CFOC4 pdf- FINAL

424 Caring for Our Children: National Health and Safety Performance Standards 9.4.2.8 facility; this record should be updated by another health Release of Child’s Records appraisal when recommended by the staff member’s primary care provider or supervisory or regulatory/ The parents’/guardians’ written requests to release their certifying personnel; child’s records must be specific about to whom the record d. The name and telephone number of the person, primary is being released, for what purpose, and what parts of the care provider, or health facility to be notified in case of record are being copied and sent. Upon parent/guardian emergency; request, designated portions or all of the child’s records e. The job description or the job expectations for staff should be copied and released to specific individuals and substitutes; named and authorized in writing by the parents/guardians f. Required licenses, certificates, and transcripts; to receive this information. The original records and the g. The date of employment or volunteer assignment; written requests should be retained by the facility. h. A signed statement of agreement that the employee RATIONALE understands and will abide by the following: The facility must retain the original records in case legal 1. Regulations and statutes governing child care; defense is required, but parents/guardians have the right 2. Human resource management and procedures; to know and have the full contents of the records. Sending 3. Health policies and procedures; the record to another source of service for the child may 4. Discipline policy; enhance the ability of other service providers to provide 5. Guidelines for reporting suspected child abuse, appropriate care for the child and family. COMMENTS neglect, and sexual abuse; Parents/guardians may want a copy of the record them- 6. Confidentiality policy. selves or may want the record sent to another source of care i. The date and content of staff and volunteer for the child. An effective way to educate parents/guardians orientation(s); on the value of maintaining the child’s developmental and j. A daily record of hours worked, including paid plan- health information is to have them focus on their own ning time and parent/guardian conference time; child’s records. Such records should be used as a mutual k. A record of professional development completed by education tool by parents/guardians and caregivers/ each staff member and volunteer, including dates and teachers. Facilities may charge a reasonable fee for clock or credit hours; making a copy. l. Written performance evaluations. TYPE OF FACILITY Center RATIONALE RELATED STANDARD Complete identification of staff, paid or volunteer, is 9.4.1.3 Written Policy on Confidentiality of Records an essential step in safeguarding children in child care. Main-taining complete records on each staff person 9.4.3 employed at the facility is a sound administrative prac- STAFF RECORDS tice. Employment history, a daily record of days worked, performance evaluations, a record of benefits, and who 9.4.3.1 to notify in case of emergency provide important infor- Maintenance and Content of Staff mation for the employer. Licensors will check the records and Volunteer Records to assure that applicable licensing requirements are met (such as identifying information, educational qualifications, Individual files for all staff members and volunteers, should health assessment on file, record of continuing education, be maintained in a central location within the facility and signed statement of agreement to observe the discipline should contain the following: policy, and guidelines for reporting suspected child abuse, a. The individual’s name, birth date, address, and neglect, and sexual abuse). Emergency contact information for staff, paid or volunteer is needed in child care in the telephone number; event that an adult becomes ill or injured at the facility. b. The position application, which includes a record of The signature of the employee confirms the employee’s notification of responsibilities that might otherwise by work experience and work references; verification of overlooked by the employee. reference information, education, and training; and records of any checking for background screenings, COMMENTS driving records, criminal records, and/or listing in If a small family child care home has employees, this child abuse registry; standard would apply. c. The health assessment record, a copy of which, having been dated and signed by the employee’s primary care TYPE OF FACILITY provider, should be kept in a confidential file in the Center, Large Family Child Care Home

425 Chapter 9: Administration RELATED STANDARDS 2.2.0.10 Using Physical Restraint 9.2.1.1 Content of Policies 1.3.1.1 General Qualifications of Directors 9.2.1.3 Enrollment Information to Parents/Guardians 1.3.1.2 Mixed Director/Teacher Role 1.3.2.1 Differentiated Roles and Caregivers/Teachers 1.3.2.2 Qualifications of Lead Teachers and Teachers 9.2.1.6 Written Discipline Policies 1.3.2.3 Qualifications for Assistant Teachers, Teacher 9.3.0.1 Written Human Resource Management Policies for Aides, and Volunteers Centers and Large Family Child Care Homes 1.3.2.4 Additional Qualifications for Caregivers/Teachers 9.4.1.3 Written Policy on Confidentiality of Records Serving Children Three to Thirty-Five Months 9.4.3.2 of Age Maintenance of Attendance Records for 1.3.2.5 Additional Qualifications for Caregivers/Teachers Staff Who Care for Children Serving Children Three to Five Years of Age 1.3.2.6 Additional Qualifications for Caregivers/Teachers Centers and large family child care homes should keep Serving School-Age Children daily attendance records listing the names of each caregiver/ 1.3.2.7 Qualifications and Responsibilities for Health teacher and/or substitute in attendance, the hours each indi- Advocates vidual worked, and the names of the children in their care. 1.3.3.1 General Qualifications of Family Child Care When a caregiver/teacher, substitute provider and/or volun- Caregivers/Teachers to Operate a Family teer cares for more than one group of children during their Child Care Home hours worked, daily attendance records will reflect the 1.3.3.2 Support Networks for Family Child Care names of the children cared for during each block of time. 1.4.2.1 Initial Orientation of All Staff RATIONALE 1.4.2.2 Orientation for Care of Children with Promoting the health and safety of individual children Special Health Care Needs requires keeping records regarding supervision of each 1.4.2.3 Orientation Topics child in care. This standard ensures that the facility knows 1.4.3.1 First Aid and CPR Training for Staff which children are receiving care at any given time and who 1.4.3.2 Topics Covered in First Aid Training is responsible for directly supervising each child. It also aids 1.4.3.3 CPR Training for Swimming and Water Play in the surveillance of child:staff ratios and provides data for 1.4.4.1 Continuing Education for Directors and program planning. Past attendance records are essential in Caregivers/Teachers in Centers and Large conducting complaint investigations including child abuse. Family Child Care Homes TYPE OF FACILITY 1.4.4.2 Continuing Education for Small Family Child Center, Large Family Child Care Home Care Home Caregivers/Teachers RELATED STANDARD 1.4.5.1 Training of Staff Who Handle Food 9.4.3.1 Maintenance and Content of Staff and 1.4.5.2 Child Abuse and Neglect Education 1.4.5.3 Training on Occupational Risk Related to Volunteer Records Handling Body Fluids 1.4.5.4 Education of Center Staff 9.4.3.3 1.4.6.1 Training Time and Professional Development Training Record Leave 1.4.6.2 Payment for Continuing Education The director of a center or a large or small family child care 1.5.0.1 Employment of Substitutes home should provide and maintain documentation or par- 1.5.0.2 Orientation of Substitutes ticipate in the state’s training/professional development 1.7.0.1 Pre-Employment and Ongoing Adult Health registry of training/professional development received by, Appraisals, Including Immunization or provided for, staff. For centers, the date of the training, the 1.8.2.2 Annual Staff Competency Evaluation number of hours, the names of staff participants, the name(s) 1.8.2.3 Staff Improvement Plan and qualification(s) of the trainer(s), and the content of the 2.2.0.6 Discipline Measures training (both orientation and continuing education) should 2.2.0.7 Handling Physical Aggression, Biting, and Hitting be recorded in each staff person’s file or in a separate train- 2.2.0.8 Preventing Expulsions, Suspensions, and Other ing file. If the state has a training/professional development Limitations in Services registry, the director should provide training documentation 2.2.0.9 Prohibited Caregiver/Teacher Behaviors to the registry. Small family child care home caregivers/teachers should keep a written record of training acquired and certificates containing the same information as the documentation recommended for centers and large homes.

426 Caring for Our Children: National Health and Safety Performance Standards RATIONALE COMMENTS The training record should be used to assess each employ- Colleges issue transcripts, workshops can issue certificates, ee’s need for additional training and to provide regulators and facility administrators can maintain individual with a tool to monitor compliance. Continuing education training logs. with course credit should be recorded and the records made available to staff members to document their applications TYPE OF FACILITY for licenses/certificates or for license upgrading. All accred- Center, Large Family Child Care Home iting bodies for child care facilities, homes and centers, require documentation of training. RELATED STANDARD 9.4.3.1 Maintenance and Content of Staff and In many states, small family child care home caregivers/ teachers are required to keep records of training. Volunteer Records

10 CHAPTER Licensing and Community Action



429 Chapter 10: Licensing and Community Action 10.1 2. U.S. Department of Health and Human Services, Administration for INTRODUCTION Children and Families, National Child Care Information and Technical Assistance Center. 2010. Understanding and supporting family, This chapter contains standards for the responsibilities of friend, and neighbor child care. http://nccic.acf.hhs.gov/resource/ agencies, organizations, and society, not for the individual understanding-and-supporting-family-friend-and-neighbor-child-care/. caregiver/teacher or child care facility. These standards provide the support systems for implementation of the 3. Child Care and Early Education Research Connections. 2010. Child care standards in the preceding chapters. licensing and regulation: A key topic resource list. 2nd ed. http://www. Although many of these standards are directed to state researchconnections.org/files/childcare/keytopics/licensing.pdf. administrative activity, they define necessary actions to assure the health and safety of children in out-of-home 4. National Association of Child Care Resource and Referral Agencies settings. The chapter addresses standards for the licensing (NACCRRA). 2010. Leaving children to chance: NACCRRA’s ranking of child care facilities, a process by which states grant offi- of state standards and oversight of small family child care homes, cial permission to operate an activity which would other- 2010 update. Arlington, VA: NACCRRA. http://www.naccrra.org/ wise be prohibited by law. Licensing can also be known as publications/naccrra-publications/publications/ “permission,” “certification,” “registration,” or “approval.” 854-0000_Lvng Children 2 Chance_rev_031510.pdf. For the purposes of simplicity, licensing will be used to convey these other terms in this chapter. The term “license” 10.2.0.2 can also be known as “permit,” “certificate,” “registration,” Adequacy of Staff and Funding for or “approval” and will be used to convey these other terms. Regulatory Enforcement 10.2 All phases of regulatory administration should have autho- REGULATORY POLICY rization, funding, and enough qualified staff to monitor and enforce the law and regulations of the state. 10.2.0.1 RATIONALE Regulation of All Out-of-Home Child Care For regulations to be effective, the regulatory body must formulate, implement, and enforce licensing requirements Every state should have a statute that identifies the licen- and assure that licensing inspectors are both sufficient in sing agency and mandates the licensing and regulation of numbers and capable of fairly and effectively developing and all full-time and part-time out-of-home care of children, applying the regulations. Funds for all phases of the licens- regardless of setting, except care provided by parents or ing process should be provided, or faulty administrative legal guardians, grandparents, siblings, aunts, or uncles operations may result; such as inadequate protection of chil- (sometimes called relative, friend, and neighbor care) or dren, formulation of irresponsible standards, inadequate when a family engages an individual in the family’s investigations, and insufficient and unfair enforcement (1). home to care solely for their children (1,2). Reference RATIONALE A state statute gives government the authority to protect 1. National Association for Regulatory Administration (NARA). 2009. children as vulnerable and dependent citizens and to pro- Recommended best practices for human care licensing agencies. The NARA tect families as consumers of child care service. Licensing Vision Series Part I. Lexington, KY: NARA. http://www.naralicensing.org/ must have a statutory basis, because it is unknown to the associations/4734/files/Recommended Best Practices.pdf. common law. The statute must address the administration and location of the responsibility. Fifty states have child 10.2.0.3 care regulatory statutes. The laws of some states exempt State Statute Support of part-day centers, school-age child care, care provided by Regulatory Enforcement religious organizations, drop-in care, summer camps, or care provided in small or large family child care homes (3). The state statute should authorize the suppression of illegal In some states the threshold for family child care homes operations and enforcement of child care regulations and being regulated leaves many children unprotected (4). statutory provisions. Reports of unlicensed care should These exclusions and gaps in coverage expose children be promptly investigated and illegally operating providers to unacceptable risks. either brought into the regulated system or forced to ter- References minate offering care. Fines for continuing to provide unlicensed care should be substantial enough to serve 1. National Association for the Education of Young Children (NAEYC). 1997. as an effective deterrent. Licensing and public regulation of early childhood programs: A position RATIONALE statement. Washington, DC: NAEYC. Without proper enforcement, especially the suppression of illegal operations, licensing could become a ritual and lose its safeguarding intent. Some state laws lack adequate provisions for enforcement. Without effective enforcement, licensing fails to meet its responsibility to protect children from harm (1). Reference 1. National Association for Regulatory Administration (NARA). 2000. Suppressing illegal operations. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

430 Caring for Our Children: National Health and Safety Performance Standards 10.3 rather than of the service itself, is desirable and LICENSING AGENCY recommended. COMMENTS 10.3.1 A good resource on licensing, regulatory, and enforcement THE REGULATION SETTING PROCESS issues is the National Association for Regulatory Adminis- tration (NARA) at http://www.naralicensing.org, an inter- 10.3.1.1 national professional organization for licensors, dedicated Operation Permits to promoting excellence in human care regulation and licensing through leadership, education, collaboration, and The licensing agency should issue permits of operation services. In addition, the “Licensing and Public Regulation to all facilities that comply with the state’s licensing of Early Childhood Programs” document published by the regulations and rules. National Association for the Education of Young Children RATIONALE (NAEYC) includes rationale for policy decisions related to Every child has a right to protective care that meets the licensing and regulation (1). In addition, the National Asso- regulations and rules, regardless of the child care setting ciation for Child Care Resource and Referral Agencies in which the child is enrolled. Public and private schools, (NACCRRA) publishes periodic reports comparing the nurseries, preschools, centers, child development programs, licensing regulations of the states against standards babysitting centers, early childhood observation centers, formulated by NACCRRA; these reports are available small and large family child care homes, drop-in care, at http://www.naccrra.org. and all other settings where young children receive care by RELATED STANDARD individuals who are not close relatives should be regulated. Appendix GG: Licensing and Public Regulation of Facilities have been able to circumvent rules and regula- tions in some states by claiming to be specialized facilities. Early Childhood Programs Nothing in the educational philosophy, religious orienta- tion, or setting of an early childhood program inherently References protects children from health and safety risks or provides assurance of quality of child care. 1. National Association for the Education of Young Children (NAEYC). 1997. Any exemptions for care provided outside the family may Licensing and public regulation of early childhood programs: A position place children at risk. In addition to the basic protection statement. Revised ed. Washington, DC: NAEYC. afforded by stipulating requirements and inspecting for licensing, facilities should be required to be authorized 2. National Association for Regulatory Administration (NARA), National for operation. Authorization for operation gives states a Child Care Association (NCCA). 2004. License exempt early care and mechanism to identify facilities and individuals that are education programs: Equal protection and quality education for every child. providing child care and authority to monitor compliance. Joint position paper. http://nara.affiniscape.com/associations/4734/files/ These facilities and individuals may be identified as poten- JointPP.pdf. tial customers for training, technical assistance, and con- sultation services. Currently, many church-run nurseries, 10.3.1.2 nursery schools, group play centers, and home-based Rational Basis of Regulations programs operate incognito in the community because they are not required to notify any centralized agency The state child care licensing agency should formulate, that they care for children (2). implement, and enforce regulations that reduce risks to The lead agency for licensing of child care in most states is children in out-of-home child care (1,2). the human services agency. However, the state public health RATIONALE agency can be an appropriate licensing authority for safe- Regulations describe the minimum performance required guarding children in some states. The education system is of a facility. Regulations must be: increasingly involved in providing services to children in a. Understandable to any reasonable citizen; early childhood. The standards should be equally stringent b. Specific enough that any person knows what is to be no matter what agency assumes the responsibility for regulating child care. done and what is not to be done; In-home care, which is the care of a child in his/her own c. Enforceable, in that they are capable of measurement; home by someone whom the parent has employed, not a d. Consistent with new technical knowledge, current family child care home, should not be licensed as a child care facility. The relationship between the parent and care- research findings and changes in public views to offer giver/teacher is that of employer and employee rather than necessary protection and to avoid unacceptable risk; that of purchaser and provider of care, thus licensing or e. Easily available in both print and electronic media. certification of the individual who provides such care, References 1. National Association for Regulatory Administration (NARA). 2000. Formulation of rules. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA. 2. Class, N. E., J. English. 1983. Formulating operationally valid standards. The administrative regulation of community care facilities with special reference to child care. A compilation of papers by Norris E. Class, Professor Emeritus, School of Social Work, University of Southern California.

