Contracted Agency Nursing

Parents may utilize contracted agency nurses in their home to provide nursing services. When the student reaches school age or is eligible to access educational programs, teams will make a determination of related service needs. 

Special Healthcare Needs Assessment

The school nurse employed by the district may be asked to complete the Special Health Care Needs Assessment Form. The school nurse working under the auspices of the school completes the Special Healthcare Needs Assessment Form and provides it to the Special Education team. This piece of data is important when the team is making a determination regarding the level of related services to provide based on the school nurse’s licensed delegation decision. A team may make a determination to provide more related services (i.e. the school nurse has indicated in documentation that they can delegate a task to a paraprofessional using professional nursing judgement and accountability, but the team would like the child's 1:1 contracted agency nurse). This form assists both the licensed educator and the licensed nurse. Parents may request unlicensed family to provide care or provide a medical note stating a family member can provide a service. As a reminder, a medical provider does not prescribe educational services. 

Licensed educators and licensed nurses are aware that parents sometimes do not understand that a school is a business and the licensed providers are held to higher regulatory standards (IAC 282.25.3; IAC 655.6) in the provision of care than the care provided by the parents at home. If the care requires licensure or qualification, the school must provide the appropriately licensed or qualified personnel, similar to other businesses.

Contracted Nursing Medicaid Guidance 

If the school or school sponsored program has a student who receives services at school or a school sponsored program from a home health private health care agency nurse, as an extension of the services provided in the home, it is recommended that the student’s Individualized Education Program (IEP) team: 

(1) review the necessity of nurse level services; 

(2) if nurse level services are found necessary, review the necessity of using a private health care agency nurse instead of an employee nurse; and 

(3) review Iowa Department of Human Services Informational Letter 1935-MC-FFS. The letter states that “Schools may choose to contract with health care agencies to provide the needed services. Contracted services are the responsibility of the school and the contracted providers should bill the school and not Medicaid for services written in the student’s IEP. While the IEP might order nursing services, the school is not obligated to use the private duty nursing agency that provides services in the student’s home before and/or after school. In addition, an IEP might require health paraprofessional services supervised by the school nurse if private duty nursing services are not medically necessary. If rejected by the IEP team, the private duty nursing agency cannot fail to provide services at the other authorized times of day. The titles below are tools your district might use to determine the necessity of nurse level services and to provide guidelines for private agency nurses.”

Sample Personnel Form

Guidelines for Contracted Health Providers Schools or programs can adapt this guideline. It is a basic agreement that the contracted agency personnel will follow policies and expectations (noninclusive examples: maintaining confidentiality, dress code, etc.)

Change in Personnel or Unfilled Positions

If the IEP determines the school will provide a registered nurse, then the school must provide a registered nurse. If the student's registered nurse resigns from the contracted nursing agency or is unable to attend the child’s school or program, the school or program must provide the related services outlined in the child’s individual education program (IEP). (Example: The 1:1 contracted agency nurse resigns effective immediately from their employment. The school registered nurse would become the 1:1 nurse for the student that the agency could not fill until a replacement registered nurse is found by the school or agency). 

Documentation Requirement 

The school or program is required to document health services provided, so if a student requires a 1:1 nurse and the school or school sponsored program uses an agency, the agency nurse would need to supply documentation to the school or program as part of the student's school or program  health record to meet IAC 281.14.2 and documentation that the program or school provided the health services.

School Nurse’s Role 

The school nurse working under the auspices of the school or program must develop an Individual Health Plan. This is not the agency plan used by the community or agency provider.  The reference guide to complete the IHP template is located in this document. Also, this is in the Nurse Practice Act when working with an LPN: 

The licensed practical nurse shall be permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student’s health plan when under the supervision of, and as delegated by, the registered nurse employed by the school district  

Also, located in IAC 281.14.2:  “Individual health plan” means the documented plan of care utilizing the nursing process as defined in 655—Chapter 6 for evidence-based management of the student’s ongoing special health service in the educational program. The school nurse may develop this plan in collaboration with the education team. The plan also includes a provision for emergencies to provide direction in managing an individual’s health condition (stable or unstable). Documentation of evaluation and updates to the plan are completed as needed and at least annually. 

“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.

School Nurse delegation to the Contracted Agency Nurse (a-d):

1. Delegation between an RN to an RN or LPN:  655.6.2(5) The registered nurse shall apply the delegation process when delegating to another registered nurse or licensed practical nurse by A-G(3).
2. b. Delegation between an RN to an unlicensed assistive personnel (anyone not licensed as a registered nurse): 655.6.3(9) The licensed practical nurse shall apply the delegation process when delegating to an unlicensed assistive personnel (UAP) by A-G
3. c. Refresher on  LPN Functions (IBON): https://dial.iowa.gov/licenses/medical/nursing-professional-midwifery/nursing-practice/rnlpn-role-scope#lpn-functions
4. Completed Consent/Delegation documentation:  The school nurse would complete a consent and delegation document for all delegated care to the contracted agency nurse.

 Other considerations for the school nurse (noninclusive list)

• How will field trips be handled?
• How will full day education programming health service delivery be provided?
• Does the child require delivery of health services when accessing transportation?
• Are  parents willing to sign a release of information, not only with the student's provider but also with the local EMS if the student has any life-threatening condition? 

The student is an integral member of the school community. The more engagement and communication between the student, their family, education team, community partners, and their healthcare provider(s) builds a greater safety net around the student.