Caring for Our Children Basics; Comment Request, 75557-75564 [2014-29649]

Agencies

• DEPARTMENT OF HEALTH AND HUMAN SERVICES
• Administration for Children and Families

[Federal Register Volume 79, Number 243 (Thursday, December 18, 2014)]
[Notices]
[Pages 75557-75564]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-29649]



[[Page 75557]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Administration for Children and Families


Caring for Our Children Basics; Comment Request

AGENCY: Administration for Children and Families (ACF), Department of 
Health and Human Services (HHS).

ACTION: Notice.

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SUMMARY: As authorized by the 2014 Omnibus Act, ACF is requesting 
public comment on a voluntary set of minimum health and safety 
standards for early care and education settings titled, ``Caring for 
Our Children Basics.''

DATES: The deadline for receipt of comments is midnight, February 17, 
2015.

ADDRESSES: Submit comments to cfocbasics@acf.hhs.gov.

SUPPLEMENTARY INFORMATION: High quality early care and education 
settings can have significant developmental benefits and other positive 
long term effects for children well into their adult years. At the same 
time, poor quality can result in unsafe environments that disregard 
children's basic physical and emotional needs leading to neglect, toxic 
stress, injury, or even death. It is not surprising that health and 
safety have been identified in multiple parent surveys as the most 
important factors to consider when evaluating child care options. For 
example, Shlay \1\ found that, regardless of race/ethnicity, parents 
consistently prioritized health and safety over other quality features 
when selecting an early care arrangement.
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    \1\ Shlay, A. (2010). African American, White and Hispanic child 
care preferences: A factorial survey analysis of welfare leavers by 
race and ethnicity. Social Science Research, 39(1), 125-141.
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    From 2009 to 2011, 27 states made changes to licensing regulations 
for center-based care, and more than half made changes to licensing 
requirements for family child care homes. With respect to health and 
safety, the largest increase was in the number of states that have 
requirements regarding safe sleep practices (Office of Child Care's 
National Center on Child Care Quality Improvement & National 
Association for Regulatory Administration, 2013). A number of states 
have taken action to strengthen health and safety requirements and 
their enforcement in reaction to tragedies where children have been 
injured or died in child care (e.g., Lexie's Law (Kansas, 2010) and 
Joshua's List (Oklahoma, 2010)). However, more work must be done to 
ensure children can learn, play, and grow in settings that are safe and 
secure.
    Health and safety standards provide the foundation on which states 
and communities build a solid system of early care and education. Yet, 
states vary widely in the number and content of health and safety 
standards as well as how they monitor compliance with these standards. 
Some early care providers may receive no monitoring while others 
receive multiple visits. In addition, some early care and education 
providers who receive funding from multiple sources may receive 
repeated monitoring visits using conflicting standards. These sources 
can include Head Start, the Child Care and Development Fund, and the 
Child and Adult Care Food Program.
    In testimony before the United States House Committee on Education 
and the Workforce, the Government Accountability Office (GAO) called 
attention to the multiple agencies that administer the federal 
investment in early learning and child care through multiple programs 
that sometimes have similar goals and are targeted to similar groups of 
children. They added that the existence of multiple programs can 
increase administrative costs associated with meeting varying 
requirements. We acknowledge that there are differences in health and 
safety requirements by funding stream (e.g., Head Start, Child Care 
Development Fund, pre-Kindergarten) and early childhood program type 
(e.g., center-based, home-based). While standards may vary depending on 
the length of the day and setting, there are some standards that must 
be in place to protect children no matter what type of variation in 
program.
    The proposed model standards are called ``Caring for our Children 
Basics.'' They represent the minimum standards experts believe must be 
in place wherever children are regularly cared for in non-parental care 
settings. ``Caring for our Children Basics'' is the first attempt to 
reduce the conflicts and redundancy found in standards that are used to 
monitor early care and education settings. These are minimum standards 
and should not be construed to represent all standards that would need 
to be present to achieve the highest quality of care and early 
learning. For example, the caregiver training requirements outlined in 
these standards are designed only to prevent harm to children, not to 
ensure their optimal development and learning.
    This call for public comment is to obtain information to help HHS 
as we further develop the voluntary set of minimum health and safety 
standards for early care and education settings. Because quality care 
cannot be achieved without consistent, basic health and safety 
practices in place, ACF seeks to provide a helpful reference for states 
and other entities as they work to improve their health and safety 
standards across program type. Our hope is that a voluntary common 
framework will assist child care licensing agencies in working towards 
and achieving a more consistent foundation for quality across the 
country upon which families can rely. In addition, ACF plans to use 
``Caring for Our Children Basics'' in aligning health and safety 
efforts in early care and education at the federal level. Public input 
will be helpful in providing HHS with practical guidance to aid in the 
refinement and application of ``Caring for Our Children Basics.''
    ``Caring for Our Children Basics'' is based on ``Caring for Our 
Children: National Health and Safety Performance Standards; Guidelines 
for Early Care and Education Programs, Third Edition.'' We would like 
to acknowledge the extensive work of the American Academy of 
Pediatrics, the American Public Health Association, the National 
Resource Center for Health and Safety in Child Care and Early 
Education, and the Maternal and Child Health Bureau, Department of 
Health and Human Services in developing these standards.