431 Chapter 10: Licensing and Community Action 10.3.1.3 b. Organizations with a child care emphasis; Community Participation in Development c. Operators, directors, owners, and caregivers/teachers of Licensing Rules reflecting various types of child care programs includ- State licensing rules should be developed with active ing for-profit and non-profit; community participation by all interested parties includ- d. Professionals with expertise related to the rules; may ing parents/guardians, service providers, advocates, pro- include pediatrics, physical activity, nutrition, mental fessionals in medical and child development fields, health, oral health, injury prevention, resource and funding and training sources (1,2). referral, early childhood education, and early child- Regulations formulated through a representative citizen hood professional development; process should come before the public at well-publicized e. Parents/guardians who reflect the diversity of the public hearings held at convenient times and places in families that are consumers of licensed child different parts of the state. The licensing rules should be care programs. re-examined and revised at least every five years, to assure This advisory board should be linked to the State Early that the rules can be informed by new relevant research Childhood Advisory Council (see Standard 10.3.2.2) as findings and significant social data. The regulatory develop- required by the Head Start Act of 2007 (1). ment process should include many opportunities for public RATIONALE debate and discussion as well as the ability to provide The advisory group should actively seek citizen participation written input. in the development of child care policy, including parents/ RATIONALE guardians, child care administrators, and caregivers/teachers. The legal principle of broad interest representation has long The licensing advisory board should report directly to the been applied to the formulation of regulations for child agency having administrative authority over licensing. care. Changes in regulation can be implemented only with RELATED STANDARD broad support from the different interests affected. State 10.3.2.2 State Early Childhood Advisory Council administrative laws and constitutional principles require public review. The interests of the child must take prece- Reference dence over all other interests. The system should allow for more frequent changes when required to protect children’s 1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc.ohs.acf.hhs. health or safety, e.g., updates on Sudden Infant Death gov/hslc/Head Start Program/Program Design and Management/Head Syndrome (SIDS) risk reduction measures. Start Requirements/Head Start Act/. References 10.3.2.2 1. National Association for Regulatory Administration (NARA). 2000. State Early Childhood Advisory Council Formulation of rules. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA. Each state should establish a state early childhood advisory council or charge an existing commission with the respon- 2. Class, N. E., J. English. 1985. Formulating valid standards for licensing. sibility for developing a early childhood plan and facilitat- J Am Public Welfare Assoc 43:32-35. ing cooperation among government public health, human service, and education departments; institutions of higher 10.3.2 education; early childhood professional development sys- ADVISORY GROUPS tems; early childhood professional organizations; as well as community-based human services agencies. Schools, 10.3.2.1 employers, parents/guardians, and caregivers/teachers Child Care Licensing Advisory Board should also be involved to ensure that the health, safety, and child development needs of children are met by the States should have an official child care licensing advisory child care services provided in the state. The council should body for regulatory and related policy issues. A child care be mandated by law, and should report to the legislature and advisory board should: to the governor at least annually. Larger communities should a. Review proposed rules and regulations prior to adoption; have a network of local councils to advise the state council. b. Recommend administrative policy; The state child care licensing advisory board (see Standard c. Recommend changes in legislation; and 10.3.2.1) should have representation on the council. d. Guide enforcement, if granted this authority via the RATIONALE Coordination among public and private sources of health, legislative process. social service, and education services is essential, especially The advisory group should include representatives from when young children are in care. Some states have separate the following agencies and groups: groups that advise the health agency, the social service agency, a. State agencies with regulatory responsibility or an the education agency, the licensing agency, the governor, and the legislature (1). Other states have some, but not all, of these interest in child care (human services, public health, advisory bodies; each of which has some relevance to child fire marshal, emergency medical services, education, care, but often with a different focus. National initiatives human resources, attorney general, safety council);

432 Caring for Our Children: National Health and Safety Performance Standards such as the Early Childhood Comprehensive Systems community has a vested interest in assuring that parents/ (ECCS) Initiative and the Healthy Child Care America guardians have facilities that provide quality care for chil- (HCCA) program have done much to encourage effective dren who are ill so parents/guardians can be productive collaboration among agencies and organizations with the in the workplace. This vested interest is likely to produce ability to impact child care within states (2). meaningful contributions from the business community Time limited task forces could be created for specific to creative solutions and innovative ideas about how to purposes, but there is a need for one standing council that approach the regulation of facilities for children who are ill. addresses early childhood as its primary responsibility. All stakeholders in the care of children who are ill should Mandating the council by law will reduce the likelihood be involved for the solutions that are developed in regula- that the council will be rendered ineffective by changes in tions to be most successful. political leadership or dissolved when its recommendations are not in agreement with a current administration. RELATED STANDARDS Large municipalities with a similarly diverse group of agen- 3.6.2.1 Exclusion and Alternative Care for Children cies, authorities, and public and private resources should also have a council to coordinate early childhood activity. Who Are Ill Participation of parent/guardian representatives in plan- 3.6.2.2 Space Requirements for Care of Children ning and implementing early childhood initiatives at the state and local levels promotes effective partnerships Who Are Ill between parents/guardians and caregivers/teachers (1). 3.6.2.3 Qualifications of Directors of Facilities That RELATED STANDARD 10.3.2.1 Child Care Licensing Advisory Board Care for Children Who Are Ill References 3.6.2.4 Program Requirements for Facilities That 1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc .ohs.acf.hhs. Care for Children Who Are Ill gov/hslc/Head Start Program/Program Design and Management/ 3.6.2.5 Caregiver/Teacher Qualifications for Facilities Head Start Requirements/Head Start Act/. That Care for Children Who Are Ill 2. Healthy Child Care America (HCCA). 2010. About us. American 3.6.2.6 Child-Staff Ratios for Facilities That Care for Academy of Pediatrics. http://www.healthychildcare.org/about.html. Children Who Are Ill 10.3.2.3 3.6.2.7 Child Care Health Consultants for Facilities That Collaborative Development of Child Care Requirements and Guidelines for Children Care for Children Who Are Ill Who Are Ill 3.6.2.8 Licensing of Facilities That Care for Children Local and state health departments, child care licensing Who Are Ill agencies, education and health professionals, attorneys, 3.6.2.9 Information Required for Children Who Are Ill caregivers/teachers, parents/guardians, and representatives 3.6.2.10 Inclusion and Exclusion of Children from of the business community, including employers, should work together to develop child care licensing requirements Facilities That Serve Children Who Are Ill and guidelines for children who are ill. RATIONALE Reference Local and state health departments have the legal responsi- bility to control infectious diseases in their jurisdictions (1). 1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: To meet this responsibility, health departments generally American Public Health Association. have the expertise to provide leadership and technical assis- tance to licensing authorities, caregivers/teachers, parents/ 10.3.2.4 guardians, and health professionals in the development of Public-Private Collaboration on Care licensing requirements and guidelines for the management of Children Who Are Ill of children who are ill. The heavy reliance on the expertise of local and state health departments in the establishment State and regional agencies should collaborate with employ- of facilities to care for children who are ill has fostered a ers to facilitate arrangements for the care of children who partnership in many states among health departments, are ill in the following settings: licensing authorities, caregivers/teachers, and parents/ guardians for the adequate care of children who are ill in a. The child’s own home, under the supervision of an adult child care settings. Early care and education professionals known to the parents/guardians and the child; can provide the information required to ensure child care settings support children’s social-emotional, language b. A separate area in the child’s own facility or in a special- and cognitive development. In addition, the business ized center, where both the caregiver/teacher and the facility are familiar to the child; c. A child’s own small family child care home; d. A space within the small family child care home net- work’s central place that serves children from partici- pating small family child care homes, where both the caregiver and the facility are familiar to the child. RATIONALE The most appropriate care of a child who is ill is at the child’s own home by a parent/guardian. This is in the best interests of the child, family, and community. Businesses

433 Chapter 10: Licensing and Community Action should be encouraged to allow the use of paid sick leave for RATIONALE this purpose. However, when parent care puts the family Individual credentialing will enhance child health and income or parent employment at risk, the child should development and protect children by ensuring that the staff receive care that is appropriate for the child. Often, when who care for children are healthy and are qualified for their faced with the pressures of the workplace, parents/guard- roles. The current system, in which the details of staff quali- ians take children who are ill to work, leave them in places fications and ongoing training are checked as part of facility where either or both the caregiver/teacher and place are inspection, is cumbersome for child care administrators unfamiliar, or leave them alone. Under the stress of illness, and licensing inspectors alike. If staff qualifications were children need familiar caregivers/teachers and familiar established as part of a separate, more central process, the places where their illnesses and their emotional needs licensing agency staff could check center records of charac- can be managed competently. ter references and whether staff members have licenses for RELATED STANDARDS the roles for which they are employed. 3.6.2.1 Exclusion and Alternative Care for Children Centralizing individual credentialing, qualifying, or licens- Who Are Ill ing (whichever term is consistent with the state’s approach to 3.6.2.2 Space Requirements for Care of Children authorizing legal professional activity) will improve control over quality, encourage a career ladder with increasing qual- Who Are Ill ifications, and reduce the risk of abuse. It will help consum- 3.6.2.3 Qualifications of Directors of Facilities That ers know that individuals who are caring for their children have met basic requirements for consumer protection. Such Care for Children Who Are Ill a process is analogous to that provided for other education 3.6.2.4 Program Requirements for Facilities That professionals (teachers), and even those service providers with less potential for harm than is involved in caring for Care for Children Who Are Ill children (such as beauticians, barbers, taxi drivers). 3.6.2.5 Caregiver/Teacher Qualifications for Facilities The cost of individual certification, credentialing, or licen- That Care for Children Who Are Ill sure will be offset by the benefits to consumers of reliable 3.6.2.6 Child-Staff Ratios for Facilities That Care for and consistent qualifications of child care personnel. Pro- gram administrators, licensors, and child care personnel, Children Who Are Ill who do not have to undertake the tedious process of verifi- 3.6.2.7 Child Care Health Consultants for Facilities That cation of each portion of an individual’s credentials during all site visits, when sites are licensed, or when individuals Care for Children Who Are Ill change jobs, will experience cost savings and assurance of 3.6.2.8 Licensing of Facilities That Care for Children compliance. Public and private policymakers should use financial and other incentives to help caregivers/teachers Who Are Ill meet credentialing requirements. They should encourage 3.6.2.9 Information Required for Children Who Are Ill community colleges to offer courses appropriate for provider 3.6.2.10 Inclusion and Exclusion of Children from training at times convenient for child care workers to attend and for other agencies to offer online courses available to Facilities That Serve Children Who Are Ill providers from their homes or places of employment. 10.3.3 Periodic renewal of the credential should be required, and LICENSING ROLE WITH should be related to requirements for continuing education STAFF CREDENTIALS, CHILD ABUSE and the absence of founded claims of child abuse or criminal PREVENTION, AND ADA COMPLIANCE convictions. The requirement for renewable certification is likely to deter people from applying for work in child care 10.3.3.1 as a way of gaining access to children for sexual purposes Credentialing of Individual Child since the process would include a background screening Care Providers that includes a check of the sex offender registry and child abuse registry (1). The state licensing agency or a credentialing body recog- nized by the state child care regulatory agency should COMMENTS credential or license all persons who provide child care or In a centralized individual credentialing system, successful who may be responsible for children or who may be alone completion of education should be verified by requiring with children in a facility. The credential should be granted the individual to submit evidence of completion of credit- to individuals who meet age, education, and experience bearing courses that have been previously approved as qualifications, whose health status facilitates providing safe meeting the state’s requirements to a central verification and nurturing care, and who have no record of conviction office where this transcript should be continually updated. for criminal offenses against persons, especially children, Background screening records should be checked by state or confirmed act of child abuse. The state should establish licensing agency staff for evidence of behavior that would qualifications for differentiated roles in child care and a procedure for verifying that the individual who is autho- rized to perform a specified role meets the qualifications and is credentialed for that role.

434 Caring for Our Children: National Health and Safety Performance Standards disqualify an individual for work in specified child care TYPE OF FACILITY roles. Evidence of a recent health examination indicating Center, Large Family Child Care Home, Small Family Child ability to care for children can be submitted at the same Care Home time. The center director then knows whether job appli- cants who have been working in the field previously are References qualified at the time they apply for the job, without lengthy waiting for background checks of a prospective employee 1. Schwilk C, Stevenson R, Bateman D. Sexual Misconduct in the Education and without having to hire before background checks have and Human Services Sector. Hershey, PA: IGI Global; 2016 been completed. By this means, children are not exposed to health and safety risks from understaffing, or to care by 2. US Department of Health and Human Services Administration for Children unqualified or even dangerous individuals employed provi- and Families. Overview of 2016 child care and development sionally because the results of a check are not yet available fund final rule. https://www.acf.hhs.gov/sites/default/files/occ/ to the director. ccdf_final_rule_fact_sheet.pdf. Accessed January 11, 2018 Reference NOTES 1. Finkelhor, D., L. M. William, N. Burns. 1988. Nursery crimes: Sexual abuse Content in the STANDARD was modified on 05/30/2018. in day care. Beverly Hills, CA: Sage Publications. 10.3.3.3 10.3.3.2 Licensing Agency Role in Communicating Background Screening the Importance of Reporting Suspected Child Abuse Every state should have a statute that mandates the licens- ing agency or other authority to obtain a comprehensive Licensing agencies should consistently make known the background screening on every prospective child care requirements for reporting and methods of reporting staff person, substitute, or volunteer, or on a family child suspected child abuse. care home provider’s family member who is older than 10 years and who comes in contact with children. RATIONALE No staff (paid or volunteer) or family member should be Child care staff and parents/guardians should be aware of unsupervised with the children in the program until all the reporting requirements and the procedures for handling background screenings have been completed and found reports of child abuse (1,2). State requirements may differ, to be acceptable. but those for whom reporting suspected abuse is mandatory RATIONALE usually include child care personnel. Information on how The Child Care and Development Block Grant, reautho- to call and how to report should be posted in licensed facili- rized in 2014, requires comprehensive background checks ties so it is readily available to parents/guardians and staff. for all child care providers caring for unrelated children Emotional abuse can be extremely harmful to children, but and for all providers receiving federal subsidies (1). A unlike physical or sexual abuse, it is not adequately defined comprehensive background check includes the items listed in most state child abuse reporting laws. State licensing in Standard 1.2.0.2. agencies need to report suspected abuse or neglect which This screening requirement may protect children from they become aware of to the State Child Protective Agency abuse and reduce liability risks while reassuring parents/ for appropriate follow-up. guardians that their children are safe from violent and Procedures for evaluating allegations of physical and emo- sexual offenders and those with related criminal histories tional abuse may or may not be the purview of the licensing (2). Some local governments regulate family child care care- agency. This responsibility may fall to another agency to givers/teachers who are not covered by state regulations or which the licensing agency refers child abuse allegations. have regulations that exceed the state requirements. For workers who enter the field as a first work experience, RELATED STANDARDS previous child abuse histories may be unknown. In many 3.4.4.1 Recognizing and Reporting Suspected Child cases juvenile records are sealed and cannot be used for background screenings. Juvenile offender records begin at Abuse, Neglect, and Exploitation age 10 years. 3.4.4.2 Immunity for Reporters of Child Abuse Some states have established definitions for regular volun- teers (for whom criminal record and child abuse registry and Neglect checks should be required) and for short-term visitors, such 3.4.4.3 Preventing and Identifying Shaken Baby as entertainers and others, who will not be unsupervised with the children. Syndrome/Abusive Head Trauma 3.4.4.4 Care for Children Who Have Been Abused/Neglected 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect References 1. Child Welfare Information Gateway. Reporting. http://www.childwelfare.gov/responding/reporting.cfm. 2. Child Help. Prevention and treatment of child abuse. http://www.childhelp.org.

435 Chapter 10: Licensing and Community Action 10.3.3.4 10.3.4 Licensing Agency Provision of Child Abuse TECHNICAL ASSISTANCE FROM Prevention Materials THE LICENSING AGENCY The licensing agency should be a resource for or have knowledge of sources of child abuse prevention materials 10.3.4.1 for child care facilities and parents/guardians. Guidance Sources of Technical Assistance to and technical assistance should also be provided related to Support Quality of Child Care their state’s child abuse/neglect statute and procedures including the facility’s responsibilities of reporting Public authorities (such as licensing agencies) and private suspected child abuse and neglect. agencies (such as resource and referral agencies), should RATIONALE develop systems for technical assistance to states, localities, Centers and small and large family child care homes are child care agencies, and caregivers/teachers that address good locations to distribute materials for the prevention the following: of abuse and host community training events (1). a. Meeting licensing requirements; COMMENTS b. Establishing programs that meet the developmental State Child Welfare Agencies are a good source of informa- tion and materials and resources on prevention and may needs of children; have designated staff who provide training in the commu- c. Educating parents/guardians on specific health and nity, including to early care and education program staff and parents/guardians. safety issues through the production and distribution Additional resources for licensing agencies can be found at: of related material. http://www.childwelfare.gov/preventing/ and http://www. RATIONALE childwelfare.gov/pubs/res_packet_2008/. The administrative practice of developing systems for tech- Reference nical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of 1. Center for the Study of Social Policy. Strengthening families. children. The chief sources of technical assistance are: http://www.strengtheningfamilies.net. a. Licensing agencies (on ways to meet the regulations); b. Health departments (on health related matters); 10.3.3.5 c. Resource and referral agencies (on ways to achieve qual- Licensing Agency Role in Communicating ity, how to start a new facility, supply and demand data, the Importance of Compliance with how to get licensed, and what parents/guardians want); Americans with Disabilities Act d. Child care health, education, mental health consultant networks; American Academy of Pediatrics (AAP) state Licensing agencies should consistently make known the chapters and child care contacts; and state Early Child- requirements under the Americans with Disabilities Act hood Comprehensive Systems (ECCS) grants are exam- that child care programs must follow. ples of partners providing technical assistance on health RATIONALE and related child care matters. Child care programs must comply with the requirements The state agency has a continuing responsibility to assist an of the Americans with Disabilities Act. applicant in qualifying for a license and to help licensees COMMENTS improve and maintain the quality of their facility. Regula- Procedures for evaluating allegations of physical and tions should be available to parents/guardians and inter- emotional abuse may or may not be the purview of the ested citizens upon request and should be translated if licensing agency. This responsibility may fall to another needed. Licensing inspectors throughout the state should agency to which the licensing agency refers child abuse be required to offer assistance and consultation as a regular allegations. part of their duties and to coordinate consultation with other technical assistance providers as this is an integral part of the licensing process. The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) and the Office of Child Care (OCC) of the Administration for Children and Families (ACF) continue to develop initia- tives that provide funding to support technical assistance to early care and education. States should check with their State Child Care Administrators, Maternal and Child Health Directors, and Head Start State Collaboration Directors, for more information.

