RATIOs for SMALL FAMILY CHILD CARE Homes
The small family child care home provider child:staff ratios shall conform to the following table:
If the small family child care home provider has no children under two years of age in care,
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then the small family child care home provider may have 1-6 children over two years of age in care
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If the small family child care home provider has 1 child under two years of age in care,
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then the small family child care home provider may have 1-3 children over two years of age in care
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If the small family child care home provider has 2 children under two years of age in care,
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then the small family child care home provider may have no children over two years of age in care
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The small family child care home provider's own children shall be included in the child:staff ratio.
TYPE OF FACILITY:
Small Family Child Care Home
RATIOS FOR LARGE FAMILY CHILD CARE HOMES AND CENTERS
Child:staff ratios in centers and large family child care homes shall be maintained as follows during all hours of operation, including transport and nap times:
During nap time, at least one adult shall be physically present in the same space as the children.
Other adults who are included in the child:staff ratio need not be in the same space with the children when all the children are napping. However, in case of emergency, these adults shall be on the same floor and shall have no barrier to their coming to help immediately. The caregiver who is in the same space with the children shall be able to summon these adults without leaving the children.
When there are mixed age groups in the same room, the child:staff ratio and group size shall be consistent with the age of most of the children when no infants or toddlers are in the mixed age group. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers shall be maintained. In large family child care homes with two or more caregivers caring for no more than 12 children, no more than three children younger than 2 years of age shall be in care.
TYPE OF FACILITY:
Center; Large Family Child Care Home
RATIOS FOR FACILITIES SERVING CHILDREN WITH SPECIAL HEALTH NEEDS
Facilities enrolling children with special needs shall determine, by an individual assessment of each child's needs, whether the facility requires a lower child:staff ratio.
TYPE OF FACILITY:
Center; Large Family Child Care Home: Small Family Child Care Home
RATIOS DURING TRANSPORTATION
Child:staff ratios established for out-of-home child care shall be maintained on all transportation the facility provides or arranges. The driver shall not be included in the ratio. No child of any age shall be left unattended in a vehicle.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
RATIOS FOR WADING AND SWIMMING
The following child:staff ratios shall apply while children are wading or swimming:
During any swimming/wading activity involving mixed developmental levels where either an infant or a toddler is present, the ratio shall always be 1 adult to 1 infant/toddler. The required ratio of adults to older children shall be met without including the adults who are required for supervision of infants and/or toddlers. An adult shall remain in direct physical contact with infants at all times during swimming or wading.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
REFERENCES AND BACKGROUND CHECKS
Directors of centers and caregivers in large and small family child care homes shall check references and examine employment history and criminal and other appropriate court records
(including fingerprinting and checks with state child abuse registries) before employing any staff member (including substitutes), even in states where licensing has not been instituted. Background checks shall be required for all child care providers.
When checking references, prospective employers shall specifically ask about previous convictions with child abuse or child sexual abuse. Failure of the prospective employee to disclose previous convictions of child abuse or child sexual abuse is grounds for dismissal.
Persons who acknowledge being sexually attracted to children or who acknowledge having physically or sexually abused children, or who are known to have committed such acts shall not be hired or allowed to work in the child care facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
PRESERVICE AND ONGOING STAFF TRAINING
In addition to the credentials listed in STANDARD 1.014, prior to employment, a director of a center or a small family child care home network enrolling 30 or more children shall provide documentation of at least 26 clock hours of training in health, psychosocial, and safety issues for out-of-home child care facilities.
Small family child care home providers shall provide documentation of at least 12 hours of training in child development and health management for out-of-home child care facilities prior to initiating operation.
All directors and caregivers shall document receipt of training that revisits the following topics every 3 years:
a) Child development knowledge and best practice, including knowledge about the developmental stages of each child in care;
b) Child care as a support to parents;
d) Ways that communicable diseases are spread;
e) Procedures for preventing the spread of communicable disease, including handwashing, sanitation, diaper changing, food handling, health department notification of reportable diseases, equipment, toy selection and proper washing, sanitizing to reduce the risk for disease and injury, and health issues related to having pets in the facility;
f) Immunization requirements for children and staff, as defined in
STANDARD 1.045;
g) Common childhood illnesses and their management, including child care exclusion policies;
h) Organization of the facility to reduce the risks for illness and injury;
i) Teaching child care staff and children about infection control and injury prevention;
j) Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
k) Emergency procedures, as defined in STANDARD 3.048 through STANDARD 3.052;
l) Promotion of health in the child care setting, through compliance with STANDARD 3.001 through STANDARD 3.089;
m) Management of a blocked airway, rescue breathing, and other first aid procedures, as required in
STANDARD 1.026;
n) Recognition and reporting of child abuse in compliance with state laws;
p) Knowledge of medication administration policies and practices;
q) Caring for children with special needs in compliance with the Americans with Disabilities Act (ADA);
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING CHILDREN BIRTH TO 35 MONTHS OF AGE
Caregivers shall be prepared to work with infants and toddlers and, when asked, shall be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:
f) Putting babies down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome (SIDS);
g) Providing
responsive and continuous interpersonal relationships and opportunities for child-initiated activities.
To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING CHILDREN 3 TO 5 YEARS OF AGE
Caregivers shall demonstrate the ability to apply their knowledge and understanding of the following, to children within the program setting:
a) Typical and atypical development of 3- to 5-year-old children;
b) Social and emotional development of children, including children's development of independence and their ability to adapt to their environment and cope with stress;
c) Cognitive, language, early literacy, and mathematics development of children through activities in the classroom;
d) Cultural backgrounds of the children in the facility's care by demonstrating cultural competence through interactions with children and families and through program activities.
To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
ADDITIONAL QUALIFICATIONS FOR CAREGIVERS SERVING SCHOOL-AGE CHILDREN
Caregivers shall demonstrate knowledge about and competence with the social and emotional needs and developmental tasks of 5- to 12-year old children, be able to recognize and appropriately manage difficult behaviors, and know how to implement a socially and cognitively enriching program that has been developed with input from parents.
To help manage atypical or disruptive behaviors of children, caregivers, in collaboration with parents, shall seek professional consultation from the child's source of routine health care or a mental health professional.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
QUALIFICATIONS OF EDUCATION COORDINATORS, LEAD TEACHERS, AND TEACHERS
Education coordinators, lead teachers, and teachers shall be at least 21 years of age and shall have at least the following education, experience, and skills:
a) A Bachelor's degree in early childhood education, child development, social work, nursing, or other child-related field, or a combination of experience and relevant college coursework;
b) One year or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care;
c) On-the-job training to provide a nurturing environment and to meet the child's out-of-home needs;
d) A valid certificate in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028;
e) Knowledge of normal child development and early childhood education, as well as knowledge of children who are not developing typically;
f) The ability to respond appropriately to children's needs;
g) The ability to recognize signs of illness and safety hazards;
h) Oral and written communication skills.
Every center, regardless of setting, shall have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care.
Additionally, facilities serving children with special needs associated with developmental delay shall have one licensed/certified teacher who is certified in special education.
initial orientation of all staff
All new full-time and part-time staff shall be oriented to, and demonstrate knowledge of, the items listed below. The director of any center or large family child care home shall provide this training to all newly hired caregivers before they begin to care for children. For centers, the director shall document, for each new staff member, the topics covered and the dates of orientation training. Staff members shall not be expected to take responsibility for any aspect of care for which their orientation and training have not prepared them.
Small family child care home providers shall avail themselves of orientation training offered by the licensing agency, a resource and referral agency, or other such agency. This training shall include evaluation that involves demonstration of the knowledge and skills covered in the training lesson.
The orientation shall address, at a minimum:
a) Regulatory requirements;
b) The goals and philosophy of the facility;
c) The names and ages of the children for whom the caregiver will be responsible, and their specific developmental needs;
d) Any special adaptation(s) of the facility required for a child with special needs for whom the staff member might be responsible at any time;
e) Any special health or nutrition need(s) of the children assigned to the caregiver;
f) The planned program of activities at the facility. See Program of Developmental Activities, STANDARD 2.001 through STANDARD 2.027;
g) Routines and transitions;
h) Acceptable methods of discipline. See Discipline, STANDARD 2.039 through STANDARD 2.043; and Discipline Policy, STANDARD 8.008 through STANDARD 8.010;
i) Policies and practices of the facility about relating to parents. See Parent Relationships, STANDARD 2.044 through STANDARD 2.057;
j) Meal patterns and food handling policies and practices of the facility. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; Food Service Records, STANDARD 8.074; Nutrition and Food Service, STANDARD 4.001 through STANDARD 4.070;
k) Occupational health hazards for caregivers, including attention to the physical health and emotional demands of the job and special considerations for pregnant caregivers. See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards, Appendix B;
l) Emergency health and safety procedures. See Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023; and Emergency Procedures, STANDARD 3.048 through STANDARD 3.052;
m) General health and safety policies and procedures, including but not limited to the following:
1) Handwashing techniques and indications for handwashing. See Handwashing, STANDARD 3.020 through STANDARD 3.024;
2) Diapering technique and toilet use, if care is provided to children in diapers and/or children needing help with toilet use, including appropriate diaper disposal and diaper-changing techniques. See Toilet, Diapering, and Bath Areas, STANDARD 5.116 through STANDARD 5.125; Toilet Use, Diapering, and Toilet Learning/Training, STANDARD 3.012 through STANDARD 3.019; Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033;
3) Identifying hazards and injury prevention;
4) Correct food preparation, serving, and storage techniques if employee prepares food. See Food Safety, STANDARD 4.042 through STANDARD 4.060;
5) Knowledge of when to exclude children due to illness and the means of illness transmission;
6) Formula preparation, if formula is handled. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; and Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021;
7) Standard precautions and other measures to prevent exposure to blood and other body fluids, as well as program policies and procedures in the event of exposure to blood/body fluid. See Prevention of Exposure to Body Fluids, STANDARD 3.026;
n) Recognizing symptoms of illness. See Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002;
o) Teaching health promotion concepts to children and parents as part of the daily care provided to children. See Health Education for Children, STANDARD 2.060 through STANDARD 2.063;
p) Child abuse detection, prevention, and reporting. See Child Abuse and Neglect, STANDARD 3.053 through STANDARD 3.059;
q) Medication administration policies and practices;
r) Putting infants down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Caregivers shall also receive continuing education each year, as specified in Continuing Education, STANDARD 1.029 through STANDARD 1.036.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
orientation for care of children with special health needs
When a child care facility enrolls a child with special needs, the facility shall ensure that staff members have been oriented in understanding that child's special needs and ways of working with that child in a group setting.
