Rule-making Standards and Procedures

7.702.62 Health Care

A. Statements of Health Status [Rev. eff. 4/1/06]

1. At the time of admission, the center must obtain health information for each child entering the center, including any known allergies, medication being taken, special diets required, or any chronic health condition. The name, address, and phone number of the child's physician and dentist must be provided. The center must also obtain information regarding all immunizations a child has had, including month, date, and year each immunization was administered. Immunizations must be recorded on the Certificate of Immunization form supplied by the Colorado Department of Public Health and Environment (CDPHE) or an approved alternate certificate approved by CDPHE. If immunizations are contraindicated because of a medical condition, a statement from the child's health care provider must be on file.

2. The parent or guardian of each child 2 1/2 years of age and over must submit a statement of the child's current health status signed and dated by an approved health care professional who has seen the child within the last 12 months. The statement of health status must be obtained at the time of admission or within 30 days after admission or for a drop-in child care center at the second visit, whichever is longer, must be kept at the center. If a child has an identified health condition or developmental concern including, but not limited to, seizures, asthma, diabetes, allergies, heart or respiratory conditions, and physical disabilities, information and instruction on care of the child must be included on the statement of health status signed by the physician. The center has the right to refuse to admit a child if a statement from an approved health care professional is not submitted.

3. Subsequent statements of the child's current health status, signed and dated by an approved health care professional, must be obtained at least annually for each child 2 to 6 years of age and whenever the director has reason to suspect that a child participating in the program may have a condition potentially hazardous to others, or finds that the child's general condition indicates the need for such examination.

4. For children 6 years of age and older or who have completed the first grade, subsequent statements of health status must be submitted every 3 years thereafter.

5. For children attending a drop-in child care center, subsequent statements are not necessary if there have been no health changes in the child and the parent(s) attest in writing to the health status of the child on an annual basis. Children with special medical needs must have the statement from a health care professional as indicated at Section 7.702.62, A, 3-4.

6. If a parent or guardian of a child wishes an exemption from the requirement for immunizations due to religious or personal beliefs, a written statement signed by the child's parent or guardian which states the reason for such an exemption and that the child is in good health must be submitted to the center.

Parents must be notified in writing prior to their child's enrollment in the center if non-immunized children are admitted to the center. This information must be contained in the policies required at Section 7.702.41, F.

7. In an infant nursery, at the time of admission or within 30 days, each infant's parent or guardian must submit a statement dated and signed by an approved health care professional. The statement must include information about the infant's health status and special needs. All immunizations must be recorded on the Certificate of Immunization supplied by CDPHE or an approved alternate certificate approved by CDPHE, including month, day, and year each immunization was administered, and must be on file the first day of admission.

Infants and toddlers under 2 years of age must follow the recommended Academy of Pediatrics schedule for routine health assessments

8. In a toddler nursery, at the time of admission or within 30 days, each toddler's parent or guardian must submit a statement of the child's health status as required at Section 7.702.62, A, 2, signed and dated by an approved health care professional who has seen the child within the last 6 months.

1. THE CENTER HAS THE RIGHT TO REFUSE TO ADMIT A CHILD IF A STATEMENT FROM A HEALTH CARE PROFESSIONAL IS NOT SUBMITTED.

2. AT THE TIME OF ADMISSION, THE PARENT(S)/GUARDIAN(S) MUST PROVIDE FOR EACH CHILD ENTERING THE CENTER:

1. 
   DOCUMENTATION OF IMMUNIZATION STATUS OR EXEMPTION AS REQUIRED BY COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (CDPHE). IMMUNIZATIONS MUST BE UPDATED AND RECORDED AS SPECIFIED ON THE CERTIFICATE OF IMMUNIZATION OR ALTERNATE CERTIFICATE OF IMMUNIZATION AS SUPPLIED AND APPROVED BY THE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (CDPHE). COLORADO LAW REQUIRES PROOF OF IMMUNIZATION BE PROVIDED PRIOR TO OR ON THE FIRST DAY OF ADMISSION.
   

