Division of Child Care Services

Effective January 31, 2005 - Day Care Center

418-1.11 Health and Infection Control

(a) The provider must prepare a health care plan on forms furnished by the office, or approved equivalents. Such plan must protect and promote the health of children in a manner consistent with the health care plan guidelines issued by the office. The guidelines describe practices to promote the health of children and special considerations for the care of mildly and moderately ill children for programs that provide care for such children. The health care plan must be on site and available upon demand by a parent or guardian or the office. The health care plan must be followed by the provider. For programs offering care to infants and toddlers, care to mildly or moderately ill children, or the administration of medications, the health care plan must be approved by the program's health care consultant. Should the health care consultant determine after a visit to the day care program that the approved health care plan is not being reasonably followed by the provider, the health care consultant may revoke his or her approval of the plan. If the health care consultant revokes his or her approval of the health care plan, the health care consultant must immediately notify the provider and the provider must immediately notify the office. In that instance, the health care consultant may also notify the office directly if he or she so desires. The health care plan must describe the following:

(1) how a daily health check of each child will be carried out by a person who is competent to recognize symptoms of illness, communicable diseases and child abuse or maltreatment;

(2) which staff members are certified to administer medications. The plan must state that only a trained, designated staff person may administer medications to children, except in those programs where the only administration of medications offered will be the administration of over-the-counter topical ointments, including sunscreen lotion and topically applied insect repellant pursuant to paragraph (11) of subdivision (j) of this section. The designated staff person may only administer medications to children if the designated staff person is at least 18 years of age, possesses a current certification in first aid and cardiopulmonary resuscitation (CPR), and has completed the administration of medication training pursuant to paragraph (13) of subdivision (j) of this section;

(3) the designation of the health care consultant of record for programs offering:

(i) care to infants and toddlers,

(ii) care to mildly or moderately ill children, or

(iii) the administration of medications, except in those programs where the only administration of medications offered will be the administration of over-the-counter topical ointments, including sunscreen lotion and topically applied insect repellant pursuant to paragraph (11) of subdivision (j) of this section;

(4) the scheduling of visits by a health care consultant to day care center programs offering:

(i) care to infants and toddlers,

(ii) care to mildly or moderately ill children, or

(iii) the administration of medications, except in those programs where the only administration of medications offered will be the administration of over-the-counter topical ointments, including sunscreen lotion and topically applied insect repellant pursuant to paragraph (11) of subdivision (j) of this section.

Visits by the health care consultant to the above programs must occur at least once during each licensing period and include review of the health care policies and procedures, and review of documentation and practice demonstrating the program's ongoing compliance with the health care plan and policies;

(5) general training that will be provided to all staff on procedures to minimize infections and, if applicable, advanced training that will be provided to staff caring for mildly or moderately ill children;

(6) staff health policies and practices, including the exclusion criteria which apply to staff who care for children or prepare food;

(7) child health policies and practices, including the level of illness in children which the provider will accommodate, exclusion criteria for children, and, if applicable, the policy and procedure for the administration of medications;

(8) the specific procedures for obtaining emergency health care for children who require such care, including transportation and the supervision of children remaining in the child day care center;

(9) the contents of the first aid kit(s) and procedures for monitoring that such kit(s) are restocked when needed;

(10) the specific procedures which the provider will use to prevent the spread of infections, including handwashing and diapering techniques; safety precautions relating to blood; sanitation of equipment and toys; and the observation of symptoms of illness in the children;

(11) the procedures for keeping a record of each child's illnesses, injuries and signs of abuse or maltreatment;

(12) the advance arrangements for the care of any child who has or develops symptoms of illness or is injured while in day care, including notifying the child's parent or guardian; and

(13) for providers caring for mildly or moderately ill children, how the provider will achieve consistency with those sections of the Office's health care plan guidelines which apply to the level of illness in children which the provider will accommodate.

(b) (1) Providers who care for infants and toddlers, or for mildly or moderately ill children, must confer with a health care consultant regarding the program's health policies and procedures. Health care consultants to the program must be familiar with the program's health care plan, must review and update such plan no less often than once every 24 months, and must approve and sign the health care plan prior to its submission to the Office.

