HOUSE BILL NO. 624

AMENDMENT IN THE NATURE OF A SUBSTITUTE

(Proposed by the House Committee on Education

on ________________)

(Patron Prior to Substitute—Delegate Cherry)

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; self-care; insertion and reinsertion of insulin pump.

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; and (iii) carry with him 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).

B. A local school board employee who is a registered nurse, or 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, or another school board employee who is authorized pursuant to applicable law and has been trained in accordance with the most recent edition of the American Diabetes Association Standards of Care in Diabetes 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. Any school board employee that is authorized pursuant to subsection H of § 54.1-3408 and meets the requirements set forth in applicable law to provide certain diabetes-related care shall (i) be exempt from nursing practice requirements pursuant to subdivision A 9 of § 54.1-3001; (ii) not be considered to be engaging in the practice of medicine pursuant to subdivision A 26 of § 54.1-2901; and (iii) be immune from civil liability for ordinary negligence in acts or omissions resulting from the rendering of certain diabetes-related care pursuant to 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.

C. No school board shall prohibit any school board employee from providing any diabetes-related care that such school board employee is authorized and meets the requirements set forth in applicable law to provide, including assisting a student with the insertion or reinsertion of an insulin pump or any of its parts pursuant to subsection B, in accordance with the most recent edition of the American Diabetes Association Standards of Care in Diabetes. However, nothing in this subsection shall be construed to prohibit a school board from placing reasonable restrictions or parameters on the provision of diabetes-related care by school board employees for the purpose of ensuring the effective, efficient, and safe administration and operation of schools and school personnel, which may be included in the school board's divisionwide plan for the care of students who are diagnosed with diabetes developed and implemented pursuant to § 22.1-274.01:2.

§ 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 each public elementary or secondary school student who is diagnosed with diabetes 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 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:

a. 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; and

b. Assistance with the insertion and reinsertion of the insulin pump or any part thereof by a school board employee who has been trained in the administration of insulin, including the use and insertion of insulin pumps, and the administration of glucagon in accordance with the provisions of subsection B of § 22.1-274.01:1.

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 submission and consideration of Diabetes Medical Management Plans, 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, 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); and (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.

3. That the Department of Education, in consultation with the Department of Health, the School Committee of the Virginia Diabetes Council, the American Diabetes Association, school board members, and such other stakeholders as it deems appropriate, shall review the Diabetes Management in Schools: Manual for Unlicensed Personnel at least biennially, revise it as necessary to ensure the information therein is current and accurate, and post it in a publicly accessible location on its website.

4. 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.

5. That the Department of Education, in collaboration with the Department of Health, shall develop, periodically review and update as necessary, make available to each school board, and post in a publicly accessible location on its website informational materials for parents on type 1 and type 2 diabetes.

6. That each school board shall make the informational materials developed pursuant to the fifth enactment of this act available to the parent of each student enrolled in the school division at the beginning of each school year.