Child Care: State Efforts to Enforce Safety and Health Requirements
Published: 2004-09-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The federal government requires states that receive funds from the Child Care and Development Fund to establish basic health and safety requirements. The federal government also requires states receiving federal funds for child care to have procedures in place to ensure that providers being paid with grant dollars comply with the applicable safety and health requirements. Because of the significant federal role in paying for child care services and congressional concerns about the way in which states ensure the safety and health of children in child care settings, we were asked to follow up on our prior report, Child Care: State Efforts to Enforce Safety and Health Requirements (GAO/HEHS-00-28, Jan. 24, 2000). This report (1) identifies changes in states' licensing and enforcement activities for various types of licensed and nonlicensed providers since 1999, (2) describes the ways child care licensing agencies organize inspection staff and use technology, and (3) provides examples of promising practices in state child care licensing and enforcement activities. To obtain data, we surveyed state licensing officials in 2004 about their 2003 activities, interviewed experts and made site visits to four states--Delaware, Florida, North Carolina and Oklahoma.
section_title: What GAO Found
paragraphs: State efforts in the licensing and oversight of child care facilities are generally about the same as they were in 1999, except that the median caseload of the number of facilities per inspector dropped from 118 to 110 in 2003. We found that in 2003, 38 states exempted all family child care providers from being regulated, compared with 39 states in 1999. Most states conducted compliance inspections at least once a year, meeting or exceeding the recommended level for all types of providers. Many states organized inspection staff by geography and used technology in many parts of the inspection process. Forty-three states reported assigning staff to geographic locations throughout the state. States also assigned staff based on specific job task and type of child care facility the staff would inspect. Many states used multiple criteria to assign staff. Forty-five states reported using technology to assist them with many aspects of licensing and enforcement functions, such as maintaining statistics on families and providers. States have adopted a number of promising practices to assist their child care licensing and enforcement activities. These practices include the use of technology to streamline licensing and enforcement processes and manage parent and provider information, rating systems to aid parents in selecting the appropriate child care for their child and to offer providers incentives to improve and maintain the quality of their care, and working with other organizations to train providers and parents.

section_title: Letter
paragraphs: The need for child care has grown dramatically over the past 25 years. In  1975, 39 percent of women with children under the age of 6 were in the  labor force; by 2003 that number had grown to 63 percent. Since 1996,  federal welfare policies have emphasized the importance of work, and  more welfare parents than ever before have moved into the workforce.  The federal government assists the work efforts of parents through the  Child Care and Development Fund (CCDF), providing $4.8 billion to states  to help parents pay child care costs and to ensure the health and safety of  children in child care. More than 1.75 million children are enrolled in  subsidized care each month.
To help protect children in child care, states license certain child care  providers and establish requirements including those focused on health  and safety. All states set licensing requirements and require some child  care providers to obtain a license to offer care. However, as allowed, most  states do not license all types of providers in all child care settings. Both  licensed and nonlicensed providers are eligible to receive funds from  CCDF, and the federal government requires states to have plans in place to  ensure that providers being paid with federal child care funds comply with  the applicable health and safety requirements established by the states.  Many of the health and safety requirements states establish are based on  practices, including inspections, recommended by national organizations.
To ensure compliance with states’ licensing requirements, states oversee  those child care providers over which they have authority by engaging in  various enforcement activities. The most intense enforcement activities  occur for licensed providers, the most highly regulated status for  providers. Licensed providers are typically subject to background checks  and facilities inspection, provided with technical assistance and training,  and are subject to sanctions—such as fines and revocation of licenses— for those who do not meet licensing standards. Licensed providers who  receive subsidies have the most stringent requirements. For nonlicensed  providers, states’ laws and policies dictate the extent to which states  engage in such enforcement activities. Consequently, some nonlicensed  providers receive less intense oversight than do licensed providers, but are  still subject to regulation (we will call these regulated nonlicensed  providers). Still other providers are exempt from state regulation because  of state law. For example, in certain states child care centers run by  religious organizations are exempt from regulation. Exempt providers who  receive federal child care funds must comply with state health and safety  requirements. Parents can choose among a number of different child care  settings. Some parents may choose to send their child to a child care  center, where many children are cared for in a nonresidential setting.  Other parents may choose a “family” care setting, in which one provider  cares for a number of children within the provider’s home.
Because of the significant federal role in paying for child care services,  some members of Congress raised concerns about the way in which states  ensure the safety and health of children in child care settings. In 1999, we  surveyed states to identify the most critical licensing and enforcement  activities. We were asked to update our 1999 study, and in this report we  (1) identify any changes in states’ licensing and enforcement activities for  various types of licensed and nonlicensed providers since 1999,   (2) describe the ways child care licensing agencies organize inspection  staff and use technology, and (3) provide examples of promising practices  in state child care licensing and enforcement activities.