(2) All providers who choose to administer medications to children must have a health care consultant of record. The provider must confer with a health care consultant regarding the program's policies and procedures related to the administration of medications. This consultation must include a review of the documentation that all staff authorized to administer medications have the necessary professional license or have completed the necessary training.

(c) Each employee and volunteer must submit a statement from a health care provider prior to beginning employment at the child day care center, and every two years thereafter. Such statement must give satisfactory evidence that the individual is physically fit to provide child day care, has no diagnosed psychiatric or emotional disorder which would preclude such individual from providing child day care, and is free from communicable disease. The medical statement also must include the results of a Mantoux tuberculin test which has been performed within the 12 months preceding the date of the statement.

(d) Consumption of, or being under the influence of, alcohol or controlled substances by staff of the child day care center is prohibited. Smoking in indoor areas, in outdoor areas in use by children, and in vehicles while children are being transported is prohibited.

(e) Other than children who are enrolled in kindergarten or a higher grade, no child may be accepted for care in a child day care center unless the provider has been furnished with a written statement signed by a health care provider stating that the child is able to participate in child day care, currently appears to be free from contagious or communicable diseases and is receiving health care, including appropriate health examinations in accordance with the American Academy of Pediatrics schedule of such care and examinations. The written statement from the health care provider must also state whether the child is a child with special health care needs and, if so, what special provisions, if any, will be necessary in order for the child to participate in day care. Where the written statement from the health care provider advises the day care provider that the child being enrolled is a child with special health care needs, the day care provider must work together with the parent and the child's health care provider to develop a reasonable health care plan for the child while the child is in the child day care program. The health care plan for the child must also address how the day care provider will obtain or develop any additional competencies that the day care provider will need to have in order to carry out the health care plan for the child. Such documentation must state that the child has received age-appropriate immunizations in accordance with New York State Public Health Law.

(1) Any child not yet immunized may be admitted provided the child's immunizations are in process, in accordance with the requirements of the New York State Department of Health, and the parent gives the provider specific appointment dates for subsequent immunizations.

(2) Any child who is not immunized because of the parent's genuine and sincere religious beliefs may be admitted if the parent furnishes the child day care center with a written statement to this effect.

(3) Any child who is missing one or more of the required immunizations may be admitted if a physician licensed to practice medicine in New York State furnishes the child day care center with a written statement that such immunizations may be detrimental to the child's health.

(4) With the exception of children meeting the criteria of paragraphs (2) or (3) of this subdivision, children enrolled in the child day care center must remain current with their immunizations in accordance with the current schedule for immunizations established by the New York State Department of Health.

(f) (1) The provider must obtain emergency health care for children who require such care and also must:

(i) obtain written consent from the parent or guardian at the time of the child's admission which authorizes the provider to obtain emergency health care for the child;

(ii) arrange for the transportation of any child in need of emergency health care, and for the supervision of the children remaining in the child day care center; and

(iii) in the event of an accident or illness requiring immediate health care, secure such care and notify the parent or guardian.

(2) Where the provider or an employee has been certified to administer medications in a day care setting in accordance with the requirements of paragraph (13) of subdivision (j) of this section, such provider or employee may administer emergency care through the use of epinephrine auto-injector devices when necessary to prevent anaphylaxis for an individual child but only when the parent or guardian and the child's health care provider have indicated such treatment is appropriate.

(g) The center must be equipped with a portable first aid kit which is accessible for emergency treatment. The first aid kit must be stocked to treat a broad range of injuries and situations and must be restocked as necessary. The first aid kit and any other first aid supplies must be kept in a clean container or cabinet not accessible to children.

(h) When a child has or develops a level of illness that is not accommodated in the provider's approved health care plan, the child must be provided with a place to rest quietly that is in view of, and under the supervision of, staff until the child is seen by a health care provider or is removed from the child day care center. In the event that a child has or develops any symptoms of illness, the provider is responsible for immediately notifying the parent.

(i) The provider must try to obtain a copy of a lead screening certificate for each child under the age of six years. If the parent does not have one, the provider may not exclude the child from child day care, but must give the parent information on lead poisoning and prevention, and refer the parent to their health care provider or the county health department for a lead blood screening test.

(j) The child day care center may administer medication or treatment only in accordance with the following:

(1) Policies regarding the administration of medications must be explained to the parent or guardian at the time of enrollment of the child in care. Parents or guardians must be made familiar with the policies of the day care provider relevant to the administration of medications.