436 Caring for Our Children: National Health and Safety Performance Standards Providing centers and networks of small or large family care providers, adult learning techniques, and ability to child care homes with guidelines and information on help establish links between facilities and community establishing a program of care is intended to promote resources. There should be collaboration among all parts appropriate programs of activities. Child care staff is rarely of the early care and education community to provide tech- trained health professionals. Since staff and time are often nical assistance and consultation to improve the quality of limited, caregivers/teachers should have access to consul- care. The licensing agency should be an integral part of the tation on available resources in a variety of fields (such as quality rating and improvement system (QRIS) in the state; physical and mental health care; nutrition; safety, including all parts of the system must collaborate to assure the most fire safety; oral health care; developmental disabilities; and effective and efficient use of resources to encourage quality cultural sensitivity) (1,2). improvement. See Glossary for definition of QRIS. The public agencies can facilitate access to children and The state regulatory agency with the Title V or State Child their families by providing useful materials to child care Care Resource and Referral Agency should provide or providers. arrange for other public agencies, private organizations or RELATED STANDARDS technical assistance agencies (such as a resource and refer- 2.4.3.1 Opportunities for Communication and Modeling ral agency) to make the following consultants available to the community of child care providers of all types: of Health and Safety Education for Parents/ a. Program consultant, to provide technical assistance for Guardians 2.4.3.2 Parent/Guardian Education Plan program development and maintenance and business 10.3.3.1 Credentialing of Individual Child Care Providers practices. Consultants should be chosen on the basis of 10.4.1.3 Licensing Agency Procedures Prior to Issuing a training and experience in early childhood education License and ability to help establish links between the facility References and community resources; b. Child care health consultant (CCHC), who has knowl- 1. American Academy of Pediatrics. 2001. The pediatrician’s role in promoting edge and expertise in child health and child develop- health and safety in child care. Elk Grove Village, IL: AAP. ment, is knowledgeable about the special needs of children in out-of-home care settings, and knows 2. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care the child care licensing requirements and available health consultation improves health and safety policies and practices. Acad health resources. A regional plan to make consultants Pediatr 9:366-70. accessible to facilities for ongoing relationships should be developed; 10.3.4.2 c. Nutritionist/registered dietitian, who also has the Licensing Agency Provision of Written knowledge of infant and child development, food Agreements for Parents/Guardians and service, nutrition and nutrition education methods, to Caregivers/Teachers be responsible for the development of policies and pro- cedures and for the implementation of nutrition stan- The licensing agency or a resource and referral agency dards to provide high quality meals, nutrition education should provide guidance, technical assistance, and training programs and appropriately trained personnel, and to to support caregivers/teachers in developing written agree- provide consultation to agency personnel, including ments between the child care facility and parents/guard- collaborating with licensing inspectors; ians, as required by licensing regulations. The written d. Early childhood education consultant, to assist centers, agreement should be available at the time of an inspection large family child care homes, and networks of small visit. family child care homes in partnering with families in RATIONALE meeting the individual development and learning needs The licensing agency and the resource and referral agency of children, including any special developmental and can develop sample agreement forms or be a resource to educational needs that a child may have. Early Child- parents/guardians and caregivers/teachers in locating the hood Education Consultants can assist providers n early appropriate materials and tools. detection and referral for identifying and addressing special learning needs, especially infants and toddlers; 10.3.4.3 e. Early childhood mental health consultant (ECMHC), Support for Consultants to Provide Technical to assist centers, large family child care homes, and Assistance to Facilities networks of small family child care homes in meeting the emotional needs of children and families. The state State agencies should encourage the arrangement and coor- mental health agency should promote funding through dination of and the fiscal support for consultants from the community mental health agencies and child guidance local community to provide technical assistance for clinics for these services. At the least, such consultants program development and maintenance. Consultants should be available when caregivers/teachers identify should have training and experience in early childhood children whose behaviors are more difficult to manage education, early childhood growth and development, issues than typically developing children; of health and safety in child care settings, business prac- tices, ability to establish collegial relationships with child

437 Chapter 10: Licensing and Community Action f. Dental health consultant, to assist centers, large family MHCs are usually social workers or professionals with child care homes and networks small family child care a child development or psychology background who are homes in meeting the oral health needs of children. trained to work in child care settings (2). There is no The dental health consultant should have knowledge formal or standardized training for ECMHCs nationally. of pediatric oral health and be able to help with policy Developmental and behavioral pediatricians, child and and procedure development in this area; adolescent psychiatrists, and child psychologists are resources for the behavioral and mental health needs of g. Physical activity consultant, who has knowledge in young children (1). Some, but not all, adolescent and child infant and child motor development (developmental psychiatrists and psychologists, social workers and child biomechanics), locomotion, ballistic, and manipulative counselors have the necessary skills to work with behavior skills, sensory-perceptual development, social, psycho- problems of this youngest age group. To find such special- social, and cultural constraints in motor development, ists, contact the Department of Pediatrics at academic and development of cardio-respiratory endurance, centers or the State Department of Mental Health. The strength and flexibility, and body composition, to be faculty at such centers can usually refer child care facilities responsible for the development of policies and proce- to individuals with the necessary skills in their area. dures for the implementation of age and developmen- The administrative practice of developing systems for tech- tally appropriate physical activity standards to provide nical assistance is designed to enhance the overall quality of children with the movement experiences needed for child care that meets the social and developmental needs of optimal growth and development, physical education/ children. The chief sources of technical assistance are: movement programs, and appropriately trained person- a. AAP Chapter Child Care Contact (contact information nel, and to provide consultation to agency personnel, including collaborating with licensing inspectors. can be found at http://www.healthychildcare.org); b. Licensing agencies (on ways to meet the regulations and A plan should be in place that supports the interdisciplin- ary collaboration of consultant support to programs to make quality improvements); ensure coordinated support, avoid duplication and stress c. Health departments (on health related matters); on programs and families, and promote efficient use of d. Resource and referral agencies (on ways to achieve qual- consultant resources. Additionally, a plan should be in place that outlines how ity, how to start a new facility, supply and demand data, the state identifies, trains, and supports consultants who, how to get licensed, and what parents/guardians want); in turn, support programs. Minimum qualifications e. Community action programs or non-profit organiza- required of consultants may be specified in state regula- tions (on health related matters including physical tions. There are resources for training consultants that education, for health education and/or quality can be integrated into state plans for supporting health improvement issues); and other early childhood consultants. States will ideally f. Local university kinesiology departments (on early take advantage of opportunities to partner with Head Start, childhood motor development and physical activity child welfare, Part C and Part B, and others to maintain issues); an ongoing system of supporting consultants and fostering g. Small business administration (on financial issues partnerships that support children, families and programs related to program operations); and help improve the overall quality of services provided in h. Subsidy agencies may fund a variety of consultants to the community. programs through the Child Care and Development Fund (CCDF) quality dollars; RATIONALE i. Education departments often administer the food Securing expertise is acceptable by whatever method program dollars and may have technical assistance is most workable at the state or local level (for example, related to the Individuals with Disabilities Education consultation could be provided from a resource and Act (IDEA). referral agency). Providers, not the regulatory agency, are responsible for securing the type of consultation that is References required by their individual facilities. Ongoing relation- ships with CCHCs, nutritionists/registered dietitians, 1. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in and ECMHCs are effective in promoting healthy and promoting health and safety in child care. Elk Grove Village, IL: AAP. safe environments (3-5). 2. Healthy Child Care America. 2006. The influence of child care health COMMENTS consultants in promoting children’s health and well-being: A status report. Several states now have mental health consultants specifi- Rockville, MD: Maternal and Child Health Bureau. cally serving the child care community. There are different models of mental health consultation. Some models are 3. Crowley, A. A., J. M. Kulikowich. Impact of training on child care health programmatic and only include the staff, others work with consultant knowledge and practice. Ped Nurs 35:93-100. individual children with behavioral and emotional prob- lems and the third model integrates both approaches. 4. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37. 5. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.

438 Caring for Our Children: National Health and Safety Performance Standards 10.3.4.4 RATIONALE Development of List of Providers Parents/guardians of children with special health care of Services to Facilities needs require support to enable their identification and evaluation of facilities where their children can receive The local regulatory agency or resource and referral agency quality child care. should assist centers and small and large family child care Parents/guardians should participate in the facility evalua- homes to formulate and maintain a list of community tion, both formally and informally. Unless the Interagency professionals and agencies available to provide needed Coordinating Council (ICC) or some similar body provides health, dental, and social services to families. information to parents/guardians, they are unlikely to be RATIONALE able to find and evaluate options for child care for children Families depend on their child care facilities to provide with special health care needs. While the professionals in- information about obtaining health and dental care and volved with the family may do this on behalf of the family, other community services. A number of communities have the parents/guardians should have every opportunity to Family Resource Centers, which are central points for play a significant role in the process. information. It is important that regulatory agencies and The state licensing agency as well as the state agencies resource and referral agencies have knowledge of family responsible for implementation of the Individuals with resource centers or can provide a directory of community Disabilities Education Act (IDEA) should assist child care services to child care facilities. caregivers/teachers to recognize the opportunity they have Partnerships among health care professionals and commu- to participate in the child’s overall care planning and to nity agencies are necessary to provide a medical home for obtain training on effective inclusion in order to provide all children. The American Academy of Pediatrics (AAP) care to the children (1). defines the medical home as care that is accessible, fami- Reference ly-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. The medical 1. U.S. Department of Health and Human Services, Health Resources and home is not a building, house, or hospital, but an approach Services Administration, Maternal and Child Health Bureau. State Title V to providing health care services in a high-quality and contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp. cost-effective manner (1,2). Health care professionals and other community service agencies are beginning to recog- 10.3.4.6 nize that child care facilities are a logical opportunity to Compensation for Participation in provide information or referral of children to a medical Multidisciplinary Assessments for Children home. Child care programs also provide opportunities for with Special Health Care or Education Needs education in health promotion and disease prevention for children and families (3). The agency (or a council of such agencies) within the References state responsible for overseeing child care for children with special health care or educational needs should assure 1. Kempe, A., B. Beaty, B. P. Englund, R. J. Roark, N. Hester, J. F. Steiner. 2000. that the Individualized Family Service Plan (IFSP) or the Quality of care and use of the medical home in a state-funded capitated Individualized Education Program (IEP) includes compen- primary care plan for low-income children. Pediatrics 105:1020-28. sation for the hours of time spent by members of the multi- disciplinary team and the staff from the child care program 2. American Academy of Pediatrics. 2008. Policy statement: The medical in developing the assessment defined in Standards 8.7.0.1 home. Pediatrics 122:450. through 8.7.0.3. RATIONALE 3. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Unless there is a source of compensation for the time spent Opportunities for health promotion education in child care. Pediatrics 116: in planning and completing assessments, these require- e499-e505. ments cannot be implemented. Funding under Individuals with Disabilities Education Act 10.3.4.5 (IDEA) makes it possible for the resources and funding for Resources for Parents/Guardians of service to follow the child. Traditionally, these funds have Children with Special Health Care Needs paid for individual therapists only, and not for others who participate in formulating the IFSP or IEP. This tradition The state agency or council of agencies responsible for child of restrained spending inhibits effective service delivery care services for children with special health care needs for children and families (1). should aid parents/guardians in their assessment of facili- COMMENTS ties for care of children with special health care needs. For more information and resources, contact the State Agencies should provide printed and audiovisual informa- Children with Special Health Care Needs Program Director. tion about assessment of specialized health care to the Contact information for each state can be found at: https:// parents/guardians. perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp. In addition, the regulatory agency should refer parents/ guardians of children with special health care needs to a medical home for assistance in development and formula- tion of a written care plan to be used within a child care program.

439 Chapter 10: Licensing and Community Action RELATED STANDARDS a. The licensing statutes and rules for child care; 8.7.0.1 Facility Self-Assessment b. Other applicable state and federal statutes and 8.7.0.2 Technical Assistance in Developing Plan 8.7.0.3 Review of Plan for Serving Children with Disabili- regulations; c. The historical, conceptual, and theoretical basis for ties or Children with Special Health Care Needs Reference licensing, investigation, and enforcement; d. Technical skills related to the person’s duties and 1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. State Title V responsibilities, such as investigative techniques, contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp. interviewing, rule-writing, due process, and data management; 10.3.4.7 e. Child development, early childhood education princi- Technical Assistance to Facilities to ples, child care programming, scheduling, and design Address Diversity in the Community of space; f. Law enforcement and the rights of licensees; Technical assistance and incentives should be provided by g. Center and large or small family child care home state, municipal, public, and private agencies to encourage management; facilities to address within their programs, the cultural and h. Child and staff health in child care; socioeconomic diversity in the broader community, not just i. Detection, prevention, and management of child abuse; in the neighborhood where the child care facility is located. j. Practical techniques and ADA requirements for inclu- RATIONALE sion of children with special needs; Children who are exposed to cultural and socioeconomic k. Exclusion/inclusion of children who are ill; diversity in early childhood are more likely to value and l. Health, safety, physical activity, and nutrition; accept differences between their own backgrounds and m. Recognition of hazards. those of others as they move through life (1,2). This attitude RATIONALE results in improved self-esteem and mental health in chil- Licensing inspectors are a point of contact and linkage for dren from all backgrounds. Facilities may be able to attract caregivers/teachers and sources of technical information participants from different income and cultural groups by needed to improve the quality of child care. This is particu- paying attention to the location of the facility and available larly true for areas not usually within the network of early subsidies for low income families. childhood professionals, such as health and safety exper- References tise. Unless the licensing inspector is competent and able to recognize areas where facilities need to improve their 1. National Childcare Accreditation Council. 2005. Diversity in programming: health and safety provisions (for example prevention of Family day care quality assurance -Factsheet #4. http://www.ncac.gov.au/ infectious disease), the opportunity for such linkages will factsheets/factsheet4.pdf. be lost. To effectively carry out their responsibilities to license and monitor child care facilities, it is critical that 2. Biles, B. Activities that promote racial and cultural awareness. http://www. licensing inspectors have appropriate, conceptually based pbs.org/kcts/preciouschildren/diversity/read_activities.html. professional development in the principles, concepts and practices of child care licensing as well as in the principles 10.3.5 and practices of the form or child care to which they are LICENSING STAFF TRAINING assigned. When developed, it will be important for licens- ing inspectors to secure NARA Licensing Credentials. 10.3.5.1 Reference Education, Experience, and Training of Licensing Inspectors 1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: Licensing inspectors, and others in licensing positions, NARA. should be pre-qualified by education and experience to be knowledgeable about the form of child care they are 10.3.5.2 assigned to inspect. Prior to employment or within the Performance Monitoring of first six months of employment, licensing inspectors should Licensing Inspectors receive training in regulatory administration based on the concepts and principles found in the National Association Licensing inspectors should receive initial and periodic for Regulatory Administration (NARA) Licensing Curricu- competency-based training on the principles and practices lum through onsite platform training or online coursework of conducting licensing and monitoring inspections for (1). In addition, they should receive no less than forty clock compliance with licensing standards. Competency should hours of orientation training upon employment (1). In addi- be initially and periodically assessed by simultaneous, tion, they should receive no less than twenty-four clock independent monitoring by a skilled licensing inspector hours of continuing education each year (1), covering the until the trainee attains the necessary skills. Consistency in following topics and other such topics as necessary based interpretation of licensing rules is essential for effective and on competency needs: equitable enforcement of the rules. Achieving consistency

