Policy Statement: Rationale, Structure, Process, Outcome Criteria

POLICY STATEMENT

The school district will establish and implement procedures which meet all the legal requirements for multidisciplinary assessments of each special education student by qualified individuals.

RATIONALE

A health assessment is necessary to identify health needs and to obtain information about a student's strengths and coping mechanisms. This facilitates the planning of appropriate goals and objectives which will enable the student to benefit from the educational process.

STRUCTURE CRITERIA

1. The school district is an authorized health provider in the school setting.

2. The School Nurse is recognized as a member of the interdisciplinary team.

3. The administrator or designee will notify the School Nurse -- in a timely manner -- of those students referred to the assessment team.

4. The student's school health record is available in the school setting.

5. Opportunities are provided for

-- record review

-- teacher conference

-- student observation

-- parent interview, and

-- student health evaluation.

PROCESS CRITERIA

The School Nurse will:

1. Collect health status data including:

-- growth and developmental history

-- health history

-- screening results

-- physical assessment

-- emotional status

-- performance level of daily living activities

-- interactional patterns (i.e., socialization) -- nutritional status

-- immunization status

-- student's perception of his/her own health status

-- student's health goals

-- cultural attributes

2. Collect data from:

-- student

-- family

-- significant others

-- school personnel

-- health care professionals

3. Obtain data by:

-- interview

-- screening procedures

-- observation

-- physical assessment

-- review of records and reports

4. Record data on the student's health record.

5. Interpret data by comparing it to norms and standards.

6. Formulate conclusions and recommendations based on a comprehensive assessment.

7. Identify the relationship between health status and the student's ability to learn.

8. Prepare a written report of the results of the assessment.

9. Interpret the relationship between health status and the student's ability to learn for the multidisciplinary team.

10. Participate in the development of the Individualized Educational Plan (IEP) and sign the document.

OUTCOME CRITERIA

1. All referred students will receive a health assessment.

2. Health problems that interfere with learning will be identified.

3. The student's IEP will address the Individualized Health Plan (IHP) when goals, objectives, and services are required to meet identified student health needs.

Federal Laws:

FEDERAL 

Three federal laws guarantee the rights of children with disabilities access to an appropriate education:

1) Individuals with Disabilities Act (IDEA) of 1990 is a special education law

2) Section 504 of the Rehabilitation Act of 1973 relates to civil rights

3) Americans with Disabilities Act (ADA) of 1990 relates to civil rights.

IDEA--Part B
IDEA--Part B regulations require the existence of a handicapping condition that adversely affects educational performance and necessitates special education and related services. Thus, children with health impairments may not qualify under IDEA if their disabilities cannot be shown to adversely affect educational performance.

§504
However, under §504 , students with a documented physical or mental impairment which substantially limits participation in major life activities can be provided related services (including school nursing) even though not eligible for special education.

ADA
And, ADA -- like §504, though not an entitlement act providing funds to state or local education agencies to support compliance with the law -- prohibits discrimination against individuals with disabilities in equal services, facilities, privileges, and accommodations.

Nebraska State Laws

State laws are substantially the same as federal laws and regulations. Thus Nebraska State Laws guarantee students with disabilities:

-- the right to school attendance in the least restrictive environment,

-- multidisciplinary evaluation for determination of eligibility under IDEA or §504,

-- access to an appropriate educational program including related services,

-- a written Individual Education Plan (IEP) under IDEA, and an Individualized Health Plan (IHP) for §504 which defines objectives, services, criteria, and timelines for evaluation, and

-- an appeal process if there is disagreement on issues relating to the educational program or access to it.

Complex clinical-legal issues regarding the provision of safe and appropriate health care to students with special needs exist.

School Nurses must be cognizant of issues relative to licensure, delegation and supervision, confidentiality, and documentation.

IDEA and Section 504: A Comparison of "Student Populations"

IDEA/504 STUDENTS

Students are qualified under one or more of thirteen (13) IDEA disabling conditions. Specially designed individual education programs are planned for each student by IEP Teams

 

SECTION 504 STUDENTS ONLY

Due to substantial mental or physical impairments that limit one or more of the students, major life activities, special accommodations to the student's program are required. A 504 accommodation plan is designed for each student according to individual need.

