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Chapter 37. Maternal and Infant Health Services
Subchapter G. Spinal Screening Program
The purpose of these rules is to implement Texas [the requirements of] Health and Safety Code, Chapter 37, concerning the detection of abnormal spinal curvature in children.
The following words and terms, when used in these sections, shall have the following meanings, unless the context clearly indicates otherwise.
(1) Abnormal spinal curvature--An anatomic, structural deviation from the normal spinal curve, such as scoliosis or kyphosis.
[(2) Child's health record--The official individual student health record(s) maintained by a school for a child.]
[(3) Conflict of interest--The use of the screening process for solicitation of follow-up services which enable the individual, his/her immediate family members or professional associates to benefit financially, or earn favors or free publicity as a result of the screening process.]
(2) Certification—The process by which the Department of State Health Services (department) trains individuals to conduct spinal screening as well as to then provide training screening procedures.
[(4) Department--The Department of State Health Services.]
(3) [(5)] Forward-bend test--A screening procedure [approved by the department] to determine whether a child may have an abnormal spinal curvature.
[(6) Health practitioner--A licensed professional who has completed a course of study in physical assessment and who is appropriately licensed under state law, including physicians, chiropractors, physical therapists, and registered nurses.]
[(7) Non-health practitioner--A person who may or may not have a health background, or whose training has not included physical assessment skills and techniques, which generally includes teachers, coaches, athletic trainers, licensed vocational nurses, health assistants, parents, and volunteers.]
(4) Licensed professional—An individual whose legally-defined scope of practice under the license includes knowledge and experience in conducting professional examinations and screenings for abnormal spinal curvature in children, all consistent with this subchapter and Health and Safety Code Chapter 37. The terms “professional examination” and “screening” are as defined in this section.
(5) [(8)] Professional examination—A diagnostic evaluation performed by an appropriately licensed professional or by a DSHS-certified individual whose expertise addresses the diagnostic needs of the individual identified as having a possible abnormal spinal curvature. A professional examination is one that is done according to the requirements of this subchapter and of Texas Health and Safety Code Chapter 37.[An evaluation performed by a health practitioner licensed under state law and whose expertise addresses the diagnostic needs of the individual identified as having a possible spinal deformity.]
(6) [(9)] School--An educational institution, public or private, that admits children who are five through twenty-one [between five-21] years of age, which includes an individual school campus.
[(10) Screener--An adult, non-student who performs the spinal screening test in a school setting. Screeners may be health practitioners who are licensed under state law or non-health practitioners who have successfully completed a department-approved course in spinal screening.]
[(11) Screener certification--Department-approved training which qualifies the individual to receive a certificate stating that the person may perform spinal screening.]
[(12) Screener recertification--A department-approved review course for screeners to extend their certification for an additional five years.]
(7) [(13)] Screening—A test or battery of tests for rapidly determining the need for a professional examination. [The forward-bend test, which is used for the determination of the need for a professional examination to diagnose a spinal deformity.]
[(14) Trainer certification--A department-approved course which qualifies the individual to receive a certificate stating the person may teach the screener certification course.]
[(15) Trainer--Individuals, including department staff and those health practitioners appropriately licensed under state law, who have successfully completed the department approved trainer certification course, and have at least two years of experience conducting spinal screening in a school-setting.]
§37.143 Spinal Screening Procedures
(a) Spinal screening is required, for all girls in grades five and seven and all boys in grade eight who attend public and private schools, to detect abnormal spinal curvature. Spinal screening, conducted under this subchapter by a person who is not a licensed professional, as the term is defined in this subchapter, must be conducted following the national standards for screening and referral set by the American Academy of Orthopaedic Surgeons, with the following exceptions:
(1) Rescreens should be conducted for reading results of 5 – 7 degrees;
(2) Referrals are recommended for reading results of 7 degrees or more.
(b) A person who is not a licensed professional, as that term is defined in this subchapter, who conducts spinal screening must be trained and certified as described in §37.146(a) of this subchapter.