440 Caring for Our Children: National Health and Safety Performance Standards across inspectors throughout the state is difficult to achieve 10.4 and maintain. Examples of effective techniques to achieve FACILITY LICENSING consistency are: development of interpretive guidelines which are designed to provide the intent of each rule, the 10.4.1 means to achieve compliance, and the criteria to be used INITIAL CONSIDERATIONS to measure compliance. RATIONALE FOR LICENSING Objective assessment of compliance is a learned skill that can be fostered by classroom and self teaching methods but 10.4.1.1 should be mastered through direct practice and apprentice- Uniform Categories and Definitions ship. To ensure consistent protection of children, licensing inspectors should undergo periodic retraining and reevalu- Each state should adopt uniform categories and definitions ation to assess their ability to recognize sound and unsound for its own licensing requirements. Every state should have practices. In addition, all staff involved in licensing such as individual standards that are applied to the following types agency directors, attorneys, policy staff, managers, clerical/ of facilities: support personnel, and information system staff need peri- a. Family child care home: A facility providing care and odic training updates. Training for licensors/inspectors should include best practice programming, child develop- education of children, including the caregiver/teacher’s ment theory, and law enforcement. The National Associa- own children in the home of the caregiver/teacher: tion for Regulatory Administration (NARA) professional 1. Small family child care home—one to six children; development system is the primary source for training in 2. Large family child care home—seven to twelve chil- the principles and practices of child care licensing (1). Interpretive guidelines (also known as indicator manuals or dren, with one or more qualified adult assistants to field guides) assist staff in consistent interpretation and also meet child: staff ratio requirements; assist providers to better understand the intent of the rules b. Center: A facility providing care and education of and how to achieve compliance. States are beginning to put any number of children in a nonresidential setting, or interpretive guidelines on their Websites for ready use by thirteen or more children in any setting if the facility providers. Licensing staff must be trained on the interpre- is open on a regular basis (for instance, if it is not a tive guidelines and treat it as a living document which is drop-in facility); frequently reviewed and revised as interpretation is refined. c. Drop-in facility: A child care program where children Another practice used by some states is to hold periodic are cared for over short periods of time on a one-time, case reviews by a licensing office with one individual pre- intermittent, unscheduled and/or occasional basis. senting the case(s) which are critiqued by others. Procedure Drop-in care is often operated in connection with a manuals, consisting of well developed and currendly used business (e.g., health club, hotel, shopping center, or procedures to be used in the enforcement of licensing rules recreation centers); and regulatinos are also effective in achieving consistency d. School-age child care facility: A facility offering activities when there is frequent training and revision as needed. to school-age children before and after school, during Documents used by the agency for achieving consistency vacations, and non-school days set aside for such activi- should be conveniently accessible to caregivers/teachers (1). ties as caregivers’/teachers’ in-service programs; Reference e. Facility for children who are mildly ill: A facility provid- ing care of one or more children who are mildly ill, 1. Stevens, C. 2008. Achieving the vision: A workbook for human care children who are temporarily excluded from care in regulatory agencies. Lexington, KY: National Association for Regulatory their regular child care setting; Administration. f. Integrated or small group care for children who are mildly ill: A facility that has been approved by the 10.3.5.3 licensing agency to care for well children and to Training of Licensing Agency Personnel include up to six children who are mildly ill; about Child Abuse g. Special facility for children who are mildly ill: A facility that cares only for children who are mildly ill, or a Staff and administrators in licensing agencies and state facility that cares for more than six children who are supported resource and referral agencies should receive mildly ill at a time. sixteen hours of training about child abuse with an RATIONALE emphasis on how child abuse occurs in child care. Lack of standard terminology hampers the ability of citi- RATIONALE zens and professionals to compare rules from state to state Licensing and resource and referral persons should be at or to apply national guidance material to upgrade the qual- least as well informed about child abuse issues as caregivers/ ity of care (1). For example, child care for seven to twelve teachers. States should establish procedures to ensure com- children in the residence of the caregiver/teacher may be pliance of the training requirement by agency personnel. referred to as family day care, a group day care home, or a mini-center in different states. While it is not essential that each state use the same terms and some variability in

441 Chapter 10: Licensing and Community Action definitions of types of care may occur, terminology should References be consistent within the state and as consistent as possible from state to state in the way different types of settings are 1. Friedman, D. E. 2007. Quality rating systems: The experiences of center classified. Child care facilities should be differentiated from directors. Child Care Exchange 173:6-12. community facilities that primarily care for those with developmental disabilities, the elderly, and other adults 2. U.S. Department of Health and Human Services, Administration for and teenagers who need supervised care (2). Children and Families, National Child Care Information and Technical Assistance Center. Quality improvement systems. http://nccic.acf.hhs.gov/ RELATED STANDARDS topics/quality-improvement-systems. 3.6.2.1 Exclusion and Alternative Care for Children 3. Mitchell, A. W. 2005. Stair steps to quality: A guide for states and Who Are Ill communities developing quality rating systems for early care and education. 3.6.2.2 Space Requirements for Care of Children Alexandria, VA: United Way of America, Success By 6. Who Are Ill 10.4.1.3 3.6.2.3 Qualifications of Directors of Facilities That Licensing Agency Procedures Prior to Issuing a License Care for Children Who Are Ill 3.6.2.4 Program Requirements for Facilities That Care Before granting a license to a facility, the licensing agency should check as specified below for a record of a physical for Children Who Are Ill examination and for educational qualifications, and should 3.6.2.5 Caregiver/Teacher Qualifications for Facilities check background screening records for all adults who are permitted to be alone with children in a facility. The licens- That Care for Children Who Are Ill ing agency should also check background screening records 3.6.2.6 Child-Staff Ratios for Facilities That Care for for all persons over ten years of age who live in a small or large family child care home where child care is provided. Children Who Are Ill a. Staff health appraisals, as specified in Standard 1.7.0.1; 3.6.2.7 Child Care Health Consultants for Facilities That b. Educational requirements, as specified in Sections 1.3 Care for Children Who Are Ill and 1.4; 3.6.2.8 Licensing of Facilities That Care for Children c. Criminal record files, for crimes of violence against per- Who Are Ill sons, especially children, within the state of residence, 3.6.2.9 Information Required for Children Who Are Ill and for personnel who have moved into the state within 3.6.2.10 Inclusion and Exclusion of Children from the past five years, federal or out of state criminal records of the other state(s) where the individual Facilities That Serve Children Who Are Ill has resided in the past five years; d. The child abuse registry, for a known history of child References abuse or neglect in the state of residence and for person- nel who have moved into the state within the past five 1. National Association for the Education of Young Children (NAEYC). 1997. years, the other state(s) where the individual has resided Licensing and public regulation of early childhood programs: A position in the past five years (1); statement. Washington, DC: NAEYC. e. The sex offender registry, for a known history of sex- related crimes in the state of residence and for personnel 2. Newacheck, P. W., B. Strickland, J. P. Shonkoff, et al. 1998. An epidemiologic who have moved into the state within the past five years, profile of children with special health care needs. Pediatrics 102:117-23. the other state(s) where the individual has resided in the past five years. 10.4.1.2 RATIONALE Quality Rating and Improvement Systems Requiring a check of both criminal records and the sex offender registry provides additional protection against States should develop a quality rating and improvement individuals avoiding detection by using other names or system (QRIS) to provide incentives to improve the quality files not being forwarded to the applicable agencies. of child care based on or using the licensing system as COMMENTS its foundation. In many cases juvenile records are sealed and cannot be used for the purposes of background checks. To determine RATIONALE the policy in your state or local jurisdiction contact the A highly functioning licensing system has to be the founda- State Attorney General’s Office or the local County tion for a quality rating and improvement system in order Prosecutor. to work properly (3). It is important to recognize the rele- RELATED STANDARD vance of health and safety in the quality criteria (1,2). 1.7.0.1 Pre-Employment and Ongoing Adult Health COMMENTS Appraisals, Including Immunization Quality rating and improvement systems (QRIS) are initia- Reference tives in states to provide incentives for improved child care in licensed child care centers and small and large family 1. National Association for Regulatory Administration (NARA). 2000. Phases child care homes. It is important for the QRIS system to of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: work closely with all parts of the early care and education NARA. system and the health care system. Examples include ensur- ing health and safety measures are part of the ratings and access to a child care health consultant is required.

442 Caring for Our Children: National Health and Safety Performance Standards 10.4.1.4 non-regulatory methods used by other parts of the early Alternative Means of Compliance care and education community to promote quality (such as professional development, quality and improvement Alternative means of compliance should be granted from rating systems, accreditation, peer support, and consumer state licensing requirements when the intent of the require- education) (3). All of these methods are most effective when ment is being met by equivalent means and does not com- they work together within a coordinated early care and promise the health, safety or protection of children (1). education system. Research has demonstrated that posting RATIONALE of licensing information on the Internet has a positive effect The ability to grant alternative means of compliance recog- on compliance with licensing rules (3). nizes the variety of settings and services that can effectively References and safely meet children’s needs. Flexibility in applying licensing regulations should be permitted to the extent 1. National Association for Regulatory Administration (NARA). 2010. Strong that children’s need for protection is met. licensing: The foundation for a quality early care and education system: Reference NARA’s call to action. http://www.naralicensing.org/associations/4734/ files/NARA_Call_to_Action.pdf. 1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: 2. National Association for Regulatory Administration (NARA). 1999. NARA. Licensing workload assessment. Technical assistance bulletin #99-01. Lexington, KY: NARA. 10.4.2 FACILITY INSPECTIONS 3. Witte, A. D., M. Queralt. 2004. What happens when child care inspections and complaints are made available on the internet? Faculty Working Paper AND MONITORING 10227, Wellesley College Department of Economics and National Bureau of Economic Research, Wellesley Child Care Research Partnership. 10.4.2.1 Frequency of Inspections for Child Care 10.4.2.2 Centers, Large Family Child Care Homes, Statutory Authorization of On-Site and Small Family Child Care Homes Inspections The licensing inspector should make an onsite inspection to The state statute should authorize the state regulatory measure compliance with licensing rules prior to issuing an agency to conduct on-site inspections of child care/early initial license and at least two inspections each year to each care and education facilities. center and large and small family child care home thereaf- RATIONALE ter. At least one of the inspections should be unannounced The National Association for the Education of Young and more if needed for the facility to achieve satisfactory Children (NAEYC) Position Statement says, “Effective compliance or is closed at any time (1). Sufficient numbers enforcement requires periodic on-site inspections on both of licensing inspectors should be hired to provide adequate an announced and unannounced basis with meaningful time visiting and inspecting facilities to insure compliance sanctions for noncompliance” (1). When unannounced with regulations inspections are used, they should be conducted at any hour The number of inspections should not include those the facility is in operation, i.e., evenings and nights included inspections conducted for the purpose of investigating if the facility operates at those times (2). NAEYC recom- complaints. Complaints should be investigated promptly, mends that all centers and large and small family child care based on severity of the complaint. States are encouraged homes receive at least one site visit per year. Unannounced to post the results of licensing inspections, including inspections have been shown to be especially effective when complaints, on the Internet for parent and public review. targeted to providers with a history of low compliance (1). Parents/guardians should be provided easy access to the References licensing rules and made aware of how to report complaints to the licensing agency. 1. National Association for the Education of Young Children (NAEYC). 1997. RATIONALE Licensing and public regulation of early childhood programs: A position Licensing inspections are important to assist facilities to statement. Washington, DC: NAEYC. achieve and maintain full compliance with licensing rules. Supervision and monitoring of child care facilities are cri- 2. U.S. Department of Health, Education, and Welfare (DHEW), Office of tical to facilitate continued compliance with the rules in Child Development (OCD). 1973. Guides for day care licensing. DHEW order to prevent or correct problems before they become Publication no. OCD 73-1053. Washington, DC: DHEW, OCD. serious (2). Technical assistance and consultation provided by licensing inspectors on an on-going basis are essential 10.4.2.3 to help programs achieve compliance with the rules and go Monitoring Strategies beyond the basic level of quality. These positive strategies are most effective when they are coupled with the The licensing agency should adopt monitoring strategies that ensure compliance with licensing requirements. These strategies should include the provision of technical assis- tance, advice and guidance to help providers achieve and maintain compliance with licensing requirements and consultation, advice and guidance to encourage upgrad- ing the quality of care to exceed licensing requirements (1). When these strategies do not include a total annual review of all licensing requirements, the agency should review

443 Chapter 10: Licensing and Community Action selected policies and performance indicators and/or con- established, conflicts can be resolved, and decisions can be duct a random sampling of licensing requirements at least reached. In small states, a state level task force may be suffi- annually. The licensing agency should have procedures and cient. In larger or more populous states, local task forces staffing in place to increase the level of compliance moni- may be needed to promote effective use of resources. toring for any facility found in significant noncompliance. RATIONALE COMMENTS Due to an insufficient number of inspectors in licensing The licensing agency can facilitate communication and agencies across the country, it is important to use various collaboration between the child care facility and the state methods in the licensing process to insure quality (2). health department, Monitoring with a focus on teaching, encouraging, Emergency Medical Services (EMS) agencies, other regula- upgrading and safeguarding, can be very successful tory agencies, funding agencies, child protection agencies, in assisting programs and providers to achieve and law enforcement agencies, community service agencies, maintain compliance with licensing requirements (2). school districts and school personnel, including school References nurses, and local government to safeguard children in child care. 1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: RELATED STANDARDS NARA. 3.4.4.1 Recognizing and Reporting Suspected Child 2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Abuse, Neglect, and Exploitation Washington, DC: U.S. Department of Health and Human Services, Office of 6.2.5.1 Inspection of Indoor and Outdoor Play Areas the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ basic-report/13-indicators-quality-child-care. and Equipment 9.2.4.1 Written Plan and Training for Handling Urgent 10.4.2.4 Agency Collaboration to Safeguard Medical Care or Threatening Incidents Children in Child Care 9.2.4.2 Review of Written Plan for Urgent Care 9.2.4.3 Disaster Planning, Training, and Communication The child care licensing, building, fire safety, and health 9.2.4.4 Written Plan for Seasonal and Pandemic Influenza authorities, as well as any other regulators (e.g., environ- 9.2.4.5 Emergency and Evacuation Drills/Exercises Policy mental, sanitation, and food safety), should work together 9.2.4.6 Use of Daily Roster During Evacuation Drills as a team to safeguard children in child care. The team 9.2.4.7 Sign-In/Sign-Out System should eliminate duplication of inspections to create more 9.2.4.8 Authorized Persons to Pick Up Child efficient regulatory efforts. Examples of activities to be 9.2.4.9 Policy on Actions to Be Followed When No coordinated include: a. Inspection of child care facility; Authorized Person Arrives to Pick Up a Child b. Reporting and surveillance systems; 9.2.4.10 Documentation of Drop-Off, Pick-Up, Daily c. Guidance in managing outbreaks of infectious diseases; d. Preventing exposure of children to hazards; Attendance of Child, and Parent/Provider e. Reporting child abuse; Communication f. Training and technical consultation; g. Disaster preparedness and response planning (1). Reference Regulatory agents should collaborate to educate caregivers/ teachers, parents/guardians, health care providers, public 1. American Academy of Pediatrics. Children and disasters. http://www.aap. health workers, licensors, and employers about their roles org/disasters/. in ensuring health and safety in child care settings. RATIONALE 10.4.3 Frequently, caregivers/teachers are burdened by compli- PROCEDURES FOR COMPLAINTS, cated procedures and conflicting requirements to obtain REPORTING, AND DATA COLLECTING clearance from various authorities to operate. To use limited resources, agencies must avoid contradictions in 10.4.3.1 regulatory codes, sim- plify inspection procedures, and Procedure for Receiving Complaints reduce bureaucratic disincentives to the provision of safe and healthy care for children. When regulatory authorities Each licensing agency should have a procedure for receiv- work as a team, collaboration should focus on establishing ing complaints regarding violation of the regulations. Such the role of each agency in ensuring that necessary services complaints should be recorded, investigated, and appro- and systems exist to prevent and control health and safety priate action, if indicated, should be taken. problems in facilities. Each member of the team gains opportunities to learn about the responsibilities of other RATIONALE team members so that close working relationships can be The telephone number, email address, or other contact method for filing complaints should be listed on material about licensing that is given to parents/guardians by the state licensing agency and the resource and referral agency.