(2) Nothing in this section shall be deemed to require any provider to administer any medication, treatment, or other remedy except to the extent that such medication, treatment or remedy is required under the provisions of the Americans with Disabilities Act.

(3) Nothing in this section shall be deemed to prevent a parent, guardian or relative within the third degree of consanguinity of the parents or step-parents of a child, even if such a person is an employee of the program, from administering medications to child while the child is attending the program even if the provider has chosen to not administer medications or if the staff person(s) designated to administer medications is not present when the child receives the medication. If the provider elects not to administer medications, the day care provider or an employee must still document the dosages and time that the medications were given to the child by the child's parent, guardian or relative within the third degree of consanguinity of the parents or step-parents of the child. If the only administration of medication in a day care program is done by a parent(s), guardian(s) or relative(s) within the third degree of consanguinity of the parents or step-parents of a child, the provider and employee(s) of the program do not have to complete the administration of medication training requirements pursuant to paragraph (13) of subdivision (j) of this section.

(4) Providers and employees may administer prescription and non-prescription (over-the-counter) medications for eyes or ears, oral medications, topical ointments and medications, and inhaled medications in accordance with the provisions of this subdivision. Providers and employees may not administer medications by injection, vaginally or rectally except as follows:

(i) in accordance with the provisions of paragraph (2) of subdivision (f) of this section;

(ii) for a child with special health care needs, where the parent, day care provider and the child's health care provider have agreed on a plan pursuant to which the provider may administer medications by injection, vaginally or rectally; or

(iii) where the provider or employee has a valid New York State license as a physician, physician's assistant, registered nurse, nurse practitioner, licensed practical nurse or advanced emergency medical technician.

(5) A day care provider who agrees to administer medications to a child must do so, unless they observe the circumstances specified by the health care provider, if any, under which the medication must not be administered. In such instances, the day care provider must contact the parent or guardian immediately.

(6) (i) Except as described in paragraphs (10), (11) and (12) of this subdivision, medication may be administered only upon written permission of the parent or guardian and written instructions from a health care provider in a language in which the day care provider is literate stating that the child day care provider may administer such medication or prescription and specifying the circumstances, if any, under which the medication or prescription must not be administered. Medication must be returned to the parent or guardian when it is no longer required by the child or, with the permission of the parent or guardian, be properly disposed of by the provider.

(ii) Where the day care provider has received written permission of the parent or guardian and written instructions from the health care provider authorizing administration of a specified medication if the day care provider observes some specified condition or change of condition in the child while the child is in care, the day care provider may administer the specified medication without obtaining additional authorization from the parent or guardian or health care provider.

(7) To the extent that such information is not included on the medication label pursuant to paragraph (8) of this subdivision, written instructions by the licensed authorized prescriber on the form provided by the Office or an equivalent form, must include the:

(i) Child's name;

(ii) Licensed authorized prescriber's name, telephone number, and signature;

(iii) Date authorized;

(iv) Name of medication and dosage;

(v) Frequency the medication is to be administered;

(vi) Method of administration;

(vii) Date the medication shall be discontinued or length of time, in days, the medication is to be given;

(viii) Reason for medication (unless this information must remain confidential pursuant to law);

(ix) Most common side effects or reactions; and

(x) Special instructions or considerations, including but not limited to possible interactions with other medications the child is receiving or concerns regarding the use of the medication as it relates to a child's age, allergies, or any pre-existing conditions.

(8) Medications must be kept in the original labeled bottle or container. Over-the-counter medication must be kept in the originally labeled container and be labeled with the child's first and last name. Prescription medications must contain the original pharmacy label that lists:

(i) Child's name;

(ii) Authorized prescriber's name;

(iii) Pharmacy name and telephone number;

(iv) Date prescription was filled;

(v) Name of the medication;

(vi) Dosage;

(vii) How often to give the medication; and

(viii) Date the medication shall be discontinued or length of time, in days, the medication is to be given.

(9) In the case of medication that needs to be given on an ongoing, long-term basis, the authorization and consent forms must be reauthorized at least once every six months. Any changes in the original medication authorization shall require a provider to obtain new instructions written by the licensed authorized prescriber and a change in the prescription.