2. 
   WITHIN THIRTY (30) DAYS AFTER ADMISSION, AND WITHIN THIRTY (30) DAYS FOLLOWING THE EXPIRATION DATE, THE PARENT(S)/GUARDIAN(S) OF EACH CHILD MUST SUBMIT A STATEMENT OF THE CHILD’S CURRENT HEALTH STATUS OR WRITTEN VERIFICATION OF A SCHEDULED APPOINTMENT WITH A HEALTH CARE PROVIDER. THE STATEMENT OF THE CHILD’S CURRENT HEALTH STATUS MUST BE SIGNED AND DATED BY A HEALTH CARE PROVIDER WHO HAS SEEN THE CHILD WITHIN THE LAST TWELVE (12) MONTHS, OR WITHIN THE LAST SIX (6) MONTHS FOR CHILDREN UNDER TWO AND ONE-HALF (2½) YEARS OLD. THE STATEMENT MUST INCLUDE WHEN THE NEXT VISIT IS REQUIRED BY THE HEALTH CARE PROVIDER. ALL HEALTH STATEMENTS MUST BE KEPT AT THE CENTER.
   

3. 
   STATEMENTS OF HEALTH STATUS OF CHILDREN UNDER TWO (2) YEARS OLD MUST BE UPDATED IN ACCORDANCE WITH THE AMERICAN ACADEMY OF PEDIATRICS RECOMMENDED SCHEDULE FOR ROUTINE HEALTH SUPERVISION OR AS REQUIRED IN WRITING BY THE HEALTH CARE PROVIDER.
   

4. 
   HEALTH STATEMENTS FOR CHILDREN OVER TWO (2) YEARS OLD TO SEVEN (7) YEARS OLD MUST BE UPDATED IN ACCORDANCE WITH THE AMERICAN ACADEMY OF PEDIATRICS RECOMMENDED SCHEDULE FOR ROUTINE WELL CHILD EXAMS.
   

5. 
   WHENEVER THE DIRECTOR HAS REASON TO SUSPECT A CHILD PARTICIPATING IN THE PROGRAM MAY HAVE A CONDITION POTENTIALLY COMMUNICABLE TO THE CHILD OR OTHERS, OR FINDS THE CHILD'S GENERAL CONDITION INDICATES THE NEED FOR EXAMINATION THE DIRECTOR MUST REQUIRE A STATEMENT FROM THE CHILD’S HEALTH CARE PROVIDER APPROVING THE CHILD TO RETURN TO GROUP CARE.
   

6. 
   FOR CHILDREN SEVEN (7) YEARS OF AGE AND OLDER OR WHO HAVE COMPLETED THE FIRST (1^ST) GRADE, SUBSEQUENT STATEMENTS OF HEALTH STATUS MUST BE OBTAINED EVERY THREE (3) YEARS.
   

7. 
   FOR CHILDREN ATTENDING A DROP-IN CENTER, PARENT(S)/GUARDIAN(S) OF EACH CHILD MUST SUBMIT A STATEMENT OF THE CHILD’S CURRENT HEALTH STATUS OR WRITTEN VERIFICATION OF A SCHEDULED APPOINTMENT WITH A HEALTH CARE PROVIDER WITIN THIRTY (30) DAYS OR BY THE SECOND VISIT, WHICHEVER IS LONGER. THE STATEMENT OF THE CHILD’S CURRENT HEALTH STATUS MUST BE SIGNED AND DATED BY A HEALTH CARE PROVIDER WHO HAS SEEN THE CHILD WITHIN THE LAST TWELVE (12) MONTHS, OR WITHIN THE LAST SIX (6) MONTHS FOR CHILDREN UNDER TWO AND ONE-HALF (2½) YEARS OLD. SUBSEQUENT STATEMENTS ARE NOT REQUIRED IF THERE HAVE BEEN NO HEALTH CHANGES IN THE CHILD AND THE PARENT(S)/GUARDIAN(S) ATTEST IN WRITING TO THE HEALTH STATUS OF THE CHILD ON AN ANNUAL BASIS. CHILDREN ATTENDING DROP-IN CHILD CARE WITH SPECIAL MEDICAL NEEDS MUST HAVE THE STATEMENT FROM A HEALTH CARE PROFESSIONAL AS INDICATED IN SECTION 7.702.62 A, 2, b-f.
   