444 Caring for Our Children: National Health and Safety Performance Standards At a minimum, the licensing agency has responsibility for medical advisor (1). Licensing agencies can make appropri- consumer protection. Complaints serve as an early warn- ate and preventive changes to licensing regulations and ing before more serious adverse events occur. A fair and program monitoring if they have accurate data on which to equitable process for handling complaints is essential to base those changes (2). protect both the person complaining and the target of RELATED STANDARDS the complaint from harassment. In most cases complaint 3.1.1.1 Conduct of Daily Health Check investigation should include an unannounced inspection. 3.4.4.1 Recognizing and Reporting Suspected Child Abuse, 10.4.3.2 Neglect, and Exploitation Whistle-Blower Protection under State Law 3.4.4.2 Immunity for Reporters of Child Abuse and Neglect 3.4.4.3 Preventing and Identifying Shaken Baby State law should ensure that caregivers/teachers and child care staff who report violation of licensing requirements in Syndrome/Abusive Head Trauma the settings where they work are immune from discharge, 3.4.4.4 Care for Children Who Have Been Abused/Neglected retaliation, or other disciplinary action for that reason 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse alone, unless it is proven that the report was malicious. RATIONALE and Neglect Staff in child care facilities are in an excellent position to 3.6.4.5 Death note areas of noncompliance with licensing requirements Reference in the setting where they work. However, so that they feel safe about reporting these deficiencies, they must be 1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child assured immunity from retaliation by the child care facil- care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: ity unless the report is malicious. This immunity is best American Academy of Pediatrics. provided when a state statute mandates it. Individuals who report problems in their own workplace may be known as 10.5 “whistle-blowers” (1). HEALTH DEPARTMENT Retaliatory complaints against a caregiver/teacher by dis- RESPONSIBILITIES AND ROLE gruntled staff or parents/guardians at times serve only to harass the provider and expend valuable licensing resources 10.5.0.1 or unnecessary work. States should recognize and develop a State and Local Health Department Role system to deal with these nuisance complaints. Reference State and local health departments should play an important role in the identification, prevention and control of injuries, 1. U.S. Department of Labor, Northern Hudson Valley Job Services Employer injury risk, and infectious disease in child care settings as Committee. 2010. Whistleblower protection laws. http://eclkc.ohs.acf.hhs. well as in using the child care setting to promote health and gov/hslc/tta-system/operations/Management and Administration/Human safety. This role includes the following activities to be con- Resources/Personnel Policies/WhistleblowerPro.htm. ducted in collaboration with the child care licensing agency: a. Assisting in the planning of a comprehensive health and 10.4.3.3 Collection of Data on Illness or Harm to safety program for children and child care providers, Children in Facilities including promoting and ensuring maintenance of a system of child care health consultation; The state regulatory agency should have access to an infor- b. Monitoring the occurrence of serious injury events mation system for collecting data relative to the incidence and outbreaks involving children or providers; of illness and injuries, confirmed child abuse and neglect, c. Alerting the responsible child care administrators about and death of children in facilities. This data should be identified or potential injury hazards and infectious shared with appropriate agencies and the child care disease risks in the child care setting; health consultant for analysis. d. Controlling outbreaks, identifying and reporting RATIONALE infectious diseases in child care settings including: Sound public policy planning in respect to health and 1. Methods for notifying parents/guardians, caregivers/ safety in facilities starts with the collection of epidemiologi- cal data. When outbreaks or emergencies occur, quick teachers, and health care providers of the problem; identification of, and appropriate response to, an unusual 2. Providing appropriate actions for the child care circumstance is critical. Conducting daily health checks and keeping symptom records is a good way to identify the provider to take; potential for an infectious disease emergency or outbreak. 3. Providing policies for exclusion or isolation of infected When children in a group seem to have similar symptoms that suggest a contagious disease is spreading, the program children; should consult with its child care health consultant or 4. Arranging a source and method for the administra- tion of needed medication;

445 Chapter 10: Licensing and Community Action 5. Providing a list of reportable diseases, including i. Promoting that health care personnel, such as qualified descriptions of these diseases. The list should specify public health nurses, pediatric and family nurse practi- where diseases are to be reported and what informa- tioners, and pediatricians serve as child care health tion is to be provided by the child care provider to consultants; the health department and to parents/guardians; j. Ensuring child care programs are included and repre- 6. Requiring that all facilities, regardless of licensure sented in local and state disaster preparedness and status, and all health care providers report certain pandemic flu planning. infectious diseases to the responsible local or state public health authority. The child care licensing RATIONALE authority should require such reporting under its A number of studies have described the incidence of in- regulatory jurisdiction and should collaborate fully juries in the child care setting (7-10). Although the injuries with the health department when the latter is engaged described have not been serious, these occur frequently, and in an enforcement action with a licensed facility; may require medical or emergency attention. Child care pro- 7. Determining whether a disease represents a potential grams need the assistance of local and state health agencies in health risk to children in out-of-home child care; planning of the safety program that will minimize the risk 8. Conducting the epidemiological investigation for serious injury (11). This would include planning for such necessary to initiate public health and safety significant emergencies as fire, flood, tornado, or earthquake interventions; (11-13). A community health agency can collect information 9. Recommending a disease prevention or control strat- that can promptly identify an injury risk or hazard and pro- egy that is based on sound public health and clinical vide an early notice about the risk or hazard (14). An exam- practices (such as the use of vaccine, immunoglobulin, ple is the recent identification of unpowered scooters as a or antibiotics taken to prevent an infection); significant injury risk for preschool children (15). Once 10. Verifying reports of infectious diseases received from the injury risk is identified, appropriate channels of commu- facilities with the assessment and diagnosis of the nication are required to alert the child care administrators disease made by a health care provider and, or the and to provide training and educational activities. local or state health department; Effective control and prevention of infectious diseases in e. Designing systems and forms for use by facilities for the child care settings depends on affirmative relationships care of children who are ill to document the surveillance among parents/guardians, caregivers/teachers, public of cared for illnesses and problems that arise in the care health authorities, regulatory agencies, and primary health of children in such child care settings; care providers. The major barriers to productive working f. Assisting in the development of orientation and annual relationships between caregivers/teachers and health care training programs for caregivers/teachers. Such training providers are inadequate channels of communication and should include specialized education for staff of facilities uncertainty of role definition (4). Public health authorities that include child who are ill, as well as those in special can play a major role in improving the relationship between facilities that serve only children who are ill. Specialized caregivers/teachers and primary care providers by dissemi- training for staff who care for children who are ill should nating information regarding disease reporting laws, pre- focus on the recognition and management of childhood scribed measures for control and prevention of diseases and illnesses, as well as the care of children with infectious injuries, and resources that are available for these activities diseases; (11). Child care health consultant networks have proven to g. Assisting the licensing authority in the periodic review be effective in improving the health and safety of children of facility performance related to caring for children in child care settings (16-18). who are ill by: 1. Reviewing written policies developed by facilities State and local health departments are legally required to regarding inclusion, exclusion, dismissal criteria and control certain infectious diseases within their jurisdictions plans for health care, urgent and emergency care, and (20). All states have laws that grant extraordinary powers to reporting and managing children with infectious public health departments during outbreaks of infectious disease; diseases (1,11,12). Since infectious disease is likely to occur 2. Assisting with periodic compliance reviews for those in child care settings, a plan for the control of infectious rules relating to inclusion, exclusion, dismissal, daily diseases in these settings is essential and often legally health care, urgent and emergency care, and reporting required. Early recognition and prompt intervention will and management of children with infectious disease; reduce the spread of infection. Outbreaks of infectious disease in child care settings can have great implications h. Collaborating in the planning and implementation of for the general community (2). Programs administered by appropriate training and educational programs related local health departments have been more successful in to health and safety in child care facilities. Such training controlling outbreaks of hepatitis A than those that rely should include education of parents/guardians, primary primarily on private physicians. Programs coordinated care providers, public health and safety workers, licens- by the local health department also provide reassurance ing inspectors, and employers about how to prevent to caregivers/teachers, staff, and parents/guardians, and injury and disease as well as promote health and safety thereby promote cooperation with other disease control of children and their caregivers/teachers;

446 Caring for Our Children: National Health and Safety Performance Standards policies (3). Infectious diseases in child care settings pose 12. American Academy of Pediatrics, Committee on Pediatric Emergency new epidemiological considerations. Only in recent decades Medicine, Task Force on Terrorism. 2006. Policy statement: The has it been so common for very young children to spend pediatrician and disaster preparedness. Pediatrics 117:560-65. most of their days together in groups. Public health authori- ties should expand their role in studying this situation and 13. National Association of Child Care Resource and Referral Agencies. designing new preventive health measures (4,5). Helping families and children cope with trauma in the aftermath of disaster. http://www.naccrra.org/for_parents/coping/trauma.php. Collaboration is necessary to use limited resources most effectively. In small states, a state level task force that includes 14. Samet, J. M. 2004. Risk assessment and child health. Pediatrics 113:952-56. the Department of Health might be sufficient. In larger or 15. Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta more populous states, local task forces in addition to coor- dination at the state level may be needed. The collaboration Paediatrics 92:50-54. should focus on establishing the role of each agency in ensur- 16. Crowley, A. A. and Kulikowich, J. M. 2009. Impact of training on child ing that necessary services and systems exist to prevent and control injuries and infectious diseases in facilities (6,19). care health consultant knowledge and practice. Pediatric Nurs 35:93-100. 17. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes Health departments generally have or should develop the expertise to provide leadership and technical assistance to of child care health consultation services for child care providers in New licensing authorities, caregivers/teachers, parents/guardians, Jersey: A pilot study. Pediatric Nursing 32:530-37. and primary care providers in the development of licensing 18. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care requirements and guidelines for the management of children health consultation improves health and safety policies and practices. who are ill. The heavy reliance on the expertise of local and Academic Pediatrics 9:366-70. state health departments in the establishment of facilities 19. Garrett, A. L., R. Grant, P. Madrid, A. Brito, D. Abramson, I. Redlener. to care for children who are ill has fostered a partnership in 2007. Children and megadisasters: Lessons learned in the new millennium. many states among health departments, licensing authorities, Advances Pediatrics 54:189-214. caregivers/teachers, and parents/guardians for the adequate 20. National Child Care Information and Technical Assistance Center. State care of children who are ill in child care settings (16-18). and territory emergency preparedness plans. http://nccic.acf.hhs.gov/ poptopics/disasterprep.html. RELATED STANDARDS 3.6.2.5 Caregiver/Teacher Qualifications for Facilities That 10.5.0.2 Written Plans for the Health Care for Children Who Are Ill Department Role 3.6.2.7 Child Care Health Consultants for Facilities That The health department’s role defined in Standard 10.5.0.1 Care for Children Who Are Ill should be described in written plans that assign the responsi- 3.6.4.3 Notification of the Facility About Infectious bilities of community agencies and organizations involved in the prevention and control of injury, injury risk, and infec- Disease or Other Problems by Parents/Guardians tious disease in facilities. The plan should identify child care 3.6.4.4 List of Excludable and Reportable Conditions for related risks and diseases as well as provide guidance for risk reduction, disease prevention and control. The health depart- Parents/Guardians ment should develop these written plans in collaboration with the licensing agency (if other than the health department), References health care providers, caregivers/teachers, and parents/ guardians to ensure the availability of sufficient community 1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: resources for successful implementation. In addition, the American Public Health Association. health department should provide assistance to the licensing agency (if other than the health department) for the promul- 2. Brady, M. T. 2005. Infectious disease in pediatric out-of-home child care. gation and enforcement of child care facility standards. These Am J Infect Control 33:276-85. services should be in addition to the health agency’s assigned responsibilities for enforcement of the state’s immunization 3. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. and other health laws and regulations. Washington, DC: American Public Health Association. In addition to Caring for Our Children (CFOC) and Stepping Stones, the following resources should be con- 4. Ginter, P. M., Wingate, M. S., A. C. Rucks, R. D. Vasconez, L. C. sulted in the development of the health department plan: McCormick, S. Baldwin, C. A. Fargason. 2006. Creating a regional a. Guidelines from the American Academy of Pediatrics pediatric medical disaster preparedness network: Imperative and issues. Maternal Child Health J 10:391-96. (AAP), including current editions of Red Book, Manag- ing Infectious Diseases in Child Care and Schools, 5. Buttross, S. 2006. Caring for children of caretakers during a disaster. Managing Chronic Health Needs in Child Care Pediatrics 117: S446-47. and Schools, and the many other relevant technical manuals on such topics as environment and nutrition; 6. Wilson, S. A., B. J. Temple, M. E. Milliron, C. Vazquez, M. D. Packard, b. Guidelines from the American Public Health Asso- B. S. Rudy. 2008. The lack of disaster preparedness by the public and it’s ciation (APHA), including Control of Communicable affect on communities. Internet J Rescue Disaster Med 7 (2): 1. Diseases Manual; c. Guidelines provided by the Centers for Disease Control 7. Murray, J. S. 2009. Disaster care: Public health emergencies and children. and Prevention (CDC); Am J Nursing 109: 28-29, 31. d. Guidelines from the U.S. Public Health Service’s Advisory Committee on Immunization Practices, as 8. Vollman, D., R. Witsaman, D. R. Comstock, G. A. Smith. 2009. reported periodically in Morbidity and Mortality Epidemiology of playground equipment-related injuries to children in the Weekly Report (MMWR); United States, 1996-2005. Clinical Pediatrics 48:66-71. 9. Gordon, R. A., R. Kaestner, S. Korenman. 2007. The effects of maternal employment on child injuries and infectious disease. Demography 44:307-33. 10. Jansson, B., A. P. De Leon, N. Ahmed, V. Jansson. 2006. Why does Sweden have the lowest childhood mortality in the world? The role of architecture and public pre-school services. J Public Health Policy 27:146-65. 11. Gaines, S. K., J. M. Leary. 2004. Public health emergency preparedness in the setting of child care. Family and Comm Health 27:260-65.

447 Chapter 10: Licensing and Community Action e. State and local regulations and guidelines regarding 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. infectious diseases in facilities; Red Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. f. Bright Futures - Guidelines for Health Supervision of Infants, Children, and Adolescents; 10.5.0.4 Use of Fact Sheets on Common Illnesses g. Current early childhood nutrition guidelines such as Associated with Child Care Preventing Childhood Obesity and Making Food Healthy and Safe for Children. Health departments should help child care providers use prepared prototype parent and staff fact sheets on common h. Current early childhood physical activity resources, illnesses associated with child care. These fact sheets should: such as Active Start: A Statement of Physical Activity a. Be provided to parents/guardians when their child Guidelines for Children From Birth to Age 5, 2nd Edition; Moving with a Purpose: Developing Programs is first admitted to the facility, to staff at the time of for Preschoolers of All Abilities; and Purposeful Play: employment and to both parents/guardians and staff Early Childhood Movement Activities on a Budget. when infectious disease notification is recommended; b. Contain the following information: RATIONALE c. Disease (case or outbreak) to which the child was exposed; Written plans help define delegation and accountability, d. Signs and symptoms of the disease that the parents/ providing the continuity of purpose that helps to institu- guardians and caregivers/teachers should watch for tionalize performance. in the child; RELATED STANDARD e. Mode of transmission of the disease; 10.5.0.4 Use of Fact Sheets on Common Illnesses Associated f. Period of communicability; g. Disease prevention measures recommended by the public with Child Care health department (if appropriate); h. Emphasize modes of transmission of respiratory disease 10.5.0.3 and infections of the intestines (often with diarrhea) and Requirements for Facilities to Report liver, common methods of infection control (such as to Health Department hand hygiene). RATIONALE The child care licensing authority should require all facili- Education is a primary method for providing information ties under its regulatory jurisdiction to report outbreaks to primary care providers and parents/guardians about the to the health department and comply with state and local incidence of infectious diseases in child care settings (1). rules and regulations intended to prevent infectious Education of child care staff and parents/guardians on the disease that apply to child care facilities. recognition and transmission of various infectious diseases RATIONALE is important to any infection control policy (1). Training State and local health departments are legally required to of child care staff has improved the quality of their health control certain infectious diseases within their jurisdictions. related behaviors and practices. Training should be available All states have laws that grant extraordinary powers to to all parties involved, including caregivers/teachers, public public health departments during outbreaks or epidemics health workers, health care providers, parents/guardians, and of infectious disease or bioterrorism attacks. Since infec- children. Good quality training, with imaginative and acces- tious disease is likely to occur in child care settings, a plan sible methods of presentation supported by well- designed for the control of infectious diseases in these settings is materials, will facilitate learning. The number of studies evalu- essential and often legally required. Early recognition and ating the importance of education of child care staff in the prompt intervention will reduce the spread of infection (1,2). prevention of disease is limited. Outbreaks of infectious disease in child care settings can The provision of fact sheets on infectious childhood diseases have great implications for the general community (1,2). at the time their child is admitted to a facility helps educate Programs coordinated by the local health department parents/guardians as to the early signs and symptoms of also provide reassurance to caregivers/teachers, staff, and these illnesses and the need to inform caregivers/teachers of parents/guardians, and thereby promote cooperation with their existence. Illness information sheets can be assembled other disease and safety control policies (1). Infectious in a convenient booklet for this purpose. Health departments diseases in child care settings pose epidemiological consid- may consult or use nationally accepted fact sheets on com- erations. Public health authorities should expand their role mon illnesses available from such agencies as the American in studying this situation and designing new preventive Academy of Pediatrics (AAP) in its current edition of health and safety measures. Managing Infectious Diseases in Child Care and Schools (1) RELATED STANDARDS and Red Book (2), and the Centers for Disease Control and 3.6.1.1 Inclusion/Exclusion/Dismissal of Children Prevention (CDC). 3.6.1.2 Staff Exclusion for Illness References 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