To address these issues, we conducted a mail survey in 2004, to state  licensing officials in all 50 states and the District of Columbia, asking  about their licensing and enforcement policies and practices in 2003.  Specifically, we asked states to report on the frequency of their  compliance inspections, background checks, training programs and  educational requirements for licensing staff, and caseload sizes. We  achieved a response rate of 98 percent, with 49 states and the District of  Columbia responding to our survey. We then compared our survey results  with a mail survey we conducted in 1999 to identify any changes that had  occurred within the past few years. We also used data from the National  Child Care Information Center for the number of states exempting family  child care providers from regulation. In addition, we conducted a  literature search and interviewed child care licensing experts and state  and federal officials to gather information about critical licensing and  enforcement activities occurring within the states. We asked experts to  identify states that had examples of promising practices in automation,  training initiatives, rating systems for providers, and enforcement  practices. We used this information to identify four states—Delaware,  Florida, North Carolina and Oklahoma—in which we conducted site visits.  For more details on our scope and methodology, see appendix I. We  conducted our work between October 2003 and July 2004 in accordance  with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: States are responsible for developing licensing criteria and health and  safety requirements and conducting enforcement activities to ensure  providers comply with them and thereby protect the safety and health of  children in child care settings. While the federal government’s role is  limited in this area, the states must certify that they have safety and health  requirements in place and procedures to ensure providers comply with all  applicable requirements to receive federal CCDF funds. The Department  of Health and Human Services (HHS) oversees CCDF.
subsections: section_title: CCDF Funding and Requirements
paragraphs: In fiscal year 2003, the amount of federal funds appropriated for CCDF  was $4.8 billion. The CCDF funds are provided to states through a block  grant mechanism which allows states to set priorities, establish policies,  and spend funds in ways that will help them achieve state child care goals.  The Child Care and Development Block Grant statute that underlies the  CCDF requires states to designate a lead agency and to establish state  plans that commit to establishing and enforcing licensing requirements  and health and safety standards for child care providers. The statute leaves  it to the states to decide what requirements are to be applicable to specific  categories of providers, but for health and safety it sets out three broad  parameters that must apply to all providers receiving federal assistance:  physical premises safety, staff training, and control of infectious diseases  (including childhood immunizations). To qualify for a subsidy provided  with funds from the CCDF, a provider must comply with these and any  other applicable state requirements.
To be eligible for CCDF subsidies, parents must be working, in training, or  attending an educational program and have children less than 13 years of  age. States can set income eligibility limits at or below 85 percent of the  state median income level. States must use a significant portion of their  CCDF funds for families receiving Temporary Assistance for Needy  Families (TANF) or families who are at risk for becoming dependent upon  public assistance. CCDF has five goals: (1) encouraging maximum  flexibility in developing state child care programs; (2) promoting parental  choice; (3) encouraging states to provide consumer education information  to parents; (4) helping states provide child care to parents trying to  become independent of public assistance; and (5) helping states  implement health, safety, licensing, and registration standards established  in state regulations. However, CCDF does not specify how the states  should meet these goals and only requires them to be included as elements  within the state child care plan. States can also determine which  enforcement activities apply to different types of child care. Types of child  care eligible to receive funding under TANF and the block grant are  described in table 1.
section_title: Oversight of Child Care Providers
paragraphs: States regulate those providers over which they have authority by setting  requirements, including those focusing on health and safety, that such  child care providers must meet and by enforcing these requirements.  State child care licensing offices are responsible for enforcing such health  and safety requirements, and engage in different oversight activities for  licensed providers and for regulated nonlicensed providers.
Licensed providers are generally subject to standard oversight, which  generally includes background checks, inspections, technical assistance  and training, and the application of sanctions when providers are found to  be out of compliance.
Regulated nonlicensed providers receive less intense oversight. Such  oversight can include self-certification that health and safety standards  have been met, background checks, and sanctions.
Providers who are legally exempt by state law from oversight are not  regulated by state child care licensing offices. For example, in certain  states, child care centers run by religious organizations may be exempt. In  addition, under federal regulations, the states are not required to apply  health and safety requirements to certain providers who only care for a  child to whom they are related. Some states may conduct background  checks and inspections of their legally exempt providers.
States vary as to which types or subtypes of child care providers fall under  each level of oversight.
