2026 SESSION

SENATE SUBSTITUTE

26106470D

SENATE BILL NO. 122

AMENDMENT IN THE NATURE OF A SUBSTITUTE

(Proposed by the Senate Committee on Education and Health

on ________________)

(Patron Prior to Substitute—Senator McPike)

A BILL to amend and reenact §§ 22.1-274 and 22.1-274.01:1 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 22.1-274.01:2, relating to school boards; student diabetes care and management in schools; divisionwide plan required.

Be it enacted by the General Assembly of Virginia:

1. That §§ 22.1-274 and 22.1-274.01:1 of the Code of Virginia are amended and reenacted and that the Code of Virginia is amended by adding a section numbered 22.1-274.01:2 as follows:

§ 22.1-274. School health services.

A. A school board shall provide pupil personnel and support services in compliance with § 22.1-253.13:2. A school board may employ school nurses, physicians, physical therapists, occupational therapists, and speech therapists. No such personnel shall be employed unless they meet such standards as may be determined by the Board. Subject to the approval of the appropriate local governing body, a local health department may provide personnel for health services for the school division.

B. In implementing subsection P of § 22.1-253.13:2, relating to providing support services that are necessary for the efficient and cost-effective operation and maintenance of its public schools, each school board may strive to employ, or contract with local health departments for, nursing services consistent with a ratio of at least one nurse per 1,000 students. In those school divisions in which there are more than 1,000 students in average daily membership in school buildings, this section shall not be construed to encourage the employment of more than one nurse per school building. Further, this section shall not be construed to mandate the aspired-to ratios.

C. The Board shall monitor the progress in achieving the ratio set forth in subsection B and any subsequent increase in prevailing statewide costs, and the mechanism for funding health services, pursuant to subsection P of § 22.1-253.13:2 and the appropriation act. The Board shall also determine how school health funds are used and school health services are delivered in each locality.

D. With the exception of school administrative personnel and persons employed by school boards who have the specific duty to deliver health-related services, no licensed instructional employee, instructional aide, or clerical employee shall be disciplined, placed on probation, or dismissed on the basis of such employee's refusal to (i) perform nonemergency health-related services for students or (ii) obtain training in the administration of insulin and glucagon. Any school board employee who does not have a specific duty to deliver health-related services may, with reasonable notice to the school division, decline to provide future health-related services. However, instructional aides and clerical employees may not refuse to dispense oral medications.

For the purposes of this subsection, "health-related services" means those activities that, when performed in a health care facility, must be delivered by or under the supervision of a licensed or certified professional.

E. Each school board shall ensure that in school buildings with an instructional and administrative staff of 10 or more (i) at least three employees have current certification or training in emergency first aid, cardiopulmonary resuscitation, and the use of an automated external defibrillator and (ii) if one or more students diagnosed as having diabetes attend such school, at least two employees have been trained in the administration of insulin and glucagon. In school buildings with an instructional and administrative staff of fewer than 10, school boards shall ensure that (a) at least two employees have current certification or training in emergency first aid, cardiopulmonary resuscitation, and the use of an automated external defibrillator and (b) if one or more students diagnosed as having diabetes attend such school, at least one employee has been trained in the administration of insulin and glucagon. For purposes of this subsection, "employee" includes any person employed by a local health department or a local government who is assigned to the public school pursuant to an agreement between the local health department or the local government and the school board. When a registered nurse, advanced practice registered nurse, physician, or physician assistant is present, no employee who is not a registered nurse, advanced practice registered nurse, physician, or physician assistant shall assist with the administration of insulin or administer glucagon. Prescriber authorization and parental consent shall be obtained for any employee who is not a registered nurse, advanced practice registered nurse, physician, or physician assistant to assist with the administration of insulin and administer glucagon.

§ 22.1-274.01:1. Students who are diagnosed with diabetes; administration of insulin; diabetes care and management services; wearable diabetes devices; liability protections; self-care.

A. Each local school board shall permit each enrolled student who is diagnosed with diabetes, with parental consent and written approval from the prescriber, as that term is defined in § 54.1-3401, to (i) carry with him and use supplies, including a reasonable and appropriate short-term supply of carbohydrates, an insulin pump, and equipment for immediate treatment of high and low blood glucose levels, and (ii) self-check his own blood glucose levels on a school bus, on school property, and at a school-sponsored activity.