448 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS g. Nutrition and eating habits including the importance of 3.2.1.1 Type of Diapers Worn breastfeeding and the prevention of obesity and related 3.2.1.2 Handling Cloth Diapers chronic diseases; 3.2.1.3 Checking for the Need to Change Diapers 3.2.1.4 Diaper Changing Procedure h. Parent/guardian education; References i. Design, use and safe cleaning of physical space; j. Care and education of children with special health 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: care needs; American Academy of Pediatrics. k. Oral health care; l. Reporting requirements for infectious disease outbreaks; 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. m. Caregiver/teacher health; Red book: 2015 report of the committee on infectious diseases. 30th Ed. n. Age-appropriate physical activity. Elk Grove Village, IL: American Academy of Pediatrics. RATIONALE 10.6 Training enhances staff competence (1,2,4). In addition to CAREGIVER/TEACHER SUPPORT low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education 10.6.1 of caregivers/teachers is a specific indicator of child care CAREGIVER/TEACHER TRAINING quality (1,2). Most states require limited training for child care staff depending on their functions and responsibilities. 10.6.1.1 Some states do not require completion of a high school Regulatory Agency Provision of Caregiver/ degree or GED for various levels of teacher positions (5). Teacher and Consumer Training and Staff members who are better trained are more able to pre- Support Services vent, recognize, and correct health and safety problems. Decisions about management of illness are facilitated by The licensing agency should promote participation in a the caregiver’s/teacher’s increased skill in assessing a child’s variety of caregiver/teacher and consumer training and behavior that suggests illness (2,3). Training should pro- support services as an integral component of its mission mote increased opportunity in the field and openings to to reduce risks to children in out-of-home child care. Such advance through further degree-credentialed education. training should emphasize the importance of conducting regular safety checks and providing direct supervision of RELATED STANDARDS children at all times. Training plans should include mecha- 1.4.2.1 Initial Orientation of All Staff nisms for training of prospective child care staff prior to 1.4.2.2 Orientation for Care of Children with Special their assuming responsibility for the care of children and for ongoing/continuing education. The higher education Health Care Needs institutions providing early education degree programs 1.4.2.3 Orientation Topics should be coordinated with training provided at the com- 10.6.2.1 Development of Child Care Provider Organizations munity level to encourage continuing education and avail- ability of appropriate content in the coursework provide and Networks by these institutions of higher education. Persons wanting to enter the child care field should be able References to learn from the regulatory agency about training oppor- tunities offered by public and private agencies. Discussions 1. U.S. General Accounting Office (USGAO); Health, Education, and Human of these trainings can emphasize critical child care health Services Division. 1994. Child care: Promoting quality in family child care. and safety messages. Some training can be provided online Report to the chairman, subcommittee on regulation, business opportunities, to reinforce classroom education. and technology, committee on small business, House of Representatives. Training programs should address the following: Publication no. GAO-HEHS-95-36. Washington, DC: USGAO. a. Child growth and development including social emo- 2. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in tional, cognitive, language, and physical development; family child care and relative care. New York: Families and Work Institute. b. Child care programming and activities; c. Discipline and behavior management; 3. Aronson, S. S., L. S. Aiken. 1980. Compliance of child care programs with d. Mandated child abuse and neglect reporting; health and safety standards: Impact of program evaluation and advocate e. Health and safety practices including injury prevention, training. Pediatrics 65:318-25. basic first aid and CPR, reporting, preventing and con- 4. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. trolling infectious diseases, children’s environmental Pediatrics 94:1108-10. health and health promotion, and reducing the risk of SIDS and use of safe sleep practices; 5. Moon, R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care f. Cultural diversity; providers? Pediatrics 112:878-82. 6. National Child Care Information and Technical Assistance Center, National Association for Regulatory Administration (NARA). 2010. The 2008 child care licensing study: Final report. Lexington, KY: NARA. http://www. naralicensing.org/associations/4734/files/1005_2008_Child Care Licensing Study_Full_Report.pdf. 10.6.1.2 Provision of Training to Facilities by Health Agencies Public health departments, other state departments charged with professional development for out of home child care providers, and Emergency Medical Services (EMS) agencies

449 Chapter 10: Licensing and Community Action should provide training, written information, consultation 10.6.2 in at least the following subject areas or referral to other CAREGIVER/TEACHER NETWORKING community resources (e.g., child care health consultants, licensing personnel, health care professionals, including AND COLLABORATION school nurses) who can provide such training in: 10.6.2.1 a. Immunization; Development of Child Care Provider b. Reporting, preventing, and managing of infectious Organizations and Networks diseases; State-level agencies and resource and referral agencies should c. Techniques for the prevention and control of infectious encourage the development of child care provider organiza- tions or networks, to attract, train, support, and encourage diseases; participation in facility quality ratings and accreditation, d. Exclusion and inclusion guidelines and care of children for those caregivers/teachers who would like to be part of an organization or system. National professional organizations who are acutely ill; should encourage the development of local child care e. General hygiene and sanitation; provider organizations and networks. f. Food service, nutrition, and infant and child-feeding; When possible, these networks should include a central facil- g. Care of children with special health care needs (chronic ity for enrichment activities for groups of children and support in-service programs for caregivers/teachers. illnesses, physical and developmental disabilities, and RATIONALE behavior problems); To enhance staff qualifications and a nurturing environment, h. Prevention and management of injury; child care providers need support (1). This especially applies i. Managing emergencies; to family child care home providers who tend to be more j. Oral health; isolated than those employed in centers. In studies of the k. Environmental health; quality of care in family child care homes, the caregivers/ l. Health promotion, including routine health supervision teachers who provided better care were those who viewed and the importance of a medical or health home for their role as a profession and acted accordingly, participating children and adults; in continuous improvement activities (2). m. Health insurance, including Medicaid and the Children’s COMMENTS Health Insurance Program (CHIP); Professional networking organizations offer professional n. Strategies for preparing for and responding to infectious encouragement, support, and training to promote rigorous disease outbreaks, such as a pandemic influenza; professional standards (3). This should include the promotion o. Age-appropriate physical activity; of quality ratings, accreditation, credentialing, and other p. Sudden Infant Death Syndrome (SIDS) and Shaken quality improvement initiatives that are based on imple- Baby Syndrome/Abusive Head Trauma. menting best practices in early childhood education. RELATED STANDARD RATIONALE 10.3.3.1 Credentialing of Individual Child Care Providers Training of child care staff has improved the quality of References their health related behaviors and practices. Training should be available to all parties involved, including caregivers/ 1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. teachers, public health workers, health care providers, parents/ Red book: 2015 report of the committee on infectious diseases. 30th Ed. guardians, and children. Good quality training, with imagi- Elk Grove Village, IL: American Academy of Pediatrics. native and accessible methods of presentation supported by well-designed materials, will facilitate learning. 2. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute. RELATED STANDARDS 1.4.4.1 Continuing Education for Directors and Caregivers/ 3. Bromer, J. 2009. The Family Child Care Network impact study: Promising strategies for improving family child care quality. Accessible at: http://www. Teachers in Centers and Large Family Child erikson.edu/wp-content/uploads/HerrCtr_FCCBrief_Final_web1.pdf. Care Homes 1.4.4.2 Continuing Education for Small Family Child 10.6.2.2 Care Home Caregivers/Teachers Fostering Collaboration to Establish 1.4.5.1 Training of Staff Who Handle Food Programs for School-Age Children 1.4.5.2 Child Abuse and Neglect Education 1.4.5.3 Training on Occupational Risk Related to Handling Public and private agencies should foster collaboration Body Fluids among the schools, child care facilities, and resource and 1.4.5.4 Education of Center Staff referral agencies to establish programs for school-age chil- 1.4.6.1 Training Time and Professional Development Leave dren, ages five to twelve and older. Such care should be 1.4.6.2 Payment for Continuing Education designed to meet the social and developmental needs of 10.5.0.1 State and Local Health Department Role children who receive care in any setting.

450 Caring for Our Children: National Health and Safety Performance Standards RATIONALE Reference More than fifteen million children in the United States are left alone after school each day (1). School-age children who 1. National Association of Child Care Resource and Referral Agencies are under-supervised (“latchkey children”) are exposed to (NACCRRA). 2008. Covering the map: Child care resource and referral considerable health and safety risks. Bringing these chil- agencies providing vital services to parents throughout the United States. dren into supervised, quality child care is a societal respon- Arlington, VA: NACCRRA. http://www.naccrra.org/publications/ sibility. In addition to providing protection for children, naccrra-publications/publications/Parent Svc Report_MECH_screen.pdf. these programs can offer homework assistance, tutoring and other support for school achievement. 10.7.0.2 Reference Coordination of Public and Private Resources to Ensure Families’ Access to Quality 1. Afterschool Alliance. Facts and research: America after 3pm. http://www. Child Care afterschoolalliance.org/AA3PM.cfm. National and state agencies should coordinate public and 10.7 private resources to ensure that all families have access to PUBLIC POLICY ISSUES AND affordable, safe, and healthy child care for their children. To RESOURCE DEVELOPMENT the extent possible, communities should coordinate multiple funding streams to support child care. Strengthening the 10.7.0.1 child care workforce through professional development Development of Resource and opportunities and commensurate compensation should Referral Agencies be a major goal in improving available child care. RATIONALE States should encourage the use of public and private Research provides clear evidence that a well qualified and resources in local communities to develop resource and consistent staff is essential to the provision of good care for referral agencies. The functions of these agencies should children (4). Quality cannot be attained by merely applying include the following: standards to caregivers/teachers; resources are necessary to a. Helping parents/guardians find developmentally meet the cost of quality care at a price that parents/guardians can afford. Quality care requires not only lower child:staff appropriate child care that protects the health and ratios and smaller group sizes, but also well trained staff safety of children; to reduce the spread of infectious diseases, provide for safe b. Giving parents/guardians consumer information to evacuation and management of emergency situations, and to enable them to know about, evaluate, and choose offer developmentally appropriate program activities (1). among available child care options; Currently, the low wages and benefits earned by child care c. Helping parents/guardians maintain a dialogue with staff result in high staff turnover, which adversely affects the their caregivers/teachers; health and safety of children. Staff wages make up the largest d. Recruiting new potential caregivers/teachers; cost in providing care, and caregiver/teacher wages in the e. Providing training, technical assistance, and consulta- United States are currently too low to attract and retain tion, including health and safety, to new facilities and qualified staff (4). Facilities cannot benefit from training to all caregivers/teachers; provided to staff if the staff members leave their jobs f. Compiling data on supply and demand to identify before the training is implemented (1). community needs for child care; See The Child Care Bureau’s Case Studies of Public-Private g. Providing information to employers on options for their Partnerships for Child Care (2) and Head Start State involvement in meeting community child care needs; Collaboration Annual Profiles (3) for examples of h. Participating in and/or supporting the state’s Quality successful state-wide collaborative projects. Rating Improvement System (QRIS) and/or similar References quality improvements; i. Assisting programs in achieving accreditation and 1. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. providers in achieving credentials. Pediatrics 94:1108-10. RATIONALE Resource and referral agencies provide a locus in the com- 2. U.S. Department of Health and Human Services (HHS), Administration for munity to assist parents/guardians in fulfilling their child- Children and Families, Child Care Bureau. 1998. The child care partnership rearing responsibilities, a mechanism to coordinate and project: Case studies of public-private partnerships for child care. Fairfax, provide the resources and services that supplement and VA: National Child Care Information and Technical Assistance Center. facilitate the functions of the family, and a mechanism for the coordination of services that helps keep children safe 3. U.S. Department of Health and Human Services, Administration for and healthy (1). Children and Families, Office of Head Start. Head Start collaboration offices. http://eclkc.ohs.acf.hhs.gov/hslc/hsd/SCO/. 4. Gable, S., T. C. Rothrauff, K. R. Thornburg, D. Mauzy. Cash incentives and turnover in center-based child care staff. Early Childhood Res Quarter 22:363-78.

Appendixes



Signs anSdigSnysmapntdoSmysmCpht Routine ERxocultuisnieonExCcrliutesrioianACprpitleicriaabAleptpolicAallbSleigtnosAallnSdigSnysmapntodmSsymptoms — Unable—t oUpnaarbtilceiptoatpea. rticipate. — Care w—o uCldarceomwopuroldmcisoemsptraofmf’sisaebsiltitayfft’os acabrileityfotrooctahreer fcohrilodtrheenr. children. — Child m—e eCthsilodthmeer eetxscoluthsieornecxrcitluesriiao.n criteria. Sign or SympStiogmn or CSoymmptonmCauCsoemsmon Causes Complaints oCroWmhpalatinMtisghort BWehSateeMnight Be Seen N Notify HealthNCotoinfysuHletaanltth ConsuP Cold SymptoCmosld SymVirputsoems s(earlyVsirtuasgeeso(femaralynsytage of man•y Coughing • Coughing Not necessaryNoutnnleescsesespai-ry unlesYs demics occurd(eiem, iRcsSVococrur (ie, RS viruses) viruses) • Runny or s•tufRfyunonsyeor stuffy nose vaccine-prevevnatcacbinlee-dpisrevaesnetable like measles loikr evamriecaeslllaes or varic • Adenovirus• Adenovirus • Scratchy th•roSact ratchy throat [chickenpox])[chickenpox]) • Coronaviru•s Coronavirus • Sneezing • Sneezing • Enterovirus• Enterovirus • Fever • Fever • Influenza v•iruIsnfluenza virus • Watery eye•s Watery eyes • Parainfluen•zaPvairrauisnfluenza virus • Respiratory• syRnecsyptiiraaltvoirryussy(nRcSyVt)ial virus (RSV) • Rhinovirus• Rhinovirus Bacteria Bacteria • Mycoplasm•a Mycoplasma • Pertussis • Pertussis Cough Cough • Common c•oldCommon cold • Dry or wet•coDugryhor wet cough Not necessaryNoutnnleescsessary unlesYs (Cough is a bo(dCyough is•a Lboowdyer resp•iraLtowryeirnrfecsptiiornat(oergy, infect•ionR(uengn, y nos•e (cRluenarn,ywnhoitsee, o(crleyaerl,lowwh-igter,eoern)yellow-greetnh)e cough is dthuee ctouagh is due to a response to sormesep-onse topsnoemuem- onia, bpronnecuhmioolnitiias,) bronchiolitis•) Sore throat• Sore throat taifnhriorginwmgtaistythshuaeaentnsyioswisnhierertatifthnihrrtiooeregainwmtgt-aistythshuaeaen•••tnsyioswisCASnhieisrrnetrotthirhutoueeamspt-ianfec•••tioASCnisrnothuumsp ianfection vaccine-prevevnatcacbinlee-dpisrevaesnet,able • Throat irrit•atioTnhroat irritation such as pertussuscish as pertussis • Hoarse voi•ce,Hboaarrksiengvociocueg, hbarking cough • Coughing f•itsCoughing fits the lungs.) the lungs•.) Bronchitis • Bronchitis • Pertussis • Pertussis • Noninfectio•usNcoanuinsfeescltiikoeus causes like allergies allergies Diaper RashDiaper R•asIrhritation by• ruIrbrbitiantgionofbdyiarpuebrbing of d•iapReerdness • Redness Not necessaryNot necessary Y material againmsat tsekrianl wageat iwnsitthskin we•t wSicthaling • Scaling urine or stoolurine or stool • Red bumps• Red bumps • Infection w•ithInyfeeacsttioonr wbaitchteyreiaast or ba•ctSeoriraes • Sores • Cracking o•f skCirnacinkidnigapoef rsrkeingiionndiaper region American AcaAdmemeryicoafnPAecdaiadtermicsy.oMf aPneadgiaintrgicIsn.feMcatinoaugsinDgisIenafescetsioiunsCDhiisldeaCsaerse iannCdhSilcdhCoaorlse: aAndQuSichkoRoelsfe: rAenQcueicGkuRideefe. rAernocnesoGnuiSdSe,. SAhroonpseoTnRS, Se,dSsh. o4pthe eTdR Used with perUmseisdsiwonithofptehremAismsieornicoafnthAecaAdmemeryicoafnPAecdaiadtermicsy,o2f0P1e7d.iatrics, 2017. Appendix A

Caring for Our Children: NaAtioPnPalEHNeaDltIhXaAnd: SSaIGfeNtySPeArfNorDmaSnYceMSPtaTnOdaMrdSs CHART Caring htaormt s Chart for Our Children: Notify Notify If Excluded, IRf eEaxdcmluidt eWdh, eRneadmit When National uPlatarennt t TPeamrepnotrarily TEexmclpuodrea?rily Exclude? Health Ys eespi- NYoe,sunless No, unless Exclusion critEexricaluasrieonrecsroitleverida. are resolved. SV or • Fever acco•mpFaenvieerdabcycobmehpaavniioerdcbhyanbgeeh.avior change. disease cella • Child looks•orCahciltds lvoeorkysilol.r acts very ill. • Child has d•iffiCchuilltdy hbaresadthififnicgu.lty breathing. and • Child has b•looCdh-irldedhaosr pbuloropdle-rreadshornpout rapslseorcaiashtendot associated with injury. with injury. Safety • Child meet•s rCouhtilidnemeexectlsusrioounticnreitexrical.usion criteria. Ys es NYoe,sunless No, unless Exclusion critEexricaluasrieonrecsroitleverida. are resolved. Performance a • Severe cou•ghS. evere cough. disease, • Rapid or di•fficRualtpibdreoartdhifnfigc.ult breathing. Yes • Wheezing i•f nWothaelereziandgyief vnaoltualtreedadayndevtraeluaatetedd. and treated. • Cyanosis (i•e, Cblyuaencoosilsor(ioef, sbkluine ocromloruocof usskin or mucous membranes).membranes). Standards • Pertussis is• dPiaegrntuossseids iasnddiangont oyseetdtraenadtendo. t yet treated. • Fever with•beFheavveior rwcihthanbgeeh.avior change. • Child meet•s rCouhtilidnemeexectlsusrioounticnreitexrical.usion criteria. NYoe,sunless No, unless Exclusion critEexricaluasrieonrecsroitleverida. are resolved. Appendix • Oozing sor•es Othoaztinlegaskobreosdythfalut ildesakoubtosdidyefltuhieds outside the diaper. diaper. • Child meet•s rCouhtilidnemeexectlsusrioounticnreitexrical.usion criteria. dR., EeldksG. r4otvheeVdi.llaEglke,GIrLo:vAemVeillraicgaen, IALc: aAdmemeryicoafnPAecdaiadtermicsy;o2f0P1e7d.iatrics; 2017. A: Signs A Aand Symptoms 453 Chart

