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Part VI – Health and Safety Requirements for Providers
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The National Resource Center for Health and Safety in Child Care (NRCHSCC) funded by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services supports a comprehensive, current, online listing of the licensing and regulatory requirements for child care in the 50 States and the District of Columbia. In lieu of requiring a State Lead Agency to provide information that is already publicly available, ACF accepts this compilation as accurately reflecting the States' licensing requirements. The listing, which is maintained by the University of Colorado Health Sciences Center School of Nursing, is available on the Web at: http://nrc.uchsc.edu/.
— Requirements for Center-based, Family, and In-home Providers21
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Health and Safety Requirements for Center-Based Providers (658E(c)(2)(F), 98.41, 98.16(j))
Are all center-based providers paid with CCDF funds subject to licensing under State law as reflected in the NRCHSCC's compilation referenced above?
More than half of all States require child care centers participating in the CCDF subsidy program to comply with State licensing laws. However, many States exempt some centers from this requirement. Although individual States have changed their position on this issue since the 2000-2001 Plan Period, the number of States in each category has remained constant. Center-based facilities exempt from licensing standards include:
- Centers operated by public or private schools, or local government for school-age care
- Drop-in centers
- Children's camps
- Religious or military facilities
- Twenty-seven States (AK, AZ, AR, DC, GA, ID, IN, IA, KS, KY, ME, MD, MA, MS, MT, NE, NJ, NM, NC, OH, OK, PA, SC, SD, TN, VT, WA) require all center-based providers paid with CCDF funds to meet State licensing laws as reflected in the NRCHSCC's compilation.
- Twenty-two States (AL, CA, CO, CT, DE, HI, IL, LA, MN, MO, NV, NH, NY, ND, OR, RI, TX, UT, VA, WV, WI, WY) do not require all center-based providers paid with CCDF funds to meet State licensing laws as reflected in the NRCHSCC's compilation.
Have center licensing requirements as related to staff-child ratios, group size, or staff training been modified since approval of the last State Plan?
- Seventeen States (AL, AK, AR, LA, MD, MT, NH, NY, NC, ND, OR, SD, TN, TX, VT, WA, WY) have modified staff-child ratios, group size, or staff training licensing requirements since their last State Plans.
- Thirty-two States (AZ, CA, CO, CT, DE, DC, GA, HI, ID, IL, IN, IA, KS, KY, ME, MA, MN, MS, MO, NE, NV, NJ, NM, OH, OK, PA, RI, SC, UT, VA, WV, WI) have not modified staff-child ratios, group size, or staff training licensing requirements since their last State Plans.
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Health and Safety Requirements for Group Home Providers (658E(c)(2)(F), 98.41, 98.16(j))
Are all group home providers paid with CCDF funds subject to licensing under State law as reflected in the NRCHSCC's compilation referenced above?
- Thirty-nine States (AL, AK, AZ, AR, CA, CO, DE, GA, HI, ID, IL, IN, IA, KS, KY, MA, MS, MO, MT, NE, NV, NH, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WV) require all group homes to be licensed under State law as reflected in the NRCHSCC's compilation.
- Only three States (CT, ME, WY) do not require all group homes to be licensed under State law as reflected in the NRCHSCC's compilation.
- Some States do not have a group home facility designation.
Have group home licensing requirements as related to staff-child ratios, group size, or staff training been modified since the approval of the last State Plan? (98.41(a)(2) &(3))
- Thirteen States (AL, AK, AR, CO, IL, MT, NH, NY, ND, TX, VT, VA, WY) modified staff-child ratios, group size, or staff training since the last State Plan.
- Twenty-nine States (AZ, CA, CT, DE, GA, HI, ID, IN, IA, KS, KY, ME, MA, MS, MO, NE, NV, NM, NC, OH, OK, OR, PA, RI, SC, SD, TN, UT, WV) have not modified staff-child ratios, group size, or staff training since the last State Plan.
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Health and Safety Requirements for Family Providers (658E(c)(2)(F), 98.41, 98.16(j))
Are all family home child care providers paid with CCDF funds subject to licensing under State law as reflected in the NRCHSCC's compilation referenced above?