Caring for Our Children Basics

Staffing

1.2.0.2 Background Screening
    Directors of early care and education centers and caregivers/
teachers in large and small family child care homes should conduct a 
complete background screening before employing any staff member (in 
addition to any individuals residing in a family child care home over 
age 18). Consent to the background investigation should be required for 
employment consideration. The comprehensive background screening should 
include:
    (a) The use of fingerprints for state checks of criminal history 
records;
    (b) The use of fingerprints for checks of Federal Bureau of 
Investigation criminal history records;
    (c) Clearance through the child abuse and neglect registry (if 
available); and
    (d) Clearance through sex offender registries (if available).
1.4.1.1/1.4.2.3 Pre-serviceTraining/Orientation
    Before or during the first 3 months of employment, training and 
orientation should detail health and safety issues

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for early care and education settings including, but not limited to, 
typical and atypical child development; first aid and CPR; safe sleep 
practices, including risk reduction of Sudden Infant Death Syndrome/
Sudden Unexplained Infant Death (SIDS/SUID); infectious disease 
prevention; emergency preparedness; nutrition and age-appropriate 
feeding; medication administration; and care plan implementation for 
children with special health care needs. All directors or program 
administrators and caregivers/teachers should document receipt of 
training.
1.4.3.1 First Aid and CPR Training for Staff
    All staff members involved in providing direct care to children 
should have up-to-date documentation of satisfactory completion of 
training in pediatric first aid and CPR skills as defined by the 
American Red Cross and American Heart Association. At least one staff 
person who has successfully completed this training should be in 
attendance at all times. Records of successful completion of training 
in pediatric first aid and CPR should be maintained in the personnel 
files of the facility.
1.4.5.2 Child Abuse and Neglect Education
    Caregivers/teachers should be educated on child abuse and neglect 
prevention to establish child abuse and neglect prevention and 
recognition measures for the children, caregivers/teachers, and 
parents/guardians. The education should address physical, sexual, and 
psychological or emotional abuse and neglect. Caregivers/teachers are 
mandatory reporters of child abuse or neglect. Caregivers/teachers 
should be trained in compliance with their state's child abuse 
reporting laws.

Program Activities for Healthy Development

2.1.1.4 Monitoring Children's Development/Obtaining Consent for 
Screening
    Programs should have a system in place for developmental and 
behavioral screening of all children at the beginning of a child's 
placement in the program, at least yearly thereafter, and as 
developmental concerns become apparent to staff and/or parents/
guardians. This process should include parental/guardian consent and 
participation as well as connection to resources and support, if 
needed.
2.1.2.1/2.1.3.1 PersonalCaregiver/Teacher Relationships for Birth to 
Five-Year-Olds
    Programs should practice relationship-based philosophies that 
promote consistency and continuity of care, especially for infants and 
toddlers. Early care and education programs should provide 
opportunities for each child to build emotionally secure relationships 
with a limited number of caregivers/teachers. Children with special 
health care needs may require additional specialists to promote health 
and safety and to support learning.
2.2.0.1 Methods of Supervision of Children
    Caregivers/teachers should directly supervise infants, toddlers, 
and preschoolers by sight and hearing at all times, even when the 
children are going to sleep, napping, or sleeping; are beginning to 
wake up; or are indoors or outdoors. Developmentally appropriate child-
to-staff ratios should be met during all hours of operation, and safety 
precautions for specific areas and equipment should be followed.
2.2.0.4 Supervision near Bodies of Water
    Constant supervision should be maintained when any child is in or 
around water. During any swimming/wading activities where either an 
infant or a toddler is present, the ratio should always be one adult to 
one infant/toddler. Caregivers/teachers should ensure that all pools 
meet the Virginia Graeme Baker Pool and Spa Safety Act.
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
    The following behaviors should be prohibited in all early care and 
education settings:
    (a) Use of corporal punishment;
    (b) Isolating a child where a child cannot be supervised;
    (c) Binding or tying to restrict movement or taping the mouth;
    (d) Using or withholding food as a punishment or reward;
    (e) Toilet learning/training methods that punish, demean, or 
humiliate a child;
    (f) Any form of emotional abuse, including rejecting, terrorizing, 
extended ignoring, or corrupting a child;
    (g) Any physical abuse or maltreatment of a child;
    (h) Abusive, profane, sarcastic language or verbal abuse, threats, 
or derogatory remarks about the child or child's family;
    (i) Any form of public or private humiliation; and
    (j) Exclusion of physical activity/outdoor time as punishment.

Health Promotion and Protection

3.1.3.1 Active Opportunities for Physical Activity
    Programs should demonstrate a commitment to active play for 
children, including infants and toddlers, indoors and outdoors every 
day.
3.1.4.1 Safe Sleep Practices and SIDS Risk Reduction
    All staff, parents/guardians, volunteers, and others who care for 
infants in the early care and education setting should follow safe 
sleep practices as recommended by the Centers for Disease Control and 
Prevention (CDC) and the National Institute of Child Health and Human 
Development (NICHD). Cribs must be in compliance with current U.S. 
Consumer Product Safety Commission (CPSC) and ASTM International safety 
standards.
3.1.5.1 Routine Oral Hygiene Activities
    Caregivers/teachers should promote the habit of regular tooth 
brushing. All children with teeth should brush or have their teeth 
brushed at least once during the hours the child is in an early care 
and education program.
3.2.1.4 Diaper Changing Procedure
    The following diaper changing procedure should be posted in the 
changing area and followed to protect the health and safety of children 
and staff:
Step 1: Before bringing the child to the diaper changing area, perform 
hand hygiene and bring supplies to the diaper changing area.
Step 2: Carry the child to the changing table, keeping soiled clothing 
away from you and any surfaces you cannot easily clean and sanitize 
after the change. Always keep a hand on the child.
Step 3: Clean the child's diaper area.
Step 4: Remove the soiled diaper and clothing without contaminating any 
surface not already in contact with stool or urine.
Step 5: Put on a clean diaper and dress the child.
Step 6: Wash the child's hands and return the child to a supervised 
area.
Step 7: Clean and disinfect the diaper-changing surface. Dispose of the 
disposable paper liner used on the diaper changing surface in a 
plastic-lined, hands-free, covered can. If clothing was soiled, 
securely tie the plastic bag used to store the clothing and send home.

