B – 001 Is it required that our mental health professional conduct observations in every classroom throughout the program year?

B – 002 Is there a requirement that Head Start accept children who are not potty trained?

B – 003 Head Start children are expected to receive both a dental exam and dental preventive care. Can the preventive care include just one of the following: dental cleaning or the application of fluoride or the application of sealants?

B – 004 Do the Head Start transportation regulations apply to providing transportation to enrolled children to and from dental appointments?

B – 005 Has a plan for Head Start grantees been developed should there be an outbreak of pandemic influenza? If a program has to shut down and home visits are not allowed, what kind of services can a local Head Start program provide? Would a program’s funding level change as a result of being shut down temporarily?

B – 006 What immunization requirements should be followed?

B – 007 If a child lives with and is supported solely by the child’s grandparents whose income is used to determine Head Start eligibility, under what circumstances can a Head Start program release the child to the grandparents and allow the grandparents to make health decisions for the child?

B – 008 Should a Head Start program remove a child from the program when, despite a mental health intervention, the child continues to display very aggressive behaviors toward other children and program staff?

B – 009 Is there a specific Head Start regulation that requires that the menus have to be reviewed and approved by a registered dietician or qualified child nutritionist?

B – 010 What is meant by the term "regular volunteer" as specified in the Head Start Program Performance Standard regarding tuberculin screening?

B – 011 Can children be on the bus for more than one hour when being transported to and from dental and medical services?

B – 012 How should a Head Start program cover the costs of providing health services to an enrolled child if the child’s family is not eligible for Medicaid/EPSDT?

B – 013 What is a program required to do when a child is under treatment for dental, medical or other health needs but is moving on to kindergarten?

B – 014 Are all Head Start and Early Head Start children required to receive a hemoglobin/hematocrit screening?

B – 015 Does having a Registered Nurse on our Health Services Advisory Committee meet the Head Start Program Performance Standards on staffing requirements for health services in Head Start and Early Head Start programs?

B – 016 What should Head Start programs do to ensure that staff have immediate access to rescue medications, such as an Epi-pen?

B – 017 Who is qualified to provide dental preventive services?

B – 018 When does the 45 day requirement for completing screenings begin?

B – 019 How often does the Health Services Advisory Committee need to meet in a program year?

B – 020 Does using infant cribs with solid plastic ends that are placed head to head in infant rooms meet the Head Start Program Performance Standards?

B – 021 Are Head Start programs required to provide free meals to assigned classroom staff and volunteers?

B – 022 How can a Head Start program meet the requirements of 1304.20(d) Ongoing care?

B – 023 Can a Head Start program begin to provide services to a child, including screenings at a Health Fair, before the program year begins?

B – 024 If a Head Start program enrolls (as part of its 10%) children from families who are not low-income and these families do not have medical insurance, how would the program pay for health services provided to these children?

B – 025 Does using a paper screening tool to assess a child’s vision and/or hearing within 45 days meet the requirements of the Head Start Program Performance Standards?

B – 026 Can Head Start program funds be used to cover a family’s health insurance co-payment, or deductible?

B – 027 Can a Head Start program’s selection criteria include a requirement that children be up-to-date on their immunizations and other health screenings (such as tuberculosis)?

B – 028 Can a child be denied entry into Head Start if they are not up to date on their physical or immunizations?

B – 029 If a Head Start child does not receive their physical examination within one year of their last physical (as required by Medicaid/EPSDT), can the child be expelled from Head Start?

B – 030 Can a child be temporarily excluded from attending Head Start classes until they show proof of an appointment for their annual medical or dental exam required by the State Medicaid\EPSDT periodicity schedule?

B – 031 Performance Standards 1304.23(b)(1)(i) require the use of the Child and Adult Care Food Program (CACFP) as the primary source for child meals. Can a Head Start program partner with and support funded enrollment in a child care provider who otherwise complies with Performance Standards but either does not qualify for or chooses not to participate in CACFP? Does the child care provider’s lack of participation in CACFP create a barrier for a Head Start child care partnership?

B – 032 What is the Office of Head Start's stance on having the children go outside everyday, even in weather that is really cold or hot?

B – 033 Can a Head Start program require that parents pay a portion of the total costs of any medical or dental treatment provided their Head Start child?

B – 034 How do I know which degree qualifies someone to serve as a mental health specialist for our Head Start program?

B – 035 If a child enrolled in a center-based program has been transported to the center on a school bus and needs to be taken home because of head lice or illness because the parent does not have transportation, can a van be used to transport that child home?

B – 036 Can a Head Start program temporarily exclude children with head lice?

B – 037 Is it necessary to send all children home and sanitize the center and bus if a child has head lice?

B – 038 If a child receives sensory screenings during a well child visit, is the Head Start program required to screen the child within 45 days of their entry into the Head Start program?

B – 039 What is a Head Start program’s responsibility if a parent provides documentation from the child’s most recent well child examination and there is no information about whether the child received sensory screenings during the visit?

B – 040 What are the requirements for lead screening for Head Start and Early Head Start children?

B – 041 I understand Head Start enrolls some preschool-age children who use diapers. What are the sanitation regulations for changing older children in diapers? Are there limits on the number of diapered children per classroom, and what is the teacher ratio per diapered children in an early childhood classroom setting?