Examples of potential 504 handicapping conditions not typically covered under IDEA are:

• communicable diseases
• HIV, Tuberculosis
• medical conditions
• asthma, allergies, diabetes, heart disease
• temporary medical conditions due to illness or accident
• Attention Deficit Disorder
• behavioral difficulties
• drug/alcohol addiction
• other conditions

With permission - National Information Center for children and youth with Disabilities

Early Intervention in Nebraska

IDEA, Part H, and Nebraska's Early Intervention Act

Effective July 1, 1979, Nebraska implemented a state mandate making local school districts responsible for providing special education and related services to all children with verified disabilities, birth to twenty-one.

These special education and related services must be provided in accordance with federal and state statutes and regulations (Nebraska Department of Education Rule 51). Thus, local districts provide diagnostic services to children via a multidisciplinary team evaluation to determine eligibility. Some districts utilize their own multidisciplinary teams; others contract with one of a number of Nebraska Department of Education approved agencies.

When a child is verified as eligible for special education and related services, the resident school district is responsible for the provision of these services. If not providing services directly, the district may contract with approved service providers such as another school district, ESU, Head Start, day care center, private preschool, other service agencies or private practitioners. Services are provided in both center-based and home-based settings, either separately or in combination. Programs include both integrated and self-contained models.

Educational and support services include: evaluation and assessment of the child; early childhood special education programs; speech, language and audiology services; physical and occupational therapy; and transportation.

P.L. 99-457 / NEBRASKA EARLY INTERVENTION ACT

 

P.L. 99-457. Part H: 14 Basic Elements Definition of developmental delay Timetable for availability of services Comprehensive multidisciplinary evaluation of needs of children and families Individualized family service plan which includes case management A comprehensive child-find and referral system Public awareness program to focus on early identification A central directory of services, resources, state experts, research and demonstration projects A comprehensive system of personnel development A single line of authority to a lead agency A policy of contracting or making arrangement with local service providers A procedure for timely reimbursement of funds Procedural safeguards Policies and procedures for personnel standards A system of compiling data regarding the early intervention program

P.L. 99-457 Early Intervention Services: Must Be Provided under public supervision Provided at no cost except where federal or state law provides for a system of payments Designed to meet a handicapped infant's or toddler's developmental needs Provided to eligible children under 3 years of age Provided in conformity with an individualized family service plan

Early Intervention Services: Must Include Family training, counseling and home visits Special instruction Speech pathology and audiology Occupational therapy Physical therapy Psychological services Case management services Medical services only for diagnostic or evaluation purposes Early identification, screening and assessment services Health services necessary to enable the infant or toddler to benefit from the other early intervention services

Roles and Standards for Providing Casemanagement

The School Nurse provides Case Management Services * to children and families at risk in order to promote early Identification, Evaluation, Diagnosis, and Coordinated Treatment in Early Intervention Service Systems.

* NOTE: Nebraska uses the term Service Coordination in place of Case Management Services.

RATIONALE:

Nurses are particularly suited to provide case management to high risk children with multiple health problems and their families. Nursing care embodies several elements of case management: it is complex, highly interactive, facilitates client's self-care capability, provides environments which assist clients to gain or maintain health, promotes the efficient use of resources and the creation of new services.

STRUCTURE CRITERIA:

1. A mechanism is in place that allows nurses participation in the identification of at-risk infants and children and the determination of their designated case manager.

2. Procedures are developed for the assignment of a nurse case manager for infants, children, and families with multiple complex health problems, and children in transition from health care facilities to the community.

3. Lines of accountability for outcomes of case management are established to assure the well being of the client.

4. Adequate resources are available to provide case management to all eligible clients.

5. Systems to protect client confidentiality.

PROCESS CRITERIA :

The School Nurse:

1. Provides case finding and screening to identify appropriate clients for case management.

2. Completes appropriate assessments.

3. Develops, implements, monitors, and modifies a plan of care through an interdisciplinary and cooperative team process in conjunction with the family.