Appendix A Signs and Symptoms Ch Sign or Symptom Common Causes Complaints or What Might Notify Health Consult Diarrhea Be Seen • Usually viral, less commonly Yes, if 1 or more case bacterial or parasitic • Frequent loose or watery stools compared with bloody diarrhea or 2 or child’s normal pattern (Note that exclusively children in same group • Noninfectious causes such as breastfed infants normally have frequent unformed diarrhea within a week dietary (drinking too much juice), and somewhat watery stools or may have several medications, inflammatory bowel days with no stools.) disease, or cystic fibrosis • Abdominal cramps • Fever • Generally not feeling well • Vomiting occasionally present Difficult or Noisy • Common cold • Common cold: stuffy/runny nose, sore throat, Not necessary except Breathing • Croup cough, or mild fever. epiglottitis • Epiglottitis • Bronchiolitis • Croup: barking cough, hoarseness, fever, possible Not necessary • Asthma chest discomfort (symptoms worse at night), or • Pneumonia very noisy breathing, especially when breathing in. • Object stuck in airway • Exposed to a known trigger of • Epiglottitis: gasping noisily for breath with mouth wide open, chin pulled down, high fever, or bluish asthma symptoms (eg, animal (cyanotic) nails and skin; drooling, unwilling to dander, pollen) lie down. Earache • Bacteria • Bronchiolitis and asthma: child is working hard • Often occurs in context of to breathe; rapid breathing; space between ribs looks like it is sucked in with each breath (retrac- common cold virus tions); wheezing; whistling sound with breathing; cold/cough; irritable and unwell. Takes longer to breathe out than to breathe in. • Pneumonia: deep cough, fever, rapid breathing, or space between ribs looks like it is sucked in with each breath (retractions). • Object stuck in airway: symptoms similar to croup (listed previously). • Exposed to a known trigger of asthma symptoms: a known trigger and breathing that sounds or looks different from what is normal for that child. • Fever • Pain or irritability • Difficulty hearing • “Blocked ears” • Drainage • Swelling around ear

hart (continued ) 454 tant Notify Temporarily Exclude? If Excluded, AAppendixA:SignsandSyCmaptroinmgsCfohrarOt ur Children: National Health and Safety Performance Standards Parent Readmit When es of Yes, if r more Yes • Directed by the local health department as part of • Cleared to return by health care provider p with for all cases of bloody diarrhea and k outbreak management. diarrhea caused by Shiga toxin-producing • Stool is not contained in the diaper for diapered Escherichia coli, Shigella, or Salmonella for Yes serotype Typhi until negative stool culture children. requirement has been met. • Diarrhea is causing “accidents” for toilet-trained • Diapered children have their stool contained children. by the diaper (even if the stools remain • Stool frequency exceeds 2 stools above normal loose) and toilet-trained children do not have toileting accidents. during the time the child is in the program because this may cause too much work for teachers/ • Stool frequency is no more than 2 stools caregivers and make it difficult to maintain good above normal during the time the child sanitation. is in the program, or what has become • Blood/mucus in stool. normal for that child when the child seems • Black stools. otherwise well. • No urine output in 8 hours. • Jaundice (ie, yellow skin or eyes). • Exclusion criteria are resolved. • Fever with behavior change. • Looks or acts very ill. Exclusion criteria are resolved. • Child meets routine exclusion criteria. Yes, if • Fever with behavior change. • Child looks or acts very ill. • Child has difficulty breathing. • Rapid or difficult breathing. • Wheezing if not already evaluated and treated. • Cyanosis (ie, blue color of skin or mucous membranes). • Cough interferes with activities. • Breath sounds can be heard when the child is at rest. • Child has blood-red or purple rash not associated with injury. • Child meets routine exclusion criteria. Yes No, unless child meets routine exclusion criteria. Exclusion criteria are resolved.

Signs and Symptoms Ch Sign or Symptom Common Causes Complaints or What Might Notify Health Consult Be Seen Eye Irritation, • Bacterial infection of the mem- Yes, if 2 or more child Pinkeye brane covering 1 or both eyes and • Bacterial infection: pink color of the “whites” of have red eyes with wa eyelids (bacterial conjunctivitis) eyes and thick yellow/green discharge. Eyelid may discharge be irritated, swollen, or crusted. • Viral infection of the membrane covering 1 or both eyes and • Viral infection: pinkish/red color of the whites of eyelids (viral conjunctivitis) the eye; irritated, swollen eyelids; watery dis- charge with or without some crusting around the • Allergic irritation of the membrane eyelids; may have associated cold symptoms. covering 1 or both eyes and eyelids (allergic conjunctivitis) • Allergic and chemical irritation: red, tearing, itchy, puffy eyelids; runny nose, sneezing; watery/stringy • Chemical irritation of the mem- discharge with or without some crusting around brane covering the eye and eyelid the eyelids. (irritant conjunctivitis) (eg, swim- ming in heavily chlorinated water, air pollution, smoke exposure) Fever • Any viral, bacterial, or parasitic Flushing, tired, irritable, decreased activity Not necessary Headache infection Notes • Vigorous exercise • Fever alone is not harmful. When a child has an • Reaction to medication or vaccine • Other noninfectious illnesses (eg, infection, raising the body temperature is part of the body’s normal defense against germs. rheumatoid arthritis, malignancy) • Rapid elevation of body temperature sometimes triggers a febrile seizure in young children; this usually is outgrown by age 6 years. The first time a febrile seizure happens, the child requires medical evaluation. These seizures are frightening but are usually brief (less than 15 minutes) and do not cause the child any long-term harm. Parents should inform their child’s health care provider every time the child has a seizure, even if the child is known to have febrile seizures. Warning: Do not give aspirin. It has been linked to an increased risk of Reye syndrome (a rare and seri- ous disease affecting the brain and liver). • Any bacterial/viral infection • Tired and irritable Not necessary • Other noninfectious causes • Can occur with or without other symptoms Appendix A

Chart (continued ) 455 tant Notify Temporarily Exclude? If Excluded, Caring for Our Children: National Health and Safety Performance StandaArpdpsendixA:Signs AandSymptomsChart Parent Readmit When dren Yes For bacterial conjunctivitis • For bacterial conjunctivitis, once parent has atery No. Exclusion is no longer required for this condition. Yes Health care providers may vary on whether to treat discussed with health care provider. Antibi- this condition with antibiotic medication. The role otics may or may not be prescribed. Yes of antibiotics in treatment and preventing spread is • Exclusion criteria are resolved. unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. Exclusion criteria are resolved. For other eye problems Exclusion criteria are resolved. No, unless child meets other exclusion criteria. Note: One type of viral conjunctivitis spreads rapidly and requires exclusion. If 2 or more children in the group have watery red eyes without any known chemical irritant exposure, exclusion may be required and health authorities should be notified to determine if the situation involves the uncommon epidemic conjunctivitis caused by a specific type of adenovirus. Herpes simplex conjunctivitis (red eyes with blister- ing/vesicles on eyelid) occurs rarely and would also require exclusion if there is eye watering. No, unless • Behavior change or other signs of illness in addition to fever or child meets other routine exclusion criteria. • Unable to participate. • Care would compromise staff’s ability to care for other children. Note: A temperature considered meaningfully ele- vated above normal, although not necessarily an indi- cation of a significant health problem, for infants and children older than 2 months is above 101°F (38.3°C) from any site (axillary, oral, or rectal). Get medical attention when infants younger than 4 months have unexplained fever. In any infant younger than 2 months, a temperature above 100.4°F (38.0°C) is considered meaningfully elevated and requires that the child get medical attention immediately, within an hour if possible. The fever is not harmful; however, the illness causing it may be serious in this age group. No, unless child meets routine exclusion criteria. Note: Notify health care provider in case of sudden, severe headache with vomiting or stiff neck that might signal meningitis. It would be concerning if the back of the neck is painful or the child can’t look at his or her belly button (putting chin to chest)—differ- ent from soreness in the side of the neck.

Appendix A Signs and Symptoms Ch Sign or Symptom Common Causes Complaints or What Might Notify Health Consulta Itching • Ringworm Be Seen Yes, for infestations su • Chickenpox lice and scabies; if more Mouth Sores • Pinworm • Ringworm: itchy ring-shaped patches on skin or 1 child in group has imp Rash • Head lice bald patches on scalp. or ringworm; for chicken • Scabies • Allergic or irritant reaction (eg, • Chickenpox: blister-like spots surrounded by red Not necessary halos on scalp, face, and body; fever; irritable. poison ivy) For outbreaks, such as • Dry skin or eczema • Pinworm: anal itching. tiple children with impe • Impetigo • Head lice: small insects or white egg sheaths that within a group • Oral thrush (yeast infection) look like grains of sand (nits) in hair. • Herpes or coxsackievirus infection • Scabies: severely itchy red bumps on warm areas • Canker sores of body, especially between fingers or toes. Many causes • Allergic or irritant reaction: raised, circular, mobile • Viral: roseola infantum, fifth rash; reddening of the skin; blisters occur with disease, chickenpox, herpesvirus, local reactions (poison ivy, contact reaction). molluscum contagiosum, warts, • Dry skin or eczema: dry areas on body. More often cold sores, shingles (herpes worse on cheeks, in front of elbows, and behind zoster), and others knees. In infants, may be dry areas on face and • Skin infections and infestations: anywhere on body but not usually in diaper area. If ringworm (fungus), scabies swollen, red, or oozing, think about infection. (parasite), impetigo, abscesses, • Impetigo: areas of crusted yellow, oozing sores. and cellulitis (bacteria) Often around mouth or nasal openings or areas of • Scarlet fever (strep infection) broken skin (insect bites, scrapes). • Severe bacterial infections: meningococcus, pneumo- • Oral thrush: white patches on tongue, gums, and coccus, Staphylococcus along inner cheeks (methicillin-susceptible S aureus; methicillin-resistant • Herpes or coxsackievirus infection: pain on swal- S aureus), Streptococcus lowing; fever; painful, white/red spots in mouth; • Noninfectious causes: allergy swollen neck glands; fever blister, cold sore; (hives), eczema, contact (irritant) reddened, swollen, painful lips dermatitis, medication related, poison ivy • Canker sores: painful ulcers inside cheeks or on gums • Skin may show similar findings with many differ- ent causes. Determining cause of rash requires a competent health care provider evaluation that takes into account information other than just how rash looks. However, if the child appears well other than the rash, a health care provider visit is not necessary. • Viral: usually signs of general illness such as runny nose, cough, and fever (except not for warts or molluscum). Some viral rashes have a distinctive appearance. • Minor skin infections and infestations: see Itching. • More serious skin infections: redness, pain, fever, pus. • Severe bacterial infections: rare. These children usually have fever with a rapidly spreading blood- red rash and may be very ill. • Allergy may be associated with a raised, itchy, pink rash with bumps that can be as small as a pinpoint or large welts known as hives. See also Itching for what might be seen for allergy or contact (irritant) dermatitis or eczema.

hart (continued ) 456 ant Notify Temporarily Exclude? If Excluded, AAppendixA:SignsandSymptomCsaChrianrgt for Our Children: National Health and Safety Performance Standards Parent Readmit When uch as For chickenpox e than Yes Yes, until lesions are fully crusted • Exclusion criteria are resolved. petigo • On medication or treated as recommended npox For ringworm, impetigo, scabies, and head lice Yes, at the end of the day by a health care provider if treatment is in- Children should be referred to a health care provider dicated for the condition. For conditions that at the end of the day for treatment. require application of antibiotics to lesions or taking antibiotics by mouth, the period of For pinworm, allergic or irritant reactions like hives, treatment to reduce risk of spread to others and eczema is usually 24 hours. For most children with No, unless appears infected as a weeping or crusty insect infestations or parasites, readmission sore as soon as the treatment has been given is acceptable. Note: Although exclusion for these conditions is not necessary, families should seek advice from the child’s health professional for how to care for these health problems. For any other itching No, unless the child meets routine exclusion criteria. Yes No, unless Exclusion criteria are resolved. • Drooling steadily related to mouth sores. • Fever with behavior change. • Child meets routine exclusion criteria. mul- Yes No, unless • On antibiotic medication for required period etigo • Rash with behavior change or fever. (if indicated). • Has oozing/open wound. • Has bruising not associated with injury. • Infestations (lice and scabies) and ringworm • Has joint pain and rash. can be treated at the end of the day with • Rapidly spreading blood-red rash. immediate return the following day. • Tender, red area of skin, especially if it is increasing • Exclusion criteria are resolved. in size or tenderness. • Child meets routine exclusion criteria. • Diagnosed with a vaccine-preventable condition, such as chickenpox.

Signs and Symptoms C Sign or Symptom Common Causes Complaints or What Might Notify Health Consult Sore Throat • Viral—common cold viruses that Be Seen Not necessary (pharyngitis) cause upper respiratory infections • Viral: verbal children will complain of sore throat; If multiple cases in sam Stomachache • Strep throat younger children may be irritable with decreased group within 1 week appetite and increased drooling (refusal to swal- • Viral gastroenteritis or strep throat low). Often see symptoms associated with upper • Problems with internal organs of respiratory illness, such as runny nose, cough, and congestion. the abdomen such as intestine, colon, liver, bladder • Strep throat: signs of the body’s fight against • Nonspecific, behavioral, and infection include red tissue with white patches dietary causes on sides of throat, at back of tongue (tonsil area), • If combined with hives, may be and at back wall of throat. Unlike viral pharyngitis, associated with a severe allergic strep throat infections are not accompanied reaction with cough or runny nose in children older than 3 years. • Tonsils may be large, even touching each other. Swollen lymph nodes (sometimes called “swollen glands”) occur as body fights off the infection. • Viral gastroenteritis or strep throat: Vomiting and diarrhea or cramping are signs of a viral infection of the stomach or intestine. Strep throat may cause stomachache with sore throat, headache, and possible fever. In children older than 3 years, if cough or runny nose is present, strep is very unlikely. • Problems with internal organs of the abdomen: persistent severe pain in abdomen. • Nonspecific stomachache: vague complaints with- out vomiting/diarrhea or much change in activity. Swollen Glands • Normal body defense response • Normal lymph node response: swelling at front, Not necessary (properly called to viral or bacterial infection in sides, and back of the neck and ear; in the armpit For outbreak swollen lymph the area where lymph nodes are or groin; or anywhere else near an area of an nodes) located (ie, in the neck for any infection. Usually, these nodes are less than upper respiratory infection) 1\" across. Vomiting • Bacterial infection of lymph nodes • Bacterial infection of lymph nodes: swollen, warm that is more than the normal lymph nodes with overlying pink skin, tender to response to infection near where the touch, usually located near an area of the body the lymph nodes are located that has been infected. Usually these nodes are larger than 1\" across. • Viral infection of the stomach or intestine (gastroenteritis) Diarrhea, vomiting, or cramping for viral gastroenteritis • Coughing strongly Appendix A • Other viral illness with fever • Noninfectious causes: food allergy (—vomiting, sometimes with hives,) trauma, dietary and medication related, headache

Chart (continued ) 457 tant Notify Temporarily Exclude? If Excluded, Caring for Our Children: National Health and Safety Performance StandarAdpspendixA:Signs AandSymptomsChart Parent Readmit When No, unless Yes • Inability to swallow. • Able to swallow. • Excessive drooling with breathing difficulty. • On medication at least 12 hours (if strep). • Fever with behavior change. • Exclusion criteria are resolved. • Child meets routine exclusion criteria. Note: Most children with red back of throat or tonsils, pus on tonsils, or swollen lymph nodes have viral infections. If strep is present, 12 hours of antibiotics is required before return to care. However, tests for strep infection are not often necessary for children younger than 3 years because these children do not develop rheumatic heart disease—the primary rea- son for treatment of strep throat. me Yes No, unless • Pain resolves. • Severe pain causing child to double over or • Able to participate. Yes • Exclusion criteria are resolved. scream. • Abdominal pain after injury. • Child is on antibiotics (if indicated). • Bloody/black stools. • Exclusion criteria are resolved. • No urine output for 8 hours. • Diarrhea (see Diarrhea). • Vomiting (see Vomiting). • Yellow skin/eyes. • Fever with behavior change. • Looks or acts very ill. • Child meets routine exclusion criteria. No, unless • Difficulty breathing or swallowing. • Red, tender, warm glands. • Fever with behavior change. • Child meets routine exclusion criteria. Yes Yes, if • Vomiting ends. • Vomited more than 2 times in 24 hours • Able to participate. • Vomiting and fever • Exclusion criteria are resolved. • Vomiting with hives • Vomit that appears green/bloody • No urine output in 8 hours • Recent history of head injury • Looks or acts very ill • Child meets routine exclusion criteria.