B. Emergency Procedures

1. At the time of admission, the center must obtain telephone numbers of the child's physician or other appropriate health care professional and numbers where the parent or guardian and at least 1 other responsible adult can typically be reached in the event of accident, illness, or other emergency.

2. The center must obtain written authority to arrange for medical care in the event of an emergency. This information must be on file the first day a child attends the center.

3. When accidents, injuries, or illnesses occur, the director or responsible adult in charge must notify the parent or guardian of the child and if necessary call the physician or medical facility as instructed in writing by the parent or guardian.

4. For every THIRTY (30) or fewer children in attendance, there must be at least one (1) staff member on duty who holds a current department-approved first aid and safety certificate (including CPR for all ages of children) and is responsible for administering first aid and CPR to children. Such individuals must be with the children at all times when the center is in operation. If children are at different locations, there must be a first aid and CPR qualified staff member at each location.

5. Children too ill to remain in the group must be comfortably cared for and supervised until they can be taken home or suitably cared for elsewhere.

6. Portable first aid kits must be available to staff at all times, including field trips, and must be located out of reach of children and maintained in a sanitary condition. First Aid kits must be checked and restocked on at least a monthly basis.

C. Medication

1. Prescription and non-prescription (over-the-counter) medications for eyes or ears, all oral medications, topical medications inhaled medications, and certain emergency injections can be administered only with the written order of a person with prescriptive authority and with written parental consent. Centers may administer medications for chronic health conditions or emergency situations. ANY ROUTINE MEDICATION, PRESCRIPTION OR NON-PRESCRIPTION (OVER-THE-COUNTER) MUST BE ADMINISTERED ONLY WITH A CURRENT WRITTEN ORDER OF A HEALTH CARE PROVIDER WITH PRESCRIPTIVE AUTHORITY AND WITH WRITTEN PARENTAL CONSENT. HOME REMEDIES, INCLUDING HOMEOPATHIC MEDICATIONS SHALL NEVER BE GIVEN TO A CHILD.

2. The written order by the licensed prescribing practitioner must BY THE PERSON WITH PRESCRIPTIVE AUTHORITY SHALL include:

--a. Child's name

--b. Licensed prescribing practitioner name, telephone number, and signature

--c. Date authorized

--d. Name of medication and dosage

--e. Time of day medication is to be given

--f. Route of medication

--g. Length of time the medication is to be given

--h. Reason for medication (unless this information needs to remain confidential)

--i. Side effects or reactions to watch for

--j. Special instructions

3. Medications must be kept in the original labeled bottle or container. Prescription medications must contain the original pharmacy label. that lists:

-- Child's name

-- Prescribing practitioner's name

-- Pharmacy name and telephone number

-- Date prescription was filled

-- Expiration date of the medication

-- Name of the medication

-- Dosage

-- How often to give the medication

-- Length of time the medication is to be given

4. Over-the-counter medication must be kept in the originally labeled container and be labeled with the child's first and last name.

45. In the case medication needs to be given on an ongoing, long-term basis, the authorization and consent forms must be reauthorized on AT LEAST an annual basis. Any changes in the original medication authorization require a new written order by the prescribing practitioner and a change in the prescription label. Verbal orders taken from the licensed prescriber may be accepted only by a licensed registered nurse.
6. ACETAMINOPHEN OR IBUPROFEN IS ABLE TO BE USED MULTIPLE TIMES WITH ONE (1) CURRENT, SIGNED MULTI-USE MEDICATION ORDER FOR UP TO THREE (3) CONSECUTIVE DAYS IF THE ORDER IS SPECIFIC ABOUT WHEN THE MEDICATION IS TO BE GIVEN. THE MULTI-USE MEDICATION ORDER MUST BE RENEWED WITH EACH UPDATED HEALTH STATEMENT.