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Step 8: Perform hand hygiene and record the diaper change, diaper 
contents, and/or any problems.
    Caregivers/teachers should never leave a child unattended on a 
table or countertop. A safety strap or harness should not be used on 
the diaper changing table.
3.2.2.1 Situations that Require Hand Hygiene
    All staff, volunteers, and children should abide by the following 
procedures for hand washing, as defined by the CDC:
    A. Upon arrival for the day, after breaks, or when moving from one 
group to another;
    B. Before and after:
     Preparing food or beverages;
     Eating, handling food, or feeding a child;
     Giving medication or applying a medical ointment or cream 
in which a break in the skin (e.g., sores, cuts, or scrapes) may be 
encountered;
     Playing in water (including swimming) that is used by more 
than one person;
     Diapering.
    C. After:
     Using the toilet or helping a child use a toilet;
     Handling bodily fluid (mucus, blood, vomit);
     Handling animals or cleaning up animal waste;
     Playing in sand, on wooden play sets, and outdoors;
     Cleaning or handling the garbage.
    Situations or times that children and staff should perform hand 
hygiene should be posted in all food preparation, hand hygiene, 
diapering, and toileting areas.
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
    Early care and education programs should adopt the use of Standard 
Precautions, developed by the CDC, to handle potential exposure to 
blood and other potentially infectious fluids. Caregivers and teachers 
are required to be educated regarding Standard Precautions before 
beginning to work in the program and annually thereafter. Training 
should comply with requirements of the Occupational Safety and Health 
Administration.
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
    Programs should follow a routine schedule of cleaning, sanitizing, 
and disinfecting. Cleaning, sanitizing, and disinfecting products 
should not be used in close proximity to children, and adequate 
ventilation should be maintained during use.
3.4.1.1 Use of Tobacco, Alcohol, and Illegal Drugs
    Tobacco use, alcohol, and illegal drugs should be prohibited on the 
premises (both indoor and outdoor environments) and in any vehicles 
used by the program at all times. Caregivers and teachers should not 
use tobacco, alcohol, or illegal drugs off the premises during the 
early care and education program's paid time, including break time.
3.4.3.1 Emergency Procedures
    Programs should have a procedure for responding to situations when 
an immediate emergency medical response is required. Child-to-staff 
ratio should be maintained, and staff may need to be called in to 
maintain the required ratio. Programs should develop contingency plans 
for emergencies or disaster situations when it may not be possible to 
follow standard emergency procedures. All staff should be trained to 
manage an emergency until emergency medical care becomes available.
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and 
Exploitation
    Because caregivers/teachers are mandated reporters of child abuse 
and neglect, each program should have a written policy for reporting 
child abuse and neglect. The program should report to the child abuse 
reporting hotline, the Department of Social Services, child protective 
services, or the police as required by state and local laws, in any 
instance where there is reasonable cause to believe that child abuse 
and neglect has occurred.
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head 
Trauma
    All programs should have a policy and procedure to identify and 
prevent shaken baby syndrome/abusive head trauma. All caregivers/
teachers who are in direct contact with children, including substitute 
caregivers/teachers and volunteers, should receive training on 
preventing shaken baby syndrome/abusive head trauma; recognition of 
potential signs and symptoms of shaken baby syndrome/abusive head 
trauma; strategies for coping with a crying, fussing, or distraught 
child; and the development and vulnerabilities of the brain in infancy 
and early childhood.
3.4.5.1 Sun Safety Including Sunscreen
    Caregivers/teachers should ensure sun safety for themselves and 
children under their supervision by keeping infants younger than 6 
months out of direct sunlight, limiting sun exposure when UV rays are 
strongest, wearing shatter resistant sunglasses with UV protection and 
hats, and applying sunscreen. Written permission from the parent/
guardian for use of sunscreen should be required, and manufacturer 
instructions should be followed.
3.4.6.1 Strangulation Hazards
    Strings and cords on toys and window coverings long enough to 
encircle a child's neck should not be accessible to children in early 
care and education programs.
3.5.0.1 Care Plan for Children with Special Health Care Needs
    Children with special health care needs are defined as

. . . those who have or are at increased risk for a chronic 
physical, developmental, behavioral, or emotional condition and who 
also require health and related services of a type or amount beyond 
that required by children generally.\2\
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    \2\ McPherson M., Arango P., Fox H., Lauver C., McManus M., 
Newacheck P., . . . Strickland B. (1998). A new definition of 
children with special health care needs. Pediatrics, 102(1), 137-
140.