(10) If a parent or guardian requests that the day care provider administer a prescription or orally administered over-the-counter medication but does not furnish the day care provider with written instructions from a health care provider or licensed authorized prescriber, the day care provider may administer such medication or prescription with the oral approval of the parent or guardian and upon obtaining verbal instructions directly from the health care provider or licensed authorized prescriber for that day only. The day care provider must document that the health care provider or licensed authorized prescriber gave verbal instructions and that the health care provider or licensed authorized prescriber was asked to send written instructions to the day care provider. If the medication is to be administered on subsequent days, written instructions must have been provided to the day care provider from the health care provider.

(11) The day care provider may administer over-the-counter topical ointments, including sunscreen lotion and topically applied insect repellant, upon the written instructions of the parent or guardian. Such administration must be consistent with any directions for use noted on the original container, including but not limited to precautions related to age and special health conditions. With such written instructions, day care providers and employees may administer over-the-counter topical ointments and sunscreen lotion without receiving the training in administration of medications otherwise required pursuant to paragraph (13) of this subdivision.

(12)(i) If an infant develops symptoms which indicate a need for over-the-counter topical ointment while in care at the program, such ointment may be given under verbal instructions from the parent or guardian for that day only if the instructions received from the parent or guardian are consistent with any directions for use of the medication or ointment noted on the original container, including but not limited to precautions related to age and special health conditions.

(ii) If a child other than an infant develops symptoms which indicate a need for over-the-counter medication, including topical ointments, while in care at the program, such medication or ointment may be given under verbal instructions from the parent or guardian for that day only if the instructions received from the parent or guardian are consistent with any directions for use of the medication or ointment noted on the original container, including but not limited to precautions related to age and special health conditions.

(iii) For all children for whom the day care provider administers over-the-counter medications pursuant to this paragraph, the day care provider must document that the parent or guardian gave verbal instructions and approval. If the medication is to be administered on subsequent days, written instructions from the parent or guardian and, in the case of orally administered medications, a health care provider or licensed authorized prescriber, must be obtained.

(13) All day care providers and employees, except those excluded in subparagraph (iii) of this paragraph and except as provided in paragraphs (3) and (11) of this subdivision, who have agreed to administer medication must complete the office-approved medication administration training or an office-approved equivalent before administering medications to children in day care. The certification of training in the administration of medications to children in day care shall be effective for a period of three years from the date of issuance. The provider or employee must complete a recertification training approved by the office in order to extend the certification for each additional three year period. If, however, the provider or employee ceases to work in a day care program for a continuous period of one year, the certification shall automatically lapse. Where a certification lapses, the provider or employee may not be recertified unless the provider or employee completes the initial medication administration training or the recertification training, as required by the office. Where enforcement action has been taken against the provider based on a failure by the provider or employee to comply with requirements for the administration of medications set forth in this section, the office may require retraining or may prohibit the provider or employee from being involved in the administration of medications.

(i) Providers or employees who will be responsible for administering medications must receive training in the methods of administering medications prior to administering any medications in a day care setting. In order to be trained in the administration of medications in a day care setting, a provider or employee must be literate in the language or languages in which health care instructions from parents and health care providers will be received. Upon completion of the training, the provider or employee must receive a written certificate from the trainer that indicates that the trainee has successfully completed this training program, as required, and demonstrated competency in the administration of medications in a day care setting. Persons who receive training in the administration of medications in day care settings pursuant to this section may not otherwise administer medications or represent themselves as being able to administer medications except to the extent such persons may be able to do so in accordance with the relevant provisions of the Education Law.

(ii) The training in the administration of medications must be provided by a health care provider who has been certified by the office to administer the office-approved curriculum. The training must be documented and must include, but need not be limited to, the following:

(a) training objectives;

(b) a description of the methods of administration including principles and techniques of application and dispensation of oral, topical, and inhalant medication, including the use of nebulizers, and the use of epinephrine auto-injector devices when necessary to prevent anaphylaxis in emergency situations with respect to the various age groups of children;

(c) administering medication to an uncooperative child;

(d) an evaluation of whether the trainee demonstrates competency in:

(1) understanding orders from the health care professional or licensed authorized prescriber;

(2) the ability to correctly carry out the orders given by the health care provider or licensed authorized prescriber;

(3) recognition of common side effects of medications and ability to follow written directions regarding appropriate follow up action;

(4) avoidance of medication errors and what action to take if an error occurs;

(5) understanding relevant commonly used abbreviations;

(6) maintaining required documentation including the parent or guardian's permission, written orders from health care professionals and licensed authorized prescribers, and the record of administration of medications;

(7) safe handling of medications, including receiving medications from a parent or guardian;

(8) proper storage of medications, including controlled substances; and

(9) safe disposal of medications.

