CHAPTER 14
SCHOOL HEALTH SERVICES
281—14.1(256) Medication administration. Each school district, area education agency, and school shall establish medication administration policy and procedures, which include the following:
	14.1(1) A statement on administration of prescription and nonprescription medication.
	14.1(2) A statement on an individual health plan pursuant to rule 281—14.2(256) when administration requires ongoing professional health judgment.
	14.1(3) A statement that persons administering medication shall include authorized practitioners, such as licensed registered nurses and physicians, and persons to whom authorized practitioners have delegated the administration of prescription and nonprescription drugs (who shall have successfully completed a medication administration course). Individuals who have demonstrated competency in administering their own medications may self-administer their medication. Individuals shall self-administer asthma or other airway constricting disease medication or possess and have use of an epinephrine auto-injector with parent and physician consent on file, without the necessity of demonstrating competency to self-administer these medications.
	14.1(4) A provision for a medication administration course provided by the department that is completed every five years with an annual medication administration procedural skills check completed with a registered nurse or pharmacist. A registered nurse or licensed pharmacist shall conduct the course. A record of course completion shall be maintained by the school.
	14.1(5) A requirement that the individual’s parent provide a signed and dated written statement requesting medication administration at school.
	14.1(6) A statement that medication shall be in the original labeled container either as dispensed or in the manufacturer’s container.
	14.1(7) A requirement that a written medication administration record shall be on file at the school and shall include:
	a. 	Date.
	b. 	Individual’s name.
	c. 	Prescriber or person authorizing administration.
	d. 	Medication.
	e. 	Medication dosage.
	f. 	Administration time.
	g. 	Administration method.
	h. 	Signature and title of the person administering medication.
	i. 	Any unusual circumstances, actions or omissions.
	14.1(8) A statement that medication shall be stored in a secured area unless an alternate provision is documented.
	14.1(9) A requirement for a written statement by the individual’s parent or guardian requesting the individual’s co-administration of medication, when competency is demonstrated.
	14.1(10) A requirement for emergency protocols for medication-related reactions.
	14.1(11) A statement regarding confidentiality of information.
[ARC 3387C, IAB 10/11/17, effective 11/15/17]
281—14.2(256) Special health services. Some individuals need special health services to participate in an educational program. These individuals shall receive special health services along with their educational program.
	14.2(1) Definitions. The following definitions shall be used in this rule, unless the context otherwise requires:
“Assignment and delegation” occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services. Primary consideration is given to the recommendation of the licensed health personnel. Each designation considers the individual’s special health service. The rationale for the designation is documented.
“Co-administration” is the eligible individual’s participation in the planning, management and implementation of the individual’s special health service and demonstration of proficiency to licensed health personnel.
“Educational program” includes all school curricular programs and activities both on and off school grounds.
“Education team” may include the individual, the individual’s parent, administrator, teacher, licensed health personnel, and others involved in the individual’s educational program. The education team may be the team required by the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of 1973 if the child is eligible under either of those statutes.
“Health assessment” is health data collection, observation, analysis, and interpretation relating to the individual’s educational program.
“Health instruction” is education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible individual’s health plan. Documentation of education and periodic updates shall be on file at school.
“Individual health plan” is the confidential, written, preplanned and ongoing special health service in the educational program. It includes assessment, nursing diagnosis, outcomes, planning, interventions, evaluation, student goals, if applicable, and a plan for emergencies to provide direction in managing an individual’s health needs. The plan is updated as needed and at least annually. Licensed health personnel develop this written plan with collaboration from the parent or guardian, individual’s health care provider or education team.
“Licensed health personnel” means a licensed registered nurse, licensed physician, or other licensed health personnel legally authorized to provide special health services and medications.
“Prescriber” means licensed health personnel legally authorized to prescribe special health services and medications.
“Qualified designated personnel” means a person instructed, supervised, and competent in implementing the eligible individual’s health plan.
