OCFS-LDSS-7020
OCFS-LDSS-7020 (Rev. 5/2010)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
HEALTH CARE PLAN (Day Care Center)
|PROVIDER/PROGRAM NAME: |REQUIRED |
| |REQUIRED |
| |REQUIRED |
|FACILITY ID NUMBER: | | |
|Date Health Care Plan submitted to the | | |
|Office of Children and Family Services | | |
|(OCFS): | | |
|REVISIONS | |
|Use this section to record the date and page number(s) of any revisions made to the original health care plan. When a revision (change, | |
|addition or deletion) is made to the original health care plan, record the date the change was made and then write the page numbers of any | |
|pages affected by the change. | |
|DATE OF REVISION |PAGE(S) | |
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|Health Care Consultant Review of Health Care Plan | |
|For programs offering care for infants and toddlers, mildly or moderately ill children, and/or administration of medication, the program’s | |
|health care consultant (HCC) must visit the program at least once during each licensing period. This visit will include: | |
|a review of the health care policies and procedures; | |
|a review of documentation and practice; and | |
|an evaluation of the program’s ongoing compliance with the health care plan (HCP) and policies. | |
|HCP review date |HCC Signature | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Sections 13-21 should be completed ONLY if the program plans to administer medication. |COMPLETE |
| |THIS |
|Section 13: For Programs that WILL Administer Medication |SECTION IF|
| |THE |
|The program will administer prescription and non-prescription medication by all routes covered in the MAT course (oral, topical, eye, ear, |PROGRAM |
|and inhaled, medications, medicated patches and epinephrine via an auto-injector device. |WILL |
| |ADMINISTER|
|The program will administer medication in accordance with the OCFS child day care regulations pertaining to the administration of |MEDICATION|
|medication in a child care setting. Only a provider who has completed the appropriate training or has appropriate licensure and is listed | |
|as a medication administrant in this health care plan will be permitted to administer medication in the program, with the exception of | |
|over-the-counter topical ointments, sunscreen and topically applied insect repellant. | |
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|Section 14. Authorized Staff to Administer Medication | |
|Section 14 must be completed if the program plans to administer medication. | |
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|Any individual listed in this section as a medication administrant is approved to administer medication using the following routes: | |
|topical, oral, inhaled, eye, ear, medicated patches and epinephrine using an auto-injector device. | |
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|If a child in the program requires medication rectally, vaginally, by injection or by another route not listed above, the regulatory | |
|requirements and the procedures outlined for children with special health care needs will be followed. | |
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|To be approved to administer medication, other than over-the-counter topical ointments, sunscreen and topically applied insect repellant, | |
|all individuals listed in the health care plan must have a valid: | |
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|Medication Administration Training (MAT) certificate | |
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|CPR certificate which covers all ages of children the program is approved to care for as listed on the program’s license | |
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|First aid certificate which covers all ages of children the program is approved to care for as listed on the program’s license | |
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|OR | |
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|exemption from the training requirements as per regulation | |
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|The individuals listed in the program’s health care plan as medication administrant(s) may only administer medication when the medication | |
|labels, inserts, instructions and all related materials are written in the language(s) indicated on the MAT certificate. All medication | |
|administrant(s) will check the Five Rights (medication, time, dose, route and child) in accordance with best practice standards whenever | |
|administering medication. | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Medication Administrant(s) |COMPLETE |
| |THIS |
|Facility ID number: |SECTION IF|
| |THE |
| |PROGRAM |
|If this form is submitted to OCFS separate from the health care plan, indicate date of submission: |WILL |
| |ADMINISTER|
| |MEDICATION|
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|This form can be sent in separately to OCFS if the program’s health care plan has already been approved and the only change to the plan is | |
|the addition or removal of a medication administrant or an update to information for a current medication administrant. Any medication | |
|administrant addition, removal or change must be approved by the program’s health care consultant and OCFS. | |
| | |
|All staff listed as medication administrant, will have first aid and CPR certificates that cover the ages of the children in care and are | |
|at least 18 years of age. Documentation of age-appropriate first aid and CPR certificates will be kept on site and is available upon | |
|request. | |
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|(Check one) ADD to list CHANGE information REMOVE from list | |
|Provider Name: | |
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|MAT certification language(s): | |
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|MAT certificate expiration date: | |
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|Health Care Consultant signature indicates approval of individual (verification of age, MAT certificate, first aid and CPR certificates): | |
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|Date: | |
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|Additional Staff information (as applicable): | |