    Any child who meets these criteria in an early care and education 
setting should have an up-to-date Routine and Emergent Care Plan, 
completed by their primary care provider with input from parents/
guardians, included in their on-site health record. The child care 
health consultant should be involved to ensure adequate information, 
training, and monitoring is available for early care and education 
staff.
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
    Staff should notify the parent/guardian when children develop new 
signs or symptoms of illness. Parent/guardian notification should be 
immediate for emergency or urgent issues. Staff should notify parents/
guardians of children who have symptoms that require exclusion, and 
parents/guardians should remove children from the early care and 
education setting as soon as possible. For children whose symptoms do 
not require exclusion, verbal or written notification to the parent/
guardian at the end of the day is acceptable. Most conditions that 
require exclusion do not require a primary care provider visit before 
re-entering care.
    When a child becomes ill but does not require immediate medical 
help, a determination should be made regarding whether the child should 
be sent home. The caregiver/teacher should determine if the illness:

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    (a) Prevents the child from participating comfortably in 
activities;
    (b) Results in a need for care that is greater than the staff can 
provide without compromising the health and safety of other children;
    (c) Poses a risk of spread of harmful diseases to others;
    (d) Causes a fever (temperature above 101 [deg]F [38.3 [deg]C] 
orally, or 100 [deg]F [37.8 [deg]C] or higher taken axillary [armpit]) 
and behavior change or other signs and symptoms (e.g., sore throat, 
rash, vomiting, diarrhea). An unexplained temperature above 100 [deg]F 
(37.8 [deg]C) (armpit) in a child younger than 6 months should be 
medically evaluated. Any infant younger than 2 months of age with fever 
should get urgent medical attention.
    If any of the above criteria are met, the child should be removed 
from direct contact with other children and monitored and supervised by 
a staff member known to the child until dismissed to the care of a 
parent/guardian or primary care provider. The local or state health 
department will be able to provide specific guidelines for exclusion.
3.6.1.4 Infectious Disease Outbreak Control
    During the course of an identified outbreak of any reportable 
illness at the program, a child or staff member should be excluded if 
the health department official or primary care provider suspects that 
the child or staff member is contributing to transmission of the 
illness, is not adequately immunized when there is an outbreak of a 
vaccine-preventable disease, or the circulating pathogen poses an 
increased risk to the individual. The child or staff member should be 
readmitted when the official or primary care provider who made the 
initial determination decides that the risk of transmission is no 
longer present.
3.6.3.1/3.6.3.2 Medication Administration and Storage
    The administration of medicines at the facility should be limited 
to:
    (a) Prescription or non-prescription medication (over-the-counter) 
ordered by the prescribing health professional for a specific child 
with written permission of the parent/guardian. Written orders from the 
prescribing health professional should specify medical need, 
medication, dosage, and length of time to give medication;
    (b) Labeled medications brought to the early care and education 
facility by the parent/guardian in the original container (with a label 
that includes the child's name; date filled; prescribing clinician's 
name; pharmacy name and phone number; dosage/instructions; relevant 
warnings as well as specific, legible instructions for administration; 
storage; and disposal).
    Programs should never administer a medication that is prescribed 
for one child to another child. Documentation that the medicine/agent 
is administered to the child as prescribed is required. Medication 
should not be used beyond the date of expiration. Unused medications 
should be returned to the parent/guardian for disposal.
    All medications, refrigerated or unrefrigerated, should:
    (a) Have child-resistant caps;
    (b) Be kept in an organized fashion;
    (c) Be stored away from food;
    (d) Be stored at the proper temperature;
    (e) Be completely inaccessible to children.
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
    Any caregiver/teacher who administers medication should complete a 
standardized training course that includes skill and competency 
assessment in medication administration. The trainer in medication 
administration should be a licensed health professional. The course 
should be repeated according to state and/or local regulation. At a 
minimum, skill and competency should be monitored annually or whenever 
an administration error occurs.

Nutrition and Food Service

4.2.0.3 Use of U.S. Department of Agriculture (USDA), Child and Adult 
Care Food Program (CACFP) Guidelines
    All meals and snacks and their preparation, service, and storage 
should meet the requirements for meals of the child care component of 
the USDA, CACFP, and 7 CFR 226.20.
4.2.0.6 Availability of Drinking Water
    Clean, sanitary drinking water should be readily available in 
indoor and outdoor areas, throughout the day.
4.2.0.10 Care for Children with Food Allergies
    Each child with a food allergy should have a care plan prepared for 
the facility by the child's primary care provider and parents/
guardians, to include:
    (a) Written instructions regarding the food(s) to which the child 
is allergic and steps to be taken to avoid that food;
    (b) A detailed treatment plan to be implemented in the event of an 
allergic reaction, including the names, doses, and methods of prompt 
administration of any medications. The plan should include specific 
symptoms that would indicate the need to administer one or more 
medications.
    Based on the child's care plan, the child's caregivers/teachers 
should receive training for, demonstrate competence in, and implement 
measures for:
    (a) Preventing exposure to the specific food(s) to which the child 
is allergic;
    (b) Recognizing the symptoms of an allergic reaction;
    (c) Treating allergic reactions.
    The written child care plan, a mobile phone, and the proper 
medications for appropriate treatment if the child develops an acute 
allergic reaction should be routinely carried on field trips or 
transport out of the early care and education setting.
    The program should notify the parents/guardians immediately of any 
suspected allergic reactions, as well as the ingestion of or contact 
with the problem food even if a reaction did not occur. The program 
should contact the emergency medical services system immediately 
whenever epinephrine has been administered.
    Individual child's food allergies should be posted prominently in 
the classroom and/or wherever food is served.
4.3.1.3 Preparing, Feeding, and Storing Human Milk
    Programs should develop and follow procedures for the preparation 
and storage of expressed human milk that ensures the health and safety 
of all infants, as outlined by the CDC, and prohibits the use of infant 
formula for a breastfed infant without parental consent. The bottle or 
container should be properly labeled with the infant's full name and 
date.
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
    Programs should develop and follow procedures for the preparation 
and storage of infant formula that ensures the health and safety of all 
infants. Formula provided by parents/guardians or programs should come 
in factory-sealed containers. The caregiver/teacher should always 
follow manufacturer's instructions for mixing and storing of any 
formula preparation. If instructions are not readily available, 
caregivers/teachers should obtain information from the World Health 
Organization's Safe Preparation, Storage and Handling of Powdered 
Infant Formula Guidelines. Bottles of prepared or ready-to-feed formula 
should be labeled with the child's full name and time and date of 
preparation.