B. A local school board employee who is a registered nurse, licensed practical nurse, or certified nurse aide and who has been trained in the administration of insulin, including the use and insertion of insulin pumps, and the administration of glucagon may assist a student who is diagnosed with diabetes and who carries an insulin pump with the insertion or reinsertion of the pump or any of its parts. For the purposes of this subsection, "employee" has the same meaning as in subsection E of § 22.1-274. Prescriber authorization and parental consent shall be obtained for any such employee to assist with the insertion or reinsertion of the pump or any of its parts. Nothing in this section shall require any employee to assist with the insertion or reinsertion of the pump or any of its parts.

As used in this section and §§ 8.01-225, 22.1-274, 54.1-2901, 54.1-3001, 54.1-3005, and 54.1-3408, "administration of insulin" or "insulin injections" includes any method of insulin delivery authorized by a prescriber and recognized in the most recent version of the American Diabetes Association Standards of Care in Diabetes.

B. Any employee among those identified pursuant to clause (ii) or (b) of subsection E of § 22.1-274 who receives prescriber authorization and parental consent to provide diabetes care for a student in the school setting, including any employee who, when applicable, is authorized pursuant to subsection H of § 54.1-3408, may (i) deliver the care and services as described therein for which the employee is authorized and that the employee understands and is prepared to deliver and (ii) for any diabetes care that cannot currently be provided, obtain clarification from the student's prescriber, receive additional training, or obtain other provisions as necessary to be able to deliver such care within 30 days. The diabetes care provided under this subsection may include assisting a student diagnosed with diabetes with the insertion or reinsertion of the student's wearable diabetes device, provided that such employee has, with respect to that device, (a) obtained prescriber authorization, (b) obtained the consent of the student's parent, and (c) received training on the use and insertion of such device. Nothing in this section shall require any employee to assist with the insertion or reinsertion of a student's wearable diabetes device. However, no school board shall prohibit an employee who meets the requirements of this subsection from providing such assistance. Employees authorized pursuant to subsection H of § 54.1-3408 shall be exempt, as provided in subdivision A 9 of § 54.1-3001, from nursing practice requirements, shall not be considered to be engaging in the practice of medicine pursuant to § 54.1-2901, and shall be immune from civil liability under subdivision A 11 of § 8.01-225. Nothing in this section shall be construed to alter or limit the protections provided to school board employees under subsection D of § 22.1-274. No registered nurse, advanced practice registered nurse, physician, physician assistant, or other school board employee shall be liable for any act or omission of an employee acting in accordance with this subsection and pursuant to subsection H of § 54.1-3408. Nothing in this subsection shall be construed to authorize the delegation or supervision by a registered nurse of the care and services described in this subsection or to alter or expand the scope of practice governed by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 or the regulations of the Board of Nursing.

C. Each school board shall permit each enrolled student who is diagnosed with diabetes, with prescriber authorization and parental consent, at any time in the school setting, to (i) carry, consume, and use his diabetes supplies, including a reasonable and appropriate supply of carbohydrates, water, and diabetes devices; (ii) self-check glucose levels; and (iii) carry and use a cell phone or smart device, pursuant to subdivision B 4 of § 22.1-79.3:1, to monitor, address, or contact his parent, the school, or his health care provider to communicate about any matter relating to diabetes care and management needs or decisions, including to self-check his own glucose levels in accordance with clause (ii).

§ 22.1-274.01:2. School boards; divisionwide plan for the care of students who are diagnosed with diabetes required.

A. As used in this section, "school board employee" has the same meaning as in subsection E of § 22.1-274.

B. Each school board shall develop, amend as necessary, and implement a divisionwide plan for the care of students diagnosed with diabetes in each public elementary or secondary school in the school division for the purpose of ensuring the maintenance of a safe and healthy learning environment and maximizing the opportunity for academic success for each student. Each such divisionwide plan shall:

1. Give consideration to and incorporate, where appropriate, the guidelines contained in the Department's Diabetes Management in Schools: Manual for Unlicensed Personnel (the Manual);