When establishing which providers will be required to obtain licenses, and  hence be subject to standard oversight, and which will be required to  comply with less intense requirements, states consider a number of  factors. For example, states consider whether certain providers are  subject to other health and safety regulating authorities, such as school- based programs that must conform to all health and safety requirements  required for public schools and are overseen by the state education  department. States also consider the staffing resources they would need to  carry out the necessary licensing and enforcement activities in light of  their budget, how to target resources toward the greatest number of  children, and the impact that licensing activities could have on child care  availability and parental choice. For example, some providers might pass  the costs of conforming with licensing requirements on to parents, which  could make such care too expensive for some parents. Currently, states  are making choices about the extent to which they license certain  providers and about which enforcement activities apply to different types  of providers.
section_title: Licensing and Enforcement Activities Recommended by National Organizations
paragraphs: There are no specified federal requirements for licensing and enforcement  activities, so many states rely on recommendations made by professional  organizations in developing their own standards. Professional  organizations recommend standards for several critical licensing and  enforcement activities, including background checks, monitoring visits,  training for licensing staff, and caseload size. Table 2 outlines  recommended practices for critical licensing and enforcement activities.
section_title: Median Inspection Caseload Size Has Decreased since 1999 although Caseloads Have Continued to Exceed Recommended Levels
paragraphs: In 2003, the median caseload size for inspectors decreased, but most  licensing and enforcement activities for licensed providers remained about  the same as those in 1999. Almost a quarter of the states maintained  caseloads at recommend levels, and fewer states had caseloads levels over  150. Most states conducted compliance inspections at least once a year,  which met or exceeded the recommended level for all types of providers.  However, most states do not require the amount of training recommended  by national professional organizations. Most states continued monitoring  exempt providers by distributing information about health and safety  requirements and asking these providers to certify that they complied with  state requirements, although some states engaged in more intense  monitoring practices for these providers.
subsections: section_title: Almost One-Quarter of the States Maintained Recommended Caseload Levels for Inspectors, and Median Caseloads Decreased
paragraphs: In 2003, almost a quarter of the states maintained caseloads at or below  the recommended level of 75 facilities to one inspector, and the number  doing so had increased by 1 since 1999. Specifically, in 1999, 11 states were  meeting the recommended caseload levels, and that number increased to  11 states and the District of Columbia by 2003. The median number of  facilities per inspector decreased during this time, from 118 facilities per  inspector to 110 facilities per inspector, but the number of facilities per  inspector was still well above the recommended level of 75 in 2003. In  1999, caseloads ranged from 52 in Missouri to 333 in Colorado, while in  2003, caseloads ranged from 35 per inspector in Hawaii to 600 per  inspector in Iowa. Although the range was broader in 2003 than in   1999, more states decreased the size of their caseloads than increased  them. Between 1999 and 2003, the caseload in 23 states and the District of  Columbia decreased while the caseload in 16 states increased. The number  of states with particularly high caseloads, over 150, dropped from 17 to   15, between 1999 and 2003. Among the states whose caseloads decreased  were several states with the some of the highest caseloads in 1999. For  example, Colorado’s caseload went from 333 to 138 as its licensing budget  nearly doubled. Figure 1 illustrates the ranges of caseload levels of  licensing staff by state in 2003; see appendix II for a comparison of  caseload by state in 1999 and 2003 and appendix III for comparisons of  licensing budgets and staffing levels by state in 1999 and 2003.
While state data showed 12 states maintaining caseloads at recommended  levels, states reported that they were visiting facilities as often as  recommended, and in 15 states, more often. States may be managing to  visit facilities as often as recommended while maintaining caseloads  higher than those recommended, in part because the caseload standard  itself is not appropriate for some states. Experts note that this standard  does not fully account for time-saving technology that might allow some  states to operate effectively with larger than recommended caseloads.  Further, licensing staff could be making trade-offs not captured in our  survey. For example, staff could be maintaining their schedule for  monitoring visits at the expense of performing other duties, including  processing applications, providing technical assistance, or documenting  inspection visits in a timely manner.
section_title: The Number of States Exempting Some Family Child Care Remained about the Same
paragraphs: According to the data reported through state surveys and NCCIC, one less  state exempted family child care providers-–sole caregivers who care for  children in a private residence other than the child’s—than were exempted  from health and safety requirements in 1999. In 1999, 39 states exempted  some family child care providers from regulation, and by 2003, 38 states  were exempting some of these types of providers. In addition, fewer states  required licensure for some types of centers in 2003 than had in 1999,  including religious centers, federal centers, and recreation centers. See  table 3.