B – 042 What type of documentation is required by Head Start in order to determine if a child is up to date on a schedule of well child care?

B – 043 What is the Head Start program’s responsibility if a child is due to have a physical or dental examination, as required by the state Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, 90 calendar days after the child‘s entry into the Head Start program?

B – 044 Are Head Start Programs required to accommodate a parent’s request that their child be served vegetarian meals while in Head Start?

B – 045 May the required parental consent for non-emergency intrusive physical examinations required by sec. 657A of the Head Start Act be obtained as part of a blanket permission at the time of the application for Head Start services?

B – 046 Are there any performance standards that address prohibiting a child that has behavioral and safety concerns from attending field trips?

B – 047 Why, for a child at or older than 12 months and at or younger than 24 months, are two blood lead tests required?

B – 048 What must Early Head Start and Head Start programs do to meet the requirements for screening of children for lead poisoning?

B – 049 Are Head Start Programs required to provide infant formula?

B – 050 May Head Start grant funds be used to pay for mental health services for parents of Head Start children?

B – 051  Some grantees are using mobile health (medical or dental) clinics. Do these mobile clinics meet the requirements of the Head Start Program Performance Standards?

Head Start regulations do not require that mental health professionals conduct classroom observations. The program must design and implement an approach that will engage the mental health professional in supporting "timely and effective identification of, and intervention in family and staff concerns about a child's mental health." (1304.24(a)(2)). There are often more effective ways to accomplish this than having the mental health professional observe all classrooms on a fixed schedule. Mental health professionals can work with teachers, child development specialists, home visitors, family service staff, and others as they use observations, screening results, and other systematic ways to identify and address children’s needs. While not required, it would be valuable for the mental health professional to observe and visit multiple classrooms and other settings in your program so that she understands your program’s design and is recognized by staff and families as an approachable team member who understands your program’s design and environment.

Requirement

45 CFR 1304.24(a)(2); 45 CFR 1304.24(a)(3)

May 15, 2007

Yes. A child’s need of toilet training cannot be the basis for denying enrollment to a child for whom Head Start is an appropriate placement. Since requiring that children be toilet-trained upon Head Start enrollment would prevent many children most in need of Head Start services from enrolling, programs should not deny enrollment to any child based on toileting skills.

Requirement

45 CFR 1305.6(a), (b), (d)

May 22, 2007

Preventive care may include a dental cleaning or fluoride application or the application of sealants. However, it may also be determined that a particular child needs more than one type of preventive care.

Requirement

45 CFR 1304.20(a)(1)(ii)(A)–(B); 1304 CFR 1304.20(c)(3)(i)–(ii)

June 12, 2007

No. Dental appointments are considered incidental trips and are not included under the definition of Transportation Services.

Requirement

45 CFR 1310.3

June 12, 2007

The Centers for Disease Control and Prevention is in the process of developing guidance for Child Care centers to follow in the event of an outbreak of pandemic influenza. This guidance is applicable to Head Start programs. When it is finalized, it will be available at the official pandemic flu web site: www.pandemicflu.gov.

Decisions about closing Head Start centers need to be made by local officials (state licensing, state and/or local health departments) and must be followed by Head Start programs.

If a Head Start program is shut down and/or home based services are prohibited, Head Start programs can provide support to families by making telephone calls and/or sending information to families through the mail.

If a Head Start program is shut down due to an outbreak of pandemic flu, decisions about the program’s funding level would be made on a case by case basis reflecting the particular circumstances of each grantee and the period of time the program will remain closed.

Informal Guidance

June 12, 2007

Children in Head Start and Early Head Start programs must be immunized according to their State Medicaid EPSDT schedule for immunizations, not according to each child’s doctor’s recommendations. In many instances, State Medicaid EPSDT immunization requirements are the same as the recommendations for childhood immunizations outlined by the Centers for Disease Control and Prevention (CDC). For Head Start programs located in a state where state Medicaid EPSDT requirements differ from the CDC recommendations, the program’s Health Services Advisory Committee may, in accordance with 1304.20(a)(1)(ii), require children receive the additional immunizations as recommended by the CDC.

Each state determines the guidelines for exemptions from immunizations due to medical, religious or other reasons. If a child in Head Start has a medical exemption that meets all the requirements of the State immunization exemption guidelines, they do not need to be immunized according to the State immunization schedule.

Requirement

45 CFR 1304.20(a)(1)(ii)

June 12, 2007

There are many low-income children in this country who are being raised by their grandparent(s). In these situations it is important for a Head Start program to gather as much information as it can in making a decision about enrolling a child. Programs should speak to the child’s grandparent(s) and gather as much information as possible about the child and the specific circumstances that resulted in the child being with his/her grandparent(s). Programs should determine whether they believe the current arrangement will be temporary or is likely to be long term. Programs also need to determine if a conversation with the child’s parents would be both possible and beneficial. If the program determines that the child is, for all intents and purposes, being raised by the child’s grandparent(s) the Head Start program should consider the income of the grandparent(s) when determining income eligibility. All of the information relevant to this process should be included in the child’s folder.