- Fifteen States (AL, AZ, DE, DC, GA, KS, ME, MD, MA, MT, NC, OH, OK, VT, WA) require family home child care providers paid with CCDF funds to meet licensing State laws as reflected in the NRCHSCC's compilation. In the 2000-2001 Plan Period, 16 States required these providers to meet State licensing laws.
- Thirty-four States (AK, AR, CA, CO, CT, HI, ID, IL, IN, IA, KY, LA, MN, MS, MO, NE, NV, NH, NJ, NM, NY, ND, OR, PA, RI, SC, SD, TN, TX, UT, VA, WV, WI, WY) do not require family home child care providers paid with CCDF funds to meet licensing State laws as reflected in the NRCHSCC's compilation.
Have family home child care provider requirements as relates to staff-child ratios, group size, or staff training been modified since the approval of the last State Plan?( 98.41(a)(2) & (3))
- Fifteen States (AL, CO, IL, IN, LA, MD, MT, NH, NJ, NY, ND, OR, TX, UT, WY) modified staff-child ratios, group size, or staff training since the approval of the last State Plan.
- Thirty-four States (AK, AZ, AR, CA, CT, DE, DC, GA, HI, ID, IA, KS, KY, ME, MA, MN, MS, MO, NE, NV, NM, NC, OH, OK, PA, RI, SC, SD, TN, VT, VA, WA, WV, WI) have not modified staff-child ratios, group size, or staff training since the approval of the last State Plan.
Section 6.4 — Health and Safety Requirements for In-home Providers (658E(c)(2)(F), 98.41, 98.16(j))
Are all in-home child care providers paid with CCDF funds subject to licensing under State law as reflected in the NRCHSCC's compilation referenced above?
- Three States (AZ, OH, VT) require all in-home child care providers paid with CCDF funds to meet State licensing laws as reflected in the NRCHSCC's compilation.
- Forty-six States (AL, AK, AR, CA, CO, CT, DE, DC, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, WA, WV, WI, WY) do not require in-home child care providers paid with CCDF funds to meet State licensing laws as reflected in the NRCHSCC's compilation.
While a number of individual States changed their policies regarding particular provider types, there has been little change in recent years in the national picture concerning whether all child care facilities must meet State licensing standards if they are to participate in the child care subsidy program. Chart 6.1 shows that the number of States that make compliance with licensing requirements mandatory for receipt of CCDF funds has remained fairly constant across both the 2000-2001 and 2002-2003 CCDF Plan Periods.
For that care (center-based, group home, family home, and in-home) that is NOT licensed, and therefore not reflected in NRCHSCC's compilation, the following health and safety requirements apply to child care services provided under the CCDF for the prevention and control of infectious disease (including immunizations), building and physical premises safety, and health and safety training:
Lead Agencies use a number of different approaches in defining health and safety requirements for license-exempt facilities. Twenty-six States (CA, CO, CT, DE, HI, IN, LA, KS, MD, MA, MS, MO, MT, NJ, NM, ND, OK, PA, RI, SC, SD, UT, VA, WA, WV, WY) require providers to self-certify or complete checklists indicating compliance with State health and safety requirements. Other approaches include:
- Relying on local fire, building, and health departments, and the Child and Adult Care Food Programs to provide health and safety monitoring (AL, CA, CO, DE, IL, LA, MD, OR, RI, UT, WV, WI).
- Giving written materials on health and safety requirements to providers and parents (CA, CO, DE, HI, IA, MD, MS, MO, NE, NH, NY, PA, RI, WA, WI).
- Requiring verification of TB tests and annual health certificates for providers (AR, DC, IA, IL, MO, NM, SD, VA, WI).
- Requiring criminal background checks for providers (CA, DE, IN, LA, MA, NC, WA).
- Mandating that immunization records for children be kept on file in facilities (DC, GA, MO, NV, NM, NC, SD, UT, WV, WY) .
- Requiring attendance at health and safety orientation training (DE, MA, TN, WI).
- Requiring pre-requisite and annual training in health and safety subjects (AR, DC, GA, IA, LA, ND, OK, SD, WV, WI).
- Encouraging training and notifying providers of training opportunities through newsletters, child care resource and referral agencies (CCR&Rs), or direct mailings (CA, IL, LA, NE, NH, NJ, NM, OR, SD, TN, UT).
