Iep

[alizesmom]

Well, I have just joined the ranks of the IEP crazed parents. Preschool was no problem since kids have been homebound but we felt Alize is well enough to do kindergarten this fall. I'm not the pushy kind and felt I was working well with the group until we got to nursing care issues. Alize absolutely must have a 1:1 nurse from door to door who can suction and change his trach. They said "oh, you'll be supplying that". Um, no. I told them state law requires that they pay for said nurse. The room went deadly silent and 7 pairs of eyes turned and just stared at me. All insisted they had never heard of such a thing and nursing didn't need to be in the IEP. I went home with an unsigned IEP. I called them as soon as I got home and quoted the part of the law that said it. Of course I was quoting to voice mails and no one called back. I'm calling again tomorrow and if no response I will hand carry a signed (and refused) IEP to them since if unsigned after 10 days they can say I approved. Any other suggestions? Karen

[mama z]

Maybe this will help. It was big news here a few years ago. Took along time in court but the district ended up paying for the nurse.

Laura


Cedar Rapids School District vs Garret F. (http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=US&vol=000&invol=96-1793)


This one is a little easier to read.

http://www.nasn.org/Default.aspx?tabid=267

IMPACT OF CEDAR RAPIDS COMMUNITY SCHOOL DISTRICT VS. GARRET F. ON SCHOOL NURSING SERVICES
printable version

List of Issue Briefs









INTRODUCTION

The 1999 United States Supreme Court ruling in Cedar Rapids Community School District v. Garret F. (hereinafter known as "Garret F.") held that the Individuals with Disabilities Education Act (IDEA) requires school districts to provide nursing services when such supportive services are necessary in order for students to access and benefit from their educational program. The implications of this decision support the leadership role of the school nurse within the school and community in advocating for the health and educational needs of students.

BACKGROUND

Garret F. held that IDEA requires a school district to be financially responsible for the provision of nursing services that students require in order to access and benefit from their educational program. The Court based its ruling on IDEA’s definition of "related services" and on the United States Supreme Court decision Irving Independent School District v. Tatro (hereinafter known as "Tatro") (1984). Garret F. involved a student who required continuous nursing services in school, including urinary bladder catheterization, tracheostomy tube suctioning, nutrition and fluids on a regular schedule, positioning, monitoring of ventilator settings, artificial ventilations by ambu bag when the ventilator malfunctioned, assessment of respiratory status for respiratory distress or autonomic hyperreflexia, blood pressure monitoring, and bowel disimpaction.

Guidance provided from Garret F. can be summarized as follows. The ruling:

clarifies that "related services" under IDEA include school health services required by a student, whether these services require a nurse for one-half hour per week or one-on-one throughout the school day. These school health services, provided by "a qualified school nurse or other qualified person" are considered "supportive services" under IDEA.
affirms the two-step "bright line" test established in Tatro to determine if a required service is a "related service" under IDEA: specifically, whether the requested services are supportive services that are required to assist a child with a disability to benefit from special education and whether the services are excluded because they are medical services that need to be performed by a physician.
establishes that students with complex medical needs are like other students with disabilities, and have the right to access a free and appropriate public education designed to meet their unique needs.
affirms that school districts are financially responsible for school health services identified in a student’s individual education program (IEP). Garret F. does not prohibit school districts from accessing other sources of funding, such as Medicaid reimbursement or a family’s medical insurance.
It is important to note that, because Garret F. is a Supreme Court case, it applies to every public school in the United States.

The National Association of School Nurses (NASN) played an active role in Garret F. and signed on to an amicus curiae (Friend of the Court) brief. This brief argued that the Supreme Court should affirm the lower courts’ decisions related to the responsibility of school districts to provide the types of nursing services required by Garret F. In addition, NASN published Issue Briefs on "Inclusion" and "School Nurses and the Individuals with Disabilities Education Act (IDEA)," as well as Position Papers on "The School Nurse and Specialized Health Care Services," "Individualized Health Care Plans," "Emergency Care Plans for Students with Special Health Care Needs," and "Caseload Assignments."