Caregivers in small family child care homes, who care for a child with special needs, shall meet with the parents and a health care worker involved with the child (if the parent has provided prior, informed, written consent) about the child's special needs and how these needs may affect his/her developmental progression or play with other children.
In addition to Orientation Training, STANDARD 1.023, the staff in child care facilities shall have orientation training based on the special needs of children in their care. This training may include, but is not limited to, the following topics:
a) Positioning for feeding and handling techniques of children with physical disabilities;
b) Proper use and care of the individual child's adaptive equipment, including how to recognize defective equipment and to notify parents that repairs are needed;
c) How different disabilities affect the child's ability to participate in group activities;
d) Methods of helping the child with special needs to participate in the facility's programs;
e) Role modeling, peer socialization, and interaction;
f) Behavior modification techniques, positive rewards for children, promotion of self-esteem, and other techniques for managing difficult behavior;
g) Grouping of children by skill levels, taking into account the child's age and developmental level;
h) Intervention for children with special health care problems;
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
first aid training for staff
The director of a center and a large
family child care home
and the caregiver in a small
family child care home shall ensure that all staff members involved in providing direct care have training in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in STANDARD 1.027.
At least one staff person who has successfully completed training in pediatric first aid, as specified in STANDARD 1.027, shall be in attendance at all times and in all places where children are in care. Instances in which at least one staff member shall be certified in CPR include when children are involved in swimming and wading and when at least one child is known to have a specific special health need as determined by that child's physician (such as cardiac arrhythmia) that makes the child more likely than a typical child to require cardiac resuscitation. In each case of a child with a special health need, the child care provider shall ask the child's physician whether caregivers with skills in the management of a blocked airway and rescue breathing will suffice, or whether caregivers require skills in cardiac resuscitation to meet the particular health needs of the child.
Records of successful completion of training in pediatric first aid, as specified in STANDARD 1.027, shall be maintained in the files of the facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
topics covered in first aid training
Management of a blocked airway and rescue breathing comprise two of the core elements of pediatric first aid training. In addition, the course must present an overview of the Emergency
Medical Services (EMS), accessing EMS, safety at the scene, and isolation of body substances, and the first aid instruction that is offered shall include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations:
a) Abrasions and lacerations;
b) Bleeding, including nosebleeds;
e) Poisoning, including swallowed, contact, and inhaled;
f) Puncture wounds, including splinters;
g) Injuries, including insect, animal, and human bites;
i) Convulsions or nonconvulsive seizures;
j) Musculoskeletal injury (such as sprains, fractures);
k) Dental and mouth injuries;
m) Allergic reactions, including information about when auto-injected epinephrine (Epi-Pen) might be required;
o) Loss of consciousness;
r) Heat-related injuries, including heat exhaustion/heat stroke;
t) Moving and positioning injured/ill persons;
u) Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner;
v) Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature of 105 degrees F or higher, or looking/acting severely ill);
x) Organizing and implementing a plan to meet an emergency for any child with a special health care need;
y) Addressing the needs of the other children in the group while managing emergencies in a child care setting.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
cpr training for swimming and wading
Facilities that have a swimming pool or use a water-filled wading pool shall require that at least one staff member with current documentation of successful completion of training in infant and child (pediatric) CPR (Cardiopulmonary Resuscitation) shall be on duty at all times during business hours.
At least one of the caregivers, volunteers, or other adults who is counted in the child:staff ratio for wading and swimming shall have documentation of successful completion of training in basic water safety and infant and child CPR according to the criteria of the American Red Cross or the American Heart Association.
For small family child care homes, the person trained in water safety and CPR shall be the caregiver. Written verification of successful completion of CPR and lifesaving training, water safety instructions, and emergency procedures shall be kept on file.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
continuing education for directors and caregivers in centers and large family child care homes
All directors and caregivers of centers and large family child care homes shall successfully complete at least 30 clock hours per year of continuing education in the first year of employment, 16 clock hours of which shall be in child development programming and 14 of which shall be in child health, safety, and staff health. In the second and each of the following years of employment at a facility, all directors and caregivers shall successfully complete at least 24 clock hours of continuing education based on individual competency needs and any special needs of the children in their care, 16 hours of which shall be in child development programming and 8 hours of which shall be in child health, safety, and staff health.
The effectiveness of training shall be assessed by change in performance following participation in training.
TYPE OF FACILITY:
Center; Large Family Child Care Home
continuing education for small family child care home providers
Small family child care home providers shall have at least 24 clock hours of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.
TYPE OF FACILITY:
Small Family Child Care Home
training of staff who handle food
All staff members with food handling responsibilities shall obtain training in food service. The director of a center or a large family child care home or the designated supervisor for food service shall obtain certification equivalent to the Food Service Manager's Protection (Sanitation) certificate.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caregivers shall use child abuse prevention education materials provided by the licensing agency, state and national organizations, or from other community agencies such as local branches of the National Committee to Prevent Child Abuse, to educate and establish child abuse prevention and recognition measures for the children, caregivers, and parents. The education and prevention shall address physical, sexual, and psychological or emotional abuse, injury prevention, the dangers of shaking infants and toddlers, as well as signs and symptoms of sexually transmitted diseases. Child care directors and head teachers shall participate in training to recognize visible signs of child abuse, including pattern marks, bruises in unusual locations, pattern or immersion burns, shaken baby syndrome, and behaviors suggesting sexual abuse. They shall know how to refer children with vaginal, penile, or rectal discharge or bleeding to their health provider. A child care provider shall refer the child to the local child protection agency for any reasonable suspicion of child abuse or neglect.
Caregivers shall be trained in compliance with their state's child abuse reporting laws.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
training on occupational risk related to handling body fluids
The director of a center or a large family child care home caregiver shall ensure that all staff members who are at risk of occupational exposure to blood or other blood-containing body fluids will be offered hepatitis B immunizations and will receive annual training in Standard Precautions. Training shall be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA Standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens") and local occupational health requirements and shall include, but not be limited to:
a) Modes of transmission of bloodborne pathogens;
c) Hepatitis B vaccine, pre-exposure, or post-exposure within 24 hours;
d) Program policies and procedures regarding exposure to blood/body fluid;
e) Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs.
TYPE OF FACILITY:
Center; Large Family Child Care Home
employment of substitutes
Substitutes shall be employed to ensure that child:staff ratios (as specified in Child:Staff Ratio and Group Size,
STANDARD 1.001 through
STANDARD 1.005) are maintained at all times. Substitutes and volunteers must meet the requirements specified in General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.013. Those without licenses/certificates shall work under direct supervision and shall not be alone with a group of children.
A substitute shall have the same clearances as the provider including criminal record check, child abuse history, and medical assessment.
TYPE OF FACILITY:
Center; Large Family Child Care Home
orientation for substitutes for small family child care homes
A short-term substitute caregiver in a small family child care home shall be oriented on the first day of employment to emergency response practices, including how to call for emergency medical assistance, how to reach parents or emergency contacts, how to arrange for transfer to medical care, and the evacuation plan.
TYPE OF FACILITY:
Small Family Child Care Home
Use of child care health consultants
Each center, large family child care home, and small family child care home network shall use the services of a health consultant qualified to provide advice for child care as defined in STANDARD 1.041. Centers and large and small family child care home providers shall avail themselves of community resources established for health consultation to child care.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Knowledge and skills of child care health consultants
A facility shall have a health consultant who is a health professional with training and experience as a child care health consultant. Graduate students in a discipline related to child health shall be acceptable as child care health consultants supervised by faculty knowledgeable in child care. A child care health consultant shall either have the full knowledge base and skills required for this role, or arrange to partner with other health professionals who can provide the necessary knowledge and skills.
The knowledge base of the child care health consultant (personally or by involving other health professionals) shall include:
a) National health and safety standards for out-of-home child care;
b) How child care facilities conduct their day-to-day operations;
c) Child care licensing requirements;
d) Disease reporting requirements for child care providers;
e) Immunizations for children;
f) Immunizations for child care providers;
g) Injury prevention for children;
h) Staff health, including occupational health risks for child care providers;
i) Oral health for children;
j) Nutrition for children;
k) Inclusion of children with special health needs in child care;
l) Recognition and reporting requirements for child abuse and neglect;
m) Community health and mental health resources for child and parent health.
The skills of the child care health consultant shall include the ability to perform or arrange for performance of the following activities:
a) Teaching child care providers about health and safety issues;
b) Teaching parents about health and safety issues;
c) Assessing child care providers' needs for health and safety training;
d) Assessing parents' needs for health and safety training;
e) Meeting on-site with child care providers about health and safety;
f) Providing telephone advice to child care providers about health and safety;
g) Providing referrals to community services;
h) Developing or updating policies and procedures for child care facilities;
i) Reviewing health records of children;
j) Reviewing health records of child care providers;
k) Helping to manage the care of children with special health care needs;
l) Consulting with a child's health professional about medication;
m) Interpreting standards or regulations and providing technical advice, separate and apart from the enforcement role of a regulation inspector.
Although the child care health consultant may have a dual role, such as providing direct care to some of the children or serving as a regulation inspector, these roles shall not be mixed with the child care health consultation role.
The child care health consultant shall have contact with the facility's administrative authority, the staff, and the parents in the facility. The administrative authority shall review, respond to, and implement the child care health consultant's recommendations. The child care health consultant shall review and approve the written health policies used by center-based facilities.
Programs with a significant number of non-English-speaking families shall seek a child care health consultant who is culturally sensitive and knowledgeable about community health resources for the parents' native culture and languages.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
frequency of child care health consultation visits
The health consultant shall visit each facility as needed to review and give advice on the facility's health component. Center-based facilities that serve any child younger than 2 years of age shall be visited at least once a month by a health professional with general knowledge and skills in child health and safety. Center-based facilities that are not open at least 5 days a week or that serve only children 2 years of age or older shall be visited at least quarterly, on a schedule that meets the needs of the composite group of children. Small and large family child care homes shall be visited at least annually. Written documentation of health consultant visits shall be maintained at the facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
PREEMPLOYMENT AND ONGOING ADULT HEALTH APPRAISALS, INCLUDING IMMUNIZATION
All paid and volunteer
staff members who work more than 40 hours per month shall have a health appraisal before their first involvement in child care work. Health appraisals shall be required every 2 years thereafter, unless the staff member's health provider recommends that this be done more frequently. If a child care provider works also at a different child care facility, a new health appraisal shall be required if there is a question about the results of the previous health appraisal, 2 years have elapsed since the previous health appraisal, or signs of ill health appear. People who work less than 40 hours per month shall be encouraged to have a health appraisal. The appraisal shall identify any accommodations required of the facility for the staff person to function in his or her assigned position. A statement from the health care provider that an appraisal covering the listed areas was completed, and details about any findings that require accommodation shall be on file at the facility.