“Special health services” includes, but is not limited to, services for eligible individuals whose health status (stable or unstable) requires:
	1.	Interpretation or intervention,
	2.	Administration of health procedures and health care, or
	3.	Use of a health device to compensate for the reduction or loss of a body function.
“Supervision” is the assessment, delegation, monitoring, and frequency of evaluation and documentation of special health services by licensed health personnel. Levels of supervision include situations in which:
	1.	Licensed health personnel are physically present.
	2.	Licensed health personnel are available at the same site.
	3.	Licensed health personnel are available on call.
	14.2(2) Special health services policy. Each board of a public school or the authorities in charge of an accredited nonpublic school shall, in consultation with licensed health personnel, establish policy and guidelines for the provision of confidential special health services in conformity with this chapter. Such policy and guidelines shall address the following:
	a. 	Licensed health personnel shall provide special health services under the auspices of the school. Duties of the licensed health personnel include:
	(1)	Participating as a member of the education team.
	(2)	Providing the health assessment.
	(3)	Planning, implementing and evaluating the written individual health plan.
	(4)	Planning, implementing and evaluating special emergency health services.
	(5)	Serving as a liaison and encouraging participation and communication with health service agencies and individuals providing health care.
	(6)	Providing health consultation, counseling and instruction with the eligible individual, the individual’s parent and the staff in cooperation and conjunction with the prescriber.
	(7)	Maintaining a record of special health services. The documentation shall include the eligible individual’s name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.
	(8)	Reporting unusual circumstances to the parent, school administration, and prescriber.
	(9)	Assigning and delegating to, instructing, providing technical assistance to and supervising qualified designated personnel.
	(10)	Updating knowledge and skills to meet special health service needs.
	b. 	Prior to the provision of special health services, the following shall be on file:
	(1)	A written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.
	(2)	A written statement by the individual’s parent requesting the provision of the special health service.
	(3)	A written report of the preplanning staffing or meeting of the education team.
	(4)	A written individual health plan available in the health record and integrated into the IEP or 504 plan, if applicable.
	c. 	Licensed health personnel, in collaboration with the education team, shall determine the special health services to be provided and the qualifications of the individuals performing the special health services. The documented rationale shall include the following:
	(1)	Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.
	(2)	Determination that the special health service, task, procedure or function is part of the person’s job description.
	(3)	Determination of the assignment and delegation based on the individual’s needs and qualifications of school personnel performing health services.
	(4)	Review of the designated person’s competency.
	(5)	Determination of initial and ongoing level of supervision, monitoring and evaluation required for safe, quality services.
	d. 	Licensed health personnel shall supervise the special health services, define the level of frequency of supervision and document the supervision.
	e. 	Licensed health personnel shall instruct qualified designated personnel to deliver and perform special health services contained in the individual health plan. Documentation of instruction, written consent of personnel as required in Iowa Code section 280.23 and periodic updates shall be on file at the school.
	f. 	Parents shall provide the usual equipment, supplies, and necessary maintenance of the equipment, unless the school is required to provide the equipment, supplies, and maintenance under the Individuals with Disabilities Education Act and 281—Chapter 41 or Section 504 of the Rehabilitation Act of 1973. The equipment shall be stored in a secure area. The personnel responsible for the equipment shall be designated in the individual health plan. The individual health plan shall designate the role of the school, parents and others in the provision, supply, storage and maintenance of necessary equipment.
	14.2(3) Relationship between this rule and other laws and rules. In complying with this rule, for children who are eligible under the Individuals with Disabilities Education Act and 281—Chapter 41 or Section 504 of the Rehabilitation Act of 1973, the school health services must comply with any additional or differing requirements imposed by those laws based on a specific child’s needs.
[ARC 3387C, IAB 10/11/17, effective 11/15/17]
281—14.3(256) School district and accredited nonpublic school stock epinephrine auto-injector voluntary supply.
	14.3(1) Definitions. For the purpose of this rule, the following definitions apply:
“Act” means 2015 Iowa Acts, Senate File 462, which amends Iowa Code section 280.16 and creates Iowa Code section 280.16A.
“Department” means the department of education.