RATIONALE

It is important to consider the current and future impact of Garret F. on school nursing in light of health, chronic disease and disability trends for children, trends in the percentage of children with disabilities and complex health needs who are educated in regular classrooms, and the number of school nurses found in public schools today.

While estimates of the actual number of children eligible for "related services" are varied, trends in health, chronic disease, and disability for children support the need for related services. These trends include (a) increases in the number of children in schools with life-threatening allergies, (b) increases in the incidence, prevalence, and severity of asthma, (c) management of HIV as a chronic disease, (d) long-term survival of students with complex medical problems due to advances in medical technology, (e) increases in the number of children who are medically-fragile and technology dependent in regular classrooms, and (f) increased parental knowledge about the rights of children to education and "related services" in the least restricted environment. In light of these health-related trends, it must also be noted that there has been a trend away from in educating these children with special needs in resource rooms or separate classes.

Given Garret F., another likely trend will be the transfer of financial responsibility for one-on-one and other IEP-required nursing services from other agencies and third-party payers to public schools. School districts are not currently staffed to meet the projected needs for school nursing services required by this decision. Most school districts do not even staff school nurses to the NASN recommended ratio of one nurse for every 750 students.

Defining the magnitude of this issue is difficult. Regardless of the actual number of students with disabilities who may require the supportive services of a nurse, school districts need to be cognizant of what these necessary and reasonable services are. They may include any level of service on the continuum from direct or indirect nursing services one hour per week to a nurse on- site in the building at all times, up to and including one-on-one nursing care throughout an entire school day. Regardless of the level of the service required, nursing services must be provided as determined in the student’s IEP. It is critical, therefore, for school nurses to be part of IEP teams for students whose health conditions have an actual or potential impact on their learning and for school districts to ensure that school nurses are integral members of their schools’ early identification and special education teams.

ROLE OF THE SCHOOL NURSE

NASN’s position is that Garret F. clearly requires public schools to provide nursing services to students if those services are necessary for students to access or benefit from an appropriate education in the least restrictive environment. The Garret F. decision supports the school nurse in effectively advocating for children with special health care needs and complex medical issues. NASN recognizes that school districts may encounter financial, administrative, and clinical challenges that can make this decision difficult to implement. Nevertheless, the mandate for students requiring in-school nursing services is clear: all children, regardless of disability or medical condition, have a right to access an appropriate public education in the least restrictive environment.

The cost of providing intensive nursing services can no longer be used as a basis for excluding students. School nurses and school nurse administrators must assist school districts in determining and identifying necessary and reasonable levels of care and are in a position to identify potential sources of payment for nursing services, such as Medicaid funds.

Because health insurance companies often have lifetime limits on coverage, some states now require school districts to disclose to families the potential impact of using their own insurance to pay for in-school services. The implication is that when parents use their own insurance benefits to cover school-based nursing services, they may be limiting their child’s future available insurance coverage. School nurses can guide districts in understanding their obligation to pay for in-school nursing services when the school nurse has determined the appropriate level of care needed and included it in the student’s IEP. This same guidance can be given when discussing these issues with families.

The school nurse plays a vital role in applying Garret F. and in explaining its implications on administrative decisions about policy, staffing, collaborative decision-making, and clinical nursing practice in the schools. Where there are shortages of qualified personnel to provide needed nursing services, school nurses should advocate for programs within their state to attract and prepare nurses for school-based roles. These may include in pre-service, in-service, certification, college preparatory and graduate level courses, and degree programs.