57. All child care Staff designated by the center director to give medications must complete the 4-hour Department-approved medication administration training and have current ANNUAL DELEGATION OR MORE OFTEN AS DETERMINED BY THE CHILD CARE HEALTH CONSULTANT. DELEGATION MUST BE FROM THE CENTER’S CURRENT CHILD CARE HEALTH CONSULTANT WHO MUST OBSERVE AND DOCUMENT THE COMPETENCY OF EACH STAFF MEMBER INVOLVED IN MEDICATION ADMINISTRATION. ALL STAFF ADMINISTERING MEDICATION MUST HAVE CURRENT CPR, First Aid and universal STANDARD precautions training prior to administering medication WITH THE FOLLOWING EXCEPTIONS:
a. STAFF DETERMINED BY THE DIRECTOR, IN CONSULTATION WITH THE CHILD CARE HEALTH CONSULTANT, TO BE RESPONSIBLE FOR PROVIDING ROUTINE EMERGENCY MEDICATIONS COVERED IN THE APPROVED MEDICATION ADMINISTRATION TRAINING FOR THE TREATMENT OF SEVERE ALLERGIES OR INHALED MEDICATIONS FOR THE TREATMENT OF ASTHMA MUST RECEIVE TRAINING AND DELEGATION FROM THEIR CHILD CARE HEALTH CONSULTANT FOR THOSE MEDICATIONS ONLY. STAFF MUST THEN PROVIDE THOSE MEDICATIONS TO CHILDREN BASED ON THE INSTRUCTIONS FROM THE CHILD’S INDIVIDUALIZED HEALTH CARE PLAN.
b. STAFF DETERMINED BY THE DIRECTOR, IN CONSULTATION WITH THE CHILD CARE HEALTH CONSULTANT, TO BE RESPONSIBLE FOR PROVIDING MEDICATIONS NOT COVERED IN THE APPROVED MEDICATION ADMINISTRATION TRAINING SHALL ALSO BE PERMITTED TO ADMINISTER MEDICATIONS AND/OR MEDICAL TREATMENTS SUCH AS RECTAL DIASTAT, INSULIN OR OXYGEN WITH INDIVIDUALIZED TRAINING AND DELEGATION FROM THE CHILD CARE HEALTH CONSULTANT BASED ON INSTRUCTIONS FROM THE CHILD’S INDIVIDUALIZED HEALTH CARE PLAN.
c. STAFF MAY BE TRAINED AND DELEGATED IN THE ADMINISTRATION OF A SINGLE RESCUE MEDICATION OR RESCUE MEDICAL INTERVENTION BY THE CENTER’S CHILD CARE HEALTH CONSULTANT. SUCH TRAINING AND DELEGATION SHALL QUALIFY THE STAFF MEMBER TO PROVIDE A RESCUE MEDICATION OR TREATMENT FOR A SPECIFIC CHILD BASED ON INSTRUCTIONS FROM THE CHILD’S INDIVIDUALIZED HEALTH CARE PLAN.

8. Staff of drop-in child care centers may MUST complete training from their nurse consultant delegating medication.

69. The center's licensed health consultant:

--a. Must observe and document the competency of each staff member involved in medication administration

--b. Must delegate to one or more of the child care staff the task of medication administration, to include routine medications only. For medications not covered in the medication training, the health consultant must provide additional training, delegate on a one-to-one (1:1) basis, and provide ongoing supervision.

79. ALL medications, EXCEPT THOSE SPECIFIED IN EMERGENCY MEDICATION ADMINISTRATION, (SEE SECTION 7.702.62,B), must be kept in THE ORIGINAL CONTAINER IN A CLEAN anD LOCKED area, locked and inaccessible to children, BUT AVAILABLE TO STAFF TRAINED IN ADMINISTERING MEDICATION. IF REFRIGERATION IS REQUIRED, THE MEDICATION MUST BE STORED IN EITHER A SEPARATE REFRIDGERATOR OR A LEAK PROOF CONTAINER IN A DESIGNATED AREA OF A FOOD STORAGE REFRIGERATOR, SEPARATE FROM FOOD AND INACCESSIBLE TO CHILDREN. Controlled medications must be counted and safely secured, and specific policies regarding their handling require special attention in the center's policies. Access to these medications must be limited (see Section 12-22-318, C.R.S.).