Many states set thresholds at which regulation begins according to the  number of children served by different types of providers and exempt  from regulation those providers falling below these thresholds. For  example, states commonly determine which family child care providers  will be regulated based on the number of children in care. Specifically, in a  given state, providers caring for 7 or more children in their home might be  regulated, while providers caring for 4 children in their home might be  exempted from regulation. As figure 2 illustrates, these regulatory  thresholds have changed very little since 1999. However, 18 states met or  exceeded the recommended practice of regulating providers who cared for  2 or more unrelated children in 2003, whereas 13 were doing so in 1999.
section_title: Inspections Still Conducted in Accordance with Recommended Practices, but Most States Short of Recommended Hours of Training
paragraphs: Although some changes had occurred since 1999, states continued to  conduct compliance inspections in accordance with recommended  practices of conducting compliance inspections at least once a year.  However, the number of states that visited facilities at least twice a year  dropped by about half for all types of settings. According to the data  reported to us through our survey, 41 states inspected centers at least  annually, and 32 states did so for group homes. Similarly, 28 states  conducted inspection visits to family child care homes at least once a year.  See figure 3 and appendix IV.
The number of states requiring providers to pursue ongoing training  increased from 26 in 1999 to 29 in  2003, and as in 1999, the same number  of states (4) specifically followed the recommended practice by requiring  at least 24 hours of training per year for center directors, and 3 states  required this of center teachers. No states required this level of training for  family child care providers. The same number of states (32) required  licensing staff to have an academic degree in a related field in 1999 and  2003. Similarly, in 1999 and 2003, the same number of states (33) required  licensing staff to have work experience in licensing or a related field  before being assigned to licensing and enforcement activities. Finally,  although very few states had required licensing staff to pass a test in   1999 (7), even fewer required this in 2004 (3).
section_title: Many States Engage in Enforcement Activities for Exempt Providers Receiving Child Care Subsidies
paragraphs: More states informed exempt, subsidized providers about the  requirements under the federal grant by sending them a package of  information about health and safety requirements in 2003 (32) as reported  doing so in 1999 (28). In addition, 17 states reported informing providers  by requiring them to attend a short briefing or orientation sessions. Of  these, 13 states both sent them a package of information and required  attendance at a briefing or orientation.
In monitoring providers exempted from regulation who were receiving  CCDF funds, states exercised the wide discretion given them by the grant  in determining how, or whether, to enforce state and local safety and  health requirements for such providers. Some states monitored such  providers relatively intensely, while others did not have the authority to do  so under state law. For example, some states conducted background  checks on exempt providers or inspected such providers. The number of  states conducting background checks and inspections for such providers  increased since 1999. For 2003, 37 states reported conducting background  checks on exempt providers, compared with 20 in 1999. Similarly, for   2003, 12 states reported conducting inspections for such providers  compared with 6 in 1999. Finally, for 2003, 9 states reported conducting  both background checks and inspections, while 4 states reported doing so  in 1999.
section_title: Many Inspection Staff Are Organized by Geographic Location, and Technology Is Used in Most Parts of the Licensing and Inspection Process
paragraphs: While 43 states assigned staff to a geographic location, those states using  this broad method varied in the specifics of such assignments. Nineteen  states also reported assigning staff based on specific job task, such as  responding to complaints. Nineteen states reported assigning staff to  inspect a particular type of child care facility, such as centers or family  homes. Some states used multiple criteria to organize their staff; these  states frequently first assigned staff based on geographic location and then  relied on secondary criteria, such as type of child care facility. See   figure 4.
Forty-five states reported using technology to assist them with many  aspects of licensing and enforcement activities. States used technology for  tracking and monitoring subsidy use, inspecting facilities, making and  reconciling payments to providers, linking state and local agencies,  maintaining statistics on providers, maintaining statistics on families, and  preparing reports to meet federal and state mandates. See figure 5.
Technology to complete some of these tasks was available in only a  limited number of locations, such as the state licensing office, while for  other tasks the technology could be accessed anywhere in the state by  authorized users. More states had the ability to maintain statistics on  providers and families (24 states) and preparing reports to meet federal  and state mandates (20 states) statewide than for any other tasks (tracing  and monitoring subsidy use (18 states), making and reconciling payments  (17 states), facility inspection checklist (16 states) or linking state and  local agencies (12 states)).
section_title: Promising Practices in Technology, Rating Systems, and Training
paragraphs: States we visited have adopted a number of promising practices to assist  in their child care licensing and enforcement activities. First, some states  used technology in ways that allowed them to streamline their licensing  and enforcement processes and to manage parent and provider  information particularly effectively. Second, the states we visited had  paired frequent inspections with technical assistance to help ensure that  child care providers would meet state health and safety regulations. Third,  three states we visited had implemented rating systems that differentiate  providers by the quality of care they provide. Such systems have helped  parents choose child care providers by allowing them to compare the  quality of different providers. In addition, these systems have helped states  determine what training and technical assistance each provider needs and  have offered providers incentives to improve and maintain the quality of  their care. Fourth, all the states we visited encouraged partnerships with  community organizations to improve the training and education of  providers. For example, states partnered with community colleges to  connect providers with educational opportunities and with resource and  referral agencies to meet the ongoing training needs of providers.
