American Disabilites Act - 504
This segment of the manual briefly describes the role of Section 504 of the Rehabilitation Act of 1973 and Special Education laws as it applies to a public school district’s duty to provide a Free Appropriate Public Education (FAPE) for students with disabilities.
Section 504 of the Rehabilitation Act of 1973
Section 504 is a federal civil rights law designed to eliminate disability discrimination in programs and activities receiving federal funding. Therefore, all public school districts that receive federal funds must comply with Section 504.
A school-aged student is considered disabled under 504 if the student has a physical or mental impairment that substantially limits one or more major life activities.
Description of terms, roles and responsibilities and the process for referral and evaluation of students for consideration of Section 504 Accommodations plan in school is outlined in: “A Parent & Educator Resource Guide to Free Appropriate Public Education (under Section 504 of the Rehabilitation Act of 1973). This guide reflects the Federal 2008 amendment that significantly broadened the definition of what constitutes a “disability.” With the expanded definitions, many students with health care needs qualify for consideration of Section 504 Accommodation plans at school.
A 504 plan is a written plan that describes the educational and related aids and services that a district 504 team determines a disabled student needs to receive a FAPE. The content of a Section 504 Plan may change within a school year or between school years as a student’s needs and services change. A district must provide the services identified in a student’s Section 504 plan.
The U.S. Department of Education enforces Section 504 through the Office of Civil Rights. In determining reasonable accommodations, OCR is a resource for both the district and the family.
Special Education Law
The Federal “Individuals with Disabilities Education Act” (IDEA) ensures that children with disabilities have access to a free appropriate public education (FAPE). IDEA is focused on improving educational results for children with disabilities. RCW 28A.155 provides the statutory basis for special education services in Washington, and WAC 392-172A provides the regulatory basis for both IDEA and RCW 28A.155.
In the Supreme Court Case of CEDAR RAPIDS COMMUNITY SCHOOL DIST. v. GARRET F. (96-1793) 526 U.S. 66 (1999) http://www.law.cornell.edu/supct/html/96-1793.ZS.html, "The IDEA requires the school district to provide [the student] with the nursing services he/ [she] requires during school hours. [...] The IDEA’s 'related services' definition broadly encompasses those supportive services that 'may be required to assist a child with a disability to benefit from special education.' Furthermore, 'related services' [... are not...] 'medical services.' [...] The Secretary of Education had reasonably determined that 'medical services' refers to services that must be performed by a physician and not to school health services."
In a more recent case known as Endrew F. v. Douglas County School District, the U.S. Supreme Court clarified the intent of Congress by affirming a high standard for the Individuals with Disabilities Education Act (IDEA). This March 2017 ruling found that public schools must provide students with disabilities more than a minimal benefit. Summary of Endrew v. Douglas County and Supreme Court FAPE Ruling March 2017
Nursing Care Services for Students
A variety of nursing care services may be necessary for students with both Section 504 Accommodation AND Special Education plans in schools. Some of the nursing care services are addressed in this manual:
• Life-Threatening conditions (See Life-Threatening Conditions)
• Clean Intermittent Catheterization (See Clean Intermittent Catheterization)
• Medication in Schools (See Medication in Schools)
• Gastrostomy Tube Feedings (See Gastrostomy Feedings)
Other nursing services which may be necessary for students in school and are not discussed in detail in this guidebook include:
• Tracheotomy care
• Assisted ventilation
• Central venous catheters
• Rectal medication
School settings need to adapt to meet the educational and health needs of students assisted by medical technology. School nurses have the licensure and education to determine the need for access to specialized nursing care and to provide services and facilitate systems that foster social, emotional, physical, cognitive, and spiritual wellness.
RCW 28A.210.260 Public and Private Schools: Administration of Medication--Conditions allows school districts and private schools which conduct any of grades kindergarten–twelfth to provide for the administration of oral medication, topical medication, eye drops, ear drops or nasal spray of any nature to students who are in the custody of the school district or school at the time of administration, but are not required to do so. Sunscreen is now considered an exception to this RCW.
RCW 28A.210.270 Public and Private Schools: Administration of Medication—Immunity from Liability, Discontinuance, Procedure states that when the conditions specified in RCW 28A.210.260 have been substantially complied with, then the employee, the school district or school, and the members of the governing board, shall not be liable in any criminal action or for civil damages as a result of the administration of the medication.,
WHAT IS REQUIRED?
The following requirements are outlined in RCW 28A.210.260 and 270:
• Administration of Medication
• Training, Delegation, and Supervision of Unlicensed Staff
• Parental Consent and Medical Authorizations
• Safeguarding Legend Drugs
• Parent-Designated Adult
• Immunity from Liability
• To accommodate students with heath needs who require medication during the school day or during school-sponsored events.
• To provide safe medical management for students receiving medication at school, protecting students from untoward effects of medication, and contributing to a safe and healthy learning environment for those students needing medication in the course of the school day or during participation in school-sponsored activities.