|(Check one) ADD to list CHANGE information REMOVE from list | |
|Provider Name: | |
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|MAT certification language(s): | |
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|MAT certificate expiration date: | |
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|Health Care Consultant signature indicates approval of individual (verification of age, MAT certificate, first aid and CPR certificates): | |
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|Date: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Additional Staff information (as applicable): |COMPLETE |
|(Check one) ADD to list CHANGE information REMOVE from list |THIS |
|Provider Name: |SECTION IF|
| |THE |
|MAT certification language(s): |PROGRAM |
| |WILL |
| |ADMINISTER|
| |MEDICATION|
|MAT certificate expiration date: | |
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|Health Care Consultant signature indicates approval of individual (verification of age, MAT certificate, first aid and CPR certificates): | |
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|Date: | |
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|Additional Staff information (as applicable): | |
|(Check one) ADD to list CHANGE information REMOVE from list | |
|Provider Name: | |
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|MAT certification language(s): | |
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|MAT certificate expiration date: | |
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|Health Care Consultant signature indicates approval of individual (verification of age, MAT certificate, first aid and CPR certificates): | |
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|Date: | |
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|The following individual(s) has a professional license or certificate which exempts him/her from the training requirements to administer | |
|medication. Copies of the individual(s) credentials are attached and will be sent to the Office | |
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|(Check one) ADD to list CHANGE information REMOVE from list | |
|Name: | |
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|License/certificate (check one): | |
|EMT-CC EMT-I EMT-P LPN | |
|RN NP PA MD DO | |
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|License/certificate expiration date: | |
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|Health Care Consultant signature indicates approval of individual (verification of age and licensure): | |
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|Date: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Section 15. Forms and Documentation Related to Medication Administration |COMPLETE |
| |THIS |
|Medication Consent Form: (check all that apply) |SECTION IF|
|X The program will accept permission and instructions to administer |THE |
|medication on the OCFS form Written Medication Consent Form |PROGRAM |
|(OCFS-LDSS-7002) |WILL |
|The program will accept permission and instructions to administer |ADMINISTER|
|medication on the attached medication consent form developed by |MEDICATION|
|the program (please attach) | |
|Permissions and instructions NOT received on the OCFS form or | |
|Program-specific form will be accepted on the condition that the | |
|required medication related information is complete | |
|Other: | |
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|Medication consent forms for on-going medication must be renewed as required by regulation. How often will written medication permissions | |
|and instructions be reviewed to verify they are current and have not expired? | |
|Each time the medication is administered. | |
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|All medication administered to a child during program hours will be documented on a child-specific medication log. | |
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|The program uses the following form to document the administration of medication during program hours: (check one) | |
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|X OCFS form Log of Medication Administration (OCFS-LDSS-7004) | |
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|The attached log of medication administration developed by the | |
|program (please attach) | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|The program uses the following form to document the application of over-the-counter topical ointments, sunscreen and topically applied |COMPLETE |
|insect repellent during program hours: (check all that apply) |THIS |
| |SECTION IF|
|X OCFS form Log of Medication Administration (OCFS-LDSS-7004) |THE |
| |PROGRAM |
|The attached log of medication administration developed by the |WILL |
|program (please attach) |ADMINISTER|
| |MEDICATION|
|Other: | |
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|Each medication log will be attached to the child’s corresponding medication consent form. | |
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|All observable side effects will be documented on the child’s medication log. Parents will be notified of any observed side effects by the| |
|end of the day. Parent notification will be immediate if the side effects are severe. If Necessary, emergency medical services will be | |
|called. | |
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|Parents will be notified of all “as needed” medication given to their child and told what symptoms were observed that required the | |
|administration of medication. | |
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|Staff will document whenever medication is not given as scheduled. The date, time and reason for this will be documented. Parents will be | |
|notified as soon as possible. If the failure to give medication as scheduled is a medication error, staff will follow all policies and | |
|procedures related to medication errors. | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Verbal permission |COMPLETE |
|The program’s policy regarding the acceptance of verbal permission and instructions when a parent is not able to provide the program with |THIS |
|written permissions and instructions is as follows: (check one) |SECTION IF|
| |THE |