2. Ensure that any training, education, and professional development opportunities for licensed or unlicensed staff relating to such care are sufficient to meet the needs of students with diabetes and are properly tailored to the unique needs that are present in each school in the school division and the skills of the staff in each such school;

3. Include procedures, consistent with subsection E of § 22.1-274, for ensuring that in each school building in the school division that is attended by one or more students diagnosed with diabetes and that has an instructional and administrative staff of (i) 10 or more, at least two employees have been trained in the administration of insulin and glucagon and (ii) fewer than 10, at least one employee has been trained in the administration of insulin and glucagon;

 4. Ensure that the provision or assistance with the provision of diabetes-related care by licensed or unlicensed school board employees is consistent with the guidance contained in the most recent revision of the Manual and is in accordance with applicable law, including provisions to:

a. Provide for assistance with the administration of insulin or glucagon by a school board employee who is not a licensed practical nurse, registered nurse, advanced practice registered nurse, physician, or physician assistant but who has been trained in the administration of insulin or glucagon in accordance with the provisions of subsection E of § 22.1-274, provided that with reasonable notice to the school division, those employees who do not have a specific duty to deliver health-related services may decline to provide future health-related services pursuant to subsection D of § 22.1-274;

b. Permit a registered nurse, advanced practice nurse, physician, physician assistant or other trained school board employee who has obtained prescriber authorization and parental consent to provide diabetes care for a student in the school setting in accordance with the prescriber authorization for such student if such employee is trained to provide the specific care provided for in the prescriber authorization, which may include insertion or reinsertion of a wearable diabetes device in accordance with the provisions of subsection B of § 22.1-274.01:1 and to provide that no employee shall be required to assist with the insertion or reinsertion of a student's wearable diabetes device and that a trained employee who assists with the insertion or reinsertion of wearable diabetes shall be exempt, as provided in subdivision A 9 of § 54.1-3001, from nursing practice requirements, shall not be considered to be engaging in the practice of medicine pursuant to §54.1-2901, and shall be immune from civil liability under subdivision A 11 of § 8.01-225. consistent with Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 and regulations of the Board of Nursing; and

c. Provide that no registered nurse, advanced practice registered nurse, physician, physician assistant, or other school board employee shall be liable for any act or omission of an employee providing diabetes care and services for a student in the school setting in accordance subsection B § 22.1-274.01:1 and pursuant to subsection H of § 54.1-3408 and that nothing in subsection B § 22.1-274.01:1 shall be construed to authorize the delegation or supervision by a registered nurse of the care and services described in that subsection or to alter or expand the scope of practice governed by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 or the regulations of the Board of Nursing;

5. Make available opportunities for parental involvement in the process of providing care for such students at school, including establishing processes and procedures for the implementation of a prescriber authorization for diabetes care upon receipt of such authorization from a parent of a student with diabetes, the development of Individualized Health Care Plans in collaboration with the school nurse or another qualified staff member, and the consideration of complaints and resolution of disputes relating to such documents or any other aspect of the provision of care for such students at school;

6. Provide interested parents with opportunities to provide input on the development or amendment of the divisionwide plan;

7. Include procedures to implement the divisionwide plan in each public elementary and secondary school in the local school division; and

8. Address such other matters as the school board deems necessary and appropriate.

C. The Department shall, alone or in consultation with such individuals or entities as it deems appropriate, provide technical assistance to school boards upon request in the development, amendment, or implementation of the divisionwide plans required pursuant to subsection B.