NASN believes that Garret F. is a clear directive to school districts to provide school nursing services to students who need those services in order to attend school and benefit from their education, whether these are one-on-one all-day services, intermittent services, or direct or indirect services for any part of the day or week. Furthermore, it provides the legal support that school nurses need to advocate for, and determine the level of nursing care required by, students with health-related disabilities, in order that they may attend school safely and benefit from their educational program. This advocacy also requires an active working knowledge of the state’s nurse practice act, state rules or guidelines for delegation, and any state guidelines for the provision of basic and specialized health care procedures in schools. Finally, it requires school nurses to develop the expertise necessary to problem-solve challenging situations and to promote a reasonable balance between safe nursing services and students’ needs to take risks in order to develop to their potential and pursue life goals.

This landmark decision solidifies and reaffirms the central role that school nurses play in the delivery of related school health services under the IDEA and the obligation of school districts to pay for such services.

REFERENCES

Cedar Rapids Community School District v. Garret F, 119 S.Ct. 992, 29 IDELR 966 (U.S. 199). To view the full decision, go to: http://supct.law.cornell.edu/supct/html/96-1793.ZS.html

Gaffrey, E. A. & Miller, W. R. (2001). Contracting with managed care organizations. In N. C. Schwab & M. B. Gelfman, Eds. Legal issues in school health services: A resource for school administrators, school attorneys and school nurses. North Branch, MN: Sunrise River Press.

Gelfman, M. H., & Schwab, N. (2000). School health services after Cedar Rapids Independent School District v. Garret F. Journal of School Nursing 16(4) 54-59.

Gelfman, M.H., & Schwab, N.C. (2001). Special education: Current issues in disputes. In N. C. Schwab & M. H. Gelfman, Eds. Legal issues in school health services: A resource for school administrators, school attorneys and school nurses. North Branch. MN: Sunrise River Press.

Irving Independent School District v. Tatro, 468 U.S. 883, EHLR 555:511 (1984).

National Association of School Nurses (1995). Issue brief – Inclusion. Scarborough, ME: NASN.

National Association of School Nurses (1996). Issue brief – School nurses and the Individuals with Disabilities Education Act (IDEA). Scarborough, ME: NASN.

National Association of School Nurses (November 2000). National Association of School Nurses membership survey results. Scarborough, ME: NASN.

National Association of School Nurses (rev. 1995) Position statement – Caseload assignments. Scarborough, ME: NASN.

National Association of School Nurses (1998). Position statement – Emergency care plans for students with special health care needs. Scarborough, ME: NASN.

National Association of School Nurses (1998). Position statement – Individualized health care plans. Scarborough, ME: NASN.

National Association of School Nurses (1996). Position statement – The school nurse and specialized health care services. Scarborough, ME: NASN.

National Association of State School Nurse Consultants. (rev. 1995). Delegation of health services to unlicensed assistive personnel: A position paper of the National Association of State School Nurse Consultants. Journal of School Nursing, 11(2):16-18.

National Information Center for Children and Youth with Disabilities. (1997). The IDEA amendments of 1997. NICHCY News Digest 26: 11-39.

Rapport, M. J. (1996). Legal guidelines for the delivery of special health care services in schools. Exceptional Children 62(6): 537-549.

U.S. Department of Education, Office of Special Education and Rehabilitative Services (1999). Annual report to Congress on the implementation of the Individuals with Disabilities Education Act, 1988-1998. Retrieved from: http://www.nces.ed.gov/pubs99

Walsh, M. (1999). Educators say ruling could drain budgets. Education Week 18(26): 1 & 12.

[emilymom]

Some good websites to help you
wrightslaw.com
schoolpsychologistfiles.com
http://millermom.proboards107.com/index.cgi?board=Education
net-haven.net

Yes they need to provide what your child needs in order to provide a free and appropriate education (FAPE).
You should write a letter of understand of what was said at the meeting. What you understood them to say yes/no to and ask for PWN prior written notice to not providing a nurse.

Please research the legal and how what steps ...You can also call SPAN statewide parent advocacy network and they can walk you thru some of this.

[mybaboo]

Every state has at least one parent training and information center, a non-profit organization that helps parents with special needs children with all sorts of issues.....especially education/iep stuff. My dh works for our local group and the folks that he works with have a wealth of info about iep's and the state/national laws. Here's the info for the centers in PA. Hopefully they can help you figure out how to solve this!

You can also sign the IEP, but hand write a note at the bottom stating that you don't agree and you're specific requests. Then your objections become part of the record.

Pennsylvania
Mentor Parent Program, Inc.
PO Box 47
Pittsfield PA 16340
814-563-3470
Fax 814-563-3445 800 1-888-447-1431 (in PA)
Serving Rural Northwest Pennsylvania
E-mail mentorparentprogram@verizon.net
Web www.mentorparent.org


Pennsylvania
Parent Education & Advocacy Leadership Center
1119 Penn Avenue, Suite 400
Pittsburgh PA 15222-4205
412-281-4404, TTY: 412-281-4409
Fax 412-281-4408 800 866-950-1040
Serving 43 counties in Central and Western PA
E-mail lhealey@pealcenter.org
Web www.pealcenter.org


Pennsylvania
Parent Education Network
2107 Industrial Hwy
York PA 17402-2223
717-600-0100 Voice & TTY
Fax 717-600-8101 800 800-522-5827 in PA
Serving Central & Eastern PA
E-mail pen@parentednet.org

[Love My 7 GEMS]

Karen, while I do agree that the schools should be responsible... consider this. If Alize has Medicaid, and if you have in home nursing (which I know you do‚) you might consider asking the Home Health company to submit to Medicaid to cover additional hours for Alize to have a nurse to go to and from school with him, as well as stay with him throughout the day. My rationale is this... if you have the agency provide the nurse, you know from day one who that nurse is. You will have trained her (or him) to work with Alize, they will develop a bond, and on those days when Alize is sick, you will still have one to one care in home to take care of him.

For 12 years, I was a one to one with my little Kelly. She was my patient, but she was also like my own child. I adored working with her. When she went to school, I went with her, when she stayed home, I stayed with her. The school talked about providing a nurse, pursuant to the 1999 ruling. Mom petitioned to keep me...as it was the best solution for all of us.

Yes, factually the school has the obligation to provide one to one nursing support. Realistically, however, you could have a different person every day of the week if the school provides the support person. School personale changes without your knowledge or consent...and while home nursing can too, the opportunity to develop a better bond with the nurses is more available in the home nursing environment. It's really a matter of personal preference, and availability through your home nursing company (as well as Medicaid) to determine if you have school based or home based support.

Dori

[fireweed]

you could write a letter stating the team agreed it was appropriate for his needs, and ask for a written notice of action denying the nursing being added to the IEP.

(seems like you know your way around IDEA already. so requesting written notice should solve your problem like in minutes/hours.)

unfortunately i'm realizing in my own life that staff are usually not fully trained in IDEA. The training they get is what their district wishes to tell them IDEA says. They may all have been led to believe this is the truth about nursing.


is there any possibility of it being paid for by insurance/medicaid? I only ask because i've heard my friends talk about with nursing in school - that there are ups and downs to who provides it, etc. I don't know enough to say more (thinking there are conflict of interest issues, etc....just like there often are with PT's, OT's, etc, but nursing is SO critical to Alize's care.)

hopefully some other moms will post about that. i'm sure the solutions are as individual as the child/district/town. (been thinking about this lately as nursing may be something we have to request soon too.)



fireweed

[fireweed]

well, i wrote that last night late - and then the wonderboy pulled a late night party. i hit send this morning, and there it is - Dori got it covered. (and others over the procedural stuff.)

:) smart moms

fireweed


p.s. since the wonderboy's aide provides what amounts to some nursing care, we have faced the issue of consistency Dori brought up just with the aide EVERY YEAR - many times a year. it's insane - to think you can provide appropriate care with inconsistent staff. (his aide makes decisions about when to change his position due to early signs of pain, when to take him to the nurse and ask for meds - decisions can't get made appropriately when you don't know what happened two hours ago, or even yesterday.)