|X The program will not accept verbal permission or instructions. All |PROGRAM |
|permission and instructions must be received in writing |WILL |
| |ADMINISTER|
|The program will accept verbal permission from the parent and |MEDICATION|
|verbal instructions from the health care provider only to the extent | |
|permitted by OCFS regulation. (Only those individuals approved | |
|in the health care plan to administer medication will accept verbal | |
|permission and instructions for all medication except over-the- | |
|counter topical ointments, sunscreen and topically applied insect | |
|repellent.) | |
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|The program will document verbal permission and instructions received and the administration of the medication on the following form: | |
|(check one) | |
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|OCFS form Verbal Medication Consent Form and Log of | |
|Administration (OCFS-LDSS-7003) | |
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|Verbal medication consent form and log developed by the | |
|program (please attach) | |
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|Other: | |
|Verbal permissions will not be accepted | |
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|All medication consents and medication logs will be kept in the following location (manner): | |
|X Child’s file | |
|X Medication log book | |
|Other: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Section 16. Handling, Storage and Disposal of Medication |COMPLETE |
|All medication must be properly labeled with the child’s first and last name and be accompanied by the necessary parental permission and, |THIS |
|when applicable, health care provider instructions in accordance with OCFS regulations before it will be accepted from the parent or |SECTION IF|
|parent representative. |THE |
| |PROGRAM |
|Non child-specific over-the-counter medication: (check one) |WILL |
|will not be stocked at the program |ADMINISTER|
|will be stocked at the program. My procedure for stocking this |MEDICATION|
|medication is attached. | |
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|All medication will be kept in its original labeled container. | |
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|Medication must be kept in a clean area that is inaccessible to children. Explain where medication will be stored. Note any medications, | |
|such as EpiPen®, which will be stored in a different area. | |
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|Medication requiring refrigeration will be stored: (check one) | |
|in a medication-only refrigerator located: | |
|in a food refrigerator in a leak-proof container separated from food | |
|and inaccessible to children | |
|Other: | |
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|Any refrigerator used to store medication will be kept at a temperature between 36(F and 46(F. | |
|Explain how often the refrigerator temperature will be checked. | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev.5/2010)
| |ONLY |
|All medications with a pharmacy label identifying the contents as a controlled substance are regulated by the Federal Drug Enforcement |COMPLETE |
|Agency. These medications will be: (check all that apply) |THIS |
|X Stored in a locked area with limited access |SECTION IF|
|X Counted when receiving a prescription bottle from a parent or guardian |THE |
|X Counted each day if more than one person has access to the area where they |PROGRAM |
|are stored |WILL |
|X Counted before given back to the parent for disposal |ADMINISTER|
|Other: |MEDICATION|
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|Explain where controlled substances will be stored and who will have access to these medications. | |
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|Medications will be kept in a secure, locked location determined by the Director. The Director and medication administrants will be the | |
|only staff with access. | |
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|Explain how often the program will check for expired medication. | |
|Weekly | |
|Monthly | |
|X Other: | |
|Prior to each administration | |
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|All left-over or expired medication will be given back to the child’s parent for disposal. Medication not picked up by the parent will be | |
|disposed of in a garbage container that is not accessible to children within: | |
|(specify time frame) one business day | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Section 17. Medication Errors |COMPLETE |
| |THIS |
|If a medication error occurs in the program, appropriate staff will immediately notify the child’s parent. If more than one child is |SECTION IF|
|involved, staff will immediately notify the parents of all involved children. Each child’s confidentiality will be maintained if more than|THE |
|one child is involved. |PROGRAM |
| |WILL |
|When any medication error occurs, the program will do the following: |ADMINISTER|
| |MEDICATION|
|The staff person notifying the parent will encourage the child’s parent to contact the child’s health care provider when the error occurs.| |
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|Program staff will notify OCFS as soon as possible. OCFS must be notified by the close of business the day after the incident. | |
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|The OCFS form Medication Error Report Form (OCFS-LDSS-7005) will be used to report all medication errors that occur in the program. If | |
|more than one child is involved in the error, a Medication Error Report Form will be completed for each child involved. | |
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|The program has decided to notify these additional people (e.g. the program’s health care consultant). If no additional notifications, put| |
|N/A in this section. | |
|The Director | |
|The Health Consultant | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Section 18. Health Consultation Information and Statement |COMPLETE |
|Section 18 must be completed by the Health Care Consultant if the program plans to administer medication. |THIS |
| |SECTION IF|
|Health Care Consultant Information: |THE |
| |PROGRAM |