Health appraisals for paid and volunteer staff members who work more than 40 hours per month shall include at a minimum:
d) Vision and hearing screening;
e) The results and appropriate follow-up of a tuberculosis (Tb) screening using the Mantoux intradermal skin test, one-step procedure. See STANDARD 6.014;
f) A review and certification of up-to-date immune status (measles, mumps, rubella, diphtheria, tetanus, polio, varicella, influenza, pneumonia, hepatitis A, and hepatitis B). See Immunizations, STANDARD 3.005 through STANDARD 3.007;
g) A review of occupational health concerns based on the performance of the essential functions of the job.
See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards, Appendix B;
h) Assessment of risk from exposure to common childhood infections, such as parvovirus, CMV, and chickenpox;
i) Assessment of orthopedic, psychological, neurological, or sensory limitations or communicable diseases that require accommodations or modifications for the person to perform tasks that typical adults can do.
All adults who reside in a family child care home who are considered to be at high risk for Tb, and all adults who work less than 40 hours in any month in child care shall have completed Tb screening as specified in STANDARD 6.014. Adults who are considered at high risk for Tb include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active Tb.
The Tb test of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation shall be on file in the facility.
All adults who work in child care shall be encouraged to have a full health appraisal.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
DAILY STAFF HEALTH Assessment
On a daily basis, the administrator of the facility or caregiver shall assess (visually and verbally) staff members, substitutes, and volunteers for obvious signs of ill health. Staff members, substitutes, and volunteers shall be responsible for reporting immediately to their supervisor any injuries or illnesses they experience at the facility or elsewhere, especially those that might affect their health or the health and safety of the children. It is the responsibility of the administration, not the ill or injured staff member, to arrange for a substitute provider.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The center's written personnel policies shall address the major occupational health hazards for workers in child care settings. Special health concerns of pregnant providers shall be carefully evaluated, and up-to-date information regarding occupational hazards for pregnant providers shall be made available to them and other workers. The occupational hazards including those regarding pregnant workers listed in Appendix B (
Major Occupational Health Hazards) shall be referenced and used in evaluations by providers and supervisors.
TYPE OF FACILITY:
Center; Large Family Child Care Home
CHAPTER 2 - PROGRAM: ACTIVITIES FOR HEALTHY DEVELOPMENT
communication in native language
At least one member of the staff shall be able to communicate in the native language of the parents and children, or the facility shall work with parents to arrange for a translator to communicate with parents and children.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Children shall play outdoors daily when weather and air quality conditions do not pose a significant health risk. Outdoor play for infants may include riding in a carriage or stroller; however, infants shall be offered opportunities for gross motor play outdoors, as well.
Weather that poses a significant health risk shall include wind chill at or below 15 degrees F and heat index at or above 90 degrees F, as identified by the National Weather Service.
Air quality conditions that pose a significant health risk shall be identified by announcements from local health authorities or through ozone (smog) alerts. Such air quality conditions shall require that children remain indoors where air conditioners ventilate indoor air to the outdoors. Children with respiratory health problems such as asthma shall not play outdoors when local health authorities announce that the air quality is approaching unhealthy levels.
Children shall be protected from the sun by using shade, sun-protective clothing, and sunscreen with UVB-ray and UVA-ray protection of SPF-15 or higher, with permission as described in STANDARD 3.081, during outdoor play. Before prolonged physical activity in warm weather, children shall be well-hydrated and shall be encouraged to drink water during the activity. In warm weather, children's clothing shall be light-colored, lightweight, and limited to one layer of absorbent material to facilitate the evaporation of sweat. Children shall wear sun-protective clothing, such as hats, long-sleeved shirts and pants, when playing outdoors between the hours of 10
AM and 2
PM.
In cold weather, children's clothing shall be layered and dry. Caregivers shall check children's extremities for maintenance of normal color and warmth at least every 15 minutes when children are outdoors in cold weather.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
personal caregiver relationships for infants and toddlers
Opportunities shall be provided for each child to develop a personal and affectionate relationship with, and attachment to, that child's parents and one or a small number of caregivers whose care for and responsiveness to the child ensure relief of distress, experiences of comfort and stimulation, and satisfaction of the need for a personal relationship. The facility shall limit the number of caregivers who interact with any one infant to no more than three caregivers in a given day and no more than five caregivers across the period that the child is an infant in child care. The caregivers shall:
a) Hold and comfort children who are upset;
b) Engage in social interchanges such as smiling, talking, touching, singing, and eating;
c) Be play partners as well as protectors;
d) Attune to children's feelings and reflect them back.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
interactions with infants and toddlers
Caregivers shall talk, listen to, and otherwise interact with young infants as they feed, change, and cuddle them.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
space and activity to support learning of infants and toddlers
The facility shall provide a safe and clean space, both indoors and outdoors, and colorful material and equipment arranged to support learning. The facility shall provide opportunities for the child to act upon the environment by experiencing age-appropriate obstacles, frustrations, and risks in order to learn to manage inner feelings and resources, as well as the occurrences and demands of the outer world. The facility shall provide opportunities for play that:
Lessen the child's anxiety and help the child adapt to reality and resolve conflicts;
Enable the child to explore the real world;
Help the child practice resolving conflicts;
Use symbols (words, numbers, and letters);
Exercise physical skills;
Encourage language development;
Strengthen the child's identity as a member of a family and a cultural community.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
personal caregiver relationships for
Facilities shall provide opportunities for each child to build long-term, trusting relationships with a few caring caregivers by limiting the number of adults the facility permits to care for any one child in child care to a maximum of 8 adults in a given year and no more than 3 in a day.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
opportunities for learning for 3- to 5-year-olds
Facilities shall provide opportunities for children to observe, explore, order and reorder, make mistakes and find solutions, and move from the concrete to the abstract in learning.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Facilities shall foster a cooperative rather than a competitive atmosphere.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caregivers shall directly supervise infants, toddlers, and preschool children by sight and hearing at all times, even when the children are in sleeping areas. Caregivers shall not be on one floor level of the building, while children are on another floor.
School-age children shall be permitted to participate in activities off the premises with written approval by a parent and by the caregiver.
Caregivers shall regularly count children on a scheduled basis, at every transition, and whenever leaving one area and arriving at another, to confirm the safe whereabouts of every child at all times.
Developmentally appropriate child:staff ratios shall be met during all hours of operation, including indoor and outdoor play and field trips, following precautions for specific areas and equipment. No center-based facility shall operate with fewer than two staff members if more than six children are in care, even if the group otherwise meets the child:staff ratio. Although centers often downsize the number of staff for the early arrival and late departure times, another adult must be present to help in the event of an emergency. The supervision policies of centers and large family child care homes shall be written policies.
Editor's Note: This standard also applies to outdoor activities.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
competence and training of transportation staff
At least one adult who accompanies or drives children for field trips and out-of-facility activities shall receive training by a professional knowledgeable about child development and procedures to ensure the safety of all children. The caregiver shall hold a valid pediatric first aid certificate, including rescue breathing and management of blocked airways, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028.
All drivers, passenger monitors, chaperones, and assistants shall receive instructions in safety precautions. If transportation is provided, these instructions shall include:
a) Use of developmentally appropriate safety restraints;
b) Proper placement of the child in the motor vehicle;
c) Handling of emergency situations. If a child has a chronic medical condition that could result in an emergency (such as asthma, diabetes, seizures), the driver or chaperone shall have written instructions including parent emergency contacts, child summary health information, special needs, and treatment plans, and shall be trained to;
1) Recognize the signs of a medical emergency;
2) Know emergency procedures to follow;
3) Have on-hand, any emergency supplies or medications necessary;
d) Map and appropriate route to emergency facility;
f) Child supervision during transport, including never leaving a child unattended in a vehicle.
The receipt of such instructions shall be documented in a personnel record for any paid staff or volunteer who participates in field trips or
transportation activities. Child:staff ratios shall be maintained on field trips and during transport, as specified in STANDARD 1.001 through STANDARD 1.005.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
qualifications for drivers
Any driver who transports children for a child care program shall be at least 21 years of age and shall have:
a) A valid driver's license that authorizes the driver to operate the vehicle being driven;
b) Evidence of a safe driving record for more than five years, with no crashes where a citation was issued;
c) No record of substance abuse or conviction for crimes of violence or child abuse;
d) No alcohol or other drugs associated with impaired ability to drive within 12 hours prior to transporting children. Drivers shall ensure that any prescription drugs taken will not impair their ability to drive;
e) No criminal record of crimes against or involving children, child neglect or abuse, or any crime of violence.
The driver's license number, vehicle insurance information, and verification of current state vehicle inspection shall be on file in the facility.
The center director shall require drug testing when noncompliance with the restriction on the use of alcohol or other drugs is suspected.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
vehicle safety restraints
When children are driven in a motor vehicle other than a bus, school bus, or a bus operated by a common carrier, the following shall apply:
A child shall be transported only if the child is fastened in an approved developmentally appropriate safety seat, seat belt, or harness appropriate to the child's weight, and the restraint is installed and used in accordance with the manufacturers' instructions for the car seat and the motor vehicle. Each child must have an individual seat belt and be positioned in the vehicle in accordance with the requirements for the safe use of air bags in the back seat;
A child under the age of 4 shall be transported only if the child is securely fastened in a developmentally appropriate child passenger restraint system that meets the federal motor vehicle safety standards contained in the Code of Federal Regulations, Title 49, Section 571.213, and this compliance is so indicated on the safety restraint device;
If small buses or vans have safety restraints installed, children weighing over 40 pounds shall have access to belt-positioning booster seats with lap and shoulder belts. Children weighing under 40 pounds shall use car safety seats;
Vehicles shall accommodate the placement of wheelchairs with four tie-downs affixed according to the manufactures' instructions in a forward-facing direction. The wheelchair occupant shall be secured by a three-point tie restraint during transport.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
emergency supplies for field trips
First aid kits shall be taken on field trips, as specified in STANDARD 5.093. Cellular phones shall be taken on field trips for use in emergency situations.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Discipline shall include positive guidance, re-direction, and setting clear-cut limits that foster the child's ability to become self-disciplined. Disciplinary measures shall be clear and understandable to the child, shall be consistent, and shall be explained to the child before and at the time of any disciplinary action.