• To prepare and protect school staff members as they provide care for students receiving medication at school.
• For any student who needs medication during the school day and/or school-sponsored events.
• For unlicensed staff administering medications to students.
• When family requests medication to be administered at school.
• Before unlicensed school staff can administer medication, the registered nurse must assess and determine that it is appropriate to delegate and then provide necessary training.
• Before the delegation process is completed and until staff is prepared to administer medication, family may come to school to administer medication if a licensed nurse is not available to do so.
PROCEDURAL GUIDELINES, ROLES, AND RESPONSIBILITIES:
Sequence of procedures at any time:
1. Family responsibilities:
o Family requests and gives written authorization for medication to be administered at school. This must be done each school year
o Family obtains and brings signed health care provider authorization with information about the medication and specific directions for administration. Authorizations are only valid for one school year.
o Family (or other adult) brings medication to school in original, labeled container.
o Family (or other adult) counts and signs for amount of medication brought to school (consider using a sign- in form to count and track medications brought to school).
o Family (or other adult) provides only one-month’s supply (approximately 20 school days) plus 3 days of disaster supply medication to be stored at school.
2. School staff member accepts medication, checks expiration date, MUST COUNT Medication brought to school, and sign form with adult who confirms count.
3. School staff members ensure that medications are kept in a secure, locked cabinet. Back-up emergency medications for anaphylaxis and asthma must be kept in a location to which the student has immediate access in the event of an asthma or anaphylaxis emergency. RCW 28A.210.370
4. Registered nurse assesses student health and functioning to determine if medication and order are appropriate for student. For students who self-carry their medication, this assessment should include an evaluation of the student’s ability to carry and administer his/her own medicine safely at the time needed and without adult supervision.
5. Registered nurse reviews medication orders to determine if there are any issues that need to be addressed so that the student is able to receive medication safely at school.
6. Registered nurse ensures that information on the medical authorization, the medication label, and the medication administration record at school are identical.
7. Registered nurse creates a system of storage for emergency medication so that there is immediate access to medication in case of emergency.
8. Registered nurse, in collaboration with building administrator, identifies appropriate school staff members who are competent, available, and willing to accept responsibility to administer medication to student.
9. Registered nurse trains and then delegates to selected school staff members the authority to administer medication to specific student. The registered nurse holds responsibility for all delegated activities and therefore the registered nurse must decide what may be delegated and what may not be delegated (and to whom) according to professional nursing assessment and RCW 28A.210.260. A registered nurse may not delegate nursing activities that include the core of the nursing process (assessment, diagnosis, planning and evaluation) or procedures that require specialized knowledge, judgment, and/or skill.
10. Registered nurse describes required methods of administration of medication using the Six Rights:
Right Student: Student says name or staff checks student picture on medication log.
Right Medication: Student names the medication and staff double-checks name of medication on medication log and medication container.
Right Dose: Student states the dose and staff double-checks the dose of medication on medication log and medication container.
Right Route: Student states the route [method of administration, e.g. by mouth] and staff double-checks the route of medication on medication log and medication container.
Right Time: Student states the time the medication is to be given and staff double-checks the time of medication administration on medication log and medication container.
Right Documentation: Staff correctly documents medication administration as soon as possible on the student’s medication record (log).
11. Any violation of the above Six Rights requires that a medication error process be initiated, including appropriate documentation.
12. Registered nurse documents training and delegation.
13. School staff members document receiving and accepting delegation responsibilities by signing delegation form.
14. Registered nurse files documentation of nurse delegation and staff signature in training/delegation file.
Sequence of procedures throughout the School Year
1. Registered nurse regularly monitors (daily, if necessary) student’s health status,
evaluates systems and plans, and modifies plans as necessary.
2. Registered nurse provides ongoing monitoring and supervision of staff who administer
medications under nurse delegation and documents his/her findings, additional training that is provided or other related action.
3. School Staff - monthly- notify families when routine medication supply must be refilled. This is necessary to ensure that students consistently receive their medication at school.
4. At the end of the school year, the school staff notifies families to pick up any remaining medication(s) so that none remains at school over the summer break. However, if a student will be attending summer school and will need medication as supplied and ordered, family notification may be delayed until the completion of summer school.
For More Information on Medication in School
Washington State Law:
● RCW 28A.210.260 Public and Private Schools: Administration of Medication—Conditions
● RCW 28A.210.270 Public and Private Schools: Administration of Medication—Immunity from Liability, Discontinuance, Procedure
● RCW 28A.210.320 - Children with life-threatening health conditions - Medication
or treatment orders – Rules
● RCW 28A.210.370 - Students with Asthma
● RCW 28A.210.380 - Anaphylaxis—Policy guidelines—Procedures—Reports
● RCW 69.51A.060 - Crimes—Limitations of chapter. (medical marijuana use in schools)
● RCW 28A.210.383 - Epinephrine auto injectors (Epi pens) – School supply – Use
● RCW 28A.210.330 - Students with Diabetes
● RCW 28A.210.355 - Students with Epilepsy
Manuals and Guidance Documents:
Fluids or liquid nutrition given through a tube surgically placed directly into the stomach. These feedings may be intermittent for specific times of the day (usually by gravity), or they may be given continuously by a mechanized pump.