(iii) A person who can produce a valid New York State license as a physician, physician's assistant, registered nurse, nurse practitioner, licensed practical nurse or advanced emergency medical technician will not be required to attend the training required by this paragraph in order to administer medications in a day care program. Documentation establishing the person's credentials in one of the above fields will be required and a copy of the documentation must be provided to the Office.

(14) Medications must be kept in a clean area that is inaccessible to children. If refrigeration is required, the medication must be stored in either a separate refrigerator or a leak-proof container in a designated area of a food storage refrigerator, separated from food and inaccessible to children. Day care programs must comply with all Federal and State requirements for the storage and disposal of all types of medications, including controlled substances.

(15) At the time of administration, the staff must document the dosages and time that the medications are given to the child. All observable side effects must be documented and shared with the parent, guardian and, when appropriate, the child's health care provider. Documentation must be made if the medication was not given and the reason for such a decision. The parent or guardian must be notified immediately and the Office must be notified by the close of the following business day of any medication administration errors. Notification to the Office must be reported on a form provided by the Office or on an approved equivalent.

(16) No child under the care of a day care center will be allowed to independently administer medications without the assistance and direct supervision of staff that are certified to administer medications pursuant to this section. Any program that elects to offer the administration of medication to children where children who attend the program independently administer medications or where children assist in the administration of their own medications must comply with all the provisions of this section.

(k) Staff must thoroughly wash their hands with soap and running water at the beginning of the day, before and after the administration of medications, when they are dirty, after toileting or assisting children with toileting, after changing a diaper, before and after food handling or eating, after handling pets or other animals, after contact with any bodily secretion or fluid, upon moving to work with a new group of children, and after coming in from outdoors.

(1) Staff must ensure that children thoroughly wash their hands or assist children with thoroughly washing their hands with soap and running water when they are dirty, after toileting, before and after food handling or eating, after handling pets or other animals, after contact with any bodily secretion or fluid, and after coming in from outdoors. For diapered children, caregivers must ensure that adequate steps are taken to clean the child after each change of diaper. Staff must assist children in keeping clean and comfortable, and in learning appropriate personal hygiene practices.

(m) Safety precautions relating to blood must be observed by all staff coming into contact with blood, as follows:

(1) Disposable gloves must be immediately available and worn whenever there is a possibility for contact with blood, including but not limited to:

(i) changing diapers where there is blood in the stool;

(ii) touching blood or blood-contaminated body fluids;

(iii) treating cuts that bleed; and

(iv) wiping surfaces stained with blood.

(2) In an emergency, a child's well-being must take priority. A bleeding child must not be denied care because gloves are not immediately available.

(3) Disposable gloves must be discarded after each use.

(4) If blood is touched accidentally, the exposed skin must be thoroughly washed with soap and running water.

(5) Clothes contaminated with blood must be placed in a securely tied plastic bag and returned to the parent at the end of the day.

(6) Surfaces that have been blood stained must be cleaned and then disinfected with a germicidal solution.

(n) Sufficient and suitable clothing must be available so that children who dirty or soil their clothing may be changed. All such clothing must be returned to parents for washing.

(o) Infants must be kept clean and comfortable at all times. Diapers must be changed whenever wet or soiled. The diaper changing area must be as close as possible to a sink that is used exclusively by staff for diaper changing. This area or sink must not be used for food preparation. Soap and hot and cold running water must be available. The diaper changing area must be washed and disinfected with a germicidal solution after each use.

(p) The provider must use disposable diapers or arrange with the parent(s) or a commercial diaper service to provide an adequate supply of cloth diapers.

(1) When disposable diapers are used, soiled diapers must be disposed of immediately into an outside trash disposal, or placed in a tightly covered plastic-lined trash can in an area inaccessible to children until outdoor disposal is possible.