If a Head Start program enrolls a child who is living with the child’s grandparent(s) who has not been designated as the child’s guardian(s), the Head Start program must help that family work with child welfare and other social service agencies to determine the best course of action for that family. Head Start programs that conclude the child is, for all intents and purposes, being raised by the child’s grandparents may release the child to the grandparents and allow the grandparents to make decisions about the health services for the child.

Informal Guidance

June 12, 2007

Programs should not withdraw services from a child with persistent aggressive behaviors. The child’s difficulties are unlikely to be resolved without intervention, and dismissing the child from Head Start reduces the likelihood he will receive such services. Determining appropriate intervention for this child requires formal evaluation of his or her needs, including classroom observations by the mental health professional. Evaluation results should address preventive strategies and outline the teacher supports and guidance needed to enable the child to learn and display more appropriate classroom behavior. This may require ongoing consultation with mental health and/or special education service providers. For some children, implementing such approaches may require that a classroom aide be assigned to work more closely with the child.

In unusual circumstances, when, despite the provision of a well-managed classroom, supplemented by well-implemented behavioral and mental health interventions, a child’s aggressive behavior presents a significant threat to his safety or the safety of others, a program may have to consider alternative means of serving this child and family. This might include temporarily providing child development services through home-visiting as the program works with the special education and mental health service providers to identify more intensive services and behavioral supports that could enable the child to re-enter and participate successfully in the Head Start classroom. Efforts to acquire needed services for the child should be carefully documented, and done in partnership with the family. In exceptional cases, when recommended by mental health professionals serving the child, transitioning to a more intensive program than Head Start may be necessary. The program must work closely with the family to support this transition. Once the transition is completed the child may be removed from the enrollment list.

Informal Guidance

June 19, 2007

No, there is no specific regulation that requires menus be reviewed and approved by a registered dietician or qualified child nutritionist. However, 1304.23(b)(1) requires that "grantee and delegate agencies must design and implement a nutrition program that meets the nutritional needs and feeding requirements of each child, including those with special dietary needs and children with disabilities. Also, the nutrition program must serve a variety of foods which consider cultural and ethnic preferences and which broaden the child’s food experience." Further, 1304.52(d)(3) specifies that "Nutrition services must be supported by staff or consultants who are registered dieticians or nutritionists."

One way for a grantee to meet this requirement is to have a registered dietician or qualified child nutritionist regularly review menus and modify them, if necessary, in order to meet the individual nutritional needs of children in the program. Another way is to establish partnerships with community agencies with expertise in this area to assist the program to meet this requirement, such as WIC. The Health Services Advisory Committee can also play a role in making referrals to providers that can assist the program in meeting the requirement as well.

Requirement

45 CFR 1304.23(b)(1); 45 CFR 1304.52(d)(3)

June 19, 2007

If State, Tribal or local law does not include a definition for "regular volunteers", the Head Start program is expected to establish policy or procedures covering "regular volunteer" requirements locally. 45 CFR 1304.52(j)(2) requires that "regular volunteers must be screened for tuberculosis in accordance with State, Tribal, or local laws. In the absence of State, Tribal or local law, the Health Services Advisory Committee must be consulted regarding the need for such screenings". 45 CFR 1304.3(a)(20) defines a volunteer as "an unpaid person who is trained to assist in implementing ongoing program activities on a regular basis under the supervision of a staff person…"

Requirement

45 CFR 1304.52(j)(2); 45 CFR 1304.3(a)(20)

June 19, 2007

Yes. Dental and medical services are considered incidental trips. Incidental trips such as might be required to transport small groups of children to and from necessary services are excluded under the definition of Transportation Services (45 CFR 1310.3). However, programs are encouraged to use the safest mode of transportation available; i.e. school buses or allowable alternate vehicles, whenever children are in transport. Programs should make every attempt to minimize time spent in transit for children.

Requirement

45 CFR 1310.3

June 26, 2007

The vast majority of Head Start families will be eligible for Medicaid/EPSDT, CHIP or some other publicly supported health care system. If a Head Start program enrolls a child whose family is not eligible for any such system, the Head Start program should seek to have services provided to the child by the program’s local health care providers at no or reduced costs. However, if all other funding sources have been exhausted, a grantee should cover any costs related to a child’s health care by using Head Start grant funds.

Requirement

45 CFR 1304.20(c)(5)

July 3, 2007

In accordance with Section 642A of the Head Start Act and 45 CFR 1304.40(h), all Head Start programs are required to take steps to coordinate with their local schools and involve Head Start parents and staff in planning and implementing the transition of Head Start children to kindergarten. Programs should provide parents and staff with the education and training necessary to ensure that they have the necessary knowledge and skills to advocate for their children by participating effectively in transition activities with the school. Transition activities include promoting the continued involvement of parents in obtaining the treatment that their child needs for their healthy development. To accomplish transition goals, Head Start programs should develop on-going channels of communication, including face-to-face meetings that enable parents and Head Start staff to discuss the child’s ongoing needs, including health needs, with kindergarten teachers and other appropriate staff. With parental consent, the Head Start program should also transfer copies of appropriate health records to the kindergarten.

Requirement

42 U.S.C. 9837A; 45 CFR 1304.40(h)

July 3, 2007

The requirements for all screenings, including hematocrit and hemoglobin, are determined by each State’s Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.