subsections: section_title: States Can Use Technology to Make Critical Licensing and Enforcement Activities More Accessible and Efficient
paragraphs: States we visited used technology to make licensing and enforcement  information more readily available to providers and parents, save time and  resources, and track payments and subsidy use. For example, Florida—the  state with the most complete, integrated, and up-to-date technology  system of the states we visited—used technology to create an online  public information system for providers and parents. Providers can use  this system to access online information about state policies and  regulations, training requirements, how to start a center, and other  information. This has helped providers increase professionalism and self- monitoring, according to state officials. Parents can use the system to  access the compliance histories of each provider.
In addition, some states have used technology to make critical licensing  and enforcement activities more efficient. For example, Florida’s Internet- based system allows providers to register for training online and access  their transcripts and final examination results. Florida officials also told us  that posting provider information online reduced the amount of time child  care licensing staff had to spend answering questions from providers and  consequently allowed them to spend more time on other enforcement  activities.
Two states we visited—Florida and North Carolina—have used laptops to  make the enforcement process more efficient. Specifically, in these states  inspectors were able to enter data into their laptops while conducting  inspections rather than having to enter this information into the computer  after returning to the office. In addition, inspectors in Florida were able to  print a copy of the compliance report for providers while on-site to  facilitate discussions of areas needing improvement. The laptops also  saved inspectors time by allowing them to quickly access provider  information, state child care regulations, noncompliance citations, and  inspection forms. Officials in both Florida and North Carolina said that  using laptop computers had helped inspectors spend less time on  administrative duties and allowed them to spend more time providing on- site technical assistance to providers. The project coordinator in Florida  said that this system which only covers child care licensing, was more  affordable than other states’ licensing systems, which are part of their  larger statewide child welfare information systems.
In another state, technology was used to make it easier for providers and  parents to manage subsidy payments and reduced the likelihood of fraud  or overpayment. Specifically, Oklahoma reported using an electronic  benefits transfer (EBT) system to automatically calculate payment rates  and to track subsidy use. Because Oklahoma reimburses providers at over  160 different rates depending upon the characteristics of the family and  provider receiving a subsidy, the likelihood of error had been significantly  higher before the system was implemented, when licensing staff were  responsible for identifying the appropriate rate. According to state  officials, this system has saved time processing paperwork. Further, the  EBT system has allowed parents receiving a child care subsidy to  document the time and attendance for their children using an EBT card  issued by the state, and providers are automatically reimbursed at the  appropriate rate.  This automated system has also has also helped  officials identify instances of child care fraud and payment abuse,  according to state officials.
We found that in the states we visited, only those that had recently  invested in computer systems, such as Florida, had been able to take  advantage of new technologies at an affordable price. In contrast, other  states that had not recently invested in computer systems, such as  Delaware, had been unable to adopt such promising practices.  Specifically, although Delaware had been on the leading edge of using  technology almost a decade ago, it had been unable to maintain this  advantage. One state official said that it is costly to implement and  maintain the technology necessary to support facilities inspection,  particularly when the state’s system is relatively old and needs to be  updated. For example, Delaware’s system was designed in 1995 to help  staff investigate child abuse, but was being used in 2003 to track the  licensing process. According to state officials, the system was difficult to  use for management purposes. To upgrade the system to adopt promising  practices such as entering data while conducting on-site inspections, the  state would need to develop the system and obtain additional equipment,  such as laptop computers. However, officials told us that despite the  increases in the state licensing budget since 1999, the state does not have  the funding to upgrade the system and purchase additional technological  equipment because these funds had been for specific purposes, such as  staffing and infant and toddler programs.
section_title: Rating Systems Helped Parents Choose Child Care and Offered Providers Incentives to Improve and Maintain the Quality of Child Care
paragraphs: Florida, North Carolina, and Oklahoma have implemented rating systems  to tie the level of reimbursement to a provider’s quality. These rating  systems helped create a market system by giving parents more information  about the quality of child care providers, and offered incentives to  providers to obtain higher levels of education and improve quality in their  facilities. In implementing rating systems, states set standards for different  tiers of quality and assessed providers against these standards. The lowest  tier included those providers who only met the state licensing criteria,  while the highest tiers in Florida and Oklahoma included those providers  who have achieved accreditation by national organizations. States differ in  the number of tiers in their systems: North Carolina has five, Oklahoma  has four, and Florida has two tiers.