(c) When a screener makes a referral based on the screening results under subsection §37.143 (a) of this section, that referral shall be to a licensed professional for a professional examination, and not to a specific individual.
(d) The requirements of this section do not apply when the individual is already actively under medical care by an appropriate licensed professional for one or more of the spinal problems for which screening is done under this section. In order to claim this exception, the individual under the scenarios described at Texas Family Code Section 32.003 or, if the individual is a minor, the individual’s parent, managing conservator or legal guardian, must submit documentation from the licensed professional to the school. The documentation must be signed and dated by the licensed professional, and must affirmatively state that the individual is under active, ongoing medical care from the licensed professional for specific spinal problems as referenced in this subsection.
§37.144 School Requirements; Department Activities
(a) The chief administrator of each facility shall ensure that each individual admitted to the school complies with the screening requirements of this subchapter, according to the following schedule:
(1) All girls in grades five and seven attending public and private schools shall be screened for abnormal spinal curvature before the end of the school year. The screening requirements may also be met by a professional examination as defined in §37.142 of this title (related to definitions).
(2) All boys in grade eight attending public and private schools shall be screened for abnormal spinal curvature before the end of the school year. The screening requirements may also be met by a professional examination as defined in §37.142 of this title (related to definitions).
(3) The screening requirements for girls entering grade five and seven may be met if the child has been screened for abnormal spinal curvature during the previous year.
(4) The screening requirements for boys entering grade eight may be met if the child has been screened for abnormal spinal curvature during the previous year.
(5) If a child is enrolled within 60 days of the date a school closes for the summer, the child’s spinal screening must be conducted within 120 days of the beginning of the following school year.
(6) New students enrolling in grades scheduled for screening (i.e., grades five and seven for girls and grade eight for boys) who have no record of having received their scheduled screening(s) shall be screened the year they enroll.
(7) Schools may offer a student enrolling in grades eight, nine, ten, eleven, or twelve for girls and grades nine, ten, eleven, or twelve for boys the opportunity for spinal screening if the student has no record of having been screened previously.
(b) A child’s parent, managing conservator, or legal guardian, or the individual under the scenarios described at Texas Family Code Section 32.003, may execute an affidavit stating that a person, other than the individual secured by the school to conduct screenings at the school, shall conduct the screening as soon as is feasible. The school may admit the child on a provisional basis for up to 60 days, or may deny admission until the screening record(s) are provided to the school.
(c) A school shall not require a child to be screened if the child’s parent, managing conservator, or legal guardian, or the individual under the scenarios described at Texas Family Code Section 32.003, submits to the school, on or before the date spinal screening is scheduled, an affidavit in lieu of the screening record(s) stating that the spinal screening conflicts with the tenets and practices of a church or religious denomination of which the affiant is an adherent or member.
(d) Only individuals who have completed high school may serve as volunteer assistants during spinal screenings. It is the responsibility of the certified screener to determine how any volunteer assistant(s) will be used during the screening process, consistent with all state and federal confidentiality requirements.
§37.145 Recordkeeping and Reporting
(a) Individuals conducting screenings under this subchapter must comply with the following recordkeeping and reporting requirements:
(1) Individuals conducting screenings at the school (and those other than licensed professionals conducting screenings outside of the school) shall document in each child’s screening record the specific screening conducted, the date the screening was conducted, observations made during the screening, and the final results of the screening. The individual shall also ensure that the following are included in the documentation: the name of the child and age or birthdate of the child. The documentation required under this subsection must also be signed and dated by the person who conducted the screening.
(2) Individuals conducting screenings at a school (and those other than licensed professionals conducting screening outside of the school) shall submit the documentation referenced at subsection (a) of this section to the school at the time of that screening.
(3) Individuals must submit documentation to the department related to certifications and refresher courses, as specified in section (a)(1) of this subchapter.
(b) Schools must comply with the following recordkeeping and reporting requirements:
(1) Each school shall maintain spinal screening records under this section onsite for at least two years.
(2) A school must maintain screening records regarding any individual claiming the exemptions found at Section §37.143(d) of this subchapter.