4. Advocates for the child and the family with appropriate community resources.

5. Coordinates service providers responsible for furnishing services needed by child and family.

6. Monitors the service plan to ensure quality, quantity, timeliness, and effectiveness of the services.

7. Monitors the child's/family's progress towards the achievement of goals specified in the care plan.

8. Periodically reassesses to assure that services are appropriate, necessary, and do not increase dependence.

9. Develops new services in local communities.

OUTCOME CRITERIA:

1 . Child's and family's self-care capability is enhanced.

2. Family has access to needed services.

3. Family receives appropriate, coordinated delivery of necessary services.

4. Families receive personalized care.

5. Families make informed decisions about services.

(This section adapted from and used with permission of the National Standards of Nursing Practice for Early Intervention Services 01993. The complete document is available from NEBRASKA HEALTH AND HUMAN SERVICES, School Nurse Coordinator.)

Recommended References and Resources on Students with Special Needs

PROJECT SCHOOL CARE
Project School Care is a program of Children's Hospital, Boston, which offers services in consultation, training and information nationally. Project School Care publishes a reference and guide book called Children Assisted by Medical Technology in Educational Settings: Guidelines for Care. This resource is specifically recommended for School Nurses serving students requiring skilled nursing care procedures. These guidelines are updated on a regular basis by medical, nursing, educational and legal experts from across the United States. All updates are provided as part of the original purchase.

To purchase a copy of Children Assisted by Medical Technology in Educational Settings: Guidelines for Care, write or call:

Project School Care
Gardner 6
300 Longwood Avenue
Boston, MA 02115
Phone: 617-735-6714
Fax: 617-735-7940

Additional References:

"A Practical Approach to Teaching Self-catheterization to Children with Myelomeningocele," Brown, J.P. (1990). Journal of Enterostomal Therapy, 17, 54-6.

AIDS/HIV: The Role of the School Nurse. (1990). Scarborough, ME: National Association of School Nurses, Inc. 201-883-2117

Care of a Percutaneous Endoscopic Gastrostomy (P.E.G.) and the Button Replacement Gastrostomy. (1987). Bard Interventional Products. (800) 826- BARD.

Clean Intermittent Catheterization. (1986) Video with manual. University of Colorado Health Sciences Center. Lawrence, KD: Learner Managed Designs, Inc.

"Developmental Assessment of the Technology-dependent Infant and Young Child," Ahmann, E. & Lipsi, K. (1992). Pediatric Nursing, 18 (3): 299-305.

Developmental Variations and Learning Disorders, Levine, M.D. (1987). Toronto: Educators Publishing Service, Inc.

Getting It Started and Keeping It Going: A Guide for Respiratory Home Care of the Ventilator Assisted Individual. (1987). Manual and video. Ventilator Assisted Care Program and Respiratory Care Department, Children's Hospital, New Orleans, LA.

Guidelines for the Delineation of Roles and Responsibilities for the Safe Delivery of Specialized Health Care in the Educational Setting. (1990). Joint Task Force for the Management of Children with Special Health Needs. Reston, VA: Council for Exceptional Children.

Guidelines for the Management of Students with Genetic Disorders: A Manual for School Nurses. Schwab, N. (Ed.). (1992). Box 682, Gorham, ME: New England Regional Genetics Group.

Healthy Care for Students with Disabilities; An Illustrated Medical Guide for the Classroom, Graff, J.C., Ault, M.M., Guess, D., Taylor, M. & Thompson, B. (1990). University of Kansas. Baltimore, MD: Paul H. Brookes Publishing Co.

Home Oxygen for Infants and Young Children (1988). Video and manual. University of Colorado Health Sciences Center. Lawrence KD: Learner Managed Designs.

How Schools Work and How to Work with Schools: A Guide for Health Professionals. (1990). Alexandria, VA: National Association of State Boards of Education. (703) 684-4000.

Integration Checklist: A Guide to the Full Inclusion of Students with Disabilities . (1990, Summer). New Hampshire Challenge. Family Support Bulletin. United Cerebral Palsy Association.

Managing the Student with a Chronic Health Condition: A Practical Guide for School Personnel, Larson, G. (Ed.). (Rev. 1990). North Branch, MN: Sunrise River Press.

Manual for Quality Nursing Intervention in the School, Hootman, J. (Rev. 1990). Multinomah Education Service District, School Health Services, 11611 NE Ainsworth Circle, Portland, OR 97220

Nursing Care of Infants and Children, fourth edition, Whaley, L. & Wong, D. (1991). St. Louis: Mosby Yearbook.