Caregivers shall guide children to develop self control and orderly conduct in relationships with peers and adults. Caregivers shall show children positive alternatives rather than just telling children "no." Caregivers shall care for children without resorting to physical punishment or abusive language. Caregivers shall acknowledge and model desired behavior.
For children 3 or over, facilities shall selectively use "time out" only to enable the child to regain control of himself or herself. The caregiver shall keep the child within visual contact. The caregiver shall take into account the child's developmental stage, tolerances, and ability to learn from "time out."
Expectations for children's behavior shall be written and shared with families and children of appropriate age.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
prohibited caregiver behaviors
The following behaviors shall be prohibited in all child care settings and by all caregivers:
a) Corporal punishment, including beating, hitting, spanking, shaking, pinching, excessive exercise, exposure to extreme temperatures, and other measures producing physical pain;
b) Withdrawal or the threat of withdrawal of food, or forcing of food, rest, or bathroom opportunities;
c) Abusive or profane language or verbal abuse, threats, or derogatory remarks about the child or child's family;
d) Any form of public or private humiliation, including threats of physical punishment;
e) Any form of emotional abuse, including rejecting, terrorizing, ignoring, isolating, or corrupting a child;
f) Binding or tying to restrict movement, such as in a car seat (except when travelling); or enclosing in a confined space such as a closet, locked room, box, or similar cubicle.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
When a child's behavior makes it necessary, for his own or others' protection, to restrain the child, the most desirable method of restraint is holding the child by another person as gently as possible to accomplish the restraint. Children shall not be physically restrained longer than necessary to control the situation. No bonds, ties, or straps shall be employed to restrain young children.
Children shall not be given medicines, drugs, or herbal or folk remedies that will affect their behavior except as prescribed by their health care provider and with specific written instructions from their health care provider for use of the medicine.
The decision to restrain the child shall be made by the staff person with the most experience in child care and shall only be made for extreme circumstances. Training in the use of any form of physical restraint shall be provided by persons with extensive child care experience including experience with children who have required restraint.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
mutual responsibility of parents and staff
There shall be a reciprocal responsibility of the family and child care staff to observe, participate, and be trained in the care that each child requires.
All aspects of child care programs shall be designed to facilitate parental input and involvement. Involved, non-custodial parents shall have access to the same developmental and behavioral information given to the custodial parent, if they have joint legal custody, permission by court order, or written consent from the custodial parent.
Caregivers shall informally share with parents daily information about their child's needs and activities.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caregivers shall inform all parents that they may visit the site at any time when their child is there, and that, under normal circumstances, they will be admitted without delay. This open-door policy shall be part of the "admission agreement" or other contract between the parent and the caregiver, if they have custody, joint custody, permission by court order, or written consent from the custodial parent. Parents are welcomed and encouraged to speak freely to staff about concerns and suggestions.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Along with short informal daily conversations between parents and caregivers, planned communication (for example, parent conferences) shall be scheduled with at least one parent of every child in care:
a) To review the child's development and adjustment to care;
b) To reach agreement on appropriate, nonviolent, disciplinary measures;
c) To discuss the child's strengths, specific health issues, and concerns such as persistent behavior problems, developmental delays, special needs, overweight, underweight, or eating or sleeping problems.
At these planned conferences a caregiver shall review with the parent the child's health report and the health record to identify medical and developmental issues that require follow-up or adjustment of the facility.
Each review shall be documented in the child's facility health record with the signature of the parent and the staff reviewer. These planned conferences shall occur:
a) As part of the intake process;
b) At each health update interval;
c) On a calendar basis, scheduled according to the child's age:
1) Every 6 months for children under 6 years of age;
2) Every year for children 6 years of age and older;
d) Whenever new information is added to the child's facility health record.
Additional conferences shall be scheduled if the parent or caregiver has a concern at any time about a particular child. Any concern about a child's health or development shall not be delayed until a scheduled conference date.
Notes about these planned communications shall be maintained in each child's record at the facility and shall be available for review.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
parents' information on their child's health and behavior
The facility shall ask parents for information regarding the child's health and behavioral status upon registration or if there has been an extended gap in the child's attendance at the facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
CHAPTER 3 - HEALTH PROMOTION AND PROTECTION IN CHILD CARE
Conduct of Daily Health Check
Every day, a trained staff member shall conduct a health check of each child. This health check shall be conducted as soon as possible after the child enters the child care facility and whenever a change occurs while that child is in care. The health check shall address:
a) Changes in behavior (such as lethargy or drowsiness) or appearance from behaviors observed during the previous day's attendance;
b) Skin rashes, itchy skin, itchy scalp, or (during a lice outbreak) nits;
c) If there is a change in the child's behavior or appearance, elevated body temperature, determined by taking the child's temperature;
d) Complaints of pain or of not feeling well;
e) Other signs or symptoms of illness (such as drainage from eyes, vomiting, diarrhea, and so on);
f) Reported illness or injury in child or family members since last date of attendance.
The facility shall gain information necessary to complete the daily health check by direct observation of the child, by querying the parent or legal guardian, and, where applicable, by conversation with the child.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
If immunizations are not to be administered because of a medical condition, a statement from the child's health care provider documenting the reason why the child is exempt from the immunization requirement shall be on file.
If immunizations are not given because of parents' religious beliefs, a waiver signed by the parent shall be on file. If a child who is not immunized is in care, the parents must be notified of the risk of the spread of preventable diseases.
Children who have not received their age-appropriate immunizations prior to enrollment and do not have documented religious or medical exemptions from routine childhood immunizations shall show evidence of an appointment for immunizations. The immunization series shall be initiated within one month and completed according to the
Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP). See Appendix G.
If a vaccine-preventable disease to which children are susceptible occurs in the facility, unimmunized children shall be excluded for the duration of possible exposure or until the age-appropriate immunizations have been completed (whichever comes first).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Scheduled Rest Periods and Sleep Arrangements
The facility shall provide an opportunity for, but shall not require, sleep and rest. The facility shall make available a regular rest period for school-aged children, if the child desires. For children who are unable to sleep, the facility shall provide time and space for quiet play.
Unless the child has a note from a physician specifying otherwise, infants shall be placed in a supine (back) position for sleeping to lower the risks of Sudden Infant Death Syndrome (SIDS). Soft surfaces and gas-trapping objects such as pillows, quilts, sheepskins, soft bumpers or waterbeds shall not be placed under or with an infant for sleeping. When infants can easily turn over from the supine to the prone position, they shall be put down to sleep on their back, but allowed to adopt whatever position they prefer for sleep.
Unless a doctor specifies the need for a positioning device that restricts movement within the child's bed, such devices shall not be used.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Routine Oral Hygiene activities
Caregivers shall promote the habit of regular tooth brushing. All children with teeth shall brush or have their teeth brushed at least once during the hours the child is in child care. Using a size-appropriate brush and a small amount of fluoride toothpaste, the caregiver shall either brush the child's teeth or supervise as the child brushes his/her own teeth. The younger the child the more the caregiver needs to be involved. After feeding, an infant's teeth and gums shall be wiped with a moist cloth to remove any remaining liquid that coats the teeth and gums and which turns to plaque causing tooth decay. Very few preschool-age children have the hand-eye coordination or the fine motor skills necessary to complete the complex process of tooth brushing. The caregiver shall be able to evaluate each child's motor activity and to teach the child the correct method of tooth brushing when the child is capable of doing this activity. The caregiver shall monitor the tooth brushing activity and thoroughly brush the child's teeth after the child has finished brushing.
The cavity-causing effect of frequent exposure to food shall be reduced by offering the children rinsing water after snacks when brushing is not possible.
Editor's Note: The rationale and comment sections of this standard indicate that a small amount equals "pea size" amount.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
All children with teeth shall have oral hygiene as a part of their daily activity. Those two years and older shall have developmentally appropriate oral health education that includes information on what plaque is, the process of dental caries development, and the importance of good oral hygiene behaviors. School-age children shall receive additional information including the preventive use of fluoride, dental sealants, mouth guards, and the importance of healthy eating behaviors and regularly scheduled dental visits. Older children shall be informed about the effect of tobacco products on their oral health and additional reasons for avoidance.
Diapers worn by children shall be able to contain urine and stool and minimize fecal contamination of the children, caregivers, environmental surfaces, and objects in the child care setting. Only disposable diapers with absorbent gelling material or carboxymethyl cellulose may be used unless the child has a medical reason that does not permit the use of disposable diapers (such as allergic reactions). When children cannot use disposable diapers for a medical reason, the reason shall be documented by the child's health care provider.
When cloth diapers are used, the diaper shall have an absorbent inner lining completely contained within an outer covering made of waterproof material that prevents the escape of feces and urine. The outer covering and inner lining shall be changed together at the same time as a unit and shall not be reused unless both are cleaned and disinfected, washed, and either chemically disinfected or heat dried at 165 degrees F or more. No rinsing or dumping of the contents of the diaper shall be performed at the child care facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The following diaper changing procedure shall be posted in the changing area, shall be followed for all diaper changes, and shall be used as part of staff evaluation of caregivers who do diaper changing. Child caregivers shall never leave a child alone on a table or countertop, even for an instant. A safety strap or harness shall not be used on the diaper changing table. If an emergency arises, caregivers shall put the child on the floor or take the child with them.
Step 1: Get organized. Before you bring the child to the diaper changing area, wash your hands, gather and bring what you need to the diaper changing table:
Non-absorbent paper liner large enough to cover the changing surface from the child's shoulders to beyond the child's feet;
Fresh diaper, clean clothes (if you need them);
Wipes for cleaning the child's genitalia and buttocks removed from the container or dispensed so the container will not be touched during diaper changing;
A plastic bag for any soiled clothes;
Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers);
A thick application of any diaper cream (when appropriate) removed from the container to a piece of disposable material such as facial or toilet tissue.
Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change.
Always keep a hand on the child;
If the child's feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child's shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing;
Put soiled clothes in a plastic bag and securely tie the plastic bag to send the soiled clothes home.
Step 3: Clean the child's diaper area.
Place the child on the diaper change surface and unfasten the diaper but leave the soiled diaper under the child.
If safety pins are used, close each pin immediately once it is removed and keep pins out of the child's reach. Never hold pins in your mouth.