(3) An individual’s screening records may be transferred among schools without the consent of the individual under the scenarios described at Texas Family Code Section 32.003 or, if the individual is a minor, the minor’s parent, managing conservator, or legal guardian, pursuant to Texas Health & Safety Code Sec. 36.006(c).
(4) The recordkeeping required in this section must be made available to the department in a timely manner upon request. The department may, directly or through its authorized representative, enter a school and inspect records maintained relating to spinal screening.
(5) On or before June 30 of each year, each school shall submit to the department a complete and accurate annual report on the spinal screening status of its aggregate population screened during the reporting year. Schools shall report in the manner specified by the department (currently found at http://chrstx.dshs.state.tx.us). Schools are required to report on the following categories: Grade screened; number screened under prior treatment; total number screened; total number rescreened; total number referred; number referred and diagnosed by a physician as “normal”; number referred and diagnosed with scoliosis by a physician; number referred and diagnosed with kyphosis by a physician; number referred and diagnosed with another type of abnormal curvature by a physician; number receiving a physician’s treatment plan of observation; number receiving a physician’s treatment plan of orthosis bracing; number receiving a physician’s treatment plan of surgery; number receiving a physician’s treatment plan of “other’; number for whom a physician’s treatment plan was unavailable.
(c) For all submissions to the department under this subchapter, use the following contact information (unless otherwise specified): Vision, Hearing and Spinal Screening Program, Mail Code 1978, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347.
§37.146 Standards and Requirements for Screening Certification and Instructor Training
Individuals who conduct spinal screening must be certified under this section unless the screening is conducted by a licensed professional. There are two options for obtaining this certification: a certificate issued directly by the department; or a certificate issued by an instructor who has been trained and authorized by the department to issue certificates. There is no cost to taking the course in either scenario.
(a) The department offers certification courses, and issues certificates to those who successfully complete them. To be eligible to take the department’s certification course, you must be a high school graduate and sign a written statement to that effect at the beginning of the course. Individuals who successfully complete the course, including passing the associated tests, will be issued a certificate by the department.
(b) The department trains instructors who themselves give certification courses, as described in this section. The eligibility requirement to attend such a course is the same as is described at subsection (d)(2) of this section. Individuals who successfully complete the course, including passing the associated tests, will be issued a certificate signed by the authorized instructor. It will have the same validity, and is subject to the same restrictions, as a certificate issued under subsection (a) of this section.
(c) Screening certificates issued under this section are subject to the following requirements:
(1) Individuals who receive a certificate are authorized to conduct spinal screening (as applicable to the course taken, and as listed on the certificate) in accordance with this subchapter. Certified screeners are required to comply with this subchapter, and failure to do so is grounds for the modification, suspension and/or revocation of the certification as provided in this section.
(2) Screening certification under this section allows the individual to screen children for abnormal spinal curvature (as applicable to the course taken, and as listed on the certificate) under this subchapter for a period of five years.
(3) Screening certification may be renewed by attending a department-approved refresher training course (either offered directly by the department or by an instructor authorized under this section). The refresher training course must be completed during the fifth year of certification from the date the preceding certificate was issued. Once a refresher training course is successfully completed, the five-year cycle begins again. If certification is not renewed within the required time period, the individual must attend the basic certification training course (i.e., a refresher course will not be sufficient).
(4) When DSHS receives information from any source that indicates a screener has not been following the requirements of this subchapter, the department may modify, suspend, or revoke the certification. The department will send a notice to the affected individual as part of any such action being taken.
(5) The affected individual has 20 days after receiving the notice, referenced in subsection (c)(4) of this section, to request a hearing on the proposed action. It is a rebuttable presumption that a notice is received five days after the date of the notice. Unless the notice letter specifies an alternative method, a request for a hearing shall be made in writing, and mailed or hand-delivered to the program at the address specified in §37.145 (c). If an individual who is offered the opportunity for a hearing does not request a hearing within the prescribed time for making such a request, the individual is deemed to have waived the hearing and the action may be taken.