Nursing Guide to the Care and Maintenance of Hickman and Broviac Catheters. (1986). A Nursing Guide and a Video. Cranston, RI: Davol Inc. (800) 556-6275.

Pediatric Adaptive Technologies: Gastrostomy Tube Feeding. Zechman, R., Ross, A, & Watkins, J. (1986). Video and workbook. Seattle, WA: University of Washington.

Primary Care of the Child with a Chronic Condition, Jackson, P. & Vessey, J. (1992). St. Louis: Mosby Yearbook.

Serving Culturally Diverse Families of Infants and Toddlers with Disabilities. Anderson, P. & Fenichel, E. (1989). Washington, D.C.: National Center for Clinical infant Programs.

These Special Children: The Ostomy Book for Parents of Children with Colostomies, Ileostomies and Urostomies, Jeter, K.F. (1982). Palo Alto, CA: Bull Publishing Company.

Your Child Has a Tracheostomy: A Guide for Home Care, Crimlisk, J.T., Murray, S.V., Judas, M.L. Jorgensen, K.M., Thompson, J.A. (1990). Department of Health and Hospitals. Boston, MA: Boston City Hospital (617) 534-4030.

Your Complete Guide to Central Venous Catheters, Viall, C.D. (1990). Nursing 90. 2, 34-41

Delegation of Nursing Care for Students with Special Health Care Needs in a School Setting

A position statement developed by The National Association of State School Nurse Consultants, Inc.

New Demands on Nursing Services

Students with special health care needs are placing new demands for services on school districts across the nation. Local school boards are being asked to provide health care staff to perform a level of nursing service not seen before in the school setting.

There are 4 reasons for these new demands on school administrators:

1. The trend toward outpatient and homebound treatment rather than treatment in an acute care setting;

2. Advances in medical technology which allow monitoring and health maintenance services outside the confines of acute care institutions;

3. The federal mandate for mainstreaming of special education students with complex health needs;

4. Parent's expectations regarding their child's right to care in the school setting.

These developments raise issues of educational placement, student safety, and school and professional liability that need to be addressed.

(This section used with permission of The National Association of State School Nurse Consultants, Inc. ©1990)

In making decisions

..about the educational placement of students with health care needs, and

..about who is to provide the nursing .service to students with health care needs

1) the primary concern must be for the health and safety of the student.

2) The secondary concern is for the legal responsibility of all involved parties (e.g., the school board, school administrators, school staff and, in particular, the School Nurse).

School administrators are legally responsible for the safety of all students - and this responsibility includes the responsibility for providing the required health services by a qualified staff.Using non-qualified staff could risk potential harm to students. In addition, administrators must realize non-licensed school staff are liable if they practice nursing or medicine without a license.

The School Nurse's Responsibility for Quality Care
The School Nurse's ultimate responsibility is to the student for the quality of nursing care rendered. If the School Nurse's decisions on care, and who can safely perform it, are in error, the student suffers. In addition, the School Nurse can be personally liable and possibly in violation of the Nurse Practice Act, which might precipitate disciplinary action against his/her license to practice.

The School Administrator's Responsibility
School district administrators have the responsibility to determine educational placement of the student. Administrators are not responsible for deciding whether or not the required nursing service must be provided by a licensed health care provider. The registered (school) nurse is required to make that decision based on the Nurse Practice Act. If another licensed health care practitioner delegates nursing care to a non- licensed individual while the nurse is responsible for the supervision, then the nurse must make delegation determinations before assuming responsibility for the activity.

Questions About Delegating Care

There are 2 critical questions involved in delegating and supervising nursing care:

1. Is this nursing task under the State's definition of nursing?

Nursing and medical activities are defined by state statute and interpreted by state boards of nursing and state boards of medicine and/or state attorneys general and courts. Based on this definition, the nurse needs to decide whether or not the procedure is one that must be performed by a registered nurse.

* (In Nebraska, nursing and medicine are regulated by the Nebraska Health and Human Services .)