10. EMERGENCY MEDICATIONS MUST BE STORED IN ACCORDANCE WITH THE CHILD CARE HEALTH CONSULTANT’S RECOMMENDATION. EMERGENCY MEDICATIONS ARE NOT REQUIRED TO BE STORED IN A LOCKED AREA. EMERGENCY MEDICATIONS MAY BE STORED IN AN AREA EASILY ACCESSIBLE AND IDENTIFIABLE TO STAFF BUT OUT OF REACH OF CHILDREN. WHEN AWAY FROM THE CLASSROOM, STAFF MUST CARRY EMERGENCY MEDICATIONS IN A BAG ON THEIR PERSON.

11. THE CENTER MUST HAVE A WRITTEN POLICY ON THE STORAGE AND ACCESS OF INHALERS AND EPINEPHRINE CARRIED BY SCHOOL-AGE CHILDREN. THE POLICY MUST INCLUDE A WRITTEN CONTRACT WITH THE PARENT(S)/GUARDIAN(S) AND CHILD ACKNOWLEDGEMENT ASSIGNING LEVELS OF RESPONSIBILITY OF EACH INDIVIDUAL. THIS CONTRACT WILL ACCOMPANY ORDERS FOR THE MEDICATION FROM A HEALTH CARE PROVIDER ALONG WITH CONFIRMATION FROM THE HEALTH CARE PROVIDER THAT THE STUDENT HAS BEEN INSTRUCTED AND IS CAPABLE OF SELF-ADMINISTRATION OF THE PRESCRIBED MEDICATIONS.

12. THE CENTER MUST HAVE A WRITTEN POLICY ON THE STORAGE AND ACCESS OF INHALERS AND EPINEPHRINE FOR ALL CHILDREN IN CARE. THIS POLICY MUST BE REVIEWED BY THE CHILD CARE HEALTH CONSULTANT.

13. Children are not allowed to bring medications to child care unless accompanied by a responsible adult. If a medication is out of date or left over, parents are responsible for picking up the medication. If parents do not respond, the center is responsible for the disposal of medications according to center policy and procedures. Disposal of medications must be documented.

914. A written medication log must be kept for each child. This log is part of the child's records. The log must contain the following:

--a. Child's name;

--b. Name of the medication, dosage, and route;

--c. Time medication is to be given;

--d. Special instructions;

--e. Name and initials of the individuals giving the medication; AND,

--f. Notation if the medication was not given and the reason.

10 15. Topical preparations such as petroleum jelly, diaper rash ointments, sunscreen, bug sprays, and other ointments may be administered to children with written parental authorization. These preparations may not be applied to open wounds or broken skin unless there is a written order by the prescribing practitioner.

D. Sun Protection

1. The center must obtain the parent or guardian's written authorization and instructions for applying sunscreen OR USE OF ANOTHER FORM OF PARENT OR GUARDIAN APPROVED SUN PROTECTION to their children's exposed skin prior to outside play. A doctor's permission is not needed to use sunscreen at the center.

2. When supplied for an individual child, the sunscreen must be labeled with the child's first and last name.

3. If sunscreen is provided by the center, parents must be notified in advance, in writing, of the type of sunscreen the center will use.

4. Children over FOUR (4) years of age may apply sunscreen to themselves under the direct supervision of a staff member.

5. THE CENTER MUST APPLY SUNSCREEN OR USE ANOTHER FORM OF PARENT OR GUARDIAN APPROVED SUN PROTECTION FOR CHILDREN PRIOR TO CHILDREN GOING OUTSIDE. SUNSCREEN MUST BE REAPPLIED AS DIRECTED BY THE PRODUCT LABEL.

E. Control of Communicable Illnesses

1. When children have been diagnosed with a communicable illness such as hepatitis, measles, mumps, meningitis, diphtheria, rubella, salmonella, tuberculosis, giardia or shigella, the center must immediately notify the local health department or the State COLORADO Department of Public Health and Environment, all staff members, and all parents and guardians of children in care. Children's confidentiality must be maintained.

2. The director must ask parents to report exposure of a child to communicable illness outside of the center, and, at the discretion of the director, the child should be excluded from the center for the period of time prescribed by the child's physician or by the local health department.