Ratings systems have helped parents choose child care providers by  allowing them to compare the quality of different providers. While some  parents might not have known whether national accreditation would mean  higher-quality care, they can easily identify that a provider with five stars  was considered to provide better quality than a provider with one star.
Rating systems also offered providers incentives to improve and maintain  the quality of their facilities by offering higher levels of reimbursement to  higher-quality providers. For example, through the star rating systems in  North Carolina and Oklahoma, providers with more stars received a higher  rate of reimbursement than providers with one star. Similarly, in Florida  high-quality providers also receive financial incentives such as a  reimbursement rate for subsidized children that is 20 percent higher than  the market rate, a tax break for high-quality providers whose clientele  does not include subsidized families, and an exemption from sales tax on  educational materials. Officials in Oklahoma said that the rating system  has provided incentives to all providers to improve the quality of their  care, even providers who do not serve subsidized children. Such providers  use the star rating as a marketing tool for their facilities, according to state  officials.
Finally, the rating systems—and the standards and indicators of quality on  which they are based—can help states focus their child care quality  efforts. For example, North Carolina’s five-star rating system forms the  core of all its child care quality efforts, according to state officials. The  Stars program provided the criteria for identifying areas in which  individual centers needed to improve and the steps centers could take to  obtain a higher rating, the basis for developing and providing full-day  professional development and workshops throughout the year, and links  with financial supports to encourage and reward participation in  professional development that could lead to higher-quality child care.
section_title: Training
paragraphs: Training is an integral part of ensuring and upgrading the quality of early  childhood education for all the states we visited. We found promising  practices in training and information programs for providers and parents.  Training and information for providers includes information on starting up  a facility and program standards that may be available in information  packages or on the Internet; orientation training; technical assistance; staff  development courses; conferences, and model observation training sites.  Parent information services includes providing information on what to  look for when evaluating child care providers, as well as related  information on vaccinations, screening and playground safety and where  to access parent support services. Delaware, North Carolina, and  Oklahoma were cited by experts as having notable training programs.  What they have in common is that each training program is part of a total  statewide system of interconnected partnerships between state and  community agencies to ensure quality early childhood care.
subsections: section_title: Prelicensing and New Providers Training
paragraphs: In these three states, licensing officials offered prelicensing training so  that potential providers could get information on state requirements to  avoid being out of compliance. In Delaware, staff from the Family &  Workplace Connection, which is the umbrella organization that provides  both training and resource and referral (R&R) services and offered a wide  range of training opportunities that included some technical assistance,  also attended new provider orientations given by the licensing office, to  meet these providers and inform them of other services they supply, like  the food program, which can furnish free food to providers, or grant  opportunities. According to one official, these supports helped providers  understand the health and safety requirements, which in turn helped  facilitate compliance. In Delaware, inspectors also walked new providers  through the health and safety regulations and addressed providers’  questions or concerns on their first walk-through of the facility.
section_title: Staff Development Training
paragraphs: The bulk of training for providers was provided by training  organizations—community colleges, early education training centers,  some R&R agencies, and universities—working in partnership with the  licensing offices for ongoing staff development. Such training is designed  to help providers meet ongoing training requirements and provide them  with technical assistance so they can improve the quality of their care by  engaging in training programs aligned with state standards and  requirements. Oklahoma, North Carolina, and Delaware pursued different  strategies to implement this alignment, and Florida demonstrated how a  comprehensive Internet information system saves time for providers,  training organizations, and state officials.
Oklahoma’s three-tiered training program comprehensively addresses all  training needs from meeting minimal requirements for child care licensing  to the most advanced professional development for early care and  education workers and center directors. Tier I is short-term, job-related  training that can be counted toward ongoing training requirements.  Providers can pursue Tier I training by attending workshops or  conferences related to their job, watching videos, and self-directed  reading, and by participating in in-service training. Tier II is in-depth  training that providers engage in by completing courses approved by the  state’s Center for Early Childhood Professional Development. Tier III  training is advanced training, formal education through credit-bearing  courses at accredited colleges, universities, and technology centers that  transfer for credit to such schools, leading to the highest levels of the  quality enhancement star system, the career development ladder, and the  Oklahoma director’s credential.
North Carolina has woven its provider training into its comprehensive  Smart Start program, which is a recognized national model of partnerships  working together to meet the needs of young children. As part of this  program, the education level of staff is one of three areas on which  providers are evaluated when their quality rating is determined. Providers  who meet higher standards for education and experience receive more  stars because, according to state officials, child care teachers with more  early childhood education and experience are prepared to provide  children with a more enriching child care experience. Providers can  improve their star rating by increasing staff education and experience  levels and by employing more teachers with early childhood education  credentials and experience. Providers can pursue such credentials by  completing certificate or higher education programs offered at community  colleges and universities. Such training activities are facilitated and  coordinated by the North Carolina Institute for Early Childhood  Professional Development.