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4.3.1.9 Warming Bottles and Infant Foods
    Bottles and infant foods can be served cold from the refrigerator 
and do not have to be warmed. If a caregiver/teacher chooses to warm 
them, bottles should be warmed under running, warm tap water or by 
placing them in container of warm water. Bottles should never be warmed 
in microwaves.
4.5.0.10 Foods that Are Choking Hazards
    Caregivers/teachers should not offer foods that are associated with 
young children's choking incidents to children under 4 years of age 
(round, hard, small, thick and sticky, smooth, compressible or dense, 
or slippery). Food for infants should be cut into pieces \1/4\ inch or 
smaller, food for toddlers should be cut into pieces \1/2\ inch or 
smaller to prevent choking. Children should be supervised while eating, 
to monitor the size of food and that they are eating appropriately.
4.8.0.1 Food Preparation Area Access
    Infants and toddlers should not have access to the kitchen in early 
care and education programs. Access by older children to the kitchen, 
or areas where hot food is prepared, should be permitted only when 
supervised by adults who are qualified to follow sanitation and safety 
procedures.
4.9.0.1 Compliance with U.S. Food and Drug Administration (FDA) Food 
Code and State and Local Rules
    The program should conform to applicable portions of the FDA Food 
Code and all applicable state and local food service rules and 
regulations for centers and family child care homes regarding safe food 
protection and sanitation practices. If the federal code and local 
regulations are in conflict, the health authority with jurisdiction 
should determine which requirement the facility must meet.

Facilities, Supplies, Equipment, Environmental Health

5.1.1.2 Inspection of Buildings
    Existing and/or newly constructed, renovated, remodeled, or altered 
buildings should be inspected by a public inspector to ensure 
compliance with applicable building and fire codes before the building 
can be made accessible to children.
5.1.1.3 Compliance with Fire Prevention Code
    Every 12 months, the early care and education facility should 
obtain written documentation to submit to the regulatory licensing 
authority that the facility complies with a state-approved or 
nationally recognized Fire Prevention Code, such as the National Fire 
Protection Association (NFPA) 1: Fire Code.
5.1.1.5 Environmental Audit of Site Location \3\
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    \3\ Family Child Care is exempt.
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    An environmental audit should be conducted before construction of a 
new building; renovation or occupation of an older building; or after a 
natural disaster, to properly evaluate and, where necessary, remediate 
or avoid sites where children's health could be compromised. The 
environmental audit should include assessments of:
    (a) Potential air, soil, and water contamination on early care and 
education facility sites and outdoor play spaces;
    (b) Potential toxic or hazardous materials in building 
construction; and
    (c) Potential safety hazards in the community surrounding the site.
    A written environmental audit report that includes any remedial 
action taken should be kept on file.
5.2.4.2 Safety Covers and Shock Protection Devices for Electrical 
Outlets
    All accessible electrical outlets should be ``tamper-resistant 
electrical outlets'' that contain internal shutter mechanisms to 
prevent children from sticking objects into receptacles. In settings 
that do not have ``tamper-resistant electrical outlets,'' outlets 
should have ``safety covers'' that are attached to the electrical 
outlet by a screw or other means to prevent easy removal by a child.
5.2.4.4 Location of Electrical Devices near Water
    No electrical device or apparatus accessible to children should be 
located so it could be plugged into an electrical outlet while a person 
is in contact with a water source, such as a sink, tub, shower area, 
water table, or swimming pool.
5.2.8.1 Integrated Pest Management
    Programs should adopt an integrated pest management program to 
ensure long-term, environmentally sound pest suppression through a 
range of practices including pest exclusion, sanitation and clutter 
control, and elimination of conditions that are conducive to pest 
infestations.
5.2.9.1 Use and Storage of Toxic Substances
    All toxic substances should be used as recommended by the 
manufacturer and stored in the original labeled containers. All toxic 
substances should be inaccessible to children. The telephone number for 
the poison center should be posted in a location where it is readily 
available in emergency situations.
5.2.9.5 Carbon Monoxide Detectors
    Programs should meet state or local laws regarding carbon monoxide 
detectors, including circumstances when detectors are necessary. 
Detectors should be tested monthly. Batteries should be changed at 
least yearly. Detectors should be replaced at least every 5 years.
5.3.1.1/5.5.0.6/5.5.0.7 Safety of Equipment, Materials, and Furnishings
    Equipment, materials, furnishings, and play areas should be sturdy, 
safe, in good repair, and meet the recommendations of the CPSC. 
Programs should attend to, including, but not limited to, the following 
safety hazards:
    (a) Openings that could entrap a child's head or limbs;
    (b) Elevated surfaces that are inadequately guarded;
    (c) Lack of specified surfacing and fall zones under and around 
climbable equipment;
    (d) Mismatched size and design of equipment for the intended users;
    (e) Insufficient spacing between equipment;
    (f) Tripping hazards;
    (g) Components that can pinch, sheer, or crush body tissues;
    (h) Equipment that is known to be of a hazardous type;
    (i) Sharp points or corners;
    (j) Splinters;
    (k) Protruding nails, bolts, or other parts that could entangle 
clothing or snag skin;
    (l) Loose, rusty parts;
    (m) Hazardous small parts that may become detached during normal 
use or reasonably foreseeable abuse of the equipment and that present a 
choking, aspiration, or ingestion hazard to a child;
    (n) Strangulation hazards (e.g., straps, strings, etc.);
    (o) Flaking paint;
    (p) Paint that contains lead or other hazardous materials; and
    (q) Tip-over hazards, such as chests, bookshelves, and televisions.
    Plastic bags, matches, candles, and lighters should not be 
accessible to children.
5.4.5.2 Cribs
    Before purchase and use, cribs must be in compliance with current 
CPSC and ASTM International safety