7.702.63 Personal Hygiene

A. Hand Washing

1. Children's hand washing must be supervised and must be taught when necessary.

B. Diapering

(See also Section 7.702.83.A.3)

The center must have one (1) or more designated diaper change areas for all children in need of diaper changing. The ALL diaper change areaS must:

1. Be a minimum of 36 by 18 inches in size and large enough to accommodate the size of the child;

2. Be adjacent to or within reach of a hand washing sink;

3. Have a place inaccessible to children for storing all diaper change supplies and disinfecting solutions and products; AND,

4. Have a sufficient supply of diapers at all times.

7.702.64 Physical Care and SUPERVISION [Rev. eff. 4/1/15]

A. General

1. All children must be under direct supervision of a responsible adult at all times.

2. The time a child arrives and leaves the center each day must be recorded. Attendance verification must be made periodically throughout the day by staff members at the center.

3. STAFF MUST BE AWAKE, ALERT AND SUPERVISING ALL CHILDREN.
4. CENTER STAFF MUST DIRECTLY SUPERVISE CHILDREN AND MAINTAIN STAFF TO CHILD RATIO DURING SPECIAL ACTIVITIES THAT OCCUR WITH AN OUTSIDE VENDOR OR PROVIDER AND WHERE THE VENDOR USES THEIR EXPERT STAFF TO FACILITATE THE ACTIVITY.

35. The center must provide a rest period WITH rest equipment OF AT LEAST THIRTY (30) MINUTES for all preschool-age children remaining in the center longer than FIVE (5) 4 hours. A rest period and. QUIET ACTIVITIES ARE PERMISSIBLE DURING THE THIRTY (30) MINUTE PERIOD. must also be provided for Older children who requireING a rest time MUST BE GIVEN ONE.

6. CHILDREN MUST NOT BE FORCED TO SLEEP. CHILDREN WHO DO NOT SLEEP AFTER THIRTY (30) MINUTES MUST BE ALLOWED TO MOVE TO ANOTHER AREA AND BE PROVIDED WITH QUIET TOYS AND EQUIPMENT TO PLAY WITH SUCH AS PUZZLES OR BOOKS.

7. CHILDREN MUST BE ALLOWED TO LEAVE THEIR NAPPING AREA WITHIN TEN (10) MINUTES OF WAKING.

48. The center must provide mats or cots and a designated rest period for all preschool age children. Drop-in child care centers must provide mats or cots for at least fifty percent (50%) of the licensed capacity of the center. Children must not be forced to sleep. Children who do not sleep after a reasonable period of time must be provided with appropriate quiet toys and equipment to play with, such as puzzles or books.

59. The center must ensure that children are dressed appropriately for the weather before going outside.

B. Infant and Toddler Nurseries PROGRAMS

1. The staff must have daily contact with adults who transport the infants and toddlers to and from the center.

2. Children must not be confined for prolonged periods of time to cribs, playpens, swings, high chairs, infant seats, or other equipment that confines movement. They must have an opportunity each day for freedom of movement, such as creeping, crawling, or walking in a safe, clean, open, uncluttered area.

3. Throughout the day, each child must have frequent, individual, personal contact and attention from an adult, such as being held, rocked, taken on walks inside and outside the center, talked to, and sung to.

4. There must be no attempt to toilet train children under the age of eighteen (18) months UNTIL THEY ARE ABLE TO VERBALIZE OR OTHERWISE INDICATE NEED, HELP MANAGE THEIR OWN CLOTHING, AND BE ABLE TO ACCESS TOILETING FACILITIES.

5. FOR EACH CHILD WHO IS LEARNING TO USE A TOILET, THE CHILD’S INDIVIDUAL DEVELOPMENTAL ABILITIES AND NEEDS MUST BE ACCOMMODATED AS STATED IN THE WRITTEN POLICIES AND PROCEDURES FOR THE CENTER.

56. Staff must investigate whenever children cry.

67. Children must be allowed to form and observe their own pattern of sleep and waking periods. Special provision must be made so that children requiring a morning nap time have a separate area for their nap apart from space used for play.

C. Safe Sleep Training for Infant Nursery Staff

All staff who work with infants must complete a Department approved safe sleep training prior to working with infants, which must be renewed on an annual basis.

DC. Safe Sleep Environments for Infants

1. Each infant up to twelve (12) months of age must be provided with an individual crib or futon approved for infants or other approved sleep/rest equipment meeting Consumer Product Safety Commission (CPSC) standards.