Delaware First, the career development program for early childhood  professionals that is operated by the Family & Workplace Connection, has  developed Core Curricula—Basic, Advanced, and Specialty—that can be  used to fulfill training requirements and also to pursue a Child  Development Associate degree or college credit.
Florida and Delaware provided training information and administrative  functions through the Internet. This has saved time for providers,  inspectors, and training organizations by allowing providers to register  online for courses offered at community colleges or other organizations  offering child care training. In addition, providers and inspectors have  been able to access providers’ transcripts online. State officials say that  this program has saved the state time and money, although no studies have  been done to quantify these savings. Other state officials have noted that  using an Internet system has promoted quality in child care by making the  process transparent and easily accessible. In Florida, for example, families  seeking quality child care can see the latest the inspection reports on a  facility because they are immediately posted on the Internet.
According to child care officials and the National Association for the  Education of Young Children (NAEYC), training opportunities are  maximized and retention rates for child care workers increased when  rewards for training and higher quality child care are linked. For example,  both North Carolina and Oklahoma offer incentives to providers to  encourage them to pursue training. These incentives are offered through a  program for college scholarships funded by state, federal, and private  dollars (T.E.A.C.H. Early Childhood). Both North Carolina and Oklahoma  have also adopted a salary supplement program called WAGE$ to reward  increased education attainment.
section_title: Parent Training
paragraphs: Parent training is provided by R&R organizations in each state, which  provide information on the Internet and by telephone, as well as through  written brochures, fact sheets, and newsletters. For example, Florida’s  R&R provides parents a database listing all legally operating child care and  early childhood providers, available options for care, indicators of quality  to look for when considering a provider, and what to consider when  checking on a child’s placement, that is, determining how well the  placement will meet a child’s needs. In Delaware, the R&R offered  workshops throughout the year to parents on over 105 topics pertaining to  children up to school age. In all four states we visited, the R&R agency  provided a system to help parents locate child care—often known as a  child care locator—as well as information about how to choose quality  care and what training opportunities were available for parents. One  expert we interviewed told us that it is important to educate parents  because they are the ones who visit the child care facility every day and  are most effective in helping to ensure provider compliance with state  child care standards.
section_title: Concluding Observations
paragraphs: By expanding who is covered by licensing requirements and parental  knowledge, states have increased oversight on child care providers since  1999.  However, some states have decreased the number of inspections per  facility per year. At the same time, states are maintaining their flexibility in  administering CCDF and providing parents with choice in the child care  options available to them. States use inspections to oversee the child care  provided in facilities with the greatest number of children and use less  intensive methods like self-certification for other facilities they regulate.  Self-certification affords less assurance that providers are meeting safety  and health requirements, but in an era when caseload sizes already exceed  recommended levels in many states and states find themselves challenged  by increasing child care demand, it helps keep low-cost child care  available.
The use of technology has also increased in the states for state licensing  staff, providers, and parents. Not only have the number of states using  technology in the areas associated with state activities in new areas,  providing information and training resources for parents licensing and  enforcement increased, but technology has also expanded into new areas,  providing information and training resources for parents, providers, and  training organizations on a broad range of topics for a number of different  functions. The obvious advantages of an up-to-date, Internet-based,  integrated information system have been demonstrated by Florida.  However, the size of the investment required for this type of system  depends on whether or not the state chooses to create an independent  licensing information system, or if the state wants its licensing system to  be part of a larger statewide child care information system. Florida found  it more affordable to do the former.
section_title: Agency Comments
paragraphs: We provided officials of the Administration for Children and Families  (ACF), HHS, an opportunity to comment on a draft of this report. ACF was  pleased with the findings and noted that the report will be especially  helpful to ACF and the states because it compares state child care health  and safety enforcement in 1999 and 2003. ACF’s comments are reproduced  in appendix VI. ACF also supplied technical comments that were  incorporated as appropriate.
Unless you publicly announce its contents earlier, we plan no further  distribution until 30 days after the date of this letter. At that time we will  send copies of this report to the Honorable Wade F. Horn, Assistant  Secretary, Administration for Children and Families, HHS; appropriate  congressional committees; and other interested parties. In addition, the  report will be available at no charge on GAO’s Web site at   http//:www.gao.gov. If you or your staff have any questions or wish to  discuss this material further, please call me on (202) 512-7215.
section_title: Appendix I: Scope and Methodology
paragraphs: To perform our work, we conducted a mail survey in 2004 of state  licensing officials in all 50 states and the District of Columbia about their  licensing and enforcement policies and practices in 2003. Specifically, we  asked states to report on the frequency of their compliance inspections,  background checks, training programs and educational requirements for  licensing staff, and caseload sizes. We achieved a response rate of   98 percent, with 49 states and the District of Columbia responding to our  survey. Maine did not respond. In our 1999 survey, we achieved a   100 percent response rate.
