Special Dietary Needs Process Updates CSNA Summer Conference Monday, June 12, 2017 11 a.m. – 12 p.m.

Together We Can Colorado Department of Education Vision All students in Colorado will become educated and productive citizens capable of succeeding in society, the workforce, and life. CDE Office of School Nutrition Mission The Office of School Nutrition is committed to ensuring all school-aged children have equal access to healthy meals by supporting, training, and connecting Colorado’s child nutrition community.

Objectives Understand the upcoming changes to special dietary needs in school meal programs. Understand the role of school nurses in special dietary needs and food allergy management in schools. Understand how to join the district 504 team. Identify best practices in school meal accommodations.

Special Dietary Needs Process Updates Kristi Rolfsen, MS, RD Program Specialist CDE Office of School Nutrition

Background of Updates ADA Amendments Act of 2008 simplified the question of whether a child has a disability USDA Memo SP 59-2016 Definition of a disability is expanded Almost all medical needs require an accommodation Medical statements are not required if request falls within meal pattern Utilization of 504 coordinators/team The ADA Amendments Act of 2008 simplified the question of whether a child has a disability by broadening the interpretation of what constitutes a disability. Anything that substantially limits a major life activity, which includes most physical and mental impairments, is considered a disability. USDA Memo SP 59-2016 was released on September 27, 2016 to align the definition of a disability with the ADA Amendments Act of 2008.

What is considered a disability? Food allergies Food intolerances Autism and/or other mental impairments Phenylketonuria (PKU) Diabetes Celiac Disease Obesity “Categories and conditions” in the ADA is not all inclusive. According to the definition of disability in the ADA, a food allergy does not need to be life-threatening or cause anaphylaxis in order to be considered a disability. If a food intolerance substantially limits a major life activity, including digestive impairments, it is considered a disability regardless of whether or not it causes severe distress. Autism is considered a disability as it may disrupt the activity of eating. For example, some autistic children will only eat certain foods due to ritualistic behavior patterns. Any physical or mental impairment that prevents a child from consuming a meal is considered a disability. If obesity substantially limits a major life activity, it can be considered a major life activity. If a child’s medical condition is not listed under “categories and conditions” in the ADA, a SFA cannot refuse an accommodation as these are not all inclusive.

Medical Statement A medical form is required when the modified meal does not meet the Program meal pattern requirements Must be signed by a MD, DO, ANP, or PA Does not need to provide a specific diagnosis What needs to be included: Information about the child’s physical or mental impairment An explanation of what must be done to accommodate the child The food or foods to be omitted AND Recommended alternatives Required information can be included in IEP or 504 Plan Follow up when additional information is required Anytime a meal falls outside of the meal pattern requirements, a written medical statement signed by a licensed healthcare professional is required to be on file. In Colorado, a physician (MD), doctor of osteopathic medicine (DO), advanced nurse practitioner (ANP), or physician assistant (PA) can sign a medical statement. The written medical statement no longer needs to identify the specific disability or use of the terms “disability” or “disabled.” A description of the child’s physical or mental impairment is sufficient to allow the SFA to make accommodations. What is required to be on the medical form? Information about the child’s physical or mental impairment An explanation of what must be done to accommodate the child The food or foods to be omitted AND Recommended alternatives In some cases, the SFA might need additional information. For example, if the child requires caloric modifications this information must be included on the medical statement. If a medical statement is unclear, or lacks sufficient detail, appropriate clarification should be obtained so a safe meal can be provided. SFAs should not allow requests for additional information to delay the If the required information is written into a student’s IEP or 504 Plan, a medical statement is not required. The IEP or 504 Plan is sufficient. Collaboration with the IEP or 504 team to have the medical statement requirements written into the plan can decrease the burden for parents. Medical statements can be rolled over from year to year.