[[Page 75562]]

standards that include ASTM F1169-10a Standard Consumer Safety 
Specification for Full-Size Baby Cribs, F406-10b Standard Consumer 
Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the 
CPSC 16 CFR 1219, 1220, and 1500--Safety Standards for Full-Size Baby 
Cribs and Non-Full-Size Baby Cribs; Final Rule.
    As soon as a child can stand up, the mattress should be adjusted to 
its lowest position. When an infant is able to reach crib latches or 
potentially climb out of a crib, they should be transitioned to a 
different sleeping environment (such as a cot or sleeping mat). 
Children should never be kept in their crib by placing, tying, or 
wedging various fabrics, mesh, or other strong coverings over the top 
of the crib.
    Cribs intended for evacuation purpose should be designed for 
carrying up to five non-ambulatory children less than 2 years of age to 
a designated evacuation area in the event of fire or other emergency.
    Staff should only use cribs for sleep purposes and should ensure 
that each crib is a safe sleep environment as defined by the CDC and 
the NICHD. No child of any age should be placed in a crib for a time-
out or for disciplinary reasons. Cribs should be placed away from 
window blinds or draperies.
5.5.0.8 Firearms
    Early care and education programs should not have firearms, pellet 
or BB guns, darts, cap pistols, stun guns, paint ball guns, or objects 
manufactured for play as toy guns on the premises at any time. If 
present in a family child care home, parents should be notified and 
these items should be unloaded, equipped with child protective devices, 
and kept under lock and key with the ammunition locked separately in 
areas inaccessible to the children. Parents/guardians should be 
informed about this policy.