2. That the Department of Education, in consultation with the Department of Health, the School Committee of the Virginia Diabetes Council, the American Diabetes Association, FOLLOWT1Ds, school board members, and such other stakeholders as it deems appropriate, shall conduct a comprehensive review of the Diabetes Management in Schools: Manual for Unlicensed Personnel and shall, no later than January 1, 2027, revise such document as deemed necessary to (i) ensure that such document is up to date and properly guides and informs the development of divisionwide plans required pursuant to § 22.1-274.01:2 of the Code of Virginia, as created by this act; (ii) define, or update the definitions of, terms relating to diabetes care to ensure consistency and currency, including the terms (a) "diabetes device" or any equivalent term that refers to any medically necessary device used in the treatment or monitoring of diabetes, including glucose monitors and meters, wearable diabetes devices, and any part or component thereof; (b) "connected diabetes technology" or any equivalent term that refers to any digital or electronic device used in conjunction with a diabetes device for the purpose of regulating the timing and amount of insulin delivery, collecting or transmitting glucose data, or assisting with the performance or monitoring of other diabetes-related care or decision-making; and (c) "designated unlicensed employee" to mean any school board employee who is not a licensed practical nurse, registered nurse, advanced practice registered nurse, physician, or physician assistant but who, consistent with applicable law, has been trained in the administration of insulin and glucagon and has been authorized by a prescriber and has parental consent to assist with the administration of insulin or administer glucagon to a student diagnosed with diabetes; (iii) include information on the immunity of a school board employee, provided pursuant to subdivision A 11 of § 8.01-225 of the Code of Virginia, from liability for civil damages for ordinary negligence in acts or omissions resulting from such employee's assistance with the administration of insulin, the insertion or reinsertion of an insulin pump or any part thereof, or the administration of glucagon to a student diagnosed with diabetes, provided that such employee has been trained in the administration of insulin and glucagon and rendered such treatment pursuant to prescriber authorization, with parental consent, and consistent with applicable law and regulation; (iv) include guidance consistent with the provisions of §§ 22.1-274 and 22.1-274.2 of the Code of Virginia and § 22.1-274.01:1 of the Code of Virginia, as amended by this act, relating to the training of and provision of or assistance with the provision of diabetes-related care by school board employees, including guidance on the training of, provision or assistance with the provision of care by, and designation of a designated unlicensed employee, as that term is defined in clause (ii) (c); (v) include guidance for (a) ensuring that each school in the school division attended by one or more students diagnosed with diabetes meets the minimum staffing requirements for employees trained in the administration of insulin and glucagon set forth in subsection E of § 22.1-274 of the Code of Virginia, as amended by this act; (b) in the event that any such school is unable to meet such minimum staffing requirements because no trained employee is available, making a good faith, ongoing effort to identify and provide for the training of a volunteer to assist with the provision of such care; (c) encouraging or incentivizing trained employees to provide diabetes-related care, in accordance with applicable law and regulation, when no school nurse or employee who is a licensed practical nurse, registered nurse, advanced practice registered nurse, physician, or physician assistant is present; and (d) determining when no school board employee who is a licensed practical nurse, registered nurse, advanced practice registered nurse, physician, or physician assistant is present and, therefore, when a trained employee is permitted to assist with the administration of insulin or administer glucagon pursuant to subsection E of § 22.1-274 of the Code of Virginia, as amended by this act; (vi) include recommendations for the training of school bus drivers who are responsible for the transportation of students diagnosed with diabetes to and from school; (vii) incorporate evidence-based practices and guidance from Virginia-based health systems and national organizations, provided that such practices and guidance do not conflict with the Code of Virginia or federal law; and (viii) be in accordance with subdivision 12 of § 54.1-3005 of the Code of Virginia and not take effect prior to the completion of a public comment period on such revision of no fewer than 30 days in accordance with § 2.2-4002.1 of the Code of Virginia. The Department of Education shall, no later than January 1, 2027, post such revised document in a publicly accessible location on its website. The Department of Education shall, at least biennially thereafter, review, revise, and repost in a publicly accessible location on its website such document to ensure that the information therein is current and accurate and incorporates evidence-based practices and guidance from Virginia-based health systems and national organizations, provided that such practices and guidance do not conflict with the Code of Virginia or federal law.

3. That the Department of Education, in consultation with the Department of Health, shall collect from each school division information on access to glucagon for students diagnosed with diabetes, including the number of students with or without a prescriber authorization, the types of glucagon prescribed, the number of administrations, storage or self-carry practices, and, when available, reasons for lacking a prescription, not carrying glucagon, or not providing it to the school. The Department of Health shall add glucagon to the medications listed on the School Health Data Dashboard and make such information publicly available. The Department of Education shall report aggregated findings to the Chairs of the House Committee on Education and the Senate Committee on Education and Health by November 1, 2026.

4. That the Board of Education shall adopt and amend any regulations as necessary in accordance with the provisions of this act.

5. That each school board shall develop and implement its divisionwide plan as required pursuant to § 22.1-274.01:2 of the Code of Virginia, as created by this act, to become effective beginning with the 2027–2028 school year.