PURPOSE: This rule establishes health requirements for child care providers and children in license-exempt child care facilities.

1. (1) Facility staff shall meet the following health requirements:

   1. (A) The director or other caregiver shall report to the local health department when any child in a facility is suspected of having a reportable communicable disease listed in 19 CSR 20-20.020(1)–(5). In the event of an unusual outbreak of a reportable communicable disease, caregivers shall implement control measures recommended by the department or local health department;
   2. (B) Caregivers shall use proper handwashing techniques with soap and warm, running water after toileting, after assisting a child with toileting, after diapering a child, and at other times as needed. Good hygiene practices shall be followed during food preparation. These practices include, but are not limited to, washing hands properly after smoking, eating, drinking, using the restroom, after touching raw food products and before preparing and serving food. Hands shall be dried with single-service towels. Caregivers shall teach and see that children wash their hands at appropriate times: before eating, after toileting and as needed when hands are soiled;
   3. (C) Caregivers shall not work when ill and likely to transmit an illness that might endanger the health or well-being of children. This may include symptoms such as fever, coughing, upper respiratory infection, vomiting or diarrhea;

   4. (D) All caregivers working in a facility during child care hours shall be in good health. They shall have a physical assessment, including a tuberculosis status assessment by a licensed physician or registered professional nurse. A physical assessment report, signed by a licensed physician or registered professional nurse, shall be on file at the time of employment or within thirty (30) days following employment.

      1. 1. Physical assessment reports shall be

completed not more than twelve (12) months before beginning work in the facility. The reports may be transferred to another facility for future employment.

1. 2. The facility may use the department’s

physical assessment form, MO 580-1879 (6- 94), or the facility may use its own form if it contains all the information on the department’s form.

1. 3. After the initial physical assessment,

all caregivers working in a facility during child care hours shall be tested for tuberculosis at least every two (2) years. Caregivers with previously positive tuberculin tests shall be under the management of a physician; and

1. (E) No person shall smoke or use tobacco products in any area of a child care facility while children are in care.

1. (2) Within thirty (30) days following the admission of an infant, toddler or preschool child, a physical assessment report signed by a licensed physician or registered professional nurse shall be on file at the facility. The facility may use the department’s physical assessment form, MO 580-1878 (6-94), or the facility may use its own form if it contains all the information on the department’s form. The report shall have been completed not more than twelve (12) months before admission.
2. (3) Child care facilities shall meet immunization requirements for children as defined by section 210.003, RSMo.
3. (4) A parent of a school-age child shall provide a statement at the time of enrollment indicating the child’s health history, any current health problems and any restrictions necessary for the child’s care.
4. (5) Each child shall be observed for contagious diseases and other signs of illness on arrival and throughout each day.
5. (6) A parent or guardian shall be contacted when signs of illness are observed.

6. (7) When a child exhibits any of the following in subsections (7)(A)–(O) of this rule, the parent(s) shall be contacted and the child shall be sent home. Parental contact shall be recorded and filed in the child’s records. Symptoms that require parental contact and sending a child home are—

   1. (A) More than one (1) abnormally loose stool;
   2. (B) Red or blue in the face or makes highpitched croupy or whooping sounds after coughing;
   3. (C) Difficult or rapid breathing—especially important in infants under six (6) months of age;
   4. (D) Yellowish skin or eyes;
   5. (E) Tears, redness of eyelid lining or irritation, followed by swelling or discharge of pus;
   6. (F) Unusual spots or rashes;
   7. (G) Sore throat or swallowing difficulty;
   8. (H) An infected skin patch—crusty, bright yellow, dry or gummy areas of the skin;
   9. (I) Unusually dark, tea-colored urine;
   10. (J) Gray or white stool;
   11. (K) Fever over one hundred one degrees Fahrenheit (101°F) by mouth or one hundred degrees Fahrenheit (100°F) under the arm;
   12. (L) Headache and stiff neck;
   13. (M) Vomiting more than once;
   14. (N) A child is in the contagious period of a disease; or
   15. (O) Severe itching of the body or scalp or scratching of the scalp which may be symptoms of lice or scabies.
7. (8) An ill child shall be kept isolated from the other children and a caregiver shall be in close proximity to the child until a parent 19 CSR 30-60

arrives. Close proximity means that a caregiver is close enough to hear any sounds a child might make that indicate a need for assistance.

1. (9) A parent of each child shall be notified when any reportable communicable disease in 19 CSR 20-20.020(1)–(5) occurs in the facility.

2. (10) Providers are not required to administer medication, but may if they choose.