- Making mandatory other health and safety standards including those relating to the following (AR, CT, DE, GA, IL, IA, MD, MA, MO, NE, NM, ND, PA, RI, SD, TN, UT, VA, WV, WI, WY):
- Smoke detectors/fire extinguishers
- Water safety
- Child abuse signs and reporting requirements
- Working phones
- Safe storage of firearms
- Hand washing
- Outdoor play area safety
- Emergency exits and emergency plans
- Safe storage of cleaning/hazardous materials
- Maintenance of emergency contact information
- Availability of running hot and cold water, inside toilet facilities, clean and free of dangerous conditions
- Safe storage of firearms
California requires license-exempt homes and in-home providers to submit certification statements on tuberculosis tests and verify that they are free of communicable diseases. A building and physical premises safety checklist is completed. A TrustLine application, with fingerprint cards, is required for criminal record and child abuse registry background checks. In addition, providers are referred to the local child care resource and referral agency for training materials and information about training opportunities.
Indiana requires license-exempt homes to meet eight requirements: 1) criminal background checks; 2) working smoke detectors; 3) annual tuberculosis tests; 4) written emergency plans for notifying parents; 5) current infant/toddler CPR and first aid training; 6) one working telephone; 7) monthly, documented fire drills; and 8) requirements for safe storage of firearms and poisons.
Montana requires license-exempt home providers to attend orientation classes that include training in prevention and control of infectious diseases and immunization requirements, building and physical premises safety, and health and safety. A self-assessment checklist is also completed.
Nevada conducts a quality assurance inspection on license-exempt homes and requires three hours of health and safety training. Exempt homes also have access to health consultants.
New Mexico monitors homes at least annually and, if homes are participating in the Child and Adult Care Food Program, they are reviewed quarterly. Providers must attend at least six hours of training each year.
North Carolina requires all nonlicensed home providers and household members over age 15 to undergo criminal background checks. In addition, they are required to complete a basic first aid course within three months of being approved and renew the training every three years.
North Dakota requires exempt centers to meet Federal Head Start standards.
In-home providers in Oklahoma must complete a minimum of six clock hours of training within 90 calendar days from the date a State-approved plan of care was signed.
In Wisconsin, license-exempt and in-home providers must complete 15 hours of training prior to certification, including a minimum of three hours of health and safety training.
California, Colorado, Louisiana, Minnesota, Nevada, Utah, and West Virginia exempt school-age centers operated by school districts or other educational entities. Health and safety oversight is provided by the educational entity.
Section 6.5—Exemptions to Health and Safety Requirements
At State option, the following relatives—grandparents, great-grandparents, aunts, uncles, or siblings who live in a separate residence from the child in care—may be exempted from health and safety requirements. (658P(4)(B), 98.41(a)(1)(ii)(A)).
- Thirty States (AK, AR, CT, DC, GA, IL, IN, IA, KY, LA, MD, MN, MS, MO, MT, NE, NH, NJ, NY, OH, OK, OR, PA, SC, UT, VT, WA, WV, WI, WY) subject all relative providers to the same health and safety requirements as described in Sections 6.1-6.4 above.
- Eleven States (AZ, CA, CO, DE, KS, MA, NC, RI, SD, TN, VA) subject some or all relative providers to different health and safety requirements from those described in Sections 6.1-6.4.
- Eight States (AL, HI, ID, ME, NV, NM, ND, TX) exempt all relative providers from all health and safety requirements.
Charts 6.2.1 and 6.2.2 summarize State policies regarding relative providers and health and safety requirements. Increasingly, States are opting to not exempt any relative providers from the health and safety requirements for center-based, group home, family home child care, and in-home providers.
Section 6.6 – Enforcement of Health and Safety Requirements
Each Lead Agency is required to certify that procedures are in effect to ensure that child care providers of services for which assistance is provided comply with all applicable health and safety requirements. (658E(c)(2)(E), 98.40(a)(2), 98.41(d)) The following is a description of how health and safety requirements are effectively enforced:
Most Lead Agencies indicated the following procedures are in effect to ensure compliance with health and safety requirements:
- Unannounced monitoring visits
- Unannounced complaint investigations
- Background checks
- Required reporting of all serious injuries while a child is in care
- Pre-licensing or certification inspections
Some Lead Agencies also indicated the following procedures are in effect to ensure compliance with health and safety requirements:
- Violations of licensing requirements are misdemeanor offenses
- Conviction of violations may result in fine assessments
- Noncompliance may result in enforcement actions such as denying applications, issuing provisional licenses, revocation, or suspension of a licenses
Are child care providers subject to routine unannounced visits?