Requirement

45 CFR 1304.20(a)(1)(ii)

July 3, 2007

No. CFR 1304.52(d)(2) requires that health services in a Head Start program be supported by staff or consultants with training and experience in public health, nursing, health education, or health administration. Members of the Health Services Advisory Committee are not considered to be Head Start staff or consultants.

Requirement

45 CFR 1304.52(d)(2)

July 3, 2007

Rescue medications do not need to be locked up, however, they must be kept out of children’s reach and be accessible to staff at all times, including when children are on the bus, playground or on a field trip. Any staff person administering rescue medications, whether in the classroom, on the bus, on the playground, or on field trips, must be trained in the administration of such medications.

Informal Guidance

July 3, 2007

Each State determines those qualifications necessary for the provision of preventive dental services. Programs should consult with their State Health Agency to determine the requirements in their State.

Requirement

45 CFR 1304.20(a)(1)(iii)

July 3, 2007

In accordance with 45 CFR 1304.20(b), Head Start programs, in collaboration with parents, are required to begin completing screenings within 45 days of the child’s entry into the program. Entry into the program is defined as the first day the child enters the Head Start classroom, or begins to participate in a home based or family child care program.

Requirement

45 CFR 1304.20(b)

July 13, 2007

The Head Start Program Performance Standards do not specify how often the committee meets. Although this is a local program decision, OHS expects Health Advisory Committees to meet as frequently as necessary to carry out their responsibilities during the year See 1304.20(a)(1)(ii); 1304.23(a)(4); and 1304.52(j)(2).

Informal Guidance

July 13, 2007

No. CFR 1304.22(e)(7) requires cribs and cots be placed at least three feet apart to avoid spreading contagious illness AND to allow easy access to each child. Cribs spaced less than three feet apart pose a safety hazard in the event the center must be evacuated during an emergency. Staff need immediate access to the children in emergency situations.

Requirement

45 CFR 1304.22(e)(7)

July 13, 2007

Yes. Since the Head Start Program Performance Standard 1304.23(c)(4) requires assigned classroom staff and volunteers to eat together with children, family style, programs must pay for their meals.

Informal Guidance

July 13, 2007

Young children’s development occurs rapidly, making it necessary for Head Start staff to record observations of changes in children’s health and development on an ongoing basis. If this is not done, children are at risk because health and developmental concerns that can adversely impact the child’s ability to learn will not be detected in a timely manner.

Head Start programs must develop and implement procedures for ongoing care in order to ensure that children remain healthy and ready to learn. The procedures should clearly identify staff responsible for observing, communicating and recording information about any concerns regarding each child’s ongoing health and development. Parents have a very important role in ongoing care and must be trained and integrally involved in all aspects of the process. Programs should ensure that staff and parents are trained in how to observe children for signs and symptoms of disease and illness or changes in emotional or behavioral patterns. Training should also include use of observation tools, and the protocols for communication (including recording as appropriate). There should also be a process for reviewing information recorded on each child and for making decisions regarding referrals for further evaluation and treatment as needed. There are a number of ways that a program can demonstrate compliance with ongoing care requirements, including: recording information about individual children’s developmental progress, changes in physical appearance, and changes in emotional and behavioral patterns in health records and/or children’s classroom files; agency policies and procedures; minutes from staff meetings and case conferences; notes from home visits and meetings with parents; observation forms; and staff training and parent workshop materials. Most programs help address the requirement for "ongoing care" through multiple methods, including a system for ongoing assessment of child progress.

Requirement

45 CFR 1304.20(d)

July 13, 2007

Yes, once a child has been enrolled into the program, the program can provide services to a child. This could include screenings or immunizations at a Health Fair, an initial home visit by Head Start staff, or other pre-entry services.

Informal Guidance

July 13, 2007

Head Start programs must seek all alternative sources of funding for the costs to provide enrolled children health services. Such sources could include Medicaid/EPSDT, CHIP or services provided by your community doctor at no or reduced cost to your program. However, when a program is unable to find alternative funding sources to cover the costs of all required health services, the program should use Head Start grant funds to cover these costs. This should be made clear in your annual budget submission or, as appropriate, in your budget revision request.

Informal Guidance

July 19, 2007

No. The Head Start Program Performance Standards (45 CFR 1304.20(b)) require programs to perform or obtain screening procedures to identify developmental, sensory (visual or auditory), behavioral, motor, language, social, cognitive, perceptual, and emotional skills. A sensory screening tool must be used to identify potential vision or hearing concerns. Paper screening tools used to assess a child’s development are not considered sensory screening tools.

Requirement

45 CFR 1304.20(b); 1308.6(b)(3)

July 31, 2007

Yes, Head Start funds may be used to cover the costs of professional medical and dental services, including health insurance co-payment or deductible, for Head Start children but only when no other source of funding is available.

Requirement

45 CFR 1304.20(c)(5)

July 31, 2007

No, a child’s immunization or screening status is not to be used as selection criteria unless there are state or local requirements which preclude enrolling children who have not received all required screening or immunizations.

Requirement

45 CFR 1305.6(b)

July 31, 2007

No, there is no Head Start Program Performance Standard that requires a child be up-to-date on their physical or immunizations prior to entering the Head Start program. However, some states prohibit a child from entering a child care center until they have a physical and/or meet State immunization requirements and in these situations a program would have no choice but to not enroll the child until the child had received all required health services.

