In July 2012, ISBE amended its regulations addressing the qualifications required for an individual to conduct medical reviews and make recommendations based on the findings of medical reviews. Medical reviews are conducted as part of the special education evaluation or re-evaluation process when the team determines that health is a domain that may affect the student’s educational performance. ISBE recently provided guidance on the requirements of the new regulation and how they will impact school districts.

Under the current version of the regulation, which remains in effect until June 30, 2013, a Certified School Nurse (CSN), physician, Advanced Practice Nurse (APN) or Registered Nurse (RN) can conduct a medical review. Beginning July 1, 2013, the new regulation provides that a CSN, physician, or APN can still conduct medical reviews, but an RN can only do so if he or she has a bachelor’s degree. Moreover, only a CSN will be able to make educational recommendations based on the medical review.

For the many school districts that do not employ CSNs or RNs with bachelor’s degrees, a careful analysis to determine whether the district needs to hire or otherwise gain access to qualified nurses for medical reviews and educational recommendations should be conducted before June 30, 2013. The following questions are prepared to assist school districts in this analysis.

What is a CSN?

According to the ISBE guidance, a CSN is a registered professional nurse who holds a school service personnel certificate with an endorsement in school nursing, or any non-certificated registered professional nurse who was employed in the school district of current employment before July 1, 1976.

For what purposes does the new law require school districts to use a CSN?

School districts are only required to use a CSN to review medical reviews and make educational recommendations. School districts can use an RN with a bachelor’s degree, an APN, or a physician to collect and review a student’s medical information and make recommendations for any needed nursing services. For all other purposes, school districts can continue to use qualified nurses as they did prior to the revised regulation and in accordance with State law.

What is a medical review?

The regulations do not define medical reviews. ISBE’s recent guidance defines a medical review as the process during the case study or reevaluation for special education services that aims to answer the question, “Is a health condition adversely affecting a student’s educational performance?” The process includes a number of activities and results in a complete review of the student’s medical and health status.

Who can handle the responsibilities for a medical review?

ISBE’s guidance goes into great detail concerning the process for completing a medical review, who is qualified to conduct the component parts, and to whom responsibilities can be delegated. To summarize, ISBE expects that a CSN, physician, RN with a bachelor’s degree, or APN will collect subjective health information (such as parental concerns, student perceptions, health history, and teacher observations) and objective health information (such as vital signs, hearing and vision screenings, height/weight/BMI, and review of records) during a medical review. The CSN, physician, RN with a bachelor’s degree, or APN will then determine whether additional information is needed and what nursing services, if any, are required to maintain the student during the school day.

Must an RN with a bachelor’s degree have a degree in nursing?

No. The regulations do not require that the RN’s degree be in a particular field. ISBE’s guidance indicates, however, that a baccalaureate degree in nursing is preferred.

Who can analyze the results of the medical review and report educationally relevant findings?

The amended regulation and ISBE’s guidance state that only a CSN may make recommendations regarding educational interventions, accommodations, or modifications to the student’s individualized educational program (IEP) based on the findings of the medical review.

Can a qualified nurse delegate any of the responsibilities of the medical review?

Yes. The ISBE guidance makes clear that the CSN, physician, RN with a bachelor’s degree, or APN may delegate portions of the medical review to other school staff, such as other nursing level staff, vision/hearing technicians, or assistants. Such delegation, however, may only be for responsibilities allowed by these other individual’s education and training. CSNs cannot delegate their responsibilities related to making educational findings and recommendations.

What responsibilities of the medical review can be delegated?

The following are examples of responsibilities that ISBE indicates may be delegated:

  • Vision screenings may be delegated to any person holding a certificate issued by the Illinois Department of Public Health (IDPH) as a vision screening technician.
  • Hearing screenings may be delegated to any person holding a certificate issued by IDPH as a hearing screening technician. 
  • Health histories, including review of objective and subjective data, may be delegated by a CSN, APN, or RN with a bachelor’s degree to an RN who does not hold a bachelor’s degree or a Licensed Practical Nurse (LPN), or by a physician to any licensed health care worker.
  • Physical assessments may be delegated by a CSN, APN, or RN with a bachelor’s degree to an RN without a bachelor’s degree or by a physician to any licensed health care worker.

What responsibilities of the medical review may not be delegated?

ISBE provides the following examples of responsibilities that a CSN may not delegate to others, except to another CSN:

  • The summary of educationally relevant medical findings and assessment of whether a student’s educational performance is adversely affected by his or her past or present health status, which may contribute to the Statement of Present Level of Educational Performance (as it relates to health) in the IEP.
  • Educational recommendations, including annual goals, short-term objectives, educational interventions, accommodations and modifications (including but not limited to recommendations that would ameliorate the adverse impact of the health condition).
  • Report on how current health conditions affect the educational environment, including the determination of the student’s least restrictive environment.
  • Make recommendations for changes to educational interventions, methods, or services that may improve the student’s ability to function within the regular classroom and/or least restrictive environment.
  • Within the IEP, the statement of specific nursing related services to be provided, duration, by whom, when, and where.
  • Regular evaluation of the IEP health goals, nursing interventions, and student progress.

Must a CSN always be present at an IEP meeting after the regulation goes into effect?

Not always, but a CSN must be present if a medical review is being discussed during an IEP meeting. ISBE’s guidance suggests the CSN, as the only person qualified to interpret the instructional implications of a medical review, must present the educationally relevant medical findings to the IEP team and work with the team to develop accommodations, modifications, goals, objectives, and evaluations related to those findings.

What is the role of the CSN on the IEP team?

The ISBE guidance indicates that the CSN is to:

  • Assist with the development of the IEP;
  • Integrate school nursing services into the student’s academic and/or functional goals;
  • Make recommendations about educational interventions, accommodations, and modifications to instruction or to the learning environment; 
  • Make recommendations regarding student health-related goals, including frequency of evaluating the student’s progress;
  • Make recommendations regarding specific school health services and school nursing services to be documented in the IEP;
  • Provide or delegate nursing interventions. Examples include direct nursing care, such as medications, tube feedings, dressing changes, skin care, respiratory care, as well as teaching the student or other providers about the student’s care, and indirect interventions, including case management activities, development of the health component of the IEP, and in-service training for staff and faculty; and
  • Write progress reports relative to the established health-related goals and evaluate the effectiveness of the interventions.  

Does the CSN have any greater say on eligibility or services than other members of the IEP team?

No. The CSN participates on the IEP team to analyze the results of the medical review, report educationally relevant findings, and make recommendations. The CSN has a voice on the team like all other IEP team members; each contributes to the team’s decisions.

What if our school district does not have a CSN or RN with a bachelor’s degree on staff?

ISBE appears to recognize that many districts do not currently employ CSNs, and identifies a shortage of people with this qualification. To address this problem, ISBE states that it is pursuing multiple strategies to assist candidates in obtaining the needed degree and certification, and suggests that districts may want to contract to share a CSN. The same approach could be taken for RNs with bachelor’s degrees. School districts that are members of a special education cooperative should check with the cooperative to determine if a CSN or RN with a bachelor’s degree is available through the cooperative.

What if our school district employs an RN with an associate’s degree (who will not be qualified to conduct medical reviews under the new regulation), can he or she be let go?

Nurses that are not CSNs are educational support personnel employees. The School Code provides that such employees can be dismissed or their hours may be reduced if certain conditions are met and proper notice is provided. Individual circumstances may vary and may depend on any relevant collective bargaining agreement, and we recommend that you consult with your attorney for more tailored guidance.