We compared our survey results with a mail survey we conducted in   1999 to identify any changes that had occurred within the past few years.  Of the 30 substantive questions on our 2004 survey, 17 were identical to  those in the 1999 survey, 1 was a version of another 1999 question, and 12  were new questions. To ensure their reliability, we pretested all new  questions with current or former state licensing officials.
Rather than using our survey data for the number of states exempting  family child care providers’ regulation, we used data from the National  Child Care Information Center (NCCIC). The responses to question 16 of  our survey (on the number of states exempting some family child care  homes from state regulation) proved problematic, as it had in the 1999  survey. Callbacks to a sample of respondents whose survey responses  differed from data produced by NCCIC showed that respondents  misunderstood our question. The NCCIC information was based on  published state standards of the regulation threshold point for the number  of children served rather than survey data. Therefore we used the NCCIC  data in this report to answer this question. Since this was similar to what  we had done to compensate for the problems in responses to that question  in the 1999 survey, the data for the 2 years are comparable.
In addition, we conducted a literature search and interviewed child care  licensing experts and state and federal officials to gather information  about critical licensing and enforcement activities occurring within the  states. The experts we interviewed included university research  professors, representatives from public policy organizations, staff from  organizations that deal with the policy and practice of providing child care  services.
With the information we gathered through these expert interviews, we  identified and conducted site visits in four states—Delaware, Florida,  North Carolina, and Oklahoma—to provide examples of promising  practices in licensing and enforcement. We conducted our work between  October 2003 and July 2004 in accordance with generally accepted  government auditing standards.
section_title: Appendix II: State Caseloads, Fiscal Years 2003 and 1999
subsections: section_title: Number of child care facilities 2003
paragraphs: Data were not available.
State that did not respond to this survey.
Iowa only provided caseload data for centers.
section_title: Appendix III: State Child Care Licensing Budget and Full-Time-Equivalent Staffing Levels, 1999 and 2003
paragraphs: Most state licensing offices reported increases in budgets and the number  of full-time equivalent (FTE) staff since1999, although an increase in one  did not necessarily reflect an increase in the other.
Some states could not provide us with FTE or budget information for particular years.
Cannot express as a percentage change because 1999 was zero.
Maine did not respond to the survey.
section_title: Appendix IV: Frequency of Licensure and Monitoring Visits in the States
subsections: section_title: Number of years for which a
paragraphs: Does the state conduct renewal  visits?
Does the state conduct renewal  visits?
Does the state conduct renewal  visits?
Does the state conduct renewal  visits?
Does the state conduct renewal  visits?
Does the state conduct renewal  visits?
Not inspected on a regular basis  At least twice a year  At least twice a year  At least twice a year  At least twice a year  Less often than once every 2 years  At least twice a year  At least twice a year  At least twice a year  At least twice a year  Family day care is provided by an individual provider in a private residence other than the child’s  home.
Group homes provide care by two or more providers in a private residence other than the child’s  home.
Centers are nonresidential facilities that provide care for children and include full- and part-time  group programs, such as nursery and preschool programs.
Maine did not respond to our survey.
section_title: Appendix V: State Survey
section_title: Appendix VI: Comments from the Department of Health and Human Services
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the person named above, Margaret Armen, Amy Buck,  Patricia Bundy, Kara Kramer, Jerry Sandau, and Jay Smale also made  major contributions to this report.
section_title: Related GAO Products
paragraphs: Child Care: Recent State Policy Changes Affecting the Availability of  Assistance for Low-Income Families. GAO-03-588, May 5, 2003.
Child Care: States Exercise Flexibility in Setting Reimbursement Rates  and Providing Access for Low-Income Children. GAO-02-894, September  18, 2002.
Child Care: States Have Undertaken a Variety of Quality Improvement  Initiatives, but More Evaluations of Effectiveness Are Needed.   GAO-02-897, September 6, 2002.
Child Care: States Increased Spending on Low-Income Families.   GAO-01-293, February 2, 2001.
Child Care: State Requirements for Background Checks.   GAO/HEHS-00-66R, February 28, 2000.
Child Care: State Efforts to Enforce Safety and Health Requirements.  GAO/HEHS-00-28, January 24, 2000.
Child Care: How Do Military and Civilian Center Costs Compare?  GAO/HEHS-00-7, October 14, 1999.
Welfare Reform: States’ Efforts to Expand Child Care Programs.  GAO/HEHS-98-27, January 13, 1998.