Requirement

45 CFR 1304.22(b)

July 31, 2007

No, a program should not disenroll any child because the child has not had a recent physical examination. Rather, as required by 45 CFR 1304.20(a)(1)(ii)(A), the program should assist the parents of any such child to bring their children up-to-date on a schedule of well child care as determined by the State Medicaid\EPSDT program.

Requirement

45 CFR 1304.20(a)(1)(ii)(A)

July 31, 2007

No. Head Start children can not be temporarily excluded from attending classes because they are not up-to-date on a schedule of well child care, including annual medical or dental exams. See 45 CFR 1304.22(b). However, if a state prohibits a child from entering a child care center until they have an annual medical or dental exam, in these situations a program would have no choice but to not allow the child to attend classes until the child had received the required examination(s).

Requirement

45 CFR 1304.22(b)

July 31, 2007

Head Start has long expected grantees to first use other sources of funding for which the grantee or the individual family is eligible before using Head Start funding so as to maximize the number of children who can receive Head Start services. Grantees who propose to enter into partnerships with providers which either choose not to or are ineligible to participate in CACFP, need to engage their Regional Office in writing as to why they believe that such an arrangement should be approved. Decisions will be made on a case by case basis. Grantees should retain documentation of their request to the Regional Office and the Regional Office’s response.

Requirement

45 CFR 1304.23(b)(1)(i)

August 8, 2007

The Head Start Program Performance Standard (1304.21(a)(5)(i)) requires that grantees provide "sufficient time, indoor and outdoor space, equipment, materials and adult guidance... [to] support the development of gross motor skills". There is not sufficient space in most classrooms for the types of equipment, materials and experiences that children need in the area of gross motor development and, therefore, most programs will need to take their children outdoors regularly. The decision about how frequently and for how long children play outside and the decision about whether on certain days children should stay indoors is one local programs need to make. Grantees are encouraged to establish policies on extreme heat and cold thresholds and on such health risks as lightning or poor air quality. Grantees should consider that some children; i.e. an asthmatic child, may have different needs in terms of, for example, air quality than other children in the program and individual children’s needs should be appropriately addressed.

Informal Guidance

August 8, 2007

No. Programs may not charge parents any fees for services provided under the authority of their Head Start grant.

Requirement

45 CFR 1305.9

August 8, 2007

The Head Start Program Performance Standards (45 CFR 1304.52(d)(4)) require that mental health services be supported by staff or consultants who are licensed or certified mental health professionals with experience and expertise in serving young children and their families. The standards do not address specific educational degrees required of these professionals. Your program must ensure that mental health professionals are licensed or certified to provide the mental health services you are asking them to deliver in your program. Each state has licensure/certification systems that review a professional’s training and experience and describe the scope of services a professional is qualified to provide to children and families in that state.

Informal Guidance

August 21, 2007

Yes. Under the definition of transportation services, this would be considered incidental transportation. Programs should take care to be certain all applicable federal, state and local safety laws are followed, including those related to the use of child safety restraint systems.

Informal Guidance

September 26, 2007

Yes. 45 CFR 1304.22(b) states: "Grantee and delegate agencies must temporarily exclude children with a short term injury or an acute or short-term contagious illness that cannot be readily accommodated from program participation in center-based activities for group experiences, but only for that generally short term period when keeping the child in care poses a significant risk to the health or safety of the child or in anyone in contact with the child." Head Start programs should refer to their state licensing laws or local health or education department regulations regarding specific illnesses that require exclusion.

A local program’s Health Services Advisory Committee can provide guidance to programs on how to access existing state and/or local laws on this topic, as well as developing local policies in accordance with state or local laws.

Requirement

45 CFR 1304.22(b)

November 20, 2007

No. This is not a Head Start Performance Standards requirement. Head Start programs should consult with their Health Services Advisory Committee (HSAC) to assist them in developing and implementing program policies on this issue that are in accordance with state and local laws. The HSAC can also assist programs in developing procedures for the daily sanitation of Head Start centers and equipment.

Informal Guidance

November 20, 2007

45 CFR 1304.20(b) requires Head Start grantee and delegate agencies to perform or obtain linguistically and age appropriate screening procedures to identify concerns regarding a child’s developmental, sensory (visual and auditory), behavioral, motor, language, social, cognitive, perceptual, and emotional skills within 45 days of entry into the program. If a parent provides the Head Start program with documentation that a linguistically and age appropriate sensory screening took place during the well child visit, it is not necessary to repeat this screening within 45 days of the child’s entry into the program.

Head Start programs should consider, however, that the population they serve is considered to be high risk, and that it may be more efficient and effective for them to provide for the uniform screening of all children’s hearing and vision using objective screening instruments. Programs may consult with their Health Services Advisory Committee for assistance in identifying linguistically and age appropriate objective screening instruments that would be most appropriate for use in their program, given the children they are serving.