   1. (A) All medication shall be given to a child only with the dated, written permission of a parent, stating the length of time the medication may be given.
   2. (B) Prescription and nonprescription medication shall be in the original container and labeled with the child’s name, instructions for administration, including the times and amounts for dosages, and the physician’s name. Sample medication provided by a physician may be used.
   3. (C) All medication shall be stored out of reach of children or in a locked container.
   4. (D) Medication shall be returned to storage immediately after use.
   5. (E) Medication needing refrigeration shall be kept in the refrigerator in a container separate from food.
   6. (F) Unused medication shall be returned to the parent or disposed of immediately after it is no longer needed.
   7. (G) The date and time(s) of administration, the name of the individual giving the medication and the quantity of medication given shall be recorded promptly after administration. This form shall be filed in the child’s record after the medication is no longer necessary.
3. (11) In case of an accident or injury to a child, the provider shall notify a parent immediately. If a child requires emergency medical care, a parent’s prior written instructions shall be followed. A form shall be completed indicating the circumstances and the date and time of the injury. The form shall be signed by the caregiver and his/her supervisor. A copy of the form shall be given to the parent the day of the accident or injury and necessary explanations shall be given. The form shall be filed in the child’s record.
4. (12) This rule expires on June 30, 2000.

AUTHORITY: section 210.221.1(3), RSMo 1994.* This rule was previously filed as 19 CSR 40-60.060. Original rule filed Dec. 1, 1994, effective July 30, 1995. Changed to 19 CSR 30-60.060 July 30, 1998. *Original authority 1949, amended 1955, 1987, 1993. apply to facilities caring for ten (10) or less children; (D) Outside doors shall not be locked to prevent exit while the building is occupied; (E) Every bathroom door lock or bathroom stall door shall be designed to permit opening from the outside in an emergency. All closet latches shall allow children to open the doors from the inside; and (F) Facilities shall have smokestop partitions with a one (1)-hour fire resistant rating between each floor. All doors providing separation between floors shall have a forty-five (45) minute fire resistant rating with an attached self-closing device. This does not apply to facilities caring for ten (10) or fewer children. (3) These requirements for detection and extinguishment systems shall be followed at all facilities: (A) Each facility caring for more than ten (10), but less than fifty (50) children at one (1) time shall have— 1. Manual pull stations by every exit or where designated by the fire inspector. They shall be connected to an alarm that is audible throughout the facility. One (1)-room facilities that exit directly to the outside are not subject to this requirement; and 2. At least one (1) Underwriter’s Labo- ratory (UL) or Factory Mutual (FM)- approved individual home-type detector shall be located on each floor and in each hazardous area. The number and location of detectors shall be determined by the fire inspector. Detectors shall be tested monthly and batteries changed as needed. A record shall be kept of the dates of testing and changing of batteries; (B) Facilities caring for fifty (50) or more children at one (1) time shall have a full-coverage electrical fire alarm system with battery back-up, smoke detectors, heat sensors and pull stations. All equipment shall be UL- or FM-certified; (C) Facilities caring for more than one hundred (100) children at one (1) time shall have a fire alarm that is transmitted to the local fire department or official authority; (D) Commercial stoves, commercial cooking ranges and deep fryers shall be equipped with a range hood and extinguishing system with an automatic cutoff of fuel supply, and an exhaust system; (E) A portable five (5) pound, 2A10BC fire extinguisher shall be located near the kitchen. The location shall be at the discretion of the fire inspector. Additional extinguishers may be required by the fire inspector; and (F) Janitor closets, maintenance shops and boiler or furnace rooms in child care space shall be separated from other parts of the building with construction having at least a one (1)-hour fire resistant rating. The opening shall have solid core doors to close off the area. (4) Heating equipment shall be installed with permanent connections and proper ventilation. (A) Space heaters, floor furnaces, wood burning stoves and fireplaces shall have a noncombustible guard or partition to prevent children from touching or tampering with them. (B) Unvented gas and oil heaters shall not be used. (C) All gas and electrical heating equipment shall be equipped with thermostatic controls. All hot water heaters shall have a temperature/pressure relief valve, be vented properly and equipped with thermostatic controls. The drain line on the pressure relief valve shall extend to approximately six inches (6") above the floor. (D) Only commercially manufactured heating equipment shall be used. (5) Fire and tornado drills shall be conducted at least every three (3) months and shall include all children in care. Unscheduled drills shall be held at the discretion of the state fire marshal or department. Each fire drill shall include a complete evacuation of all persons from the building. (A) An emergency plan for fires and tornadoes shall be posted conspicuously and shall include the route for the drills and special instructions for nonambulatory infants and children. (B) A written record shall be kept of the dates and types of drills conducted. (6) This rule expires on June 30, 2000. AUTHORITY: sections 210.221.1(3), RSMo (1994).* This rule was previously filed as 19 CSR 40-60.080. Original rule filed Dec. 1, 1994, effective July 30, 1995. Changed to 19 CSR 30-60.080 July 30, 1998.

*Original authority 1949, amended 1955, 1987, 1993.