(6) Appeals and administrative hearings will be conducted in accordance with the department’s fair hearing rules, at §§1.51-1.55 of this title (relating to Fair Hearing Procedures).
(d) Individuals who successfully complete a department instructor training course, including all associated testing, are authorized to conduct screening trainings and issue screening certificates to individuals who successfully complete the screening training (including all associated testing), subject to the requirements of this section. Instructors may not charge any kind of fees for their activities under this section.
(1) Individuals wishing to take the instructor course must first meet the following qualifications:
(A) have a current, valid DSHS screening certification, and have experience performing screenings under that certificate;
(B) have experience conducting trainings to groups of adults; and
(C) be physicians, chiropractors, physical therapists, or registered nurses and must have the applicable Texas license, current and in good standing under Texas law.
(2) Department authorization for instructors to conduct trainings is valid for five years from the date certification was issued. The individual must successfully complete a department-approved instructor training refresher course (including passing any associated tests) and submit documentation of successful completion to the department within 30 days of completion of the course. Such refresher training must be completed during the fifth year of certification from the date the preceding certificate was issued. Failure to comply with these requirements, by the deadline given, means that the individual must then attend the basic instructor training course (i.e., a refresher course will not be sufficient).
(3) Once authorized by the department to conduct trainings, instructors must do so using training materials obtained from the department.
(4) All proposed screening training sessions must be approved by the department at least 15 working days prior to the training session. The instructor must provide all information sought by the department, by the deadlines given.
(5) Instructors in good standing under this section may teach screening refresher courses as described in subparagraph (c)(3) of this section. Such refresher courses are subject to the same requirements under this section as those pertaining to initial screening courses.
(6) When a department-authorized instructor issues a certificate of spinal screening, the instructor has 14 days to submit the participant rosters and evaluations to the department. These original documents should be submitted to the program at the address found at §37.145 (c). The instructor should maintain a copy.
(7) When DSHS receives information from any source that indicates a screening instructor has not been following the requirements of this subchapter, the department may modify, suspend, or revoke the certification. The department will send a notice to the affected individual as part of any such action being taken.
(8) The affected individual has 20 days after receiving the notice, referenced in subsection (d)(7) of this section, to request a hearing on the proposed action. It is a rebuttable presumption that a notice is received five days after the date of the notice. Unless the notice letter specifies an alternative method, a request for a hearing shall be made in writing, and mailed or hand-delivered to the program at the address specified in §37.145 (c). If an individual who is offered the opportunity for a hearing does not request a hearing within the prescribed time for making such a request, the individual is deemed to have waived the hearing and the action may be taken.
(9) Appeals and administrative hearings will be conducted in accordance with the department’s fair hearing rules, at §§1.51-1.55 of this title (relating to Fair Hearing Procedures).
§37.147 [§37.149] Responsibilities of Parent, Managing Conservator, or Guardian
When screening indicates possible abnormal spinal curvature, the child's parent, managing conservator, or guardian is responsible for securing the services of a qualified health practitioner to perform a professional examination to diagnose the problem.
§37.148 [§37.152] Nondiscrimination Statement
No person shall be excluded from participation, be denied benefits, or be otherwise subjected to discrimination in the Department of State Health Services Spinal Screening Program on the grounds of race, color, national origin, sex, creed, handicap, or age.
[§37.143 Stages of the Department’s Authorization
The department, in cooperation and coordination with the Texas Education Agency and other department bureaus, divisions or programs serving school-age children, shall develop, implement, and administer a program for the detection of abnormal spinal curvature in children. The program shall be known as the Department of State Health Services Spinal Screening Program, and is authorized to:
(1) provide certification training for spinal screening to non-health practitioners through the Regional Education Service Centers and other locations;
(2) approve spinal screener certification, screener recertification, and trainer certification programs, including approval of trainers for these training programs;
(3) establish the standard spinal screening tests and referral criteria;
(4) coordinate spinal screening activities of school districts, private schools, state agencies, volunteer organizations, and other entities to prevent duplication;
(5) monitor the quality of spinal screening activities in Texas;
(6) issue reporting forms;
(7) provide educational and other materials to assist local spinal screening activities; and
(8) keep a roster of approved trainers and screeners who have become certified under these sections.]