“Epinephrine auto-injector” means a disposable drug delivery device that has a spring-activated concealed needle and is designed for immediate self-administration or administration by another trained individual of a measured dose of epinephrine to a student or individual at risk of anaphylaxis.
“Licensed health care professional” means a person who has prescriptive authority and is licensed under Iowa Code chapter 148 to practice medicine and surgery, an advanced nurse practitioner licensed pursuant to Iowa Code chapter 152, or a physician assistant licensed to practice under the supervision of a physician as authorized in Iowa Code chapters 147 and 148C.
“Medication administration course” means a course approved or provided by the department that includes safe storage of medication, handling of medication, general principles, procedural aspects, skills demonstration and documentation requirements of safe medication administration in schools.
“Medication error” means the failure to administer an epinephrine auto-injector to a student or individual by proper route, failure to administer the correct dosage, or failure to administer an epinephrine auto-injector according to generally accepted standards of practice.
“Medication incident” means accidental injection of an epinephrine auto-injector into a digit of the authorized personnel administering the medication.
“Personnel authorized to administer epinephrine” means a school employee who has successfully completed the medication administration course requirements and who completes an annual anaphylaxis training program approved by the department and conducted by the school nurse, including a return-skills demonstration on the use of an epinephrine auto-injector.
“School building” means each attendance center within a school district or accredited nonpublic school where students or other individuals are present.
“School nurse” means a registered nurse holding current licensure recognized by the Iowa board of nursing who practices in the school setting to promote and protect the health of the school population by using knowledge from the nursing, social, and public health sciences.
	14.3(2) Applicability. This rule applies to and permits:
	a. 	A licensed health care professional to prescribe a stock epinephrine auto-injector in the name of a school district or accredited nonpublic school for use in accordance with the Act and this rule,
	b. 	A pharmacist to dispense epinephrine auto-injectors pursuant to a prescription issued in the name of a school district or accredited nonpublic school, and
	c. 	A school district or accredited nonpublic school to acquire and maintain a stock supply of epinephrine auto-injectors pursuant to a prescription issued in accordance with the Act.
	14.3(3) Prescription for stock epinephrine auto-injector. A school district or accredited nonpublic school may obtain a prescription for epinephrine auto-injectors from a licensed health care professional annually in the name of the school district or accredited nonpublic school for administration to a student or individual who may be experiencing an anaphylactic reaction. The school district or accredited nonpublic school shall maintain the supply of such auto-injectors in a secure, dark, temperature-controlled location in each school building. If a school district or accredited nonpublic school obtains a prescription pursuant to the Act and these rules, the school district or accredited nonpublic school shall stock a minimum of one pediatric dose and one adult dose epinephrine auto-injector for each school building. A school district or accredited nonpublic school may obtain a prescription for more than the minimum and may maintain a supply in other buildings.
	14.3(4) Authorized personnel and stock epinephrine auto-injector administration. A school nurse or personnel trained and authorized may provide or administer an epinephrine auto-injector from a school supply to a student or individual if the authorized personnel or school nurse reasonably and in good faith believes the student or individual is having an anaphylactic reaction.
	a. 	The following persons, provided they have acted reasonably and in good faith, shall not be liable for any injury arising from the provision, administration, failure to administer, or assistance in the administration of an epinephrine auto-injector:
	(1)	Authorized personnel and the school nurse,
	(2)	The school district or accredited nonpublic school employing the personnel or school nurse,
	(3)	The board of directors in charge of the school district or authorities in charge of the accredited nonpublic school, and
	(4)	The prescriber of the epinephrine auto-injector.
	b. 	Pursuant to Iowa Code section 280.23, authorized personnel will submit a signed statement to the school nurse stating that the authorized personnel agree to perform the service of administering a stock epinephrine auto-injector to a student or individual who may be experiencing an anaphylactic reaction.
	c. 	Emergency medical services (911) will be contacted immediately after a stock epinephrine auto-injector is administered to a student or individual, and the school nurse or authorized personnel will remain with the student or individual until emergency medical services arrive.
	d. 	The administration of an epinephrine auto-injector in accordance with this chapter is not the practice of medicine.
