The Child Care and Development Block Grant (CCDBG) Act of 2014 includes significant adjustments to ensure the health and safety of children in early care and education (ECE) settings. These changes include provisions related to health and safety, training, and monitoring that Child Care and Development Fund (CCDF) Lead Agencies must implement for all providers receiving CCDF payments. Although these requirements will protect all children in child care, including infants and toddlers, some specifically address issues that only occur in infant and toddler settings. The following suggestions for addressing health and safety requirements can be found in Child Care Reauthorization and Opportunities for TANF and CCDF (Office of Child Care, 2016).

• Conduct comprehensive criminal background checks on all child care providers, including prospective staff and all staff who have unsupervised access to children, and all providers who are legally exempt from licensing and who receive CCDF funds (unless they are related to all children in their care). Specify disqualifying crimes.
• Allow provisional hiring under certain conditions, aligned with Head Start provisional hiring requirements that include important protections for children.
• Require preservice and ongoing training for CCDF child care providers in the following basic health and safety areas:
  • Prevention and control of infectious diseases;
  • Prevention of Sudden Infant Death Syndrome and promotion of safe sleep practices;
  • Administration of medication;
  • Prevention and response to emergencies due to food and allergic reactions;
  • Building and physical premises safety;
  • Prevention of Shaken Baby Syndrome and abusive head trauma;
  • Emergency preparedness and response planning for emergencies;
  • Handling and storage of hazardous materials;
  • Safe transportation of children;
  • First aid and CPR;
  • Recognizing and reporting child abuse and neglect (in order to comply with child abuse reporting requirements); and
  • Training in child development for children from birth to 13 years of age.
• Certify that child care providers will comply with child abuse reporting requirements.
• Have standards for CCDF providers regarding group size limits and appropriate child-staff ratios based on the age of children in care.
• Require emergency preparedness planning and statewide disaster plans for child care.
• Monitor and inspect all CCDF providers, including those who are license exempt. (This and the following two requirements are addressed in more depth in the Monitoring chapter of this resource guide).
• Conduct prelicensure and annual unannounced inspections of licensed CCDF providers and annual inspections of license-exempt CCDF providers.
• Establish qualifications and training for licensing inspectors and appropriate inspector-to-provider ratios.

Since infants and toddlers are often served in license-exempt care, especially those from families receiving Temporary Assistance for Needy Families (TANF), strategies to ensure their health and safety in those settings is of critical concern. As recommended in Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education, “States may opt to exempt relative providers from some or all of the health and safety requirements. ACF believes that all children in child care should be in settings that meet minimum health and safety standards, which is a prerequisite for high quality child care” (Office of Child Care, 2016, p. 8)

There are opportunities for Lead Agencies for TANF and CCDF to coordinate their efforts and ensure that children in TANF-funded child care are in settings that meet CCDF health and safety standards. There are also opportunities for providers who care for only TANF-funded children to be included in outreach, training, and technical assistance to help them meet health and safety requirements. CCDF quality funds can be used to support the increased quality of all child care, not just in settings where children receive CCDF subsidies (Office of Child Care, 2016).

Licensing Trends

As we consider the health and safety of infants and toddlers in child care, it is valuable to begin that exploration by looking at the primary system of protection for most children in child care: licensing regulations. Health and safety requirements for child care centers and homes are usually found in the State’s or Territory’s licensing requirements, although there may be other requirements for license-exempt providers who serve CCDF-funded children. Licensing regulations establish the foundational requirements necessary to protect the health and safety of the children in those programs. (Some States call the regulatory process “certification” or “registration.”) Health and safety standards higher than a State’s licensing requirements can sometimes be found in the quality rating and improvement system (QRIS) or other quality improvement initiatives.

According to the research brief Trends in Child Care Center Licensing Regulations and Policies for 2014 from the National Center on Early Childhood Quality Assurance (National Center on Early Childhood Quality Assurance, 2015a, p. 4), “more than 60 percent of states have made changes to their licensing regulations for child care centers.” Some of these changes specifically address the care of infants and toddlers. Some of the changes include “increased preservice qualifications required for teachers and directors”; such as, increased annual training hours; requirement of a comprehensive background and criminal history check (including fingerprint records at state and federal level, child abuse and neglect registries, and sex offender registry); requirement of safe sleep procedures and Sudden Infant Death Syndrome (SIDS) reduction training; and reporting requirements for serious injuries and deaths.

These areas of changes align with the new CCDF health and safety requirements. States with center regulations related to SIDS reduction have almost doubled from 2005 to 2014 (National Center on Early Childhood Quality Assurance, 2015a). While almost half of States have requirements about a primary, consistent caregiver, fewer have staff qualification requirements that are specific to the ages of children served (ECQA Center, 2015a).