WHAT IS REQUIRED?
• If the student qualifies as disabled under Section 504 of the Rehabilitation Act of 1973, the provision of gastrostomy tube feedings at school may be a necessary accommodation.
• The registered nurse may provide or delegate gastrostomy tube feedings at school if following a registered nursing assessment, it is safe to do so. (Unlicensed Practice Task Force Recommendations, Nursing Care Quality Assurance Commission – March, 1991). The registered nurse holds responsibility for all delegated activities and therefore must decide what nursing activity may be delegated and what may not be delegated (and to whom) according to professional nursing assessment. A registered nurse may not delegate nursing activities that include the core of the nursing process (assessment, diagnosis, planning and evaluation) or procedures that require specialized knowledge, judgment, and/or skill. Parental Consent and Licensed Health Care Provider (LHP) Authorization are required.
Some students are unable to ingest adequate hydration and/or nutrition by swallowing.
• To provide safe medical management for students needing G Tube feedings or hydration- including protection from untoward effects of G Tube feedings or hydration, and to contribute to a safe and healthy learning environment for students needing G Tube medical management at school or school sponsored activities.
• To prepare and protect school staff members as they provide care for students needing G Tube feedings.
• For every student who requires G Tube feedings at school.
• For school staff who assist with or perform G Tube feedings: in-service training and ongoing supervision of procedures and symptoms of complications of G Tube feedings.
• When family and LHP request G Tube feedings be given at school.
• Before staff may perform or assist with G Tube feedings the registered nurse must provide training and delegation and thereafter, ongoing supervision.
PROCEDURAL GUIDELINES, ROLES, AND RESPONSIBILITIES:
Sequence of procedures at any time:
1. Family responsibilities:
o Requests G Tube feedings or hydration at school and gives written authorization for feedings or hydration to be performed at school.
o Obtains and brings signed LHP authorization with information about the procedure and orders for the procedure to be performed at school.
2. Registered nurse initiates LHP authorization for G Tube feeding at school (if not done by family).
3. School staff members accept LHP authorization for G Tube feeding at school and give to registered nurse for review.
4. Registered nurse assesses student health and functioning to determine if G Tube feeding order is appropriate for student at school.
5. Registered nurse reviews G Tube feeding order to determine if it is in the best interest for the student to receive feeding at school.
6. Registered nurse develops an Individual Health Plan (IHP) consistent with health care provider orders. IHP describes explicit step-by-step actions of the procedure, signs of problems that might occur with the procedure, and what actions to take if problems occur.
7. Registered nurse develops format for documentation of G Tube procedure consistent with LHP orders. Form is to be completed by school staff members trained to perform G Tube feeding/hydration.
8. Registered nurse develops or ensures that documentation of care form is consistent with LHP orders.
9. Registered nurse in collaboration with building administrator, identifies appropriate school staff members who are competent, available, and willing to accept responsibility to provide or assist with G Tube feeding/hydration for student.
10.Registered nurse delegates specific school staff to perform or assist with G Tube for a specific student. The RN holds responsibility for all delegated activities and therefore the registered nurse must decide what may be delegated and what may not be delegated according to professional nursing assessment. A registered nurse may not delegate nursing activities that include:
o The core of the nursing process (assessment, diagnosis, planning and evaluation) or procedures that require specialized knowledge, judgment, and/or skill.
11. Registered nurse documents training, delegation and ongoing supervision of staff.
12. School staff members document receiving and accepting delegation responsibilities by signing delegation form.
13. Registered nurse files documentation of nurse delegation and staff signature in training/delegation file.
14. Registered nurse regularly monitors (often-daily) student’s health status, evaluates systems and plans, and modifies plans as necessary.
Sequence of procedures for student's first day of school:
1. Registered nurse ensures that staff is prepared and that all necessary forms and equipment are in place so that student can safely attend school.
Sequence of procedures throughout the school year:
1. Registered nurse provides ongoing monitoring and supervision of staff to provide or assist with
G Tube feeding under registered nurse delegation.
For More Information on Gastrostomy in School
● Registered Nurse Delegation in School Settings: Kindergarten-Twelve (K-12) Grades, Public and Private Schools. Department of Health Nursing Care Quality Assurance Commission Advisory Opinion NCAO 15.00 https://www.doh.wa.gov/Portals/1/Documents/6000/NCAO15.pdf
● Seattle Children's information on gastrostomy tube care and feeding: