ARC 7041C

ARC 7041C

EDUCATION DEPARTMENT[281]

Adopted and Filed

Rule making related to school health services

The State Board of Education hereby amends Chapter 14, "School Health Services," Iowa Administrative Code.

Legal Authority for Rule Making

This rule making is adopted under the authority provided in Iowa Code section 256.7(5).

State or Federal Law Implemented

This rule making implements, in whole or in part, 2022 Iowa Acts, House Files 771, 803, and 2573.

Purpose and Summary

House File 771 allowed schools to obtain stock supplies of bronchodilator medication and equipment, as well as authorized the self-administration of bronchodilator medication by students. House File 803 made changes to authorized practice by physician assistants and directed the State Board to amend certain rules in Chapter 14. House File 2573 allowed school districts to obtain prescriptions for stock opioid antagonist medication. These three pieces of legislation are addressed in this rule making.

Public Comment and Changes to Rule Making

Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on February 8, 2023, as ARC 6880C. A public hearing was held on February 28, 2023, at 8:30 a.m.in Room B50, Grimes State Office Building, Des Moines, Iowa. No one attended the public hearing.

The Department received two written public comments from the American Lung Association and the Iowa School Nurse Organization. Both organizations were largely in favor of the proposed rule making; however, both organizations suggested changes to the proposed rule making.

Physician assistants. One commenter questioned the role of physician assistants in the proposed rule making and asked that advanced registered nurse practitioners be specifically included in certain sections. The Department made some changes from the Notice to emphasize the broad statutory definition of "licensed health care professional" (which addresses some of the commenter's concerns), but 2022 Iowa Acts, House File 803, required that physician assistants be specifically named in relevant rules.

Requirements specific to epinephrine auto-injectors. One commenter recommended adding more global language that is inclusive of bronchodilator treatments. Several changes from the Notice were made to that effect.

Withdrawal of privilege to self-administer medication. One commenter objected to the language allowing the privilege to self-administer medications to be withdrawn because of abuse of the privilege. Because this language is part of the statute, no changes from the Notice were made based on this comment.

Medication administration course issue. One commenter requested that the medication administration course be required every three years, rather than five, because school employees' "primary field of work is not health care." While more training might be preferable, and would certainly be a matter of local district discretion, the Department is not convinced that the additional training burden is necessary to achieve the purposes of Chapter 14. The commenter also requested that additional organizations be allowed to provide the medication administration course. This particular comment, not being directly responsive to the three statutes underlying this rule making, is deferred for further consideration by the Department as part of the Department's review under Executive Order 10.

Standing orders for stock supplies. Both commenters requested the addition of a rule authorizing another entity, such as the state medical director, to issue a standing order for all schools to obtain stock supplies. That suggestion is outside of the State Board's jurisdiction and is better directed to the Legislature or another state entity.

Withdrawal of delegation. One commenter asked that the rules explicitly state that delegation to unlicensed personnel based on errors or improper uses may be withdrawn. Because the ability to withdraw a delegation is inherent in the assessment and supervision that delegation requires, no changes from the Notice have been made based on this comment.

Contacting emergency services. One commenter noted that one rule requires contacting 911 after administering an epinephrine auto-injector and recommended addressing the responsibility for aftercare for the administration of a bronchodilator canister or a bronchodilator canister and spacer. The comment is well-founded, and the rule has been modified to provide that the school nurse directs the aftercare in such situations based on the nurse's professional judgment.

Prescription details. One commenter requested that the rules provide greater specificity regarding prescriptions for stock supplies, such as specific medications, dosages, and frequencies. These comments are more appropriately addressed to the professional writing the prescription. If statewide rules are required, other state agencies have the authority and expertise to promulgate them. No changes from the Notice have been made based on this comment.

Adoption of Rule Making

This rule making was adopted by the State Board on June 8, 2023.

Fiscal Impact

This rule making has no fiscal impact to the State of Iowa.

Jobs Impact

After analysis and review of this rule making, no impact on jobs has been found.

Waivers

Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the State Board for a waiver of the discretionary provisions, if any, pursuant to 281—Chapter 4.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee's meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

Effective Date

This rule making will become effective on August 2, 2023.

The following rule-making action is adopted:

Item 1. Amend subrule 14.1(3) as follows:

14.1(3) A statement that authorized persons administering medication shall include authorized practitioners, licensed health personnel working under the auspices of the school, such as licensed registered nurses , and physicians, physician assistants, 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 , use a bronchodilator canister or bronchodilator canister and spacer, or possess and have use of an epinephrine auto-injector with parent and physician (or physician assistant) consent on file for each school year, without the necessity of demonstrating competency to self-administer these medications. If a student misuses this privilege, it may be withdrawn. For purposes of this chapter, "self-administration" and "medication" mean the same as defined in Iowa Code section 280.16(1).

Item 2. Amend subrule 14.1(4) as follows:

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 licensed health personnel. A registered nurse, licensed physician assistant, or licensed pharmacist shall conduct the course. A record of course completion shall be maintained by the school.

Item 3. Amend paragraph 14.1(7)"d" as follows:

d. Medication name and purpose, including the use of a bronchodilator canister or a bronchodilator canister and spacer or the use of an epinephrine auto-injector.

Item 4. Amend subrule 14.2(1), definition of "Licensed health personnel," as follows:

"Licensed health personnel" means a licensed registered nurse, licensed physician, licensed physician assistant, or other licensed health personnel legally authorized to delegate or provide special health services and medications under the auspices of the school.

Item 5. Rescind rule 281—14.3(256) and adopt the following new rule in lieu thereof:

281—14.3(256) School district and accredited nonpublic school stock epinephrine auto-injector, bronchodilator canister, or bronchodilator canister and spacer 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 amended Iowa Code section 280.16 and created Iowa Code section 280.16A.

"Bronchodilator" means the same as defined in Iowa Code section 280.16(1)"a."

"Bronchodilator canister" means the same as defined in Iowa Code section 280.16(1)"b."

"Department" means the department of education.

"Epinephrine auto-injector" means the same as defined in Iowa Code section 280.16(1)"c."

"Licensed health care professional" means the same as defined in Iowa Code section 280.16(1)"d."

"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, bronchodilator, or bronchodilator canister and spacer 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 or a bronchodilator" means the same as defined in Iowa Code section 280.16A(1)"e."

"School building" means each attendance center within a school district or accredited nonpublic school where students or other individuals are present.

"School nurse" means the same as defined in Iowa Code section 280.16A(1)"f."

"Spacer" means the same as defined in Iowa Code section 280.16A(1)"g."

14.3(2) Applicability. This rule applies to and permits:

a. A licensed health care professional to prescribe a stock epinephrine auto-injector, a bronchodilator canister, or a bronchodilator canister and spacer 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 a stock supply pursuant to paragraph 14.3(2)"a"; and

c. A school district or accredited nonpublic school to acquire and maintain a stock supply pursuant to paragraphs 14.3(2)"a" and 14.3(2)"b."

14.3(3) Prescription for stock epinephrine auto-injectors, bronchodilator canisters, and bronchodilator canisters and spacers. A school district or accredited nonpublic school may obtain a prescription for epinephrine auto-injectors, bronchodilator canisters, and bronchodilator canisters and spacers 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 or may require treatment for respiratory distress, asthma, or other airway constricting disease. The school district or accredited nonpublic school shall maintain the supply of such auto-injectors, bronchodilator canisters, and bronchodilator canisters and spacers according to manufacturer instructions. If a school district or accredited nonpublic school obtains a prescription pursuant to the Act and these rules for epinephrine auto-injectors, the school district or accredited nonpublic school shall stock a minimum of one pediatric dose and one adult dose 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, bronchodilator canister, or bronchodilator canister and spacer administration. A school nurse or personnel trained and authorized may provide or administer an epinephrine auto-injector, bronchodilator canister, or bronchodilator canister and spacer from a school supply to a student or individual in circumstances authorized by Iowa Code section 280.16.

a. 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 or administering a bronchodilator canister or a bronchodilator canister and spacer to a student or individual experiencing respiratory distress, asthma, or other airway constricting disease.

b. 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. In the event of administration of a stock bronchodilator or bronchodilator canister and spacer to a student or individual, the school nurse will be contacted and will determine, based on professional judgment, the necessary care of a student or individual.

c. The administration of an epinephrine auto-injector, a bronchodilator, or a bronchodilator canister and spacer in accordance with this rule is not the practice of medicine.

14.3(5) Stock epinephrine auto-injector, bronchodilator, or bronchodilator canister and spacer 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, asthma, or airway constricting disease 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, bronchodilator canister, and bronchodilator canister and spacer using information from the training, using authorized prescriber instructions, and as directed by the prescription 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 one or more of the services described in this rule.

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 involving the administration of stock epinephrine auto-injectors, bronchodilators, or bronchodilator canisters and spacers 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, bronchodilators, or bronchodilator canisters and spacers 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, bronchodilators, or bronchodilator canisters and spacers.

14.3(6) Procurement and maintenance of stock epinephrine auto-injector, bronchodilator, or bronchodilator canister and spacer supplies. A school district or accredited nonpublic school may obtain a prescription to stock, possess, and maintain epinephrine auto-injectors, bronchodilators, or bronchodilator canisters and spacers.

a. Stock epinephrine auto-injectors, bronchodilator canisters, and bronchodilator canisters and spacers 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, and in accordance with the manufacturing label of the stock epinephrine auto-injector, bronchodilator canister, or bronchodilator canister and spacer.

b. A school district or school will designate an employee to routinely check stock epinephrine auto-injectors, bronchodilator canisters, and bronchodilator canisters and spacers and document the following in a log monthly throughout the calendar year:

(1)The expiration date;

(2)Any visualized particles or color change, for epinephrine auto-injectors; or

(3)Bronchodilator canister damage.

c. The school district or school shall develop a protocol to replace as soon as reasonably possible any logged epinephrine auto-injector, bronchodilator canister, or bronchodilator canister and spacer that is used, is damaged, is close to expiration, or is discolored or has particles visible in the epinephrine auto-injector liquid.

14.3(7) Disposal of used stock epinephrine auto-injectors, bronchodilators, or bronchodilator canisters and spacers. The school district or school that administers epinephrine auto-injectors, bronchodilators, or bronchodilator canisters and spacers shall dispose of used cartridge injectors as infectious waste pursuant to the department's medication waste guidance and bronchodilators or bronchodilator canisters and spacers pursuant to the department's medication waste guidance. For purposes of this rule, a multiuse bronchodilator canister is considered "used" when it no longer contains sufficient active ingredient to be medically useful.

14.3(8) Reporting. A school district or school that obtains a prescription for stock medications under this rule shall report to the department within 48 hours, using the reporting format approved by the department, each medication incident or error with the administration of a stock epinephrine injector, bronchodilator canister, or bronchodilator canister and spacer or administration of a stock epinephrine auto-injector.

14.3(9) School district or accredited nonpublic school policy. A school district or school may stock epinephrine auto-injectors, bronchodilator canisters, or bronchodilator canisters and spacers. The board of directors in charge of the school district or authorities in charge of the accredited nonpublic school that stocks epinephrine auto-injectors, bronchodilator canisters, or bronchodilator canisters and spacers shall establish a policy and procedure for the administration of a stock epinephrine auto-injector, bronchodilator canister, or bronchodilator canister and spacer, 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, bronchodilator canisters, or bronchodilator canisters and spacers. An election not to maintain such a stock shall not be considered to be negligence.

14.3(11) Opioid antagonists. A school district may obtain a valid prescription for an opioid antagonist and maintain a supply of opioid antagonists in a secure location at each location where a student may be present for use as provided in this rule. Any school district which does so must comply with rules and procedures adopted by the department of health and human services.

[Filed 6/8/23, effective 8/2/23]

[Published 6/28/23]

Editor's Note: For replacement pages for IAC, see IAC Supplement 6/28/23.