[§37.144 Certification Training for Non-health Practitioners
The department shall monitor the quality of spinal screener training activities under the following guidelines.
(1) The department shall provide screener certification for non-health practitioners.
(2) The screener certification of non-health practitioners shall be by department staff or department-approved trainers.
(3) The spinal screening course shall include:
(A) definition of abnormal spinal curvature;
(B) causes, consequences, and management of abnormal spinal curvature;
(C) procedure for performing the forward-bend test;
(D) notification of screening results and follow-up procedures;
(E) spinal screening program standards and responsibilities; and
(F) the reporting of statistical data.
(4) Department staff or department-approved trainers shall issue a certificate to an individual who successfully completes a department-approved spinal screener certification. The certificate will indicate that the screener is approved by the department to perform spinal screening for a period of five years.
(5) The certificate described in paragraph (4) of this section will be renewable upon successful completion of a department-approved screener recertification.]
[§37.145 Approval of Certification Courses and Trainers
(a) In order to become an approved trainer, a health practitioner must be appropriately licensed under state law and successfully complete the department-approved trainer certification course consisting of a minimum of four hours of instruction by department staff that includes:
(1) legal requirements in spinal screening;
(2) workshop outline and materials to be used;
(3) an update on the latest advances in the management of spinal deformity;
(4) spinal screening program requirements;
(5) approaches to spinal screening training; and
(6) the role of the different health practitioners in spinal screening.
(b) The individual must have a minimum of two years of school spinal-screening experience.
(c) A certificate verifying trainer status will be issued upon successful completion of the requirements stated in subsections (a) and (b) of this section.
(d) In order to maintain trainer status, the individual must successfully complete each updated continuing education course provided by the program upon notification of the availability of such a course.
(e) All screener certification, screener recertification, and trainer certification workshops must be approved by the department prior to the training session. The criteria which the department will consider for approval are submission of:
(1) department's request for spinal screening training workshop form; and
(2) verification by the department that the trainer conducting the workshop is department-certified.
(f) Once approved, the department may provide instructional materials, as they are available, to the approved instructors.]
[§37.146 Termination of Screener or Trainer Participation
(a) Approval of a trainer may be suspended or terminated if the trainer:
(1) fails to follow the department's rules for screener certification;
(2) fails to maintain instructor status by participating in the continuing education courses provided by the department;
(3) makes unethical referrals, i.e., referrals that could indicate a conflict of interest on the part of the instructor; or
(4) violates the Family Educational Rights and Privacy Act of 1974, 20 United States Code §1232g, et seq.
(b) The department may suspend or terminate a screener's approval if the screener:
(1) fails to maintain screener certification;
(2) fails to screen according to department rules;
(3) fails to report screening results according to department rules;
(4) makes unethical referrals, i.e., referrals that would indicate a conflict of interest on the part of the screener; or
(5) violates the Family Educational Rights and Privacy Act of 1974, 20 United States Code §1232g, et seq.
(c) Before the department suspends or terminates an individual's participation in the program, the department will give the individual the opportunity for a hearing in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).]
[§37.147 Standards for Spinal Screening Testing
The department and school districts, private schools, state agencies, volunteer organizations, and other entities performing spinal screening shall adhere to the following standards.
(1) The basic spinal screening test, known as the forward-bend test, shall be used to screen children for abnormal spinal curvature. A description of the test is available from the Department of State Health Services, Health Screening and Case Management Unit, MC 1938, P.O. 149347, Austin, Texas 78714-9347.
(2) In order to avoid over-referrals, children failing the initial screening shall be rescreened using the forward-bend test prior to parental notification of the possible presence of an abnormal spinal curvature.]
[§37.148 Responsibilities of Public and Private Schools
(a) All children in grades six and nine attending public and private schools shall be screened for abnormal spinal curvature before the end of the school year. The screening requirements may also be met by a professional examination as defined in §37.142 of this title (relating to Definitions).