Reasonable Modifications Change or alteration in policies, practices, and/or procedures to accommodate a disability Offer vs. Serve can be utilized only when the child can still select all components In most cases, a generic brand is sufficient A reasonable modification is a change or alteration in policies, practices, and/or procedures to accommodate a disability that ensures a child has equal opportunity to participate in the program. Reasonable modifications must be made on a case-by-case basis. This might include ensuring served meals do not contain a potential allergen, separate storage areas or specific staff training or expertise. Offer vs. serve can only be utilized when the child can still select all five components. For example, if a child cannot consume gluten, a non-gluten bread/grain choice must still be available for the child. If a specific brand is requested, a generic brand is sufficient in most cases. If the brand name is deemed medically necessary and is expensive or difficult to procure, the SFA should work with the 504 team and family to decide on a different substitute that is safe and appropriate.

What this means for SFAs SFAs should not weigh medical evidence Focus: ensure equal opportunity to participate Collaboration with parents What does this mean for SFAs? SFAs and LEAs should not weigh medical evidence against legal requirements to determine if a medical condition is severe enough to be considered a disability. New focus of meal accommodations: what can be done to ensure equal opportunity for all students to participate in school meal programs. Providing modified meals should be as inclusive as possible. SFAs should use a team approach by working with parents or legal guardians to ensure the accommodations are both safe and fair for the student. If a 504 or IEP team exists in the school, this team can be utilized to address a child’s nutritional needs.

Procedural Safeguards LEAs should provide notice and information on how to request a modification SFAs are encouraged to work with the Section 504 coordinator Parent involvement develops rapport and prevents miscommunication LEAs are required to provide notice and information to parents and guardians regarding how to request a reasonable modification and their procedural rights. Procedures that are already in place through Section 504 of the Rehabilitation Act of 1973 may be used to fill this requirement. SFAs are encouraged to work with the Section 504 coordinator or team to develop a holistic plan to create a safe environment for the child. Meal accommodations should be as inclusive as possible and parents should be included in the process. Parent involvement develops rapport with the family and prevents miscommunication.

The New Look of CDE Materials Replacement of old CDE OSN special diet forms with one medical form and one preference form Updated resources: Frequently Asked Questions Standard Operating Procedure Template Accommodating Special Dietary Needs Summary Chart Medical Statement Flow Chart Currently, CDE has a SD-1 form (dietary disability), SD-2 form (non-disability), and SD-6 form (religious, cultural) that districts can utilize. With this new guidance, the forms will be condensed into two forms: a medical form and a preference form. Any request turned in on the medical form (signed by a recognized medical authority) requires accommodations. The district has the option of whether or not they want to accommodate preference form requests. It is recommended to have a preference form filled out for students whose accommodations fall within the meal patterns (i.e. allergies).

Section 504 Teams, Food Allergy Protocols Kathleen Patrick, RN Assistant Director CDE Health and Wellness Unit

504 / ADA Disability A person has a physical or mental impairment that substantially limits a major life activity or bodily function

Schools must identify disabled students Section 504 Regulations Institutions receiving federal funds, including public schools, must comply Schools must identify disabled students Schools must establish standards and procedures for the evaluation and placement of disabled students Schools must meet individual needs of disabled students to insure that they have the same access to education as non-disabled students 504 should not lower the standards just level the playing field

The School 504 Team Must comprise of persons who have knowledge and information relevant to the determination of the student’s eligibility, including the parents, and to placement options Must determine eligibility under 504 If eligibility is confirmed, must design accommodation plan based on specific needs of student

How Food Service Staff can Advocate for Participation Introduce yourself to the 504 Coordinator for the school Determine which 504s include accommodations for nutrition If appropriate, attend the 504 meetings Meet the School Nurse assigned to the school Obtain list of students with health concerns that: Food Service staff might need to respond to in an emergency Students who may need changes to their lunches and would require provider authorization

Individualized Health Plan: IHP vs 504 Individualized Health Plan: Outlines medical management or emergency response Can be part of the 504 plan Section 504 Plan Food allergy likely to substantially limit the major life activities of breathing and respiratory function Student has right to an evaluation, placement and procedural safeguards if disability determined

To Summarize Following 504 procedure is of primary importance to OCR 504 Team should include nutrition services if disability will impact diet Student’s impairment does not have to impact learning for student to qualify under 504 Individualized Healthcare Plan (IHP) can be part of the 504 but is not a substitute for the 504 Parents request 504 plan (in addition to IHP) because they want greater legal protection and recourse, and they are entitled to 504 process

