Quality Rating Improvement Systems (QRIS) frequently include the Infant-Toddler Environment Rating Scale-Revised (ITERS-R) as part of rating and improving child care quality. However, studies utilizing the ITERS-R consistently report low quality, especially for basic caregiving items. This research examined whether the low scores reflected the absence of basic health practices or challenges with the scoring procedures and quality standards of the instrument. Classroom observations (N = 95) using an alternative scoring system for the ITERS-R showed that most classrooms met more indicators than the traditional scoring methods captured. Additional data collected for hand washing, diaper changing, and table washing in a subset of classroom (n = 41) indicated that few classrooms consistently met the embedded standards for the basic caregiving items. Although the additional data showed the absence of table washing and hand washing in many classrooms, more variability existed than with the traditional scoring. If the traditional scoring method of the instrument does not capture the true variability of classroom practice, its use in the field should be examined. Classrooms in centers meeting higher standards of structural quality scored better on the basic caregiving items than classrooms meeting licensing requirements. Implications for child care quality improvement efforts are discussed. (author abstract)