- Two States (DC and ID) do not subject child care providers to routine unannounced visits.
- Forty-seven States (AL, AK, AZ, AR, CA, CO, CT, DE, GA, HI, IL, IN, IA, KS, KY, LA, ME, MD, MA, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY) reported that they subject child care providers to routine unannounced visits.
Of the 35 States that identified the frequency of unannounced monitoring visits for licensed child care centers, most reported doing so annually.
- Tennessee conducts six visits a year.
- Two States (AR and OK) conduct three visits a year.
- Three States (AL, NV, OH) conduct two visits a year.
- Twenty-seven States (AZ, CA, DE, GA, HI, IL, IN, IA, KS, LA, MD,22 MS, NE,23 NJ, NM, NC, ND, OR, SC, SD, TX, UT, VA,24 WA, WV,24 WI, WY) conduct one visit a year.
- Connecticut conducts visits once every two years.
- New Hampshire conducts visits once every three years.
Of the 30 States that identified the frequency of unannounced monitoring visits for licensed family child care homes:
- Tennessee conducts six visits a year
- Two States (AR and OK) conduct three visits a year.
- Four States (AL, AZ, NV, OH) conduct two visits a year.
- Nineteen States (CA,25 CT,26 DE, HI, IL, IN, IA,27 KS, MS, NE, NJ, NM, SC, TX, UT, VA,28 WA, WI, WY) conduct one visit a year to some or all family child care homes.
- Three States conduct visits once every two years (MD, NC, SD). North Carolina conducts visits on a randomly selected number of homes.
- New Hampshire conducts visits once every three years.
Are child care providers subject to background checks?
- Only the District of Columbia does not subject child care providers to background checks. However, DC reported new regulations will be passed to make background checks mandatory.
- Forty-eight States (AL, AK, AZ, AR, CA, CO, CT, DE, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY) subject child care providers to background checks.
- Of those 48 States, 28 States (AK, AZ, AR, CA, CO, GA, HI, IA, KS, KY, MD, MS, MO, MT, NJ, NM, NY, NC, OK, PA, TN, TX, UT, VT, VA, WA, WV, WY) specifically identified the background checks as criminal background checks.
- Eleven States (CA, HI, KS,29 KY, MA, MO, MT, NE, VT, VA, WV) require background and child abuse registry checks on licensed and registered providers.
- Ten States (AR, CO, IA, MD, NJ,30 PA, TN, UT, WA, WY) require background and child abuse registry checks on licensed providers.
- Ten States (AK, AZ, AR, CO, HI, MD, NM, PA, UT, WA) require both State and FBI criminal background checks.
- In three States (CO, MN, NY) counties decide whether to conduct background checks on license-exempt providers. Nevada leaves the decision up to parents.
Colorado implemented a double criminal background check. It includes a fingerprint check through the Colorado Bureau of Investigation (and, for providers residing in the State less than two years, the Federal Bureau of Investigation) and court disposition information through the judicial system's database.
New Jersey will be implementing an electronic fingerprinting system known as Live-Scan. The system scans fingerprints and electronically transmits the prints to the Division of State Police for processing.
Does the State require that child care providers report serious injuries that occur while a child is in care? (Serious injuries are defined as injuries requiring medical treatment by a doctor, nurse, dentist, or other medical professional.)
- Thirty-six States (AL, AK, AR, CA, CO, DE, DC, GA, IL, IN, KS, KY, LA, ME, MD, MA, MN, MS, MT, NE, NV, NJ, NM, NC, ND, OH, OK, OR, SC, TN, TX, UT, VT, WA, WI, WY) require that child care providers report serious injuries that occur while a child is in care.
- Three States (AZ, CT, WV) require some child care providers to report serious injuries that occur while a child is in care.
- Ten States (HI, ID, IA, MO, NH, NY, PA, RI, SD, VA) do not require child care providers to report serious injuries that occur while a child is in care.