|Name of HCC: |WILL |
| |ADMINISTER|
|Profession: |MEDICATION|
|(A HCC must have a valid NYS license to practice as a physician, physician assistant, nurse practitioner or registered nurse) (check all | |
|that apply): | |
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|Physician | |
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|License number: | |
|Exp. Date: | |
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|Physician Assistant | |
|License number: | |
|Exp. Date: | |
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|Nurse Practitioner | |
|License number: | |
|Exp. Date: | |
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|Registered Nurse | |
|License number: | |
|Exp. Date: | |
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|As the program’s Health Care Consultant, I will: | |
|Review and approve the program’s health care plan. My approval of the health care plan indicates that the policies and procedures | |
|described herein are safe and appropriate for the care of the categories of children in the program. | |
|Verify that all staff authorized to administer medication are at least 18 years old and have the necessary professional credentials or | |
|have completed all required trainings as per the NYS OCFS day care regulations (MAT, age-appropriate CPR and first aid training). | |
|Notify the program if I revoke my approval of the health care plan. If I choose to do so, I may also notify the Office of Children and | |
|Family Services of this revocation at 1-800-732-5207. | |
|Notify the program immediately if I am unable to continue as the health care consultant of record. | |
|Other: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|I will visit the program at least once every licensing period to check compliance with the health care plan. List how often you plan to |COMPLETE |
|visit the program. |THIS |
| |SECTION IF|
| |THE |
| |PROGRAM |
| |WILL |
| |ADMINISTER|
|Health Care Consultant Signature _______________________________________ |MEDICATION|
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|Date: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|Section 19. Confidentiality Statement |COMPLETE |
| |THIS |
|Information about any child in the program is confidential and will not be given to anyone except the Office, its designees or other |SECTION IF|
|persons authorized by law unless the child’s parent gives written permission. |THE |
| |PROGRAM |
|Information about any child in the program will be given to the social services district if the child receives a day care subsidy from the|WILL |
|district, where the child has been named in a report of suspected child abuse or maltreatment or as otherwise allowed by law. |ADMINISTER|
| |MEDICATION|
|Section 20. ADA Statement for Programs | |
| | |
|The program will comply with the provisions of the Americans with Disabilities Act. If any child enrolled in the program now or in the | |
|future is identified as having a disability covered under the Americans with Disabilities Act, the program will assess the ability of the | |
|program to meet the needs of the child. If the program can meet the needs of the child without making a fundamental alteration to the | |
|program, the program will not exclude the child from care. | |
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|Section 21. Provider Statement | |
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|This health care plan and all health and infection control day care regulations will be followed by all program staff and volunteers. | |
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|The program will have a Health Care Consultant (HCC) of record who will review and approve the policies and procedures described in this | |
|health care plan as appropriate for providing safe care for children. The HCC will have a valid NYS license to practice as a physician, | |
|physician assistant, nurse practitioner or registered nurse. | |
| | |
|The program director or program representative will notify the health care consultant and the Office of Children and Family Services | |
|(OCFS) of all new staff certified to administer medication and have the health care consultant review and approve his/her certificates | |
|before the assistant or alternate caregiver(s) is allowed to administer medication to any child in day care. | |
| | |
|The program director or program representative will notify the Office of Children and Family Services and the parents of children in care,| |
|immediately, if the health care plan is revoked for any reason by the health care consultant. Documentation of these notifications is | |
|required. | |
| | |
|The health care consultant and OCFS must review and approve the program’s health care plan before any policies and procedures can be | |
|implemented. | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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OCFS-LDSS-7020 (Rev. 5/2010)
| |ONLY |
|The health care consultant and OCFS must review and approve any changes or revisions to the health care plan before the program can |COMPLETE |
|implement the changes, including additions, removal or changes to individuals listed in the health care plan’s medication administrant. I |THIS |
|will notify the HCC and OCFS to changes in medication administrant credentials and termination of medication administrant at my program. |SECTION IF|
| |THE |
|Once the health care consultant and OCFS approve the health care plan, the program director or program representative will notify |PROGRAM |
|parents/guardians of the health care plan. |WILL |
| |ADMINISTER|
|The health care plan will be made available to parents at enrollment, whenever changes are made and upon request. |MEDICATION|
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|Day Care Provider’s Name (please print): | |
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|Provider/Facility License or Registration #: | |
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|Day Care Provider’s Signature: | |
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|Date: | |
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|PROVIDER INITIALS |DATE |HCC INITIALS |DATE |PAGE | |
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