A family child care home (FCCH) is defined as “one individual who provides child care services for fewer than 24 hours per day per child, as the sole caregiver, in a private residence other than the child’s residence, unless care in excess of 24 hours is due to the nature of the parent(s)’ work” (National Center on Early Childhood Quality Assurance, 2015b, p. 3). The research brief Trends in Family Child Care Home Licensing Regulations and Policies for 2014 (National Center on Early Childhood Quality Assurance, 2015b) shares that “in 2011, more than 50 percent of States have made changes to their licensing regulations for FCCHs” (p.4). Some of the changes in requirements relate to preservice qualifications for providers and assistants; increased number of annual training hours; checks of criminal history, Federal fingerprint records, and the sex offender registry; safe sleep practices and SIDS reduction training; emergency preparedness; and requirements to help prevent obesity and maintain healthy weight in young children. All of these new licensing changes made by States for FCCHs match the areas of changes in requirements for centers and group homes and align with the new CCDF health and safety requirements. Some address the specific needs of infant and toddlers. It should be noted that nearly all of the 46 States that license FCCHs set a limit on the number of infants and toddlers that can be in FCCHs (National Center on Early Childhood Quality Assurance, 2015b).

A group child care home (GCCH) is defined in the CCDF Final Rule as “two or more individuals who provide child care services for fewer than 24 hours per day per child, in a private residence other than the child’s residence, unless care in excess of 24 hours is due to the nature of the parent(s)’ work” (National Center on Early Childhood Quality Assurance, 2015c, p.3). Trends show since 2011, “more than 58 percent of States have made changes to their licensing regulations for GCCHs” (National Center on Early Childhood Quality Assurance, 2015c, p. 4). Some of the changes in requirements relate to preservice qualifications for staff; increased number of annual training hours; checks of criminal history, Federal fingerprint records, and the sex offender registry; safe sleep practices and SIDS reduction training; and emergency preparedness (National Center on Early Childhood Quality Assurance, 2015c). As with changes in requirements for centers, to a great degree these changes align with the new CCDF health and safety requirements, and some specifically address the needs of infants and toddlers.

Considerations for Creating Health and Safety System Strategies That Address the Needs of Infants and Toddlers

The process of revising existing and creating new requirements can be challenging and time consuming. If the State’s strategy is to change the licensing regulations, but child care licensing and CCDF administration are not in the same agency, there are additional challenges to overcome. The following strategies can be explored in collaboration with the State’s licensing administrator or with other partners.

Comprehensive Criminal Background Checks

Consider a state-level strategy for comprehensive criminal background checks. For example, for efficiency and consistency of results, coordinate or merge the process with an existing background check process at the state level, i.e., create a cross-state background check. The same or similar criminal background check requirements may exist in other state agencies for groups such as staff in nursing homes, teachers, medical facility staff, foster and adoptive parents, and others. Requirements may be similar across agencies (use of fingerprints for state-level and federal-level checks, and checks of the child abuse and neglect registry and the sex offender list). Even if the disqualifying crimes list and disqualification process may need to be individualized to different groups, there can be an opportunity to identify cost efficiencies and increase the consistency of quality assurance.

Training: Content and Preservice and Annual Requirements

With their developing bodies and immune systems, infants and toddlers are particularly vulnerable to health and safety hazards. They need caregivers and program directors who have preservice and ongoing annual training in the basic health and safety areas listed above. In addition, those directors and caregivers will need intentional and sequential education in child development programming and child health and safety and staff health. Information about these requirements, resources, state examples, and trends, including what is incorporated in States’ licensing regulations, is in the National Center on Early Childhood Quality Assurance’s CCDF Health and Safety Requirements Brief #9: Health and Safety Training (2016), which is available at https://childcareta.acf.hhs.gov/resource/ccdf-health-and-safety-requirements-fact-sheet-health-and-safety-training.The following are suggestions for providing health and safety training.

• Create training modules addressing the health and safety areas ensuring that the specific needs of infant and toddlers are met.
• Provide a credential that is awarded upon completion of all modules.
• Create a credential specific to infant and toddler care.
• Work with the higher education partners in the state to incorporate the health and safety training in an introductory course that could be included in a certificate, diploma, or degree program. Ensure that the training content addresses the specific vulnerabilities and needs of infants and toddlers.
• Review the content of existing training and any new training materials to ensure that the needs of all groups of children are addressed, including infants and toddlers.
• Review prelicensing orientation or other requirements and materials to ensure that preservice health and safety training is addressed and the needs for infants and toddlers are specifically included in all content.

Child Abuse Reporting Certification

Recognizing and reporting child abuse and neglect is required of child care staff in both center and family and home-based settings. States and Territories must prepare child care staff to recognize the signs of abuse and neglect, and understand their role in the reporting process. Some States have created a child abuse certification system.

New York and California are examples of two States that require child care providers and school-age care workers to be certified in reporting child abuse and maltreatment. These States have created child abuse prevention and identification training programs. See the short article Child Abuse Certification: Health and Safety for Infants and Toddlers in this Resource Guide, for more detailed information about these two state certification systems.