Lift the child's legs as needed to use disposable wipes to clean the skin on the child's genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe each time. Put the soiled wipes into the soiled diaper or directly into a plastic-lined, hands-free covered can.
Step 4: Remove the soiled diaper without contaminating any surface not already in contact with stool or urine.
Fold the soiled surface of the diaper inward.
Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents or laundry service.
If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
Whether or not gloves were used, use a disposable wipe to clean the surfaces of the caregiver's hands and another to clean the child's hands, and put the wipes into the plastic-lined, hands-free covered can.
Check for spills under the child. If there are any, use the paper that extends under the child's feet to fold over the disposable paper so a fresh, unsoiled paper surface is now under the child's buttocks.
Step 5: Put on a clean diaper and dress the child.
Slide a fresh diaper under the child.
Use a facial or toilet tissue to apply any necessary diaper creams, discarding the tissue in a covered, plastic-lined, hands-free covered can.
Note and plan to report any skin problems such as redness, skin cracks, or bleeding.
Fasten the diaper. If pins are used, place your hand between the child and the diaper when inserting the pin.
Step 6: Wash the child's hands and return the child to a supervised area.
Use soap and water, no less than 60 degrees F and no more than 120 degrees F, at a sink to wash the child's hands, if you can.
If a child is too heavy to hold for handwashing or cannot stand at the sink, use commercial disposable diaper wipes or follow this procedure:
Wipe the child's hands with a damp paper towel moistened with a drop of liquid soap.
Wipe the child's hands with a paper towel wet with clear water.
Dry the child's hands with a paper towel.
Step 7: Clean and sanitize the diaper-changing surface.
Dispose of the disposable paper liner used on the diaper changing surface in a plastic-lined, hands-free covered can.
Clean any visible soil from the changing surface with detergent and water; rinse with water.
Wet the entire changing surface with the sanitizing solution (e.g. spray a sanitizing bleach solution of 1/4 cup of household liquid chlorine bleach in one gallon of tap water, mixed fresh daily).
Put away the spray bottle of sanitizer. If the recommended bleach dilution is sprayed as a sanitizer on the surface, leave it in contact with the surface for at least 2 minutes. The surface can be left to air dry or can be wiped dry after 2 minutes of contact with the bleach solution.
Step 8: Wash your hands according to the procedure in STANDARD 3.021 and record the diaper change in the child's daily log.
In the daily log, record what was in the diaper and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation). Report as necessary.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Situations That Require Handwashing
All staff, volunteers, and children shall follow the procedure in STANDARD 3.021 for handwashing at the following times:
a) Upon arrival for the day or when moving from one child care group to another;
Eating, handling food, or feeding a child;
Playing in water that is used by more than one person.
Using the toilet or helping a child use a toilet;
Handling bodily fluid (mucus, blood, vomit), from sneezing, wiping and blowing noses, from mouths, or from sores;
Handling uncooked food, especially raw meat and poultry;
Handling pets and other animals;
Cleaning or handling the garbage.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Children and staff members shall wash their hands using the following method:
a) Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
b) Turn on warm water, no less than 60 degrees F and no more than 120 degrees F, to a comfortable temperature.
c) Moisten hands with water and apply liquid soap to hands.
d) Rub hands together vigorously until a soapy lather appears, and continue for at least 10 seconds. Rub areas between fingers, around nailbeds, under fingernails, jewelry, and back of hands.
e) Rinse hands under running water, no less than 60 degrees F and no more than 120 degrees F, until they are free of soap and dirt. Leave the water running while drying hands.
f) Dry hands with the clean, disposable paper or single use cloth towel.
g) If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel.
h) Throw the disposable paper towel into a lined trash container; or place single-use cloth towels in the laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping of hands, if desired.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Assisting Children with Handwashing
Caregivers shall provide assistance with handwashing at a sink for infants who can be safely cradled in one arm and for children who can stand but not wash their hands independently. A child who can stand shall either use a child-size sink or stand on a safety step at a height at which the child's hands can hang freely under the running water. After assisting the child with handwashing, the staff member shall wash his or her own hands.
If a child is unable to stand and is too heavy to hold safely to wash the hands at the sink, caregivers shall use the following method:
Wipe the child's hands with a damp paper towel moistened with a drop of liquid soap. Then discard the towel.
Wipe the child's hands with a clean, wet, paper towel until the hands are free of soap. Then discard the towel.
Dry the child's hands with a clean paper towel.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Procedure For Nasal Secretions
Staff members and children shall blow or wipe their noses with disposable, one-use tissues and then discard them in a plastic-lined, covered, hands-free trash container. After blowing the nose, they shall wash their hands, as specified in STANDARD 3.021 and STANDARD 3.022.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Prevention of Exposure to Blood and Bodily Fluids
Child care facilities shall adopt a modified version of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention as defined in this standard and as may be recommended by the Centers for Disease Control and Prevention for child care settings in the future. This modified version of Standard Precautions shall be used to handle potential exposure to blood, including the blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.
In child care settings, exceptions to Standard Precautions as defined by the Centers for Disease Control and Prevention for hospital settings shall include:
a) Use of non-porous gloves is optional unless blood or blood containing body fluids may be involved. Gloves are not required for feeding human milk or cleaning up of spills of human milk.
b) Gowns and masks are not required.
c) Sufficient barriers include materials such as disposable diaper table paper that is moisture resistant, and non-porous gloves.
The staff shall be educated regarding routine precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. The staff training shall comply with requirements of the Occupational Safety and Health Administration (OSHA), where applicable.
Procedures for Standard Precautions shall include:
a) Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be sanitized. Use of materials that can be sterilized is not required.
b) The staff shall use barriers and techniques that:
1) Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges and
2) Reduce the spread of infectious material within the child care facility.
Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are sanitized before further contact occurs with them by other objects or individuals.
c) When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges, and human milk occur, these spills shall be cleaned up immediately, and further managed as follows:
1) For spills of vomit, urine, human milk, and feces, all floors, walls, bathrooms, tabletops, toys, kitchen counter tops, and diaper-changing tables in contact shall be cleaned and sanitized as for the procedure for diaper changing tables in STANDARD 3.014, Step 7.;
2) For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area shall be cleaned and sanitized. Care shall be taken to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
3) Blood-contaminated material and diapers shall be disposed of in a plastic bag with a secure tie.
4) Floors, rugs and carpeting that have been contaminated by body fluids shall be cleaned by blotting to remove the fluid as quickly as possible, then sanitized by spot-cleaning with a detergent-disinfectant, and shampooing, or steam-cleaning the contaminated surface.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Feeding Of Human Milk To Another Mother's Child
If a child has been fed another child's bottle of expressed human milk, this shall be treated as an accidental exposure to a potential HIV-containing body fluid. Providers shall:
a) Inform the parents of the child who was given the wrong bottle that:
1) Their child was given another child's bottle of expressed human milk;
2) The risk of transmission of HIV is very small;
3) They should notify the child's physician of the exposure;
4) The child should have a baseline test for HIV and a follow-up test six months later.
5) The mother of the child should have an HIV test immediately and a follow-up test six months later.
b) Inform the mother who expressed the human milk of the bottle switch and ask:
1) If she has ever had an HIV test and, if so, if she would be willing to share the results with the parents of the exposed child;
2) If she does not know if she has ever had an HIV test, if she would be willing to contact her obstetrician and find out, and if she has, share the results with the parents;
3) If she has never had an HIV test, if she would be willing to have one immediately and a follow-up test six months later and share results with the parents;
4) If the mother has had a previous test more than six months prior to the incident, if she would be willing to have a test immediately and a follow-up test six months later and share results with the parents;
5) When the human milk was expressed and how it was handled before being brought to the facility.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Routine Frequency of Cleaning and Sanitation
The routine frequency of cleaning and sanitation in the facility shall be as indicated in the table below. This frequency shall be increased from baseline routine frequencies whenever there are outbreaks of illness, there is known contamination, visible soil, or when recommended by the health department to control certain infectious diseases. All surfaces, furnishings, and equipment that are not in good repair or that have been contaminated by body fluids shall be taken out of service until they are repaired, cleaned, and, if contaminated, sanitized effectively.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Use of potty chairs shall be discouraged. If potty chairs are used, they shall be emptied into a toilet, cleaned in a utility sink, sanitized after each use, and stored in the bathroom. After the potty is sanitized, the utility sink shall also be sanitized.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Rags and Disposable Towels Used for Cleaning
Disposable towels shall be preferred for cleaning. If clean reusable rags are used, they shall be laundered separately between uses for cleaning. Disposable towels shall be sealed in a plastic bag and removed to outside garbage. Cloth rags shall be placed in a closed, foot-operated receptacle until laundering.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
use of toys that can be washed and sanitized
Toys that cannot be washed and sanitized shall not be used. Toys that children have placed in their mouths or that are otherwise contaminated by body secretion or excretion shall be set aside where children cannot access them. They must be set aside until they are washed with water and detergent, rinsed, sanitized, and air-dried by hand or in a mechanical
dishwasher that meets the requirements of STANDARD 4.063 through STANDARD 4.065. Play with plastic or play foods shall be closely supervised to prevent shared mouthing of these toys.
Machine washable cloth toys shall be for use by one individual only until these toys are laundered.
Indoor toys shall not be shared between groups of infants or toddlers unless they are washed and sanitized before being moved from one group to the other.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Objects Intended For the Mouth
Thermometers, pacifiers, teething toys, and similar objects shall be cleaned and reusable parts shall be sanitized between uses. Pacifiers shall not be shared.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Routine Checks of Play Equipment
A staff member shall be assigned to check all play equipment at least monthly to ensure that it is safe for children. In addition, the staff shall observe equipment while children are playing on it to ensure that it is safe for children.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Tobacco Use and Prohibited Substances
Tobacco use, alcohol, and illegal drugs shall be prohibited on the premises of the facility at all times.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Supervision Near Bodies of Water
Children shall not be permitted to play without constant supervision in areas where there is any body of water, including swimming pools, built-in wading pools, tubs, pails, sinks, or toilets, ponds and irrigation ditches.
