Basic Services

(1) Nursing Services. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (a) The PCCC must have an organized nursing service that provides twenty-four (24) hour nursing services furnished or supervised by a registered nurse. A registered nurse must be on the premises at all times during business hours. (b) The PCCC must have a well-organized service with a plan of administrative authority and delineation of responsibilities for child care. The nursing director must be a licensed registered nurse who is responsible for the operation of the nursing service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for the PCCC. (c) The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all children as needed. There must be supervisory and staff personnel for each department or unit of the PCCC to ensure, when needed, the immediate availability of a registered nurse. (d) There must be a procedure to ensure that nursing personnel for whom licensure is required have valid and current licenses. (e) A registered nurse must assess, supervise and evaluate the nursing care for each child. (f) The PCCC must ensure that an appropriate individualized plan of care is prepared for each child. (g) A registered nurse must assign the nursing care of each child to other nursing personnel in accordance with the child’s needs and the specialized qualifications and competence of the nursing staff available. All nursing personnel shall have specialized training and a program in-service and continuing education commensurate with the duties and responsibilities of the individual. All training shall be documented for each individual so employed, along with documentation of annual competency skills. Orientation of any new personnel must be conducted within the first two weeks of employment. (h) Non-employee licensed nurses who are working in the PCCC must adhere to the policies and procedures of the facility. The nursing director must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing service. Annual competency and skill documentation must be demonstrated on these individuals just as on employees, if they perform clinical activities. (i) All drugs, devices and related materials must be administered by, or under the supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing requirements. (j) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the child. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they must be: 1. Accepted only by personnel that are authorized to do so by policies and procedures, consistent with federal and state law; and 2. Signed or initialed by the prescribing practitioner according to policy. (k) Intravenous medications must be administrated in accordance with state law and approved policies and procedures. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (l) There must be a procedure for reporting adverse drug reactions and errors in administration of drugs. (2) Physician Services. (a) Policies and procedures concerning services provided by the PCCC shall be available to the children’s primary care physicians as requested. (b) If children with mental, physical or other impairments or with a medical disorder are enrolled, and special care is needed, a physician’s statement shall identify the condition and give the appropriate care professional special instructions for the child’s care. (c) Children shall be aided in receiving dental care as deemed necessary. (d) Consultation with a physician shall occur at least annually to review medical care provided within the PCCC and shall include, but not be limited to: 1. Evaluate the delivery of emergency and medical care when the child’s primary physician or his/her designated alternative is unavailable; 2. Review reports of accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator; 3. Review performance improvement, infection control and safety action plans for appropriate actions; 4. Monitor the health status of facility personnel to ensure that no health conditions exist which would adversely affect children; and 5. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control. (3) Educational Services. (a) The PCCC will provide parent(s) education services by including them in care related conferences and teaching them how to perform necessary therapies and how to meet the developmental and psychological needs of their child at home. (b) Monthly educational development programs shall be conducted and documented. These programs shall be provided to: 1. Develop collaborative relationships between health professionals and parent(s). 2. Increase understanding and coping with the effects of childhood illness, and shall cover a variety of topics including: (i) Issues of death and dying; (ii) Awareness of services available; (iii) Fostering of advocacy skills; (iv) Impact of illness on child development; and STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (v) Parenting an ill child. 3. Develop case management skills to assist the family in setting priorities and planning and implementing the child’s care at home. 4. Develop a comprehensive Plan of Care to include the medical, nutritional, developmental and psychosocial needs of medically/technologically dependent children, including training in the implementation of new technology. 5. Prepare for management of emergency medical situations. (c) A comprehensive orientation to acquaint the parent(s) with the philosophy and services of the PCCC shall be provided at the time of the child’s placement in the PCCC. (d) Activities shall be used for the children based on developmentally appropriate educational practices. (e) To the extent that children are physically able to participate, a daily program shall provide opportunities for learning, self-expression, and participation in a variety of creative activities such as art, music, literature, dramatic play, science and health. (f) Indoor physical activities, requiring children to use both large and small muscles, shall be provided for children of each age group who are physically able to participate. (g) Activities for infants/toddlers shall provide experience for the development of language, gross motor, fine motor, social/personal, cognitive, and self-help skills. Examples of such activities include music, dramatic play, story-time, free activity periods, outdoor play, and the opportunity to explore many materials, situations, and roles. (h) Because of the importance of language development and communication skills to infants and toddlers, they shall be talked to, listened to, read to and sung to, in addition to other language experience activities, including but not limited to, finger plays, patty cake, and flannel board activities. (4) Nutritional Services. (a) The PCCC must have an organized dietary service that is directed and staffed by adequate qualified personnel. A facility may contract with an outside food management company if the company has a dietitian who serves the facility on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this paragraph and provides for consultant liaison with the facility staff for recommendations on dietetic policies affecting the children’s treatment. If an outside contract is utilized for management of its dietary services, the facility shall designate a full-time employee to be responsible for the overall management of the services. (b) The PCCC must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. The food and dietetic services director shall be: 1. A qualified dietitian; or, 2. A graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or, STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 3. An individual who has successfully completed in-person or online coursework that provided ninety (90) or more hours of classroom instruction in food service supervision. If the course has not been completed, this person shall be enrolled in a course and making satisfactory progress for completion within the time limit specified by the course requirement; or, 4. An individual who is a certified dietary manager (CDM), or certified food protection professional (CFPP); or, 5. A current or former member of the U.S. military who has graduated from an approved military dietary manager training program. (c) There must be a qualified dietitian, full-time, part-time, or on a consultant basis, who is responsible for the development and implementation of a nutrition care process to meet the needs of health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the child and treatment through diet therapy, counseling and/or use of specialized nutrition supplements. (d) Menus must meet the needs of the children. 1. Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the children and must be prepared and served as prescribed. 2. Special diets shall be prepared and served as ordered. 3. Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the children. 4. A current therapeutic diet manual approved by the dietitian and nursing director must be readily available to all nursing and food service personnel. (e) Educational programs, including orientation, on-the-job training, inservice education, and continuing education, shall be offered to dietetic services personnel on a regular basis. Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food. (f) A minimum of three (3) meals in each twenty-four (24) hour period shall be served. A supplemental night meal shall be served if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishment shall be provided to children with special dietary needs. A minimum of three (3) days supply of food shall be on hand. (g) Menus shall be prepared at least one week in advance. A dietitian shall be consulted to help write and plan the menus. If any change in the actual food served is necessary, the change shall be made on the menu to designate the foods actually served to the children. Menus of food served shall be kept on file for a thirty (30) day period. (h) The dietician or designee shall have a conference, dated on the medical record with each child and/or family within two (2) weeks of admission to discuss the diet plan indicated by the physician. The child’s dietary preferences shall be recorded and utilized in planning his/her daily menu. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (i) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination whether in storage or while being prepared and served and/or transported through hallways. (j) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140°F or above) or cold (45°F or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used. (k) Food shall not be forced on or withheld from children. Food shall not be used as a reward, nor shall food be used or withheld as punishment. (l) Specific feeding instructions given by parents shall be in writing. If staff feel instructions to be inappropriate or in conflict with established policy or the therapeutic diet prescribed by the practitioner, staff shall initiate discussion with the parent to resolve the conflict. (m) New foods shall be introduced to infants and toddlers; foods shall be introduced one at a time over a five-to-seven day period with parental approval. (n) The feeding schedule for infants shall be in accordance with the child’s need rather than according to the hour. (Infants fed breast milk may require more frequent feedings than formula-fed babies.) (o) Parents and caregivers shall work together when weaning an infant to insure consistency in the weaning process. Weaning shall be delayed until after an infant adjusts to group care. (p) Children shall not be permitted to carry a bottle with them throughout the day. (q) All formulas and food brought from home shall be labeled with child’s name. Milk shall be placed immediately in the refrigerator. Once milk has been warmed, it shall not be rewarmed or returned to the refrigerator. For optimum digestion, formula is to be served at body temperature. (r) Frozen breast milk shall be dated when expressed. Bottled breast milk shall not be heated in a microwave oven. To prevent scalding, extreme caution shall be taken when a microwave oven is used to heat food. (s) Previously opened baby food jars shall be not accepted in the PCCC. (t) Infants shall be held while being fed if they are unable to sit in a high chair, an infant seat, or at the table. Bottles shall not be propped. A child shall not be given a bottle while lying flat. (u) When children are capable of using a high chair, they shall be allowed to do so and to experiment with food, with feeding themselves, and to eat with fingers or spoon. Children shall not be left unattended while eating. (v) Dishwashing machines shall be used according to manufacturer specifications. (w) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (x) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Services Sanitation Manual”: (y) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods. (z) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45°F. Freezers shall be kept at a temperature not to exceed 0°F. (aa) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments,” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation. (5) Pharmaceutical Services. (a) The PCCC shall have pharmaceutical services that meet the needs of the children and are in accordance with the Tennessee Board of Pharmacy statutes and rules. The administrator is responsible for developing policies and procedures that minimize drug errors. (b) All internal and external medications and preparations intended for human use shall be stored separately. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use, and the key must be in the possession of the supervising nurse or other authorized persons. Poisons or external medications shall not be stored in the same compartment and shall be labeled as such. (c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication. (d) Every PCCC shall comply with all state and federal regulations governing Schedule II drugs. (e) A notation shall be made in a Schedule II drug book and in the child’s medical chart each time a Schedule II drug is given. The notation shall include the name of each child receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug. (f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days. (g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the child. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be: 1. Accepted only by personnel that are authorized to do so by policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to policy. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (h) Medications not specifically limited as to time or number of doses when ordered are controlled by automatic stop orders or other methods in accordance with written policies. No Schedule II drug shall be given or continued beyond seventy-two (72) hours without a written order by the physician. (i) Medication administration records (MAR) shall be maintained for each child. Each dose shall be properly recorded in the medical record after it has been administered. (j) Preparation of doses for more than one scheduled administration time shall not be permitted. (k) Medication shall be administered only by licensed medical or nursing personnel or other licensed health professionals acting within the scope of their licenses. (l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the child, the drug, the physician, the prescription number and the date dispensed. (m) Legend drugs shall be dispensed by a licensed pharmacist. (n) Any unused portions of prescriptions shall be turned over to the parent(s) or only on discharge. A notation of drugs released shall be entered into the medical record. All unused prescriptions not taken by the parent and left at the PCCC must be destroyed on the premises and recorded by a pharmacist. Such record shall be kept in the PCCC. (6) Rehabilitation Services. (a) Physical therapy, occupational therapy and speech therapy shall be provided directly or through contractual agreement by individuals who meet the qualifications specified by PCCC policy and consistent with state law. (b) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10. (c) A licensed physical therapist shall be in charge of the physical therapy service and a licensed occupational therapist shall be in charge of the occupational therapy service. (d) Direct contact shall exist between the child and the therapist for those children that require treatment ordered by a physician. (e) If ordered by a physician, the physical therapist and the occupational therapist shall provide treatment and training designed to preserve and improve abilities for independent functions, such as: range of motion, strength, tolerance, coordination and activities of daily living. (f) Therapy services shall be coordinated with the nursing service and made a part of the child’s treatment plan. (g) Sufficient staff shall be made available to provide the service ordered. (7) Psychologist/Social Work Services. (a) Social services and psychological services must be available to the children, the child’s family and other persons significant to the child, in order to facilitate adjustment of STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 these individuals to the impact of the child’s illness and to promote maximum benefits from the health care services provided. (b) Social work services shall include psychosocial assessment, counseling, coordination of discharge planning, community liaison services, financial assistance and consultation. (c) Psychological services shall include psychoanalysis, psychotherapy, psychological testing, psychoeducational evaluation therapy remediation and consultation. (d) A child’s social history shall be obtained within two (2) weeks of admission and shall be appropriately maintained. (e) Social work services shall be provided by a qualified social worker. (f) Facilities for social work services shall be readily accessible and shall permit privacy for interviews and counseling. (8) Respiratory Care Services (Optional). (a) If the PCCC provides respiratory care services, the PCCC must meet the needs of the patients in accordance with acceptable standards of practice. (b) The organization of the respiratory care services must be appropriate to the scope and complexity of the services offered. (c) There must be adequate numbers of licensed respiratory therapists, respiratory technicians, and other personnel to provide the ordered services. (d) Services must be delivered in accordance with physician directives. (e) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. (9) Infection Control. (a) The PCCC must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. (b) The administrator shall assure that an infection control program, including members of the multidisciplinary staff such as nursing and administrative staff, develop guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the program shall include the establishment of: 1. Written infection control policies; 2. Techniques and systems for identifying, reporting, investigating and controlling infections in the facility; 3. Written procedures governing the use of aseptic techniques and procedures in the facility; 4. Written procedures concerning food handling, laundry practices, disposal of environmental and human wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers; STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 5. A log of incidents related to infectious and communicable diseases; 6. Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections. (c) The administrator must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas. (d) Parents of every child enrolled shall be notified immediately if one of the following communicable diseases has been introduced into the child care center: hepatitis A, foodborne outbreaks (food poisoning) salmonella, shigella, measles, mumps, rubella, pertussis, polio, haemophilus influenza type B, meningococcal meningitis. The PCCC shall report the occurrence of the above diseases to the local health department. (e) Impetigo and diagnosed strep shall be treated appropriately for 24 hours prior to readmission to the center. Children having scabies or lice shall have proof of treatment to be readmitted. The PCCC shall provide care and/or isolation for a child with a contagious condition only if written instructions of a licensed physician or certified health care provider are obtained first. (f) The PCCC shall develop policies and procedures for testing a child’s blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a child’s blood or other body fluid. The testing shall be performed at no charge to the child and the test results shall be confidential. (g) The facility and its employees shall adopt and utilize standard or universal precautions of the Centers for Disease Control (CDC) for preventing transmission of infections, HIV, and communicable diseases. (h) All PCCCs shall adopt appropriate policies regarding the testing of children and staff for HIV and any other identified causative agent of acquired immune deficiency syndrome. (i) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated. (j) Space and facilities for housekeeping equipment and supplies shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from child care areas. The building shall be kept in good repair, clean, sanitary and safe at all times. (10) Performance Improvement. (a) The PCCC must ensure that there is an effective, facility-wide performance improvement program to evaluate child care and performance of the organization. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (b) The performance improvement program must be ongoing and have a written plan of implementation which assures that: 1. All organized services related to child care, including services furnished by a contractor, are evaluated; 2. Nosocomial infections and medication therapy are evaluated; and, 3. All services performed in the facility are evaluated as to the appropriateness of diagnosis and treatment. (c) The PCCC must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its children. (d) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action. (e) Performance improvement program records shall be disclosable to the Department to demonstrate compliance with this section. (f) Good faith attempts by the performance improvement program committee to identify and correct deficiencies will not be used as a basis for sanctions. (11) Transportation Services (If Provided). (a) If a PCCC provides transportation, its management shall recognize its full responsibility for the child between home and facility and on field trips. On field trips or when transporting children between home and the facility, staff shall maintain an accurate list of children being transported and shall take roll frequently. The driver or accompanying staff member shall assure that every child is received by a parent or other designated person. The owner of the vehicle shall carry adequate liability insurance. (b) Parents shall be notified of each field trip and notification documented. (c) Vehicles used to transport children shall be maintained in safe working condition. Regular scheduled inspections shall be documented. Documentation of regular maintenance shall be kept on file in the facility. (See Appendix A) (d) The driver shall comply with the health requirements as specified in Appendix C of these rules. (e) On field trips off premises, at least two (2) adults shall be in the vehicle, in addition to the driver. (f) Children shall always be attended by a licensed nurse while in a vehicle. (g) The number of infants and other non-ambulatory children transported by one licensed nurse shall be limited to six. A second licensed nurse shall be in the vehicle supervising the children when seven or more children are being transported. (h) Transportation provided by the PCCC or under PCCC auspices shall comply with state law. STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (i) All children and the driver shall be secured in individual passenger restraint devices at all times during the transportation by the PCCC or under PCCC auspices. Exception: Children four (4) years of age and older transported by a school bus or public transportation are not required to be restrained because these vehicles are not required to be equipped with restraint devices. (j) No child shall be allowed to ride on the floor of a vehicle, and no child shall be placed with another child in the same restraint device. (k) Drivers of any vehicle used to transport children shall