[Carly'sMa]

Dori - while you idea is a nice one, in my state, if it is the responsibility of the school district, Medicaid won't pay for the nurse at school. Plus, the school district gets money from medicaid for each child on medicaid (special needs) in the district.

Also, would giving the school the nurse paid by medicaid (if that was possible) lessen any hours you might need for nursing at home?

Each state education department has a complaince office. I would call that office and tell them what happened and ask for the proper citations for the state regulations which require the school provide the nurse as a health related service so that Alize can attend school.

[Love My 7 GEMS]

In California, it's technically the school's responsibility, BUT... there are some children so medically fragile, like Kelly was/is that it is too iffy to have a 'school hours only' situation. There were ways around the 'letter of the law', and we took full advantage of them. I know that every state has thing set up a certain way, but also that there are loopholes around those statutes. I know that for us, having Kelly in a situation where if someone did not "KNOW" her, or her health history, she literally would have been in grave danger many times... and other times the reactionary nurses at the school would have been doing things for her that they never should have done, simply because they were not intimately familiar with her.

I think our school only got money from Medicaid IF we allowed them to do procedures on her, which we did not. I did all her procedures. We did not allow them to do anything for her. Technically, they couldn't touch her, unless it was a 911 emergency, which she did have 2 times (both on my day's off... go figure)

Dori

[alizesmom]

You've all given me a lot of information to take in. PA is also a state where once the child is in school, medical assistance doesn't pay for those nursing hours. I had another face-to-face meeting with the supervisor who admitted that I was right about them having to pay. He then tried to offer the nurse who rotates between the medical needs kids (and has no trach experience). I think they are trying to figure out what I know and how far I will push. I am continuing to push for 1:1 and door to door. He did take the name of my nursing agency and the contact name as well. I have asked for another meeting and a mediator if neccessary. In the meantime, the IEP was returned to them signed but as unacceptible. Thanks for the help. Karen

[mama z]

You've all given me a lot of information to take in. PA is also a state where once the child is in school, medical assistance doesn't pay for those nursing hours. I had another face-to-face meeting with the supervisor who admitted that I was right about them having to pay. He then tried to offer the nurse who rotates between the medical needs kids (and has no trach experience). I think they are trying to figure out what I know and how far I will push. I am continuing to push for 1:1 and door to door. He did take the name of my nursing agency and the contact name as well. I have asked for another meeting and a mediator if neccessary. In the meantime, the IEP was returned to them signed but as unacceptible. Thanks for the help. Karen

I don't think I'd presume he's trying to figure out how much you know. My guess is he already knows because you were able to recite the IDEA to him. It is more likely that he is trying to problem solve from his end and asking you if you would be willing to make any concessions or if you have any ideas how to provide the service. Yes, and also to see how hard you'll push.

Laura

[hannah's mom]

It looks like you're heading in the right direction, but there re still some more things you can do to strengthen your case.

I've got exactly this battle on a yearly basis, over whether DOE or DOH is paying for Hannah's nursing hours. Yes, it should be the responsibility of DOE, but in fact DOH (through the waiver program) has been paying for it since Hannah transitioned into school.

It is helpful if you can give the school a letter from your neurologist, stressing the potentially life-threatening ramifictions if your son child is cared for by a nurse unfamiliar with his disabilities.

Your school district already has a nursing agency under contract to provide services within the schools. Find out which agency and you can make sure your existing nurses go to work for the second agency as well. Or if you're really lucky maybe its the same agency. :)

I'm worried that your clock is running on the time you have left after receipt of the IEP to file for due process, and what the ramifications are in your case if you dont file. You dont want a mediator, you need an advocate who knows all your child's federal civil rights and can ensure the school people have no legal way to worm round them. The organizations that Lori mentioned earlier in the post should know the answers, and know as well how best to preserve Alize's rights.

Best of luck!
Summer