Other methods used to ensure health and safety requirements are effectively enforced:
Thirty-three States (AL, AK, AR, CA, CO, DE, DC, GA, IL, IN, KS, KY, LA, MA, MS, MO, MT, NE, NY, NC, ND, OH, OR, PA, SD, TN, TX, VT, VA, WA, WV, WI, WY) reported additional methods to ensure effective enforcement of health and safety requirements:
- Offering technical assistance to providers.
- Initiating corrective actions, including denying, revoking, suspending, or issuing probationary or provisional licenses.
- Imposing fines or bringing civil
or criminal actions against facilities with serious compliance violations.
In Alaska, child care providers submit self-monitoring reports annually.
Colorado conducts monitoring visits on a risk-based schedule that ranges from once a month to once every three years. Monitoring staff use an evaluation checklist.
Massachusetts provides ongoing training, conferences, new provider meetings, director group forums, and technical assistance to reinforce providers' knowledge of regulatory requirements.
In New York, complaint information is automated and facility records are made available to the public.
North Carolina supports health and safety initiatives that help programs meet playground safety requirements and assistance with obtaining appropriate car seats and safety restraints for vehicles.
In Tennessee, a rated licensing program is being implemented that combines a star system with environmental rating scales.
In Vermont, a combination of technical assistance, consumer education, and regulatory monitoring is used to assure health and safety requirements are enforced.
In Washington, the Division of Child Care and Early Learning surveyors and licensors and the Division of Licensed Resources/Child Protective Services coordinate licensing, monitoring, health certifications, child abuse investigations, investigations of complaints, and technical assistance activities.
Section 6.7 – Exemptions from Immunization Requirements
The State assures that children receiving services under the CCDF are age-appropriately immunized, and that the health and safety provisions regarding immunizations incorporated (by reference or otherwise) the latest recommendations for childhood immunizations of the State public health agency (98.41(a)(1)).
Lead Agencies reported that they take measures to assure that children receiving child care assistance are age-appropriately immunized. Many States also elect to exempt some children from immunization requirements, using some combination of exemption condition provided in the State Plan Preprint. Table 6.7 summarizes the exemption policies.
- Fourteen States (AL, CO, DE, ID, IN, KS, ME, MA, MO, ND, PA, TN, TX, WA) exempt children from immunization under four conditions: 1) children cared for by relatives; 2) children who receive care in their own homes; 3) children whose parents object due to religious grounds; and 4) children whose medical condition contraindicates immunization.
- Four States (AZ, NM, NC, OK) exempt children from immunization under three conditions: 1) children cared for by relatives; 2) children whose parents object due to religious grounds; and 3) children whose medical condition contraindicates immunization.
- Montana exempts children from immunization under three conditions: 1) children cared for by relatives; 2) children who receive care in their own homes; and 3) children whose medical condition contraindicates immunization.
- Twenty-eight States (AK, AR, CA, CT, DC, GA, HI, IL, IA, KY, LA, MD, MN, NV, NH, NJ, NY, OH, OR, RI, SC, SD, UT, VT, VA, WV, WI, WY) exempt children from immunization under two conditions: 1) children whose parents object due to religious grounds; and 2) children whose medical condition contraindicates immunization.
- Two States (MS and NE) do not exempt children from immunization requirements.
Note:
21. Because Territories are not included in
the NRCHSCC compilation, they are only asked to list the health and safety requirements
for child care services provided under CCDF, not to indicate whether all providers
are subject to licensing. Therefore, Puerto Rico is not included in the counts
in this section.
22. Maryland conducts annual visits to 20 percent of all centers.
23. Nebraska conducts visits once a year to facilities with
less than 30 children, and twice a year to facilities with more than 30 children.
24. Virginia and West Virginia conduct visits twice a year;
however, only one is announced.
25. California conducts visits on 10 percent of homes.
26. Connecticut conducts visits to 33 percent of homes.
27. Iowa and New Jersey both conduct visits to 20 percent
of homes.
28. Virginia conducts visits twice a year; however, one is
announced.
29. Kansas conducts a child abuse registry check only on relative
and in-home providers.
30. New Jersey conducts a child abuse registry check only
on family child care homes.
Continue to Appendix:
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