Play Areas/Playgrounds and Transportation

6.1.0.6/6.1.0.8/6.3.1.1 Location of Play Areas near Bodies of Water/ 
Enclosures for Outdoor Play Areas/Enclosure of Bodies of Water
    The outdoor play area should be enclosed with a fence or natural 
barriers. Fences and barriers should not prevent the observation of 
children by caregivers/teachers. If a fence is used, it should conform 
to applicable local building codes in height and construction. Fence 
posts should be outside the fence where allowed by local building 
codes. These areas should have at least two exits, with at least one 
being remote from the buildings.
    Outside play areas should be free from bodies of water. If present, 
all water hazards should be enclosed with a fence that is 4 to 6 feet 
high or higher and comes within 3\1/2\ inches of the ground. Gates 
should be equipped with self-closing and positive self-latching closure 
mechanisms that are high enough or of a type such that children cannot 
open it. The openings in the fence and gates should be no larger than 
3\1/2\ inches. The fence and gates should be constructed to discourage 
climbing. Play areas should be secured against inappropriate use when 
the facility is closed.
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
    Equipment used for climbing should not be placed over, or 
immediately next to, hard surfaces such as asphalt, concrete, dirt, 
grass, or flooring covered by carpet or gym mats not intended for use 
as surfacing for climbing equipment.
    All pieces of playground equipment should be placed over a shock-
absorbing material that is either the unitary or the loose-fill type, 
as defined by the CPSC guidelines and ASTM International Standards ASTM 
F1292-13 and ASTM F2223-10, extending at least 6 feet beyond the 
perimeter of the stationary equipment. Organic materials that support 
colonization of molds and bacteria should not be used. This standard 
applies whether the equipment is installed outdoors or indoors.
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
    The indoor and outdoor play areas and equipment should be inspected 
daily for basic health and safety, including, but not limited to:
    (a) Missing or broken parts;
    (b) Protrusion of nuts and bolts;
    (c) Rust and chipping or peeling paint;
    (d) Sharp edges, splinters, and rough surfaces;
    (e) Stability of handholds;
    (f) Visible cracks;
    (g) Stability of non-anchored large play equipment (e.g., 
playhouses);
    (h) Wear and deterioration.
    Observations should be documented and filed, and the problems 
corrected before the playground is used by children.
6.3.2.1 Lifesaving Equipment
    Each swimming pool more than 6 feet in width, length, or diameter 
should be provided with a ring buoy and rope, a rescue tube, or a 
throwing line and a shepherd's hook that will not conduct electricity. 
This equipment should be long enough to reach the center of the pool 
from the edge of the pool, should be kept in good repair, and should be 
stored safely and conveniently for immediate access. Caregivers/
teachers should be trained on the proper use of this equipment. 
Children should be familiarized with the use of the equipment based on 
their developmental level.
6.3.5.2 Water in Containers
    Bathtubs, buckets, diaper pails, and other open containers of water 
should be emptied immediately after use.
6.5.1.2 Qualifications for Drivers
    In addition to meeting the general staff background check 
standards, any driver or transportation staff member who transports 
children for any purpose should be at least 21 years of age and have:
    (a) A valid driver's license that authorizes the driver to operate 
the type of vehicle being driven;
    (b) A safe driving record for more than 5 years, with no crashes 
where a citation was issued, as evidenced by the state Department of 
Motor Vehicles records;
    (c) No tobacco, alcohol, or drug use before or while driving;
    (d) No medical condition that would compromise driving, 
supervision, or evacuation capability;
    (e) Valid pediatric CPR and first aid certificate if transporting 
children alone.
    The driver's license number and date of expiration, vehicle 
insurance information, and verification of current state vehicle 
inspection should be on file in the facility.
6.5.2.2 Child Passenger Safety
    When children are driven in a motor vehicle other than a bus, all 
children should be transported only if they are restrained in a 
developmentally appropriate car safety seat, booster seat, seat belt, 
or harness that is suited to the child's weight, age, and/or 
psychological development in accordance with state and federal laws and 
regulations. The child should be securely fastened, according to the 
manufacturer's instructions. The child passenger restraint system 
should meet the federal motor vehicle safety standards contained in 49 
CFR 571.213 and carry notice of compliance. Child passenger restraint 
systems should be installed and used in accordance with the 
manufacturer's instructions and should be secured in back seats only.
    Car safety seats should be replaced if they have been recalled, are 
past the manufacturer's ``date of use'' expiration date, or have been 
involved in a crash

[[Page 75563]]

that meets the U.S. Department of Transportation crash severity 
criteria or the manufacturer's criteria for replacement of seats after 
a crash.
6.5.2.4 Interior Temperature of Vehicles
    The interior of vehicles used to transport children for field trips 
and out-of-program activities should be maintained at a temperature 
comfortable to children. All vehicles should be locked when not in use, 
head counts of children should be taken after transporting to prevent a 
child from being left unintentionally in a vehicle, and children should 
never be intentionally left in a vehicle unattended.
6.5.3.1 Passenger Vans \4\
---------------------------------------------------------------------------

    \4\ Family Child Care is exempt.
---------------------------------------------------------------------------

    Early care and education programs that provide transportation for 
any purpose to children, parents/guardians, staff, and others should 
not use 15-passenger vans whenever possible. Caregivers/teachers should 
be knowledgeable about the laws of the state(s) in which their 
vehicles, including passenger vans, will be registered and used.

Infectious Disease

7.2.0.1 Immunization Documentation
    Programs should require that all parents/guardians of enrolled 
children provide written documentation of receipt of immunizations 
appropriate for each child's age. Infants, children, and adolescents 
should be immunized as specified in the ``Recommended Immunization 
Schedules for Persons Aged 0 Through 18 Years,'' developed by the 
Advisory Committee on Immunization Practices of the CDC, the American 
Academy of Pediatrics, and the American Academy of Family Physicians. 
Children whose immunizations are not up-to-date or have not been 
administered according to the recommended schedule should receive the 
required immunizations, unless contraindicated or for legal exemptions.
7.2.0.2 Unimmunized Children
    If immunizations have not been or are not to be administered 
because of a medical condition, a statement from the child's primary 
care provider documenting the reason why the child is temporarily or 
permanently medically exempt from the immunization requirements should 
be on file. If immunizations are not to be administered because of the 
parents'/guardians' religious or philosophical beliefs, a legal 
exemption with notarization, waiver, or other state-specific required 
documentation signed by the parent/guardian should be on file. The 
parent/guardian of a child who has not received the age-appropriate 
immunizations prior to enrollment and who does not have documented 
medical, religious, or philosophical exemptions from routine childhood 
immunizations should provide documentation of a scheduled appointment 
or arrangement to receive immunizations. An immunization plan and 
catch-up immunizations should be initiated upon enrollment and 
completed as soon as possible.
    If a vaccine-preventable disease to which children are susceptible 
occurs in the facility and potentially exposes the unimmunized children 
who are susceptible to that disease, the health department should be 
consulted to determine whether these children should be excluded for 
the duration of possible exposure or until the appropriate 
immunizations have been completed. The local or state health department 
will be able to provide guidelines for exclusion requirements.
7.2.0.3 Immunization of Caregivers/Teachers
    Caregivers/teachers should be current with all immunizations 
routinely recommended for adults by the Advisory Committee on 
Immunization Practices of the CDC as shown in the ``Recommended Adult 
Immunization Schedule'' in the following categories:
    (a) Vaccines recommended for all adults who meet the age 
requirements and who lack evidence of immunity (i.e., lack 
documentation of vaccination or have no evidence of prior infection); 
and
    (b) Recommended if a specific risk factor is present.
    If a staff member is not appropriately immunized for medical, 
religious, or philosophical reasons, the early care and education 
facility should require written documentation of the reason.
    If a vaccine-preventable disease to which adults are susceptible 
occurs in the facility and potentially exposes the unimmunized adults 
who are susceptible to that disease, the health department should be 
consulted to determine whether these adults should be excluded for the 
duration of possible exposure or until the appropriate immunizations 
have been completed. The local or state health department will be able 
to provide guidelines for exclusion requirements.