Requirement

45 CFR 1304.20(b)

November 20, 2007

45 CFR 1304.20(a)(ii)(A) requires Head Start programs to assist the parent in bringing their child up-to-date on a schedule of well child care according to the state Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. If there is no evidence that the child received sensory screenings during the well child visit, the program must work with the parent to obtain the necessary documentation from their child’s health care provider. In some instances, the Head Start program and the parent may call the provider’s office to see if there is additional documentation that can be sent showing the child received sensory screenings. If it is determined that the screenings did not take place, the Head Start program may decide it is more efficient for them to provide the sensory screenings at the Head Start program rather than sending the child back to the health care provider’s office. The program’s Health Services Advisory Committee may assist the program in developing program policies on screening Head Start children. The Head Start program may also meet with local health care providers to explain to them the Head Start Program Performance Standards requirements and the state EPSDT requirements for well child care in their state.

Requirement

45 CFR 1304.20(a)(ii)(A)

November 20, 2007

The Head Start Program Performance Standard 45 CFR 1304.20(a)(1)(ii) requires a determination of whether a child is up-to-date on a schedule of age appropriate preventive and primary health care. This schedule must incorporate the requirements for well child care utilized by the State’s Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. The EPSDT Program of the Centers for Medicare and Medicaid Services (CMS) requires a screening blood lead test be performed to determine the blood lead level for all Medicaid eligible children at 12 and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. At this time, States may not adopt a statewide plan for screening children for lead poisoning that does not require lead screening for all Medicaid-eligible children. State Medicaid programs (and therefore Head Start programs) must comply with this requirement. A “risk assessment” (i.e. a paper and pencil questionnaire or parent interview) does not meet this requirement. A local program’s Health Services Advisory Committee can not determine whether or not a child should receive a lead screening.

If a parent can not provide written documentation from their child’s medical provider that their child received a screening blood lead test at ages 12 months and at 24 months, it is a CMS requirement that the child receive a screening blood lead test between the ages of 36 and 72 months. Head Start programs must work in partnership with parents to make sure every enrolled child receives this screening.

If a child’s provider will not perform this screening, the Head Start program is required to assist the family in seeking this screening from other sources within the community in accordance with 45 CFR 1304.20(a)(1)(ii)(A). If there are no other sources in the community that can provide this service, then Head Start can provide it. If a Head Start program provides this screening, they must comply with the Head Start Program Performance Standards requirement 45 CFR 1304.52(d)(2) that health procedures be performed only by a licensed certified health professional.

Requirement

45 CFR 1304.20(a)(1)(ii); 45 CFR 1304.20(a)(1)(ii)(A); 45 CFR 1304.52(d)(2)

November 20, 2007

The Head Start Program Performance Standards (45 CFR 1304.22(e)(5) require agencies to adopt sanitation and hygiene procedures for diapering; these procedures should be appropriate for the children served. The performance standards do not outline adult-to-child ratio requirements that apply when preschool children in classrooms require special assistance with toileting, including diapering. Programs must design and implement an approach that ensures staff have the time and training needed to conduct diapering properly. If the level of toileting/diapering assistance required significantly impacts the adult supervision needed in the classroom, then adaptations in staffing assignments may be a necessary modification. (Programs must also determine whether any child care regulations in their additional requirements may apply based upon child care regulations in their state.)

45 CFR 1304.22(e)(5)--Grantee and delegate agencies must adopt sanitation and hygiene procedures for diapering that adequately protect the health and safety of children served by the program and staff. Grantee and delegate agencies must ensure that staff properly conducts these procedures.

45 CFR 1308.4(c) The plan must include provisions for children with disabilities to be included in the full range of activities and services normally provided to all Head Start children and provisions for any modifications necessary to meet the special needs of the children with disabilities.

Requirement

45 CFR 1304.22(e)(5); 45 CFR 1308.4(c)

December 13, 2007

45 CFR 1304.51(g) requires Head Start programs to establish and maintain efficient and effective record-keeping systems to provide accurate and timely information regarding children, families and staff. In order to document that a child is up to date on a schedule of well child care and to comply with the requirement that they establish and maintain efficient and effective record keeping systems, Head Start programs must keep written documentation about each child’s health status. This documentation should be from the child’s health care provider. Parental reports regarding examinations or treatment is not considered to be efficient and effective record keeping.

Requirement

45 CFR 1304.51(g)

December 13, 2007

45 CFR 1304.20(a)(1)(ii)(A) requires that Head Start programs work in partnership with the parent to ensure that the child continues to follow the recommended schedule for well child care as outlined by the state Medicaid EPSDT program. Head Start programs can develop systems that ensure regular communication between staff and parents occurs so that parents are aware of the need to keep their child up-to-date and that parents can inform staff about support services they may need, such as transportation, child care, etc., in order to keep medical and/or dental appointments.

Requirement

45 CFR 1304.20(a)(1)(ii)(A)

December 13, 2007

Yes. 45 CFR 1304.23(a)(2) requires Head Start programs to collect information about family eating patterns when designing a nutritional program that meets the needs and feeding requirements of each child [45 CFR 1304.23(b)(1)].