2. Can the procedure be rendered by non-licensed school staff under the supervision of a registered nurse?

Nursing activities not specifically addressed in statute or legal interpretations can be performed by a non-licensed individual:

-- if the activity does not require the exercising of nursing judgment and

-- if delegated and supervised by a registered nurse.

Determination Required in Each Case

By answering the above two questions, the delegating and supervising registered nurse makes the following determinations for each student with health care needs and each nursing activity required on a case-by-case basis:

1. The nurse validates the necessary physician orders (including emergency orders) parent/guardian authorization, and any other legal documentation necessary for implementing the nursing care.

2. The nurse conducts an initial nursing assessment.

3. Consistent with the Nursing Practice Act and related regulations of each state's board of nursing, and with his/her assessment of the student, the nurse determines who can be delegated the task -­ licensed (registered nurse or licensed practical vocational nurse), unlicensed health care provider or other staff person.

4. The nurse determines the amount of in-service training required for the individual performing the nursing service consistent with the Board of Nursing regulations governing the practice by unlicensed personnel. * Nebraska has no such rules/regulations at this time.

5. The nurse evaluates the competence of the individual to safely perform the task prior to delegation.

6. The nurse provides a written care plan to be followed by the unlicensed staff person.

7. The nurse determines the amount and type of registered nurse supervision necessary.

8. The nurse determines the frequency and type of routine student health reassessment and reevaluation necessary for ongoing safety and efficacy.

9. The nurse provides in the care plan for instances when a change in student condition, performance of procedure or change in other circumstance warrants registered nurse intervention and/or reassessment.

10. The nurse determines and requires the amount and type of documentation to be done by unlicensed staff, consistent with the State's Nurse Practice Act and rules promulgated by each State Board of Nursing.

11. The nurse documents activities appropriate to the nursing actions listed above.

If the School Is Not the Best Setting for Care

If the delegating and/or supervising nurse determines that a requested procedure may cause harm or cannot safely and efficaciously be performed in the school setting, the nurse should take the following steps:

1. Write a memo to his/her immediate supervisor explaining the situation in specific detail, including:

a. The reason the procedure should not be performed in school, and a rationale to support this; or

b. Recommendations for safe performance of the procedure in the school

2. Maintain a copy of the memo for the School Nurse's personal file.

3. Forward copy(ies) of the memo to one or all of the following as indicated:

-- The State Board of Nursing

-- the District Superintendent, and

-- the state School Nursing Consultant/Coordinator

4. Repeat notification that the requested procedure should not be performed in school until resolution of the issue;

Selected Federal Statutes

STATUTES Affecting the Education and Civil Rights of Children and Youth with Disabilities*

P.L. 89-10, The Elementary and Secondary Education Acts of 1965.
Provided a comprehensive plan for re-addressing the inequality of educational opportunity for economically underprivileged children. It became the statutory basis upon which early special education legislation was drafted.

P.L. 89-313, The Elementary and Secondary Education Act Amendments of 1965.
Authorized grants to state institutions and state-operated schools devoted to the education of children with disabilities. It was the first federal grant program specifically targeted for children and youth with disabilities.

P.L. 89-750, The Elementary and Secondary Education Amendments of 1966.
This law amended the Title VI of P.L. 89-10 and established the first federal grant program for the education of children and youth with disabilities at the local school level, rather than at state-operated schools or institutions. It established the Bureau of Education of the Handicapped (BEH) and the National Advisory Council (now called the National Council on Disability).

P.L. 91-230, The Education of the Handicapped Act of 1970.
This law amended Title VI of P.L. 89-750 and established a core grant program for local educational agencies. This program is known as Part B. This law also authorized a number of discretionary programs.

P.L. 93-112, The Rehabilitation Act of 1973.
This law provides a comprehensive plan for providing rehabilitation services to all individuals, regardless of the severity of their disability. It also provided for civil rights enforcement under Section 504. This law was amended by P.L 98-221 in 1983, and by P.L. 99-506 in 1986.

* Adapted from: DeStefano and Snauwaert (1989), with permission, National Information Center for Children and Youth with Disabilities.