Policies

9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or 
Threatening Incidents
    The program should have a written plan for reporting and managing 
any incident or unusual occurrence that is threatening to the health, 
safety, or welfare of the children, staff, or volunteers. Staff 
training procedures should also be included. The management, 
documentation, and reporting of the following types of incidents should 
be addressed:
    (a) Lost or missing child;
    (b) Suspected maltreatment of a child (also see state's mandates 
for reporting);
    (c) Suspected sexual, physical, or emotional abuse of staff, 
volunteers, or family members occurring while they are on the premises 
of the program;
    (d) Injuries to children requiring medical or dental care;
    (e) Illness or injuries requiring hospitalization or emergency 
treatment;
    (f) Mental health emergencies;
    (g) Health and safety emergencies involving parents/guardians and 
visitors to the program;
    (h) Death of a child or staff member, including a death that was 
the result of serious illness or injury that occurred on the premises 
of the early care and education program, even if the death occurred 
outside of early care and education hours;
    (i) The presence of a threatening individual who attempts or 
succeeds in gaining entrance to the facility.
9.2.4.3 Disaster Planning, Training and Communication
    Early care and education programs should consider how to prepare 
for and respond to emergency or natural disaster situations that may 
require evacuation, lock-down, or shelter-in-place and have written 
plans, accordingly. The following topics should be addressed, 
including, but not limited to, regularly scheduled practice drills, 
procedures for notifying and updating parents, and the use of the daily 
class roster(s) to check attendance of children and staff during an 
evacuation or drill when gathered in a safe space after exit and upon 
return to the program.
9.2.4.7 Sign-In/Sign-Out System
    Programs should have a sign-in/sign-out system to track those who 
enter and exit the facility. The system should include name, contact 
number, relationship to facility (e.g., parent/guardian, vendor, guest, 
etc.), and recorded time in and out.

[[Page 75564]]

9.2.4.8 Authorized Persons To Pick Up Child
    Children may only be released to adults authorized by parents or 
legal guardians and whose identity has been verified by photo 
identification. Names, addresses, and telephone numbers of persons 
authorized to take a child under care out of the facility should be 
obtained during the enrollment process and regularly reviewed, along 
with clarification/documentation of any custody issues/court orders. 
The legal guardian(s) of the child should be established and documented 
at this time.
9.4.1.12 Record of Valid License, Certificate, or Registration of 
Facility
    Every facility should hold a valid license, certificate, or 
documentation of registration prior to operation as required by the 
local and/or state statute.
9.4.2.1 Contents of Child Records
    Programs should maintain a confidential file for each child in one 
central location on-site and should be immediately available to the 
child's caregivers/teachers (who should have parental/guardian consent 
for access to records), the child's parents/guardians, and the 
licensing authority upon request. The file for each child should 
include the following:
    (a) Pre-admission enrollment information;
    (b) Admission agreement signed by the parent/guardian at 
enrollment;
    (c) Initial and updated health care assessments, completed and 
signed by the child's primary care provider, based on the child's most 
recent well care visit;
    (d) Health history completed by the parent/guardian at admission;
    (e) Medication record;
    (f) Authorization form for emergency medical care;
    (g) Written informed consent forms signed by the parent/guardian 
allowing the facility to share the child's health records with other 
service providers.
10.4.2.1 Frequency of Inspections for Child Care Centers, Large Family 
Child Care Homes, and Small Family Child Care Homes
    The licensing inspector or monitoring staff should make an onsite 
inspection to measure compliance with licensing/regulatory rules prior 
to issuing an initial license and at least two inspections each year to 
each center and large and small family child care home thereafter. At 
least one of the inspections should be unannounced, and more if they 
are needed for the facility to achieve satisfactory compliance or if 
the facility is closed at any time. Sufficient numbers of licensing 
inspectors should be hired to provide adequate time visiting and 
inspecting programs to ensure compliance with regulations.
    The number of inspections should not include those inspections 
conducted for the purpose of investigating complaints. Complaints 
should be investigated promptly, based on severity of the complaint. 
States are encouraged to post the results of licensing inspections, 
including complaints, on the Internet for parent and public review. 
Parents/guardians should be provided easy access to the licensing rules 
and made aware of how to report complaints to the licensing agency.

     Dated: December 12, 2014.
Linda K. Smith,
Deputy Assistant Secretary for Early Childhood Development, 
Administration for Children and Families, U.S. Department of Health and 
Human Services.
[FR Doc. 2014-29649 Filed 12-17-14; 8:45 am]
BILLING CODE 4184-01-P