2. In the infant room, soft bedding or materials that could pose a suffocation hazard are not permitted in cribs, futons approved for infants or other approved sleep/rest equipment. Soft bedding means, but is not limited to, any soft sleep surface like bumper pads, pillows, blankets, quilts, comforters, sleep positioning devices, sheepskins, blankets, flat sheets, cloth diaper bibs, plush toys, and stuffed animals.

3. An infant must be placed on his/her back for sleeping.

4. Alternative sleep positions for infants must only be allowed with a health care plan completed and signed by the child’s physician.

5. Swaddling of infants must only be allowed with a health care plan completed and signed by the child’s physician.

6. Each infant up to twelve (12) months of age WHO USES A PACIFIER must have the pacifier offered when being put down to sleep, unless the parent directs otherwise. If the infant refuses the pacifier, s/he should not be forced to take it. After the infant falls asleep, there is no need to reinsert the pacifier if it falls out. Pacifiers should not be coated in any sweet solution, and they should be cleaned and replaced regularly. THE PACIFIER SHOULD BE SUITABLE FOR THE AGE AND SIZE OF THE INFANT.

7. All sleep/rest equipment must be safe, sturdy, and free from hazards including, but not limited to: broken or loose slats, torn mattress, chipping paint or loose screws.

8. Approved sleeping equipment must be firm and mattresses must fit snugly ensuring no more than two fingers are able to be inserted between the mattress and the side of the approved sleeping equipment.

9. Toys, including mobiles and other types of play equipment that are designed to be attached to any part of sleeping equipment, must be kept away from sleeping infants and out of sleep environments, including hanging toys. Blankets and other items must not be hung from or draped over the sides or any part of sleeping equipment.

10. Drop side and stacking cribs are prohibited.

11. Bassinets and playpens are prohibited in child care centers unless licensed as a teen parent program when the teen parent(s) remain(s) on site.

12. Other sleep equipment not manufactured for commercial use is prohibited.

13. Infant monitors may only be used in separate sleeping rooms for infants under the following conditions:

a. The sound monitoring equipment is able to pick up the sounds of all sleeping infants.

b. The receiver of the sound monitoring equipment is actively monitored by staff at all times.

c. All sleeping infants must be physically observed at least every ten (10) minutes by a staff member.

d. Sound monitoring equipment must be regularly checked to ensure it is working correctly.

14. After December 31, 2015, separate sleep rooms must be prohibited in new construction, change of governing body and change of capacity in child care centers.

15. Infants who fall asleep in a car safety seat, bean bag chair, bouncy seat, infant seat, swing, jumping chair, play pen or play yard, highchair, chair, sofa, adult futon, adult bed or other piece of equipment not approved for sleep must immediately be moved to their approved sleep area and placed on their back to sleep.

16. Cribs must be used for sleeping, not extended play or confinement.

17. Children who are awake must not be confined for more than fifteen (15) minutes at a time to cribs, playpens, swings, high chairs, infant seats, or other equipment that inhibits freedom of movement. Children who are actively eating may be in a high chair or other approved feeding equipment for longer than fifteen (15) minutes. Children must be moved away from the feeding location once feeding is complete.

18. If music is played in the infant sleep area, the music must not be played at a loud volume that would prevent infants from being heard by staff. Music equipment must not be placed under a crib or within three (3) feet of the sleeping infant.

19. Supervised tummy time must be offered to infants one month of age or older up to twenty to thirty (20-30) minutes per day. If the infant falls asleep during tummy time, immediately place him/her on their back in approved sleeping equipment.

20. When staff place infants in approved sleeping equipment for sleep, they must check to ensure that the temperature in the room is comfortable for a lightly clothed adult, check the infants to ensure that they are comfortably clothed (not overheated or sweaty), and that bibs, necklaces, and garments with ties or hoods are removed. Clothing sacks or other clothing designed for sleep must be used in lieu of blankets if needed for additional warmth.

21. Infants must not be placed to sleep in the same crib or futon as another infant or child, and must never sleep with an adult in a bed, on a couch, or in any other setting or manner.

ED. The facility must have a policy on the protection of infants from second hand smoke.