Children who need assistance with toileting shall not be allowed in toilet or bathroom facilities without direct visual supervision. Children less than 5 years of age shall not be left unattended in a bathtub or shower.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
When an immediate response is required, the following emergency procedures shall be utilized:
a) First aid shall be employed, and the emergency medical response team shall be called, as indicated;
b) The facility shall implement a plan for emergency transportation to a local hospital or health care facility;
c) The parent or parent's emergency contact person shall be called as soon as practical;
d) A staff member shall accompany the child to the hospital and will stay with the child until the parent or emergency contact person arrives.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Written Plan For Medical Emergency
Facilities shall have a written plan for immediate management and rapid access to medical care as appropriate to the situation. This plan shall:
a) Describe for each child any special emergency procedures that will be used, if required, by the caregiver or by a physician or registered nurse available to the caregiver;
b) Note any special medical procedures, if required by the child's condition, that will be used or might be required for the child while he/she is in the facility's care, including the possibility of a need for cardiac resuscitation;
c) Include in a separate format, any information to be given to an emergency responder in the event that one must be called to the facility for the child. This information shall include:
1) Any special information needed by the emergency responder to respond appropriately to the child's condition;
2) A listing of the child's health care providers in the event of an emergency.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Reporting Suspected Child Abuse, Neglect, Exploitation
The facility shall report to the department of social services, child protective services, or police as required by state and local laws, in any instance where there is reasonable cause to believe that child abuse, neglect, or exploitation may have occurred.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Immunity of Reporters of Child Abuse From Sanction
Caregivers who report abuse in the settings where they work shall be immune from discharge, retaliation, or other disciplinary action for that reason alone, unless it is proven that the report was malicious.
Facility Layout To Reduce Risk of Abuse
The physical layout of facilities shall be arranged so that all areas can be viewed by at least one other adult in addition to the caregiver at all times when children are in care. Such a layout reduces the risk of abuse and likelihood of extended periods of time in isolation for individual caregivers with children, especially in areas where children may be partially undressed or in the nude.
Video surveillance equipment, parabolic mirrors, or other devices designed to improve visual access shall be installed to enhance safety for the children.
Editor's Note: This standard applies to outdoor areas as well.
The child care facility shall have a seizure care plan and ensure that all caregivers receive training to successfully implement the plan. If a child in care has epilepsy or a history of febrile seizures that are not considered a form of epilepsy, the child's seizure care plan shall include the following:
a) Types of seizures the child has (such as partial, generalized, or unclassified), as well as a description of the manifestation of these types of seizures in this child;
b) The current treatment regimen for this child, including medications, doses, schedule of administration, guidelines, route of administration, and potential side effects for routine and as-needed medications;
c) Restrictions from activities that:
1) Could be dangerous if the child were to have a seizure during the activity;
2) Could precipitate a seizure (examples include swimming and falling from a height);
d) Recognizing and providing first aid for a seizure;
e) Guidelines on when emergency medical help should be sought for the child who has epilepsy, such as:
1) A major convulsive seizure lasting more than 5 minutes;
2) One seizure after another without waking up between seizures;
3) The child is completely unresponsive for 20 minutes after the seizure;
f) Documentation in the child's health report that indicates:
1) Whether the child has had a history of any type of
seizures;
2) Whether the child is currently taking medication to control the seizures;
3) What observations caregivers should make to help the child's clinician adjust the medication;
4) The type and frequency of reported seizures as well as seizures observed in the facility;
g) Plans for support of the child with epilepsy and the child's family.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Training For Staff To Handle Seizures
Staff members shall be trained in, and shall be prepared to follow, the prescribed procedure when a child has a seizure. These procedures include proper positioning, keeping the airway open, and knowing when and whom to call for medical assistance. All staff members shall be instructed about the relevant side effects of any anti-convulsant medications that children in the facility take and how to observe and report them.
Telephone numbers for emergency care shall be posted, as specified in Posting Documents, STANDARD 8.077.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Management of Children With Asthma
When a child who has had a diagnosis of asthma by a health professional attends the child care facility, the following actions shall occur:
a) Each child with asthma shall have a special care plan prepared for the facility by the child's source of health care, to include:
1) Written instructions regarding how to avoid the conditions that are known to trigger asthma symptoms for the child;
2) Indications for treatment of the child's asthma in the child care facility;
3) Names, doses, and method of administration of any medications, e.g., inhalers, the child should receive for an acute episode and for ongoing prevention;
4) When the next update of the special care plan is due;
b) Based on the child's special care plan, the child's caregivers shall receive training, demonstrate competence in, and implement measures for:
1) Preventing exposure of the asthmatic child to conditions likely to trigger the child's asthma;
2) Recognizing the symptoms of asthma;
3) Treating acute episodes;
c) Parents and staff shall arrange for the facility to have necessary medications and equipment to manage the child's asthma while the child is at the child care facility;
d) Properly trained caregivers shall promptly and properly administer prescribed medications according to the training provided and in accordance with the special care plan;
e) The facility shall notify parents of any change in asthma symptoms when that change occurs. See the
Special Care Plan for a Child with Asthma, Appendix M;
f) The facility shall try to reduce these common asthma triggers by:
1) Encouraging the use of allergen impermeable nap mats or crib/mattress covers;
2) Prohibiting pets (particularly furred or feathered pets);
3) Prohibiting smoking inside the facility or on the playground;
4) Discouraging the use of perfumes, scented cleaning products, and other fumes;
5) Quickly fixing leaky plumbing or other sources of excess water;
6) Ensuring frequent vacuuming of carpet and upholstered furniture at times when the children are not present;
7) Storing all food in airtight containers, cleaning up all food crumbs or spilled liquids, and properly disposing of garbage and trash;
8) Using integrated pest management techniques to get rid of pests (using the least hazardous treatments first and progressing to more toxic treatments only as necessary);
9) Keeping children indoors when local weather forecasts predict unhealthy ozone levels or high pollen counts.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caring for Children Who Require Medical Procedures
A facility that enrolls children who require tube feedings, endotrachial suctioning, oxygen, postural drainage, or catheterization daily (unless the child requiring catheterization can perform this function on his/her own) or any other special medical procedures performed routinely, or who might require special procedures on an urgent basis, shall receive a written report from the health care provider who prescribed the special treatment (such as a urologist for catheterization). A facility shall receive a written report from the child's clinician about any special preparation to perform urgent procedures other than those that might be required for a typical child, such as cardiac resuscitation. This report shall include instructions for performing the procedure, how to receive training in performing the procedure, and what to do and who to notify if complications occur. Training for the child care staff shall be provided by a qualified health care professional in accordance with state practice acts.
TYPE OF FACILITY:
Center; Large Family Child Care; Small Family Child Care Home
Inclusion/Exclusion/Dismissal of Children
The parent, legal guardian, or other person the parent authorizes shall be notified immediately when a child has any sign or symptom that requires exclusion from the facility. The facility shall ask the parents to consult with the child's health care provider. The child care provider shall ask the parents to inform them of the advice received from the health care provider. The advice of the child's health care provider shall be followed by the child care facility.
With the exception of head lice for which exclusion at the end of the day is appropriate, a facility shall temporarily exclude a child or send the child home as soon as possible if one or more of the following conditions exists:
a) The illness prevents the child from participating comfortably in activities as determined by the child care provider;
b) The illness results in a greater need for care than the child care staff can provide without compromising the health and safety of the other children as determined by the child care provider;
c) The child has any of the following conditions:
1) Fever, accompanied by behavior changes or other signs or symptoms of illness until medical professional evaluation finds the child able to be included at the facility;
2) Symptoms and signs of possible severe illness until medical professional evaluation finds the child able to included at the facility. Symptoms and signs of possible severe illness shall include
lethargy that is more than expected tiredness,
inexplicable irritability or persistent crying,
other unusual signs for the child;
3) Diarrhea, defined by more watery stools, decreased form of stool that is not associated with changes of diet, and increased frequency of passing stool, that is not contained by the child's ability to use the toilet. Children with diarrheal illness of infectious origin generally may be allowed to return to child care once the diarrhea resolves, except for children with diarrhea caused by
Salmonella typhi, Shigella or
E. coli 0157:H7. For
Salmonella typhi, 3 negative stool cultures are required. For
Shigella or
E. coli 0157:H7, two negative stool cultures are required. Children whose stools remain loose but who, otherwise, seem well and whose stool cultures are negative, need not be excluded. See also Child-Specific Procedures for Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections, STANDARD 6.023, for additional separation and exclusion information for children with diarrhea; STANDARD 3.066, on separate care for these children; and STANDARD 3.084 and STANDARD 3.087, on notifying parents;
4) Blood in stools not explainable by dietary change, medication, or hard stools;
5) Vomiting illness (two or more episodes of vomiting in the previous 24 hours) until vomiting resolves or until a health care provider determines that the cause of the vomiting is not contagious and the child is not in danger of dehydration. See also STANDARD 3.066, on separate care for these children;
6) Persistent abdominal pain (continues more than 2 hours) or intermittent pain associated with fever or other signs or symptoms;
7) Mouth sores with drooling, unless a health care provider or health department official determines that the child is noninfectious;
8) Rash with fever or behavior change, until a physician determines that these symptoms do not indicate a communicable disease;
9) Purulent conjunctivitis (defined as pink or red conjunctiva with white or yellow eye discharge), until after treatment has been initiated. In epidemics of nonpurulent pink eye, exclusion shall be required only if the health authority recommends it;
10) Pediculosis (head lice), from the end of the day until after the first treatment. See STANDARD 6.038;
11) Scabies, until after treatment has been completed. See STANDARD 6.037;
12) Tuberculosis, until a health care provider or health official states that the child is on appropriate therapy and can attend child care. See STANDARD 6.014 and STANDARD 6.015;
13) Impetigo, until 24 hours after treatment has been initiated;
14) Strep throat or other streptococcal infection, until 24 hours after initial antibiotic treatment and cessation of fever. See also Group A Streptococcal (GAS) Infection, STANDARD 6.012 and STANDARD 6.013;
15) Varicella-Zoster (Chickenpox), until all sores have dried and crusted (usually 6 days). See also STANDARD 6.019 and STANDARD 6.020;
16) Pertussis, until 5 days of appropriate antibiotic treatment (currently, erythromycin, which is given for 14 consecutive days) has been completed. See STANDARD 6.009 and STANDARD 6.010;
17) Mumps, until 9 days after onset of parotid gland swelling;
18) Hepatitis A virus, until 1 week after onset of illness, jaundice, or as directed by the health department when passive immunoprophylaxis (currently, immune serum globulin) has been administered to appropriate children and staff members. See STANDARD 6.023 through STANDARD 6.026;
19) Measles, until 4 days after onset of rash;
20) Rubella, until 6 days after onset of rash;
21) Unspecified respiratory tract illness, see STANDARD 6.017;
22) Shingles (herpes zoster). See STANDARD 6.020;
23) Herpes simplex, see STANDARD 6.018.