	14.3(5) Stock epinephrine auto-injector training. School employees may obtain a signed certificate to become authorized personnel.
	a. 	Training to obtain a signed certificate may be accomplished by:
	(1)	Successfully completing, every five years, the medication administration course provided by the department;
	(2)	Annually demonstrating to the school nurse a procedural return-skills check on medication administration;
	(3)	Annually completing an anaphylaxis training program approved by the department;
	(4)	Demonstrating to the school nurse a procedural return-skills check on the use of an epinephrine auto-injector using information from the training, authorized prescriber instructions regarding the administration of the stock epinephrine auto-injector, and as directed by the prescription epinephrine auto-injector’s manufacturing label; and
	(5)	Providing to the school nurse a signed statement, pursuant to Iowa Code section 280.23, that the person agrees to perform the service of administering a stock epinephrine auto-injector to a student or individual who may be experiencing an anaphylactic reaction.
	b. 	Training required after a medication error or medication incident. Authorized personnel or the school nurse directly involved with a medication error or medication incident with the administration of stock epinephrine auto-injectors shall be required to follow the medication error or medication incident protocol adopted by the board of directors of the school district or authorities in charge of the school district or accredited nonpublic school. To retain authorization to administer stock epinephrine auto-injectors in the school setting, authorized personnel directly involved with a medication error or medication incident will be required to provide a procedural skills demonstration to the school nurse demonstrating competency in the administration of stock epinephrine auto-injectors.
	14.3(6) Procurement and maintenance of stock epinephrine auto-injector supply. A school district or accredited nonpublic school may obtain a prescription to stock, possess, and maintain epinephrine auto-injectors.
	a. 	Stock epinephrine auto-injectors shall be stored in a secure, easily accessible area for an emergency within the school building, or in addition to other locations as determined by the school district or accredited nonpublic school, that is dark and maintained at room temperature (between 59 to 86 degrees) or in accordance with the manufacturing label of the stock epinephrine auto-injector.
	b. 	A school district or school will designate an employee to routinely check stock epinephrine auto-injectors and document in a log monthly throughout the calendar year for:
	(1)	The expiration date;
	(2)	Any visualized particles; or
	(3)	Color change.
	c. 	The school district or school shall develop a protocol to replace as soon as reasonably possible any logged epinephrine auto-injector that is used, close to expiration, or discolored or has particles visible in the liquid.
	14.3(7) Disposal of used stock epinephrine auto-injectors. The school district or school that administers epinephrine auto-injectors shall dispose of used cartridge injectors as infectious waste pursuant to the department’s medication waste guidance.
	14.3(8) Reporting. A school district or school that obtains a prescription for stock epinephrine auto-injectors shall report each medication incident with the administration of stock epinephrine, medication error with the administration of stock epinephrine, or the administration of a stock epinephrine auto-injector to the department within 48 hours, using the reporting format approved by the department.
	14.3(9) School district or accredited nonpublic school policy. A school district or school may stock epinephrine auto-injectors. The board of directors in charge of the school district or authorities in charge of the accredited nonpublic school that stocks epinephrine auto-injectors shall establish a policy and procedure for the administration of a stock epinephrine auto-injector, which shall comply with the minimum requirements of this rule.
	14.3(10) Rule of construction. This rule shall not be construed to require school districts or accredited nonpublic schools to maintain a stock of epinephrine auto-injectors. An election not to maintain such a stock shall not be considered to be negligence.
[ARC 2311C, IAB 12/9/15, effective 1/13/16]
281—14.4(256,280) Severability. If any provisions of these rules or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these rules which can be given effect, and to this end the provisions of these rules are declared to be severable.
[ARC 2311C, IAB 12/9/15, effective 1/13/16]
These rules are intended to implement 2015 Iowa Acts, Senate File 462.
[Filed ARC 2311C (Notice ARC 2183C, IAB 10/14/15), IAB 12/9/15, effective 1/13/16]
[Filed ARC 3387C (Notice ARC 3088C, IAB 6/7/17), IAB 10/11/17, effective 11/15/17]