Requirement

45 CFR 1304.23(a)(2); 45 CFR 1304.23(b)(1)

January 7, 2008

No. While section 657A of the Act does not specify the timing or manner of the required permission other than by specifying that parental permission must be in writing and that it be secured “before administration of any nonemergency intrusive physical examination,” the fact that the statute establishes a entirely new section of the Head Start Act to address nonemergency intrusive physical examinations indicates the statutory requirement is intended to facilitate parents’ thoughtful, individualized decision making regarding nonemergency intrusive physical examinations separate and apart from decision making regarding other program services. Therefore, written parental permission must be obtained before any nonemergency intrusive physical exam and such permission must be obtained immediately preceding any proposed covered physical examination or as proximate to the proposed exam as possible. Whenever written permission is sought and obtained, the written permission maintained by the Head Start agency should clearly and plainly describe the “nonemergency intrusive physical examination” for which permission is sought and indicate the parent’s express permission, including any limitations.

Informal Guidance

Section 657A of the Head Start Act

February 6, 2008

There are no performance standards prohibiting children who present behavioral and safety concerns from attending a field trip. If a child has recognized difficulties with social behavior, your mental health professional (and special education partner if this is a child with an identified disability) should be working with you to identify and implement the appropriate modifications and supports that can enable this child to participate in the full range of program activities, including field trips. When appropriate, programs may also consider adding more adults to assist during the field trip.

Informal Guidance

July 15, 2008

A child's risk of exposure to sources of lead in the environment is in part determined by that child's advancing motor skills. As the child progresses from crawling to standing to walking, or from reaching to climbing, the child’s ability to gain access to potential sources of lead (such as peeling paint chips on a window sill) increases. For this reason, during the critical period of rapid motor development between 12 and 24 months of age, two blood lead tests are required. In most countries, including the United States, blood lead levels peak at around 2 years of age.

The purpose of screening for lead poisoning by blood lead testing at 12 and 24 months is to determine:

• Whether there has been a lead exposure by the age of 12 months, and;
• Whether there is an elevated blood lead level at 24 months of age.

Supplemental references:

CDC Lead Poisoning Prevention Program
http://www.cdc.gov/nceh/lead/

"Preventing Lead Poisoning in Young Children – A Statement by the Centers for Disease Control and Prevention August 2005"
http://www.cdc.gov/nceh/lead/Publications/PrevLeadPoisoning.pdf

American Academy of Pediatrics Policy Statement
"Lead Exposure in Children: Prevention, Detection, and Management"

Committee on Environmental Health
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1036

Informal Guidance

December 18, 2008

In March, 2008, the Office of Head Start issued an Information Memorandum, ACF-IM-HS-08-07, describing the lead poisoning screening requirement within the Head Start Program Performance Standards (HSPPS). The HSPPS lead poisoning screening requirement references the requirements of the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT) schedule of the Centers for Medicare and Medicaid Services (CMS), which are as follows:

“Lead Toxicity Screening - All children are considered at risk and must be screened for lead poisoning. CMS requires that all children receive a screening blood lead test at 12 months and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test must be used when screening Medicaid-eligible children. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (fingerstick) must be confirmed using a venous blood sample.”
(From: http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.)

In order for programs to meet and comply with Head Start Program Performance Standards, programs must ensure that all children are screened for lead poisoning by blood lead testing as described above. The standard applies to all Early Head Start and Head Start enrolled children, not only to Medicaid-eligible children.

For purposes of clarity, the requirements for blood lead testing may be best understood by describing separately the requirements for Early Head Start and Head Start programs.

The requirements for an Early Head Start enrolled child are:

• For a child enrolled before the age of 12 months, the program must obtain documentation that a blood lead test was done when the child reached the ages of 12 and 24 months;
• If there is no documentation that a blood lead test was performed at 12 months for a child enrolled between 12 and 24 months of age, a blood lead test must be performed as soon as possible. A second blood lead test will be required to be performed for the child at 24 months of age;
• The program is required to obtain documentation that a blood lead test was performed at 24 months of age or soon thereafter for a child enrolled at age 24 months or older.

The requirement for a Head Start enrolled child is:

• The program must obtain documentation that a blood lead test was performed at 24 months. If a blood lead test was not performed at 24 months, the program must obtain documentation that it was performed soon thereafter.

Head Start programs must work in partnership with parents to make sure that every enrolled child receives this screening. The standard applies to all Early Head Start and Head Start enrolled children.

For the child who does not have documentation of blood lead testing that meets the CMS/EPSDT requirements, the program must assist the parents to obtain the required blood lead testing as soon as possible.

The best possible resource to obtain or perform blood lead testing is the child’s clinical provider/medical home. This assures that other potentially relevant health circumstances that may increase a child’s susceptibility to lead poisoning risk are recognized, and that the results of blood lead testing are incorporated into the child’s primary care health record and ongoing plan of care. In circumstances where the primary care provider will not perform blood lead testing, local health departments and other community resources (such as clinics and other public health programs) may be utilized.

Requirement

45 CFR 1304.20(a)(1)(ii)(A)

December 18, 2008

Yes. For infants and toddlers, formula may be the sole or main source of nutrition. Early Head Start grantee and delegate agencies are required to provide a nutrition program for infants and toddlers that meets their nutritional needs and feeding requirements. Grantee and delegate agencies may not require families to provide the food that the child consumes within the program including formula for infants and toddlers, or for children with special dietary needs or disabilities.

Grantee and delegate agencies must work with families to identify each child’s nutritional needs, special dietary requirements, food intolerances and preferences. This information must be used in providing nutritional services that include the purchase of formula designed to accommodate a child’s special dietary requirement, formula intolerance, or preference. For infants and toddlers, this may also include the current feeding schedule, whether breast milk, formula, or baby food is used, and the amounts and types of food provided.