have a proper license and endorsement required for the transportation of the number of passengers transported and the vehicle size and weight as required in Chapter 50 of Title 55 of the Tennessee Code Annotated. (l) A vehicle used to transport children shall have fire extinguishers, emergency reflective triangles, a first aid kit and a blood-borne pathogenic clean-up kit, and an adult familiar with the use of this equipment on board. Emergency exiting procedures shall be practiced by all staff responsible for transporting children on a regular basis. (m) Storage of firearms is prohibited in vehicles used to transport children. (n) A minimum of ten (10) inches seat space per child is required in a vehicle transporting children. (o) Children shall not spend more than ninety (90) minutes traveling one way. (12) Recreational Services. (a) The PCCC shall provide opportunities for recreational activities appropriate to the needs, interests, and ages of the children being served. (b) Equipment Needs for Children: 1. General (i) All indoor and outdoor equipment shall be well made and safe. There shall be no dangerous angles, no sharp edges, splinters, or nails sticking out, no open S-hooks or pinch points within children’s reach. (ii) Damaged equipment shall be repaired or removed from the room or playground immediately. (iii) Equipment shall be kept clean by washing frequently with soap and water. (iv) There shall be developmentally appropriate equipment and furnishings for each age group in attendance. (v) Material and equipment shall be provided to meet the needs of all the children enrolled. (vi) Individual lockers, separate hooks and shelves or other containers (placed at children’s reaching level for mobile children) shall be provided for each child’s belongings. 2. Indoor Play Equipment STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 (i) Pieces of equipment, such as television sets, bookcases and appliances, shall be secured or supported so that they will not fall or tip over. (ii) Indoor equipment, materials, and toys shall be available to: (I) Meet active and quiet play needs of all children enrolled; (II) Provide a variety of developmentally appropriate activities so that each child has at least three choices during play time; and (III) Adequately provide for all the activities required in other sections of this rule. (iii) Toys, educational and play materials shall be organized and displayed within children’s reach so that, if physically able, they can select and return items independently. (iv) Teaching aids that are small or that have small parts that can be inhaled or swallowed shall be inaccessible to infants and toddlers. 3. Outdoor Play Equipment (Optional) (i) All outdoor play equipment shall be sufficient in amount and variety so that children can take part in many kinds of play each day. (ii) The Consumer Products Safety Commission’s “Handbook on Public Playground Safety” or similar authority shall be used for guidance on playground construction and maintenance. (iii) All outdoor play equipment shall be placed to avoid injury. Fall zones shall extend at least four (4) feet and preferably six (6) feet away from the perimeter of equipment and away from retainer structures, fences, and other equipment and out of children’s traffic paths. (iv) Resilient surfacing material shall cover fall zones at a recognized acceptable depth. (See Appendix B) (v) Supports for climbers, swings, and other heavy equipment that could cause injury if toppled shall be securely anchored to the ground, even if the equipment is designed to be portable. (13) Environmental Services. (a) Environmental services shall be provided to assure the clean and sanitary condition of the PCCC and to provide a safe and hygienic environment for children and staff. Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and PCCC policy; and (b) There shall be verification of regular continuing education and competency for basic housekeeping principles. (c) Each facility shall have routine cleaning of articles and surfaces such as furniture, floors, walls, ceilings, supplies, exhaust, grills and lighting fixtures. (d) Sufficient and proper cleaning supplies and equipment shall be available to housekeeping staff. Cleaning supplies, toxic substances and equipment shall be STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 secured at all times to prevent access by children. Toxic substances shall not be left unattended when not secured. (e) A closet for janitorial supplies shall be provided. (f) Storage for bulk supplies and equipment shall be located away from child care areas. Storage shall not be allowed in the outmost shipping carton. (g) The building shall be kept in good repair, clean, sanitary and safe at all times. (14) Infection Control. A Prescribed Child Care Center shall have an annual influenza vaccination program which shall include at least: (a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Prescribed Child Care Center will encourage all staff and independent practitioners to obtain an influenza vaccination; (b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider); (c) Education of all employees about the following: 1. Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza; (d) An annual evaluation of the influenza vaccination program and reasons for non- participation; and (e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee. (15) Laundry Services. (a) Laundry services shall: 1. Provide space for storage of clean linen within nursing units and for bulk storage within clean areas of the PCCC; and 2. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination. (b) The PCCC shall name an individual who is responsible for laundry service. This individual shall be responsible for: 1. Establishing a laundry service, either within the PCCC or by contract, that provides the facility with sufficient clean, sanitary linen at all times; 2. Knowing and enforcing infection control rules and regulations for the laundry service; STANDARDS FOR PRESCRIBED CHILD CARE CENTERS CHAPTER 0720-15 3. Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules and procedures.