(2) Non-disposable diapers must not be laundered in the child day care center, and must be stored in a securely covered receptacle until returned to the diaper service. When parents provide non-disposable diapers, soiled diapers must be placed in a securely tied plastic bag and returned to the parent at the end of the day.

(q) Toilet facilities must be kept clean at all times, and must be supplied with toilet paper, soap and disposable towels accessible to the children.

(r) Toileting equipment, such as potty chairs, appropriate to the toilet training level of the children in the group must be provided. When more than one child in the center is being toilet trained, potty chairs must be emptied and sanitized with a germicidal solution after each use. If only one child in the center is being toilet trained, potty chairs must be emptied and rinsed after each use and sanitized with a germicidal solution daily. Potty chairs must not be washed out in a handwashing sink, unless that sink is washed and disinfected after such use.

(s) All rooms, equipment, surfaces, supplies and furnishings accessible to children must be cleaned and disinfected as needed to protect the health of children, and in a manner consistent with the health care plan guidelines issued by the Office. The premises must be kept free from dampness, odors, vermin, and the accumulation of trash.

(1) Equipment that is frequently used or touched by children on a daily basis must be cleaned and disinfected when soiled and at least once weekly.

(2) Carpets contaminated with body fluids must be spot cleaned.

(3) Extensive cleaning, such as shampooing carpets or washing windows and walls, must occur when children are not present.

(4)(i) Any application of pesticides (as the term pesticide is defined in section 33-0101 of the Environmental Conservation Law) shall be completed in accordance with the requirements of section 390-c of the Social Services Law and sections 33-1004 and 33-1005 of the Environmental Conservation Law.

(ii) In addition to the requirements of section 390-c of the Social Services Law, each day care facility must send a notice home with each child or otherwise provide notification to the parent of each child not less than forty-eight hours prior to the application of pesticides. Such notice must include:

(a) the location and specific date of the application of pesticides and may include two alternate dates in the event that an outdoor application cannot be made due to weather conditions;

(b) the pesticide product name and pesticide registration number assigned by the United States Environmental Protection Agency;

(c) the following statement: "This notice is to inform you of a pending pesticide application at this facility. You may wish to discuss with a representative of the day care facility what precautions are being taken to protect your child from exposure to these pesticides. Further information about the product or products being applied, including any warnings that appear on the label of the pesticide or pesticides that are pertinent to the protection of humans, animals or the environment, can be obtained by calling the National Pesticide Telecommunications Network Information line at 1-800-858-7378 or the New York State Department of Health Center for Environmental Health Info Line at 1-800-458-1158"; and

(d) the name of a representative of the day care facility and contact number for additional information.

(iii) Any day care provider that fails to send the appropriate notice of pesticide application as set forth in subparagraph (ii) of this paragraph shall, for a first such violation of this subdivision, be issued a written warning in lieu of penalty. For a second violation, such provider shall be subject to a penalty not to exceed one hundred dollars. For any subsequent violation, such provider shall be subject to a penalty not to exceed two hundred fifty dollars for each violation. No penalty may be assessed by the Commissioner without affording the provider with notice and an opportunity for a hearing pursuant to section 413.5 of this Article.

(iv) Any finding by the Department of Environmental Conservation of a violation by the provider of the requirements set forth in sections 33-1004 or 33-1005 of the Environmental Conservation Law shall be deemed a safety hazard to children in care and a violation of this subdivision.

(5) Garbage receptacles must be covered, and cleaned as needed after emptying.

(6) Thermometers and toys mouthed by children must be washed and disinfected before use by another child.

(7) Individual drinking cups, disposable paper cups or bubbler drinking fountains of the angle jet type must be provided. The use of shared drinking cups is prohibited.

(8) Linens, blankets and bedding must be cleaned at least weekly and before use by another child. Cribs, cots, beds, mats and mattresses must be cleaned thoroughly between uses by different children and at least monthly.

(9) Either disposable towels or individual cloth towels for each child must be used. If individual cloth towels are used, they must be laundered daily. Sharing personal hygiene items, such as washcloths, towels, toothbrushes, combs and hairbrushes, is prohibited.

(10) After use, dishes and all utensils must be washed with soap and hot water, and rinsed in hot running water.

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