities and commensurate compensation should be a major goal in improving available child care.

RATIONALE: Research provides clear evidence that a well qualified and consistent staff is essential to the provision of good care for children (4). Quality cannot be attained by merely applying standards to caregivers/teachers; resources are necessary to meet the cost of quality care at a price that parents/guardians can afford. Quality care requires not only lower child:staff ratios and smaller group sizes, but also well trained staff to reduce the spread of infectious diseases, provide for safe evacuation and management of emergency situations, and to offer developmentally appropriate program activities (1). Currently, the low wages and benefits earned by child care staff result in high staff turnover, which adversely affects the health and safety of children. Staff wages make up the largest cost in providing care, and caregiver/teacher wages in the United States are currently too low to attract and retain qualified staff (4). Facilities cannot benefit from training provided to staff if the staff members leave their jobs before the training is implemented (1).

See The Child Care Bureau’s Case Studies of Public-Private Partnerships for Child Care (2) and Head Start State Collaboration Annual Profiles (3) for examples of successful state-wide collaborative projects.

REFERENCES:

1. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. Pediatrics 94:1108-10.

2. U.S. Department of Health and Human Services (HHS), Administration for Children and Families, Child Care Bureau. 1998. The child care partnership project: Case studies of public-private partnerships for child care. Fairfax, VA: National Child Care Information and Technical Assistance Center.

3. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. Head Start collaboration offices. http://eclkc.ohs.acf.hhs.gov/hslc/hsd/SCO/.

4. Gable, S., T. C. Rothrauff, K. R. Thornburg, D. Mauzy. Cash incentives and turnover in center-based child care staff. Early Childhood Res Quarter 22:363-78.