Group Size and Ratios

Infants and toddlers need individualized care provided by a primary caregiver in a small group setting to create an environment that is conducive to their healthy and safe development. This requires small groups and staff-child ratios that are part of relationship-based care. The following are suggested actions to support the inclusion of small groups and primary caregiving:

• Assess the State or Territory’s requirements on group size and ratios for alignment with the Administration for Children and Families’ Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education (2015) using the National Center on Early Childhood Quality Assurance’s Caring for Our Children Basics Health and Safety Standards Alignment Tool for Child Care Centers and Family Child Care Homes (2016), which is available at https://childcareta.acf.hhs.gov/resource/caring-our-children-basics-health-and-safety-standards-alignment-tool-child-care-centers.
• Consider a change to state licensing so that requirements are specific to the needs of infants and toddlers, and identify supports providers will need to meet the requirements. The Office of Child Care’s Revising State Licensing Requirements: Readiness for Change (2013) resource may be helpful in evaluating a State’s readiness and capacity to implement changes. It is available at https://childcareta.acf.hhs.gov/resource/revising-state-licensing-requirements-readiness-change.
• Add group size and reduced ratios to QRIS or other quality improvement initiatives as a standard or as a requirement for receiving financial incentives, including higher reimbursement rates. Group size and age ranges within groups is of particular importance for the health and safety of infants and toddlers in group home and family child care homes, where it is harder to create separate groups by age range.
• Use Early Head Start-Child Care partnerships to provide strategies to support improved ratios and group size in child care programs.
• Add group size and reduced ratios for infants and toddlers as a requirement for CCDF-funded providers. 

Emergency Preparedness

Emergency preparedness addresses procedures for responding to emergency situations: the need for urgent medical care, threatening incidents, and disasters. Infants and toddlers are particularly vulnerable during times of emergency, both physically and emotionally. Under such circumstances, intentional planning for infants and toddlers will help programs keep them safe and continue providing essential responsive, supportive care. The following suggestions can help programs prepare for emergency situations:

• Provide resources to help programs create and maintain a current, readily available and posted emergency preparedness plan that includes initial training and regular drills for staff about procedures.
• Build resources to help child care programs assess the strength and completeness of the plan with regards to addressing the needs of infants and toddlers.
• Identify who will help providers create such plans, who will monitor that the plans remain current and readily available, and who will monitor that staff have current in training for response.

The following resources by the National Center on Early Childhood Quality Assurance can be helpful when developing state-level emergency preparedness planning strategies. They contain excerpts from Federal CCDF program requirements, excerpts of relevant language from the Administration for Children and Families’ 2015 Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education (available at https://www.acf.hhs.gov/ecd/caring-for-our-children-basics), state examples, and a list of resources.

CCDF Health and Safety Requirement Brief #6: Emergency Preparedness and Response Planning (2016) https://childcareta.acf.hhs.gov/resource/ccdf-health-and-safety-requirements-brief-6-emergency-preparedness-and-response-planning

CCDF Health and Safety Requirements Brief #3: Prevention of and Response to Emergencies Due to Food and Allergic Reactions (2016) https://childcareta.acf.hhs.gov/resource/ccdf-health-and-safety-requirements-brief-3-prevention-and-response-emergencies-due-food

References

Child Care and Development Fund Program, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2016, September 30). Child Care and Development Fund (CCDF) Program. Federal Register, 81(190), 67438-67595. Retrieved December 7, 2016, from https://www.federalregister.gov/d/2016-22986/p-130

National Center on Early Childhood Quality Assurance, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2015a, November). Research Brief #1: Trends in child care center licensing regulations and policies for 2014. Retrieved December 6, 2016, from https://childcareta.acf.hhs.gov/resource/research-brief-1-trends-child-care-center-licensing-regulations-and-policies-2014

National Center on Early Childhood Quality Assurance, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2015b, November). Research Brief #2: Trends in family child care home licensing regulations and policies for 2014. Fairfax, VA. Retrieved December 6, 2016, from https://childcareta.acf.hhs.gov/resource/research-brief-2-trends-family-child-care-home-licensing-regulations-and-policies-2014

National Center on Early Childhood Quality Assurance, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2015c, November). Research Brief #3: Trends in group child care home licensing regulations and policies for 2014. Fairfax, VA. Retrieved December 6, 2016, from https://childcareta.acf.hhs.gov/resource/research-brief-3-trends-group-child-care-home-licensing-regulations-and-policies-2014

Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2015, June) Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education. Retrieved December 6, 2016 from https://childcareta.acf.hhs.gov/sites/default/files/cfocb_alignment_tool.

Office of Child Care, Administration for Children and Families, U.S Department of Health and Human Services. (2016, February). Child care reauthorization and opportunities for TANF and CCDF. Information Memorandum (CCDF-ACF-IM-2016-02). Retrieved December 6, 2016, from https://www.acf.hhs.gov/occ/resource/im-2016-02