Does USDA reimbursement include infant meals?

Yes. The United States Department of Agriculture (USDA) Child Nutrition Programs reimburse Early Head Start and Migrant and Seasonal Head Start programs for the costs of serving nutritious meals, including breast milk, formula, and baby food (such as infant cereal, strained baby food, and finger foods) to infants

This is described in 7 CFR PART 226—CHILD AND ADULT CARE FOOD PROGRAM 226.20 (b):

"(b) What are the requirements for the infant meal pattern?

(1) Feeding meals to infants.
Meals served to infants ages birth through 11 months must meet the requirements described in paragraph (b)(6) of this section. Foods included in the infant meal must be of a texture and a consistency that are appropriate for the age of the infant being served. The foods must be served during a span of time consistent with the infant’s eating habits. For those infants whose dietary needs are more individualized, exceptions to the meal pattern must be made in accordance with the requirements found in paragraph (h) of this section.

(2) Breastmilk and iron-fortified formula.
Either breastmilk or iron-fortified infant formula, or portions of both, must be served for the entire first year. Meals containing breastmilk and meals containing iron-fortified infant formula supplied by the facility are eligible for reimbursement. However, infant formula provided by a parent (or guardian) and breastmilk fed directly by the infant’s mother, during a visit to the facility, contribute to a reimbursable meal only when the facility supplies at least one component of the infant’s meal."

Please refer to 7 CFR 226.20 (b) and (h) for additional information.

Where can a Head Start program find a list of infant formulas that can be offered to infants in the child nutrition programs that do not require medical statements to be obtained?

The USDA maintains a current list of infant formulas that do not require medical statements on their web site at www.usda.gov.

When must a Head Start program have a medical statement on file for an infant formula to be part of a reimbursable meal?

The Head Start program must determine whether the formula is listed as an FDA Exempt Infant Formula. An exempt formula is labeled for use by infants who have inborn errors of metabolism or low birth weight, or who otherwise have unusual medical or dietary problems (21 CFR 107.3). Formulas classified as Exempt Infant Formulas by FDA require a medical statement in order to be served to infants under the CACFP as part of a reimbursable meal. A medical statement must be signed by a licensed physician or a recognized medical authority specified by the State agency if an infant is considered disabled according to USDA’s regulation or if an infant has medical or other special dietary needs. To check whether or not an infant formula is an FDA Exempt Infant Formula, visit FDA’s website at http://www.cfsan.fda.gov/~dms/inf-exmp.html.

Requirement

45 CFR 1304.23; 7 CFR 226

March 20, 2009

Yes, in some instances. When Head Start program staff, in the course of their work with families, identify possible mental health concerns for a parent they should first follow their program’s procedures for consulting with their program’s mental health professional on how to work with the family to access community resources that address the concerns identified. Typically, a program should be able to support the parent in accessing these services at no cost to the program.

However, while not required to do so by the Head Start Program Performance Standards, programs may, in exceptional circumstances use Head Start funds, if available, to provide time-limited, specific support for services addressing the immediate mental health needs of the parent of an enrolled child.

An example would be when the program’s mental health professional advises that a parent in crisis needs emergency mental health services that cannot be obtained from community resources in a timely manner and that waiting for community services to become available would significantly interfere with the enrolled child’s ability to benefit from the program. Following this consultation with the program’s mental health professional, and with the review and approval of the Head Start/Early Head Start director of the expenditure, the program may use Head Start funds to acquire specific, time-limited services designed to address the immediate need. Early Head Start programs may also secure such mental health services for enrolled pregnant women. If, following a brief period of mental health assessment and intervention supported by Head Start funds, the parent requires further mental health support or intervention, the program should work with the parent and with the program’s mental health professional to identify appropriate mental health services in their community that a family could receive at no cost to the program.

Programs that expend Head Start funds to support a parent of an enrolled child or an enrolled pregnant woman should document the relevant circumstances, the process that was followed, and the rationale for the decisions that were made.

Informal Guidance

April 15, 2009

45 CFR 1304.20(a)(1)(i) requires that "grantee and delegate agencies must: make a determination as to whether or not each child has an ongoing source of continuous, accessible health care. If a child does not have a source of ongoing health care, grantee and delegate agencies must assist the parents in accessing a source of care." It is up to each grantee to determine whether or not any particular mobile clinic is providing services in a manner that could reasonably be described as providing an ongoing source of continuous, accessible care to Head Start children and families. 

It should also be noted that there are additional requirements in 1304.20 that mandate programs obtain from a health care professional a determination of a Head Start child’s health status and "for children who are not up-to-date on an age-appropriate schedule of well child care, grantee and delegate agencies must assist parents in making the necessary arrangements to bring the child up-to-date." Even if a particular mobile health clinic is not an ongoing source of continuous, accessible care, the mobile clinic could provide a Head Start child with those medical and dental services necessary to bring that child “up-to-date.” In that case, the program must continue to assist parents in accessing an “ongoing source of continuous, accessible care.”

Each agency may wish to consult with its Health Services Advisory Committee in making a determination of the appropriateness of using mobile clinics.

Informal Guidance

July 27, 2009