P.L. 93-380, The Education Amendments of 1974.
These amendments to the Elementary and Secondary Education Act contained two important laws. One is the Education of the Handicapped Act Amendments of 1974. This law was the first to mention the provision of an appropriate education for all children with disabilities. It also re-authorized the discretionary programs. The second important law, the Family Education Rights and Privacy Act, often called the Buckley Amendment, gives parents and students under the age of 18, and students age 18 and over, the right to examine records kept in the student's personal file.

P.L. 94-142, The Education for All Handicapped Children Act of 1975.
This law mandates a free appropriate public education for all children with disabilities, ensures due process rights, mandates education in the least restrictive environment, and mandates Individualized Education Programs, among other things. It is the core of federal funding for special education.

P.L. 98-199, The Education of the Handicapped Act Amendments of 1983.
This law re-authorized the discretionary programs, including the establishment of services to facilitate the transition from school to work for youths with disabilities through research and demonstration projects; the establishment of parent training and information centers; and funding for demonstration projects and research in early intervention and early childhood special education.

P.L. 98-524, The Carl D. Perkins Vocational Education Act of 1984.
This law authorized funds to support vocational education programs to include youths with disabilities. The law stated that individuals who are members of special populations must be provided with equal access to recruitment, enrollment, and placement activities in vocational education.

P.L. 99-372 The Handicapped Children's Protection Act of 1986.
This law provides for reasonable attorney's fees and costs to parents and guardians who prevail in administrative hearings or court when there is a dispute with a school system concerning their child's right to a free appropriate special education and related services.

P.L. 99-457, The Education of the Handicapped Act Amendments of 1986
This law mandates services for preschoolers with disabilities and established the Part H program to assist states in the development of a comprehensive, multidisciplinary, and statewide system of early intervention services for infants and toddlers (birth to age 3). This law also re-authorized the discretionary programs and expanded transition programs.

P.L. 100-407, The Technology-Related Assistance for Individuals with Disabilities Act of 1988.
The primary purpose of this law is to assist states in developing comprehensive, consumer-responsive programs of technology-related assistance and to extend the availability of technology to individuals with disabilities to their families. Assistive technology device is broadly defined in the law to give the states flexibility in the programs to be developed. Assistive technology services under this law include 8 activities related to developing consumer-responsive services with federal funds.

P.L. 101-127, The Children with Disabilities Temporary Care Reauthorization Act of 1989.
This law is actually a part of a large federal law, the Children's Justice Act, P.L. 99-401. Title II of this law includes provisions to fund temporary child care (e.g., respite care) for children who have disability or chronic illness and crisis nurseries for children at risk of abuse or neglect. In 1989, P. L. 101-127 extended and expanded this program for two years and included an increase in funding for these programs from $5 million to $20 million in 1990 and 1991. By July, 1990, 87 grants were awarded to states to develop and establish respite care programs and crisis nurseries.

P.L. 101-336, The Americans with Disabilities Act of 1990.|
This law, based on the concepts of the Rehabilitation Act of 1973, guarantees equal opportunity for individuals with disabilities in employment, public accommodation, transportation, State and local government services, and telecommunications. The ADA is the most significant federal law assuring the full civil rights of all individuals with disabilities.

P.L. 101-392, The Carl D. Perkins Vocational and Applied Technology Education Act of 1990.
This law amended P.L. 98-524 for the purpose of making the United States more competitive in the world economy. This law is closely interwoven with the Education of the Handicapped Act (P.L. 94-142) toward guaranteeing full vocational education opportunity for youth with disabilities.

P.L. 101-476, The Education of the Handicapped Act Amendments of 1990.
This law changed the name of EHA to the Individuals with Disabilities Education Act (IDEA). This law re-authorized and expanded the discretionary programs, mandated transition services and assistive technology services to be included in a child's or youth's IEP, and added autism and traumatic brain injury to the list of categories of children and youth eligible for special education and related services.

P.L. 101-496, The Developmental Disabilities Assistance and Bill of Rights Act of 1990.
This law authorizes grants to support the planning, coordination, and delivery of specialized services to persons with developmental disabilities. In addition, this law provides funding for the operation of state protection and advocacy systems for persons with developmental disabilities. The original law was enacted in 1963 by P.L. 88-164. In 1987, P.L. 100-146 significantly expanded the Act to include persons with mental retardation, autism, cerebral palsy, and epilepsy.