Some states have regulations governing isolation of persons with communicable diseases including some of those listed here. Providers shall contact their health consultant or health department for information regarding isolation of children with diseases such as chickenpox, pertussis, mumps, hepatitis A, measles, rubella, and tuberculosis. If different health care professionals give conflicting opinions about the need to exclude an ill child on the basis of the risk of transmission of infection to other children, the health department shall make the determination.
The child care provider shall make the decision about whether a child meets or does not meet the exclusion criteria for participation and the child's need for care relative to the staff's ability to provide care. If parents and the child care staff disagree, and the reason for exclusion relates to the child's ability to participate or the caregiver's ability to provide care for the other children, the child care provider shall not be required by a parent to accept responsibility for the care of the child during the period in which the child meets the providers's criteria for exclusion.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
During the course of an identified outbreak of any communicable illness at the facility, a child shall be excluded if the health department official or health care provider suspects that the child is contributing to transmission of the illness at the facility. The child shall be readmitted when the health department official or health care provider who made the initial determination decides that the risk of transmission is no longer present.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Staff Exclusion For Illness
Please note that if a staff member has no contact with the children, or with anything with which the children come into contact, this standard does not apply to that staff member.
A facility shall not deny admission to or send home a staff member or substitute with illness unless one or more of the following conditions exists. The staff member shall be excluded as follows:
a) Chickenpox, until all lesions have dried and crusted, which usually occurs by 6 days;
b) Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
c) Rash with fever or joint pain, until diagnosed not to be measles or rubella;
d) Measles, until 4 days after onset of the rash (if the staff member or substitute is immunocompetent);
e) Rubella, until 6 days after onset of rash;
f) Diarrheal illness, three or more episodes of diarrhea during the previous 24 hours or blood in stools, until diarrhea resolves; if
E.coli 0157:H7 or
Shigella is isolated, until diarrhea resolves and two stool cultures are negative;
g) Vomiting illness, two or more episodes of vomiting during the previous 24 hours, until vomiting resolves or is determined to result from noncommunicable conditions such as pregnancy or a digestive disorder;
h) Hepatitis A virus, until 1 week after onset or as directed by the health department when immunoglobulin has been given to appropriate children and staff in the facility;
i) Pertussis, until after 5 days of appropriate antibiotic therapy (which is to be given for a total of 14 days) and until disease preventive measures, including preventive antibiotics and vaccines for children and staff who have been in contact with children infected with pertussis, have been implemented;
j) Skin infection (such as impetigo), until 24 hours after treatment has been initiated;
k) Tuberculosis, until noninfectious and cleared by a health department official;
l) Strep throat or other streptococcal infection, until 24 hours after initial antibiotic treatment and end of fever;
m) Head lice, from the end of the day of discovery until after the first treatment;
n) Scabies, until after treatment has been completed;
o) Purulent conjunctivitis, defined as pink or red conjunctiva with white or yellow eye discharge, often with matted eyelids after sleep, and including eye pain or redness of the eyelids or skin surrounding the eye, until 24 hours after treatment has been initiated;
p)
Haemophilus influenzae type b (Hib), prophylaxis, until antibiotic treatment has been initiated;
q) Meningococcal infection, until all staff members, for whom antibiotic prophylaxis has been recommended, have been treated. See STANDARD 6.006 through STANDARD 6.008;
r) Respiratory illness, if the illness limits the staff member's ability to provide an acceptable level of child care and compromises the health and safety of the children.
Child care providers who have herpes cold sores shall not be excluded from the child care facility, but shall:
1) Cover and not touch their lesions;
2) Carefully observe handwashing policies;
3) Refrain from kissing or nuzzling infants or children, especially children with dermatitis.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Space Requirements for Care of Ill Children
Environmental space utilized for the care of children who are ill with infectious diseases and cannot receive care in their usual child care group shall meet all requirements for well children and include the following additional requirements:
a) If the program for ill children is in the same facility as the well-child program, well children shall not use or share furniture, fixtures, equipment, or supplies designated for use with ill children unless it has been cleaned and sanitized before use by well children;
b) Indoor space that the facility uses for ill children, including hallways, bathrooms, and kitchens, shall be separate from indoor space used with well children; this reduces the likelihood of mixing supplies, toys, and equipment. The facility may use a single kitchen for ill and well children if the kitchen is staffed by a cook who has no child care responsibilities other than food preparation and who does not handle soiled dishes and utensils until after food preparation and food service are completed for any meal;
c) Children whose symptoms indicate infections of the gastrointestinal tract (often with diarrhea) or liver, who receive care in special facilities for ill children shall receive this care in a space separate from other children with other illnesses to reduce the likelihood of disease being transmitted between children by limiting child-to-child interaction, separating staff responsibilities, and not mixing supplies, toys, and equipment;
d) If the facility cares for children with chickenpox, these children shall receive care in a separate room that is ventilated externally.
e) Each child care room shall have a handwashing sink that can provide a steady stream of water, no less than 60 degrees F and no more than 120 degrees F, at least for 10 seconds. Soap and disposable paper towels shall be available at the handwashing sink at all times.
f) Each room where children who wear diapers receive care shall have its own diaper changing area adjacent to a handwashing sink.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Inclusion and Exclusion of Children From Facilities That Serve Ill Children
Facilities that care for ill children who have conditions that require additional attention from the caregiver shall arrange for or ask the health consultant to arrange for a clinical health evaluation, by a licensed health care professional, for each child who is admitted to the facility. These facilities shall include children with conditions listed in STANDARD 3.065 if their policies and plans address the management of these conditions, except for the following conditions which require exclusion from all types of child care facilities that are not medical care institutions (such as hospitals or skilled nursing facilities):
a) Fever and a stiff neck, lethargy, irritability, or persistent crying;
b) Diarrhea (three or more loose stools in an 8-hour period or more stools compared to the child's normal pattern, with more stool water or less form) and one or more of the following:
2) Blood or mucus in the stool, unless at least one stool culture demonstrates absence of
Shigella, Salmonella, Campylobacter, and
E. coli 0157:H7. See STANDARD 3.065 and STANDARD 6.023;
3) Diarrhea attributable to
Salmonella, Campylobacter, or Giardia except that a child with diarrhea attributable to
Campylobacter or
Giardia may be readmitted 24 hours after treatment has been initiated if cleared by the child's physician;
c) Diarrhea attributable to
Shigella and
E. coli 0157:H7, until diarrhea resolves and two stool cultures taken 48 hours apart are negative;
d) Vomiting three or more times, or signs of dehydration;
e) Contagious stages of pertussis, measles, mumps, chickenpox, rubella, or diphtheria, unless the child is appropriately isolated from children with other illnesses and cared for only with children having the same illness;
f) Untreated infestation of scabies or head lice;
g) Untreated tuberculosis;
i) Abdominal pain that is intermittent or persistent;
j) Difficulty in breathing;
k) Lethargy such that the child does not play;
l) Undiagnosed jaundice (yellow skin and whites of eyes);
m) Other conditions as may be determined by the director or health consultant.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Permissible Administration of Medication
The administration of medicines at the facility shall be limited to:
a) Prescribed medications ordered by a health care provider for a specific child, with written permission of the parent or legal guardian;
b) Nonprescription (over-the-counter) medications recommended by a health care provider for a specific child or for a specific circumstance for any child in the facility, with written permission of the parent or legal guardian.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Labeling and Storage of Medications
Any prescribed medication brought into the facility by the parent, legal guardian, or responsible relative of a child shall be dated, and shall be kept in the original container. The container shall be labeled by a pharmacist with:
a) The child's first and last names;
b) The date the prescription was filled;
c) The name of the health care provider who wrote the prescription, the medication's expiration date;
d) The manufacturer's instructions or prescription label with specific, legible instructions for administration, storage, and disposal;
e) The name and strength of the medication.
Over-the-counter medications shall be kept in the original container as sold by the manufacturer, labeled by the parent, with the child's name and specific instructions given by the child's health professional for administration.
All medications, refrigerated or unrefrigerated, shall have child-resistant caps, shall be kept in an organized fashion, shall be stored away from food at the proper temperature, and shall be inaccessible to children. Medication shall not be used beyond the date of expiration.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Training of Caregivers To Administer Medication
Any caregiver who administers medication shall be trained to:
a) Check that the name of the child on the medication and the child receiving the medication are the same;
b) Read and understand the label/prescription directions in relation to the measured dose, frequency, and other circumstances relative to administration (such as in relation to meals);
c) Administer the medication according to the prescribed methods and the prescribed dose;
d) Observe and report any side effects from medications;
e) Document the administration of each dose by the time and the amount given.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Notification of The Facility About Communicable Disease or Other Problems By Parents
Upon registration of each child, the facility shall inform parents that parents must notify the facility within 24 hours after their child or any member of the immediate household has developed a known or suspected communicable disease as required by the health department. When the child has a disease requiring exclusion or dismissal, the parents shall inform the facility of the diagnosis.
The facility shall encourage parents to inform the caregivers of any other problems which may affect the child's behavior.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Written Policy For Reporting Illness To The Health Department
The facility shall have a written policy that complies with the state's reporting requirements for ill children. All communicable diseases shall be reported to the health department. The facility shall have the telephone number of the responsible health authority to whom confirmed or suspected cases of these diseases, or outbreaks of other communicable diseases, shall be reported, and shall designate a staff member as responsible for reporting the disease.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
If a facility experiences the death of a child, the following shall be done:
a) If the child dies while at the facility:
1) Immediately notify emergency medical personnel;
2) Immediately notify the child's parents;
3) Notify the Licensing agency;
4) Provide age appropriate information for children and parents;
b) For a suspected Sudden Infant Death Syndrome (SIDS) death or other unexplained deaths:
1) Seek support and information from local, state, or national SIDS resources;
2) Provide SIDS information to the parents of the other children in the facility;
3) Provide age-appropriate information to the other children in the facility;
c) If the child dies while not at the facility:
1) Provide age-appropriate information for children and parents;
2) Make resources for support available to parents and children.
d) Release specific information about the circumstances of the child's death that the child's family agrees the facility may share.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
CHAPTER 4 - NUTRITION AND FOOD SERVICE
Availability of Drinking Water
Clean, sanitary drinking water shall be readily available throughout the day.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Written Menus, Introduction of New Foods
Facilities shall develop, at least one month in advance, written menus showing all foods to be served during that month and shall make them available to parents. The facility shall date and retain these menus; amended to reflect any changes in the food actually served. Any substitutions shall be of equal nutrient value.