(b) The screening requirement for children entering grade six or nine may be met if the child has been screened for spinal deformities during the previous year. Schools may implement a program that includes screening in grades five and eight in lieu of grades six and nine.
(c) New students enrolling in grades scheduled for screening (i.e., grades six and nine or five and eight) who have no record of having received their scheduled screening(s) shall be screened the year they enroll. Schools may offer a student enrolling in grades 10, 11, or 12 the opportunity for spinal screening if the student has no record of having been screened previously.
(d) The chief administrator of each school shall ensure that every child complies with the state-mandated spinal screening requirements or submits an affidavit of exemption. An affidavit shall be signed by the child's parent, managing conservator, or guardian that spinal screening conflicts with the tenets and practices of a recognized church or religious denomination of which the child is an adherent or a member. This affidavit shall be submitted to the school's chief administrator on or before the day of the screening procedure each year the screening is performed, to meet the requirements of the Act. A copy of this affidavit shall be filed in the child's health record.
(e) A parent, managing conservator, or guardian who declines participation in the spinal screening provided by the school must submit to the school's chief administrator documentation of a professional examination which includes the results of a forward-bend test. This documentation must be submitted to the school during the school year the student is scheduled for screening, or, if the professional exam is obtained during the following summer, at the beginning of the following school year.
(f) If the spinal screening test indicates that a child may have an abnormal spinal curvature, the individual performing the test shall fill out a report on a form prescribed by the department. The chief administrator of the school shall retain one copy of such report and send the original to the parent(s), managing conservator, or guardian of the child screened. The form shall contain information regarding the results of the screening and shall be accompanied by a letter advising the parent, managing conservator or guardian of his/her responsibility to select an appropriate health practitioner for the examination.
(g) A copy of the previously mentioned report shall be filed at the child's school and an entry shall be made in the child's health record. The original is returned with the final diagnosis and the plans for treatment, as indicated.
(h) The chief administrator of each school shall monitor the referral process and encourage a professional exam, and may provide information about services to families without insurance or unable to afford private care. These services may include but are not limited to Medicaid, Children's Health Insurance Plan, Children with Special Health Care Needs, or local resources.
(i) A list of children who failed the spinal screening test may be kept to assist in determining whether a professional examination has occurred.
(j) Proof of screening shall be provided by an entry in the child's health record stating that the child has undergone screening tests that meet the standards outlined in these sections. Such an entry shall also include the results of screening.
(k) Personnel performing screening may maintain a list of children screened for spinal deformities as proof of screening.
(l) In cases when a professional examination was performed in lieu of the required screening test, the date, results, name, and title of the professional performing the exam shall be entered in the child's health record.
(m) The chief administrator of each school shall ensure that each individual complies with the screening requirements in these sections.
(n) Each school shall submit to the department an annual report of spinal screening performed during the school year no later than June 30 of the reporting year. The report shall be submitted by the chief administrator of each school district as specified on a form issued by the department.
(o) The child's health record shall be acceptable as proof of screening if such record contains entries of screening results. In such a case, the original or a true and correct copy of that record may be transferred between schools and shall be honored by the governing body of the school upon transfer of a student from another school in Texas or another school within the United States.]
[§37.150 Further Responsibilities of the Department
(a) Quality assurance activities.
(1) In order to monitor the quality of spinal screening services, department personnel may enter schools during normal hours and inspect records maintained on children subject to screening in each school for the purpose of ascertaining statistical information, and may directly observe the spinal screening process.
(2) The department shall compile records and statistics from all spinal screening activities reported to this program in order to collect data concerning the quality of the diagnostic outcomes of children with possible abnormal spinal curvature.
(b) Coordination and cooperation. The department shall encourage coordination and cooperation among entities in areas where more than one entity provides spinal screening so that the efforts of each entity are complementary, rather than duplicative.]
[§37.151 Confidentiality of Information
The department shall maintain the confidentiality of all information concerning those individuals screened, to the extent permitted by law.]