SY 2015-2016 – 71 reports of anaphylaxis/epinephrine administration Epinephrine Reports SY 2015-2016 – 71 reports of anaphylaxis/epinephrine administration Report must be made within 10 days of incident of either anaphylaxis and/or epinephrine administration http://fs24.formsite.com/305medicaid/form5 /index.html ASK/CDE/Allergy Home: online module that includes Colorado specific rules http://www.allergysafekids.org/staff- trainings.html So far 80 this year

  2014-2015 2015-2016 Total incidents 65 71 Known allergy Yes No unknown 49 10 5 60 (84.5%) 10 (14.1% 1 (1.4%) Action plan available yes no 46 17 60 Trigger food insect sting exercise medication latex inhaled unknown/other 37 26 43 2 1 18 Exposure route ingestion contact other 33 6 39 8

Location Reaction Occurred: off school grounds classroom cafeteria health office playground bus other   1 39 11 7 3 4 2 36 14 5 9 School District in Washington School District saw a 94 percent reduction in life-threatening allergic reactions aggressively worked on policy related to anaphylaxis Most related to sharing food Teachers prohibited using food as rewards, incentives and celebrations Increased staff training including informing staff of students with food allergies 2014-2015: median age = 12 yrs 4-11 yrs = 28 12-18 yrs = 35 2 had no age listed 2014-2015: median age = 11 yrs 5-11 yrs = 40 12-18 yrs = 29 1 adult = 49 years old 1 had no age listed

Contact Information For questions, contact: Kathleen Patrick, RN Colorado Department of Education Health and Wellness Unit 303-866-6779 patrick_k@cde.state.co.us School District in Washington School District saw a 94 percent reduction in life-threatening allergic reactions aggressively worked on policy related to anaphylaxis Most related to sharing food Teachers prohibited using food as rewards, incentives and celebrations Increased staff training including informing staff of students with food allergies

Best Practices and Challenges in Special Diets Hannah Phillips, RDN, SNS Administrative Dietitian Pueblo City Schools

What We’ll Cover Today Promoting best practices for special diet accommodations. Overcoming challenges to accommodate special diets.

District Special Diet Accommodation Process Receive completed SD Form Nurse Schedules Special Diet Meeting Special Diet Menu Meeting (Parent, Student Nurse, Counselor, Kitchen Manager, RD) Make Corrections/ Changes to menu Train Kitchen Staff Start Special Diet District Special Diet Accommodation Process

Staff Special Diet Training Training Participants: Area Supervisor Kitchen Manager Cook Assistant/Assistan t Manager RD Training Content: Menu Recipes Explanation of Special Diet Start Date Food Safety Practice Special Diet Foods List

Special Diet Menu & Recipe Week Monday Tuesday Wednesday Thursday Friday 1 1 cup GF Cereal ½ cup Fruit or Vegetable 4oz Juice (apple/orange) 1 cup Milk GF Breakfast Sandwich 1 cup Fruit or Vegetable   13 GF Crackers 1 ea Cheese Stick 2 GF Oatmeal

Menu/Recipe Development Challenges Present special diet menu to parent and student Menu provides a like item when possible Allow student input into menu- this creates buy in and they are more likely to eat what you prepare (ask student preference on cereal options that you provide) Be creative Gluten free corn tortillas- The possibilities are endless! Use as many current school food services products as possible

Staff Training Challenges Provide a full explanation of the student’s special diet need and what can happen if diet is not followed. Recipes and menu binder Training documentation Develop relationships with staff Staff feel comfortable asking questions or voicing concerns Train staff if they are unsure if a product is safe then do not serve it until clarification is determined by RD.

Questions?

Resources CDE OSN Special Dietary Needs webpage CDE Health and Wellness Unit – Health Conditions webpage CDC Toolkit for Managing Food Allergies in Schools Institute of Child Nutrition Food Allergy Resources Allergy Safe Kids (ASK) Training Modules