B458 Caring for Our Children: National Health and Safety Performance Standards Appendix B: Major Occupational Health Hazards APPEMNADJIOX RB:OMCACJOURPAOTCIOCUNPAALTHIOENAALLTHHEHAALZTAHRHDASZARDS Infectious Diseases and Organisms Injuries and Noninfectious Diseases Back injuries General Types of Infectious Diseases Bites Diarrhea (infectious) Dermatitis Respiratory tract infection Falls Specific Infectious Diseases and Organisms Environmental Exposure Adenovirus Art materials Astrovirus Cleaning, sanitizing, and disinfecting solutions Caliciviruses Indoor air pollution Campylobacter jejuni/coli Outdoor air pollution Chickenpox (varicella) Noise Clostridium difficile Odor Cytomegalovirus (CMV) Escherichia coli (STEC) Stress Giardia intestinalis Fear of liability Haemophilus influenzae type b (Hib) Inadequate break time, sick time, and personal days Hepatitis A Inadequate facilities Hepatitis B Inadequate pay Hepatitis C Inadequate recognition Herpes 6 Inadequate training Herpes 7 Insufficient professional recognition Herpes simplex Lack of adequate medical/dental health insurance Herpes zoster Responsibility for children’s welfare Human Immunodeficiency Virus (HIV) Undervaluing of work Impetigo Working alone/Isolation Influenza and H1N1 Lice Reference: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Measles Red Book: 2009 Report of the Committee on Infectious Diseases. Meningitis (bacterial, viral) 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. Meningococcus (Neisseria meningitidis) Mumps Parvovirus B19 Pertussis Pinworm Ringworm Rotavirus Rubella Salmonella organisms Scabies Shigella organisms Staphylococcus aureus Streptococcus, Group A Streptococcus pneumoniae Tuberculosis Appendix B

459 Qualifications CCarinAgppfoenr dOixuCr: NCuhtrilidtiorennS:peNcaiatliiostn, RaelgHiseteareltdhDaientditiaSna, LfeicteynsPederNfuotrrmitioannicste, CSontasunltdaanrt,dasnd Food Service Staff NAUPTPNREIuTNtIrDOitINiXoCInCSoT:SnN, pCsUueOTlcNtRiaaSInTlUitIs,OLtTa,NAnRSNdePTgFE,ioACsoItNAedDrLeSIFSdeOTrD,OvRiiDecEteGSitEISiSaRtTnaVE,fIfRCLQEEicDuSeaTDnAlsiIfEFeicTFdaIQTNtIiUoAuAnNtrLs,iItLFioIICCnEAisNTtSI,OENDS TITLE LEVEL OF PROFESSIONAL EDUCATION AND EXPERIENCE RESPONSIBILITY Nutrition Develops policies and Current registration with the Commission on Specialist/ procedures for implementation Dietetic Registration of the American Dietetic Registered of nutrition food standards Association or eligibility for registration with Dietitian/Licensed statewide and provides a Bachelor’s and Master’s degree in nutrition Nutritionist/Child consultation to state agency (including or supplemented by course(s) in child Care Nutrition personnel, including staff growth and development), plus at least two years Consultant (state involved with licensure. of related experience as a nutritionist or dietitian level) in a health program including services to infants and children is preferred. A Master’s degree from an approved program in public health nutrition may be substituted for registration with the Commission on Dietetic Registration. Current state licensure or certification as a nutritionist or dietitian is acceptable. Nutrition Provides expertise to child Registered Dietitian, as above. At least one year Specialist/ care center director and of experience as described above. Registered provides ongoing guidance, Dietitian (local consultation, and inservice level) training to facility’s nutrition component. The number of sites and facilities for one child care Nutrition Specialist will vary according to size and complexity of local facilities. Food Service Has overall supervisory High school diploma or GED. Successful Manager responsibility for the food completion of a food handler food protection service unit at one or more class. Coursework in basic menu-planning facility sites. skills, basic foods, introduction to child feeding programs for managers, and/or other relevant courses (offered at community colleges). Two years of food service experience. Food Service Under the supervision of the High school diploma or GED. Successful Worker (Cook) Food Service Manager, carries completion of a food handler food protection out food service operations class. Coursework in basic menu-planning skills including menu planning, food and basic foods (offered through adult education preparation and service, and or a community college). One year of food service related duties in a designated experience. area. Food Service Aide Works no more than four High school diploma or GED. Must pass the hours a day, under the food handler test within one to two months of supervision of an employee at employment. No prior experience is required for a higher level in food service semi-skilled persons who perform assigned tasks unit. in designated areas. Appendix C

460 Appendix D: Gloving APPENDIX D: GLOVING STOP GLOVING DISEASE 1. Put on a clean pair of gloves. 2. Provide appropriate care. 3. Remove each glove carefully. Grab 4. Ball up the dirty glove in the the first glove at the palm and palm of the other gloved hand. strip the glove off. Touch dirty surfaces only to dirty surfaces. 5. With the clean hand, strip the glove off from 6. Discard the dirty gloves immediately underneath at the wrist, turning the glove inside in a step can. Wash your hands. out. Touch clean surfaces only to clean surfaces. Rev. 06/2018 California Childcare Health Program cchp.ucsf.edu Used with permission from California Child Care Health Program. Health and Safety in the Child Care Setting: Prevention of Infectious Disease. A Curriculum for the Training of Child Care Providers. Module 1, 2nd ed. Oakland, CA: California Child Care Health Program; 2001. https://cchp.ucsf.edu/sites/cchp.ucsf. edu/files/idc2book.pdf

Appendix W 461 Child Care Staff Health AssessmentCFOC3 Std. 1.7.01 Appendix E: Child Care Staff Health Assessment APPENDIX E: CHILD CARE STAFF HEALTH ASSESSMENT Employer should complete this section. Name of person to be examined: Employer for whom examination is being done: Employer’s location: Phone number: Purpose of examination: ¨ preemployment (with conditional offer of employment) ¨ annual reexamination Type of activity on the job: ¨ lifting, carrying children ¨ close contact with children ¨ food preparation ¨ facility maintenance ¨ desk work ¨ driver of vehicles Parts I and II must be completed and signed by a licensed physician or certified registered nurse practitioner. Based on a review of the medical record, health history, and physical examination, does this person have any of the following conditions or problems that might affect job performance or require accommodation? Date of examination: (circle) yes no Part I: Health Problems yes no yes no Visual acuity less than 20/40 (combined, obtained with lenses if needed)? yes no Decreased hearing (less than 20 dB at 500, 1,000, 2,000, 4,000 Hz)? yes no Respiratory problems (asthma, emphysema, airway allergies, current smoker, other)? yes no Heart, blood pressure, or other cardiovascular problems? yes no Gastrointestinal problems (ulcer, colitis, special dietary requirements, obesity, other)? Endocrine problems (diabetes, thyroid, other)? yes no Emotional disorders or addiction (depression, drug or alcohol dependency, difficulty handling yes no stress, other)? yes no Neurologic problems (epilepsy, Parkinson disease, other)? yes no Musculoskeletal problems (low back pain, neck problems, arthritis, limitations on activity)? yes no Skin problems (eczema, rashes, conditions incompatible with frequent hand washing, other)? yes no Immune system problems (from medication, illness, allergies, susceptibility to infection)? yes no Need for more frequent health visits or sick days than the average person? Dental problems assessed in a dental examination within the past 12 months? Other special medical problem or chronic disease that requires work restrictions or accommodation?

A41p76p82endix E: CMhoidldelCCahriled SCtaareffHHeaelathltPhoAlicsiessessment Part II: Infectious Disease Status The following immunizations are due/overdue per recommendations for adults in contact with children. Include those listed as follows and any others currently recommended by the Centers for Disease Control and Prevention at www.cdc.gov/vaccines: Tdap (once, no matter when the most recent Td was given) yes no no MMR (2 doses for persons born after 1989; 1 dose for those born in or after 1957) yes no no Polio (OPV or IPV in childhood) yes no no Hepatitis B (3-dose series) yes no Varicella (2 doses or had the disease) yes no no Influenza yes Pneumococcal vaccine yes Other vaccines Female of childbearing age susceptible to CMV or parvovirus who needs counseling about risk? yes Evaluation of TB status shows a risk for communicable TB? yes Check test used. ¨ Tuberculin skin test (TST) ¨ Interferon gamma release assay (IGRA) test Test date Result The results and appropriate follow-up of a tuberculosis (TB) screening, using the TST or IGRA, is required once on entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter. Anyone with a previously positive TST or IGRA who has symptoms suggestive of active TB should have a chest x-ray. All newly positive TB skin or blood tests should be followed by x-ray evaluation. Please attach additional sheets to explain all “yes” answers. Include the plan for follow-up. MD DO CRNP DATE SIGNATURE PRINTED LAST NAME TITLE Phone number of licensed physician, physician assistant, or certified registered nurse practitioner: I have read and understand this information. DATE PATIENT’S SIGNATURE Original document in Model Child Care Health Policies, 5th Edition. Copyright © 2014 Pennsylvania Chapter of the American Academy of Pediatrics (AAP). All rights reserved. Permission is granted to reproduce or adapt content for use within a child care setting. The AAP does not review or endorse modifications of this document and in no event shall the AAP be liable for any such changes.

Child Care Staff Health AssessmentCFOC3 Std. 1.7.01 463 Appendix E: Child Care Staff Health Assessment Employer should complete this section. Name of person to be examined: Employer for whom examination is being done: Employer’s location: Phone number: Purpose of examination: ¨ preemployment (with conditional offer of employment) ¨ annual reexamination Type of activity on the job: ¨ lifting, carrying children ¨ close contact with children ¨ food preparation ¨ facility maintenance ¨ desk work ¨ driver of vehicles Parts I and II must be completed and signed by a licensed physician or certified registered nurse practitioner. Based on a review of the medical record, health history, and physical examination, does this person have any of the following conditions or problems that might affect job performance or require accommodation? Date of examination: (circle) yes no Part I: Health Problems yes no yes no Visual acuity less than 20/40 (combined, obtained with lenses if needed)? yes no Decreased hearing (less than 20 dB at 500, 1,000, 2,000, 4,000 Hz)? yes no Respiratory problems (asthma, emphysema, airway allergies, current smoker, other)? yes no Heart, blood pressure, or other cardiovascular problems? yes no Gastrointestinal problems (ulcer, colitis, special dietary requirements, obesity, other)? Endocrine problems (diabetes, thyroid, other)? yes no Emotional disorders or addiction (depression, drug or alcohol dependency, difficulty handling yes no stress, other)? yes no Neurologic problems (epilepsy, Parkinson disease, other)? yes no Musculoskeletal problems (low back pain, neck problems, arthritis, limitations on activity)? yes no Skin problems (eczema, rashes, conditions incompatible with frequent hand washing, other)? yes no Immune system problems (from medication, illness, allergies, susceptibility to infection)? yes no Need for more frequent health visits or sick days than the average person? Dental problems assessed in a dental examination within the past 12 months? Other special medical problem or chronic disease that requires work restrictions or accommodation?

464 1A7p8pendix E: MChodiledl CChairldeCSatraefHf HeaeltahltPholAicsiessessment Part II: Infectious Disease Status The following immunizations are due/overdue per recommendations for adults in contact with children. Include those listed as follows and any others currently recommended by the Centers for Disease Control and Prevention at www.cdc.gov/vaccines: Tdap (once, no matter when the most recent Td was given) yes no no MMR (2 doses for persons born after 1989; 1 dose for those born in or after 1957) yes no no Polio (OPV or IPV in childhood) yes no no Hepatitis B (3-dose series) yes no Varicella (2 doses or had the disease) yes no no Influenza yes Pneumococcal vaccine yes Other vaccines Female of childbearing age susceptible to CMV or parvovirus who needs counseling about risk? yes Evaluation of TB status shows a risk for communicable TB? yes Check test used. ¨ Tuberculin skin test (TST) ¨ Interferon gamma release assay (IGRA) test Test date Result The results and appropriate follow-up of a tuberculosis (TB) screening, using the TST or IGRA, is required once on entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter. Anyone with a previously positive TST or IGRA who has symptoms suggestive of active TB should have a chest x-ray. All newly positive TB skin or blood tests should be followed by x-ray evaluation. Please attach additional sheets to explain all “yes” answers. Include the plan for follow-up. MD DO CRNP DATE SIGNATURE PRINTED LAST NAME TITLE Phone number of licensed physician, physician assistant, or certified registered nurse practitioner: I have read and understand this information. DATE PATIENT’S SIGNATURE Original document in Model Child Care Health Policies, 5th Edition. Copyright © 2014 Pennsylvania Chapter of the American Academy of Pediatrics (AAP). All rights reserved. Permission is granted to reproduce or adapt content for use within a child care setting. The AAP does not review or endorse modifications of this document and in no event shall the AAP be liable for any such changes.

Child Care Staff Health AssessmentCFOC3 Std. 1.7.01 465 Appendix E: Child Care Staff Health Assessment Employer should complete this section. Name of person to be examined: Employer for whom examination is being done: Employer’s location: Phone number: Purpose of examination: ¨ preemployment (with conditional offer of employment) ¨ annual reexamination Type of activity on the job: ¨ lifting, carrying children ¨ close contact with children ¨ food preparation ¨ facility maintenance ¨ desk work ¨ driver of vehicles Parts I and II must be completed and signed by a licensed physician or certified registered nurse practitioner. Based on a review of the medical record, health history, and physical examination, does this person have any of the following conditions or problems that might affect job performance or require accommodation? Date of examination: (circle) yes no Part I: Health Problems yes no yes no Visual acuity less than 20/40 (combined, obtained with lenses if needed)? yes no Decreased hearing (less than 20 dB at 500, 1,000, 2,000, 4,000 Hz)? yes no Respiratory problems (asthma, emphysema, airway allergies, current smoker, other)? yes no Heart, blood pressure, or other cardiovascular problems? yes no Gastrointestinal problems (ulcer, colitis, special dietary requirements, obesity, other)? Endocrine problems (diabetes, thyroid, other)? yes no Emotional disorders or addiction (depression, drug or alcohol dependency, difficulty handling yes no stress, other)? yes no Neurologic problems (epilepsy, Parkinson disease, other)? yes no Musculoskeletal problems (low back pain, neck problems, arthritis, limitations on activity)? yes no Skin problems (eczema, rashes, conditions incompatible with frequent hand washing, other)? yes no Immune system problems (from medication, illness, allergies, susceptibility to infection)? yes no Need for more frequent health visits or sick days than the average person? Dental problems assessed in a dental examination within the past 12 months? Other special medical problem or chronic disease that requires work restrictions or accommodation?

466 1A7p8pendix E: MChodiledl CChairldeCSatraefHf HeaeltahltPholAicsiessessment Part II: Infectious Disease Status The following immunizations are due/overdue per recommendations for adults in contact with children. Include those listed as follows and any others currently recommended by the Centers for Disease Control and Prevention at www.cdc.gov/vaccines: Tdap (once, no matter when the most recent Td was given) yes no no MMR (2 doses for persons born after 1989; 1 dose for those born in or after 1957) yes no no Polio (OPV or IPV in childhood) yes no no Hepatitis B (3-dose series) yes no Varicella (2 doses or had the disease) yes no no Influenza yes Pneumococcal vaccine yes Other vaccines Female of childbearing age susceptible to CMV or parvovirus who needs counseling about risk? yes Evaluation of TB status shows a risk for communicable TB? yes Check test used. ¨ Tuberculin skin test (TST) ¨ Interferon gamma release assay (IGRA) test Test date Result The results and appropriate follow-up of a tuberculosis (TB) screening, using the TST or IGRA, is required once on entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter. Anyone with a previously positive TST or IGRA who has symptoms suggestive of active TB should have a chest x-ray. All newly positive TB skin or blood tests should be followed by x-ray evaluation. Please attach additional sheets to explain all “yes” answers. Include the plan for follow-up. MD DO CRNP DATE SIGNATURE PRINTED LAST NAME TITLE Phone number of licensed physician, physician assistant, or certified registered nurse practitioner: I have read and understand this information. DATE PATIENT’S SIGNATURE Original document in Model Child Care Health Policies, 5th Edition. Copyright © 2014 Pennsylvania Chapter of the American Academy of Pediatrics (AAP). All rights reserved. Permission is granted to reproduce or adapt content for use within a child care setting. The AAP does not review or endorse modifications of this document and in no event shall the AAP be liable for any such changes.

Appendix F Enrollment / Attendanc Classroom ______________ NAME AGE IN DAILY 1 2 3 4 5 FOR EACH CHILD, EACH DAY CODE MONTHS HOURS IN COD CARE 6 7 8 9 10 11 12 13 TOTAL PLACED NUMBER OF DAYS FACILITY WAS OPEN ON REGISTER Symptom Codes: 1 = ASTHMA, WHEEZING, 2 = BEHAVIOR CHANGE WITH NO OTHER SYMPTOM, 3 = DIARRHEA, 4 = SORE THROAT, PINK EYE), 8 = STOMACHACHE, 9 = URINE PROBLEM, 10 = VOMITING, 11 = OTHER (SPECIFY ON BACK This form was adapted from Pennsylvania Chapter, American Academy of Pediatrics. 2002. Model child care health policies. 4th ed. W

ce / Symptom Record 467 MONTH 20 Appendix F: Enrollment/Attendance/Symptom Record TOP BOX “+” = PRESENT or “O” = ABSENT, N = NOT SCHEDULED 29 30 31 Caring for Our Children: National Health and Safety Performance Standards DE BOTTOM BOX “O” = WELL or “ “ SYMPTOM CODE FROM BOTTOM OF PAGE. F APPENDIXF:ENROLLMENT/ATTENDANCE/SYMPTOMRECORD 3 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 FEVER, 5 = HEADACHE, 6 = RASH, 7 = RESPIRATORY (COLD, COUGH, RUNNY NOSE, EARACHE, K OF FORM) Washington, DC: National Association for the Education of Young Children.