To avoid problems of food sensitivity in very young children, child care providers shall obtain from the child's parents, a list of foods that have already been introduced (without any reaction), and then serve some of these foods to the child. As new foods are introduced, child care providers shall share and discuss these foods with the parents prior to their introduction.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Before any child enters a child care facility, the facility shall obtain a written history of any special nutrition or feeding needs the child has. The staff shall review this history with the child's parents. If further information is required, along with the parents' written consent, the program may consult with the child's primary health care provider.
The written history of special nutrition or feeding needs shall be used to develop individual feeding plans and, collectively, to develop facility menus. Disciplines related to special nutrition needs, including nursing, speech, and occupational and physical therapy, shall participate when needed and/or when they are available to the facility. With the exception of children on special diets, the general nutrition guidelines for facilities in General Requirements, STANDARD 4.001 through STANDARD 4.010; Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021; Nutrition for Toddlers and Preschoolers, STANDARD 4.022 through STANDARD 4.024; and Nutrition for School-age Children, STANDARD 4.025, shall be applied.
The feeding plan shall include steps to take when a situation arises that requires rapid response by the staff (such as a child's choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis). The completed plan shall be on file and accessible to the staff.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Care for Children With Food Allergies
When children with food allergies attend the child care facility, the following shall occur:
a) Each child with a food allergy shall have a special care plan prepared for the facility by the child's source of health care, to include:
1) Written instructions regarding the food(s) to which the child is allergic and steps that need to be taken to avoid that food;
2) A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan shall include specific symptoms that would indicate the need to administer one or more medications;
b) Based on the child's special care plan, the child's caregivers shall receive training, demonstrate competence in, and implement measures for:
1) Preventing exposure to the specific food(s) to which the child is allergic;
2) Recognizing the symptoms of an allergic reaction;
3) Treating allergic reactions;
c) Parents and staff shall arrange for the facility to have necessary medications, proper storage of such medications, and the equipment and training to manage the child's food allergy while the child is at the child care facility;
d) Caregivers shall promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the special care plan;
e) The facility shall notify the parents of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur;
f) The facility shall notify the child's physician if the child has required treatment by the facility for a food allergic reaction;
g) The facility shall contact the emergency medical services system immediately whenever epinephrine has been administered;
h) Parents of all children in the child's class shall be advised to avoid any known allergies in class treats or special foods brought into the child care setting.
i) Individual child's food allergies shall be posted prominently in the classroom and/or wherever food is served.
j) On field trips or transport out of the child care setting, the written child care plan for the child with allergies shall be routinely carried.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Techniques for Bottle Feeding
When bottle feeding, caregivers shall either hold infants or feed them sitting up. Infants who are unable to sit shall always be held for bottle feeding. The facility shall not permit infants to have bottles in the crib or to carry bottles with them either during the day or at night.
A caregiver shall not bottle feed more than one infant at a time.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Expressed human milk shall be placed in a clean and sanitary bottle and nipple that fits tightly to prevent spilling during transport to home or facility. The bottle shall be properly labeled with the infant's name. The bottle shall immediately be stored in the refrigerator on arrival. Expressed human milk shall be discarded if it presents a threat to a baby such as:
Human milk is in an unsanitary bottle;
Human milk that has been unrefrigerated for an hour or more;
A bottle of human milk that has been fed over a period that exceeds an hour from the beginning of the feeding.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Preparation and Handling of Bottle Feeding
Only cleaned and sanitized bottles, or their equivalent, and nipples shall be used. All filled containers of human milk shall be of the ready-to-feed type, identified with a label which won't come off in water or handling, bearing the date of collection and child's full name. The filled, labeled containers of human milk shall be kept frozen or refrigerated, and iron-fortified formula shall be refrigerated until immediately before feeding. Any contents remaining after a feeding shall be discarded. Prepared bottles of formula from powder or concentrate or ready-to-feed formula shall be labeled with the child's name and date of preparation, kept refrigerated, and shall be discarded after 48 hours if not used. An open container of ready-to-feed or concentrated formula shall be covered, refrigerated, and discarded after 48 hours if not used.
Unused expressed human milk shall be discarded after 48 hours if refrigerated, or by three months if frozen, and stored in a deep freezer at 0 degrees F. Unused frozen human milk which has been thawed in the refrigerator shall be used within 24 hours. Frozen human milk shall be thawed under running cold water or in the refrigerator.
Human milk from a mother shall be used only with that mother's own child.
A bottle that has been fed over a period that exceeds an hour from the beginning of the feeding or has been unrefrigerated an hour or more shall not be served to an infant.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Warming Bottles and Infant Foods
Bottles and infant foods shall be warmed under running warm tap water or by placing them in a container of water that is no warmer than 120 degrees F. Bottles shall not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods shall not be warmed in a microwave oven. After warming, bottles shall be mixed gently and the temperature of the milk tested before feeding. Infant foods shall be stirred carefully to distribute the heat evenly. A caregiver shall not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way.
If a slow-cooking device, such as a crock pot, is used for warming infant formula, human milk, or infant food, this slow-cooking device shall be out of children's reach, shall contain water at a temperature that does not exceed 120 degrees F. and shall be emptied, sanitized, and refilled with fresh water daily.
Adults shall not consume hot liquids in child care areas. They shall keep hot liquids and hot foods out of the reach of infants, toddlers, and preschoolers. Adults shall not place hot liquids and foods at the edge of a counter or table, or on a tablecloth that could be yanked down, while the adult is holding or working with a child. Electrical cords from coffee pots shall not be allowed to hang within the reach of children. Food preparers shall position pot handles toward the back of the stove.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Location of The Adult Supervising Children Feeding Themselves
Children in mid-infancy who are learning to feed themselves shall be supervised by an adult seated within arm's reach of them at all times while being fed. Children over 12 months of age who can feed themselves shall be supervised by an adult who is seated at the same table or within arm's reach of the child's highchair or feeding table.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Food That Are Choking Hazards
Caregivers shall not offer to children under 4 years of age foods that are implicated in choking incidents (round, hard, small, thick and sticky, smooth, or slippery). Examples of these foods are hot dogs (whole or sliced into rounds), raw carrot rounds, whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels, chips, peanuts, popcorn, marshmallows, spoonfuls of peanut butter, and chunks of meat larger than can be swallowed whole.
TYPE OF FACILITY
: Center; Large Family Child Care Home; Small Family Child Care Home
Progression of Experiences with Food Textures
For infants, foods shall be fed which are age and developmentally appropriate. Foods shall progress from pureed to ground to finely mashed to finely chopped as an infant develops. When children are ready for chopped foods, these foods shall be cut into small pieces no larger than ¼-inch cubes or thin slices. For toddlers, foods shall be cut up in small pieces no larger than ½-inch cubes.
TYPE OF FACILITY
: Center; Large Family Child Care Home; Small Family Child Care Home
Caregivers shall encourage, but not force, children to eat. Caregivers shall not use food as a reward or punishment.
TYPE OF FACILITY
: Center; Large Family Child Care Home; Small Family Child Care Home
The food preparation area of the kitchen shall be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted, and shall not be used as a passageway while food is being prepared. Food preparation areas shall be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children.
Infants and toddlers shall not have access to the kitchen in child care centers. Access by older children to the kitchen of centers shall be permitted only when supervised by staff members who have been certified by the Child Care Nutrition Specialist (see Appendix C) or the center director as qualified to follow the facility's sanitation and safety procedures.
In all types of child care facilities, children shall never be in the kitchen unless they are directly supervised by a caregiver. Children of preschool-age and older shall be restricted from access to areas while hot food is being prepared. School-age children may engage in food preparation activities. Parents and other adults shall be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility shall check with local health authorities about any additional regulations that apply.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Maintenance of Food Service Surfaces and Equipment
All surfaces that come into contact with food, including tables and countertops, as well as floors and shelving in the food preparation area shall be in good repair, free of cracks or crevices, and shall be made of smooth, nonporous material that is kept clean and sanitized. All kitchen equipment shall be clean and shall be maintained in operable condition according to the manufacturer's guidelines for maintenance and operation. The facility shall maintain an inventory of food service equipment that includes the date of purchase, the warranty date, and a history of repairs.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Staff Restricted From Food Handling
No one who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be covered, or who
potentially or actually is infected with bacteria,
viruses or parasites
that can be carried in food, shall be responsible for food handling. Plastic gloves, which shall be kept clean and replaced when soiled, shall be used when food is served by hand. No one with open or infected injuries shall work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl) gloves.
In centers and large family child care homes, staff members who are involved in the process of preparing or handling food shall not change diapers. Staff members who work with diapered children shall not prepare or serve food for older groups of children. When staff members who are caring for infants and toddlers are responsible for changing diapers, they shall handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers who prepare food shall wash their hands carefully before handling food, regardless of whether they change diapers. Plastic gloves shall be used in addition to handwashing. When caregivers must handle food, staffing assignments shall be made to foster completion of the food handling activities by caregivers of older children, or by caregivers of infants and toddlers before the caregiver assumes other caregiving duties for
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Precautions for a Safe Food Supply
All foods stored, prepared, or served shall be safe for human consumption by observation and smell. The following precautions shall be observed for a safe food supply:
a) Home-canned food, food from dented, rusted, bulging, or leaking cans, and food from cans without labels shall not be used;
b) Foods shall be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy shall be discarded;
c) Meat shall be from government-inspected sources or otherwise approved by the governing health authority;
d) All dairy products shall be pasteurized and Grade A where applicable;
e) Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs shall not be used. Freshly squeezed fruit or vegetable juice prepared in the child care facility prepared just prior to serving is permissible;
f) Unless a child's health provider documents a different milk product, children from 12 months to 2 years of age shall be served only whole milk. Children older than 2 years of age shall be served whole, skim, 1%, or 2% milk. If allowed by funding resources, dry milk and milk products may be reconstituted in the facility for cooking purposes only, provided that they are prepared, refrigerated, and stored in a sanitary manner, labeled with the date of preparation, and used or discarded within 24 hours of preparation;
g) Meat, fish, poultry, milk, and egg products shall be refrigerated or frozen until immediately before use;
h) Frozen foods shall be defrosted in the refrigerator, under cold running water, as part of the cooking process, or by using the defrost setting of a microwave oven;
i) All fruits and vegetables shall be washed thoroughly with water prior to use;
j) Frozen foods shall never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature.
k) Food shall be served promptly after preparation or cooking or maintained at temperatures of not less than 140 degrees F for hot foods and not more than 40 degrees F for cold foods.
