R 400.11119 - Health Services Policy

Health Services Policy

Legal Reference: R 400.11119 Health Service Policy

1. A camp shall have and follow a written health service policy that is appropriate to the population served and the environment of the campsite.
2. A camp shall establish the health service policy in consultation with, and reviewed annually by a licensed physician.
3. A camp’s health service policy shall cover all the following subjects:
   1. Procedures for camper health screening.
   2. Arrangements for on-call health care consultation services.
   3. Arrangements for emergency health care services and emergency transportation to an emergency health care facility.
   4. First aid and health care supplies.
   5. The storage and administration of prescription and nonprescription drugs and medications.
   6. Medical procedures for camper trips away from a campsite.
   7. Procedures for daily observation of each camper’ s physical state.
   8. Procedures for prompt and responsive notification of the camper’s authorized person.
   9. Health officer staffing.
   10. Procedures for preventing disease transmission/universal precautions equivalent to the procedures in the American Red Cross manual number 655107, which is adopted by reference in R 400.11103.

Technical Assistance:

Camp operators are required to provide for the health and welfare of campers within their camp programs or at their campsite. A written health policy must be up to date, providing clear and easily understood procedures. This health policy must be developed in consultation with, and reviewed annually by, a licensed physician. Documentation of this consultation may occur using the Health Service Policy Self-Certification form found on the Camp Licensing website. The administrative rules list several required subjects that need to be developed within the health services policy. A communicable disease outbreak will significantly impact operations at camp. Be sure to adhere to the most recent regulations and guidelines from the Michigan Department of Health and Human Services and your local Health Department.

Many camp directors will structure their health services policies with the subject headings outlined by administrative rule. Camp Health Officers are required in camps by R 400.11121, R 400.11122, and R400.11143, but all staff have a responsibility for the health and welfare of campers. The health services policy provides for a continuum of procedures from prevention to intervention. A health policy that is well organized and clearly written increases the likelihood that the policies will be consistently followed by the camp staff. The following subjects must be addressed:

1. Procedures for camper health screening – A camper health screening is required to be conducted within the first 24 hours of the camper initial arrival at camp. [R 400.11127 (7)]. The camper health screening must include:
   • Checking of prescription and non-prescriptions in original containers.
   • Review of health history statement.
   • Discussion of camper health needs.
   • Observation of camper's physical state paying particular attention to potentially contagious diseases and possible abuse.
   • Camper health screening procedures vary depending on the camp; however, health officers regularly screen for physical illness, injury, camper limitations, lice, and contagious diseases. The procedures need to be detailed including who is conducting the health screening, what type training is being provided to the health screening staff, where the health screening occurs, and how is the health screening occurring and being documented.
2. Arrangements for on-call health care consultation services - On call health care consultation must be utilized when the health needs of campers is beyond the knowledge or skill set of your health officer. This consultation is about seeking the services of a higher-level health care provider to determine the most appropriate course of treatment. On call health care consultation can be provided in a variety of methods, consulting physician of your health service policy, local clinic, local urgent care, telehealth, and local health departments. Arrangement is a listing of the contact information of the on-call health care consultation.
3. Arrangements for emergency health care services (EMS) and emergency transportation to an emergency health care facility - Emergency health care services involve advanced medical pre-hospital treatment and transportation to an emergency health care facility. The camp must have arrangements with a local EMS service and identify the location of the closest, appropriate emergency health care facility. These arrangements include the address, contact information and directions to the facility. For traveling groups, travel and troop camps, or camps offering offsite activities, a plan for emergency services notification, transportation and treatment locations must be arranged.
4. First aid and health care supplies - Camp must have a sufficient quantity of first aid, health care supplies and equipment for the population served and for the environment of the campsite. Camp health officer must have certification and/or training to administer the available first aid and health care supplies. The health officer should practice within the scope of their training.
   • A detailed list of first aid and health care supplies required for the health office, camp first aid kits and medical supplies taken with offsite traveling groups, travel and troop camps, or offsite activities.
   • A description of the locations of the first aid kids and health care supplies.
5. The storage and administration of prescription and nonprescription drugs and medications - Prescription and nonprescription medication storage and administration must be identified in detail and include:
   • How medication is received on opening day. Camps need to establish procedures for receiving medications in original containers, confirmation of accuracy of prescription with details provided on the health form and documenting receipt of the medication. The use of inhaler or epinephrine auto-injector by a camper needs to be discussed with the guardian. A minor child may have approval to possess and use an inhaler or epinephrine. [MCL 722.127(a)].
   • How medication is stored securely. A camp must have all prescription and nonprescription drugs and medications in secure locked storage unless medically contraindicated. [R 400.11123(3)] Medications requiring refrigeration must follow this same rule. Camp must identify who has access to the medication and how to access it. Camp staff must comply with secure locked storage of medications.
   • How medication is administered and documented. A camp shall follow any instructions provided by a camper’s physician or authorized person to meet the health and behavior needs of a camper admitted to the camp. [R 400.11127(5)] A camp needs to identify the administration procedures including when, where, how, and by whom. At times there are special circumstances that require specific procedures on how the camp will handle missed medication. The camp must have a permanent (duration of an active license) medical record that includes the medical treatment of a camper and documentation of medication dispensed. Documentation must include the date of treatment, name of camper, ailment, treatment prescribed, or medication dispensed, and identification of the person providing the treatment. [R 400.11127(8)]
   • How medications given back on closing day. Camps need to establish procedures for how medications will be returned to guardians.
6. Medical procedures for camper trips away from a campsite - Camps needs to develop medical procedures for trips away from camp (i.e. fieldtrips, trips, troop and traveling groups):
   • Contact information for emergency services and health care facilities at your final destination.
   • Medication storage and administration including documentation while away from camp.
   • First aid supplies appropriate to the population served and for the environment of the final destination.
   • Notification of camp director and/or guardian. [R 400.11127(9) and R 400.11145(2)]
   • If you are leaving your local geographical areas a camp shall ensure that the emergency treatment consent form, the health history statement, and the authorized person emergency contact information for each camper shall accompany the group. [R 400.11127(6)]
7. Procedures for daily observation of each camper’s physical state – Camps need to develop procedures for observing the camper’s physical, mental, and emotional health. Observation means that at any point of time campers are within sight or sound of adult staff member responsible for direct supervision. Observation includes preventative and responsive procedures which encompass some of the following:
   • Preventative procedures to ensure the wellness of the campers.
     • Adequate sleep, food and drink
     • Balanced schedule for age of population and environment (i.e. rest period, indoor and outdoor activities, etc.)
     • Communication procedures of a camper’s physical limitations and special health or behavioral considerations with all appropriate staff.
     • Adult staff member responsible for direct observation understands the camper’s physical limitations and special health or behavioral considerations.
     • Awareness of what circumstances require involving the health officer and/or camp director.
   • Responsive procedures
     • Ongoing observation, treatment, and documentation of injury and illness by appropriate adult staff member.
     • Reaching out to community resources for additional support as needed (poison control, community mental health)
     • Reporting incidents to appropriate agencies (CPS, law enforcement, state licensing) and guardians while maintaining confidentiality.
8. Procedures for prompt and responsive notification of the camper’s authorized person - Camps must develop procedures for when to communicate with guardians and who will be responsible for the communication. Circumstances that require communication with a camper’s guardian are as follows:
   • Immediately in the event of death.
   • Immediately following admission to the hospital.
   • The day following an overnight stay in the Health Cabin.
   • As soon as possible if Health Officer and/or physician recommends that camper returns home due to serious injury or illness.
   • At Health Officer’s and/or physician’s discretion if the matter requires the guardian’s attention related to the health of their child.
   • Instructions provided by the guardian related to notification. [R 400.11127(5)]
   • Inquiry by a guardian about their child [R 400.11107]
9. Health officer staffing - Camps need to establish procedures for appropriately staffing the camps health facilities. Appropriate staff qualifications for day camps are outlined in R 400.11121, for residential camps in R 400.11122, and traveling groups in R 400.11145. Health officer staffing procedures must include:
   • A health officer must be on duty or in residence at the camp during all hours that campers are present. [R. 400.11121 (1), (2) and R 400.11122(2)]
   • Health officer schedule including staffing during absence of health officer.
   • Emergency vehicle available at all times for use in an emergency [R 400.11143(6)]
   • Procedures for staff accompany campers involved in emergency transportation.
   • Day camps utilizing an agreement for the provision of EMS with the local emergency service provider within five minutes
     • The agreement must be written and signed by an authorized representative of the EMS agency. The EMS agency attests that the average response time is within five minutes. A written agreement should include the following:
       1. A signed agreement by an authorized person for the emergency medical provider.
       2. A brief description of the medical services and license level of the department including the staffing level: full-time, paid on call, or volunteer.
       3. Location of the closest fire station or EMS station.
       4. Confirmation according to R400.11121(1) that the emergency medical provider or EMT is within an average five-minute response time to the location of the campsite.
       5. The address of the campsite where camp is operating and operating dates.
     • Procedures for when to notify local EMS.
     • Fieldtrips that take the campers outside of the area of the local emergency service provider area.
     • For traveling groups, staff qualification considerations should be made regarding access to definitive care throughout the itinerary.
       • An emergency medical system at their final destination means a medical system that can provide definitive care. Definitive care means comprehensive care for the full spectrum of injuries and illness beyond the initial assessment and basic life support. (i.e. hospital, urgent care, and/or clinic)
       • Final destination for this rule is considered the destination at the end of the day.
       • Traveling groups where access to the emergency medical systems at their final destination is less than 60 minutes the minimum certification to meet the equivalency as identified in R 400.11103 manual number 165137 and 152161.
       • Traveling groups where access to the emergency medical systems at their final destination is more than 60 minutes the minimum certification to meet the equivalency as identified in R 400.11103 manual number 16175.
10. Procedures for preventing disease transmission/universal precautions - Communicable diseases, also known as infectious or contagious diseases, are illnesses that result from an infection ranging in severity from asymptomatic (without symptoms) to severe and fatal. For
    additional information see Public Health Code Sec 333.5101(2)(b). There are different ways that an individual could become infected including through body fluids, airborne, contact surface, or indirectly from a plant or animal host.

The risk of exposure to communicable disease increases in camps because of the environment and number of people gathered. All camp staff must be trained in recognizing potential risks of exposure, mitigation strategies to reduce exposure, and specific actions to take when an exposure occurs. Some examples of communicable diseases are: norovirus, COVID-19, hepatitis, tuberculosis, strep/staph infections, measles, chicken pox, influenza, West Nile virus, Eastern Equine Encephalitis, and Zika. View MDHHS' Communicable Diseases (A-Z) website.

Infectious control procedures written in the camp health service policy must include details that specify:

1. Procedures for prevention that include:
   • Proper handwashing
   • Cleaning and sanitizing [R 400.11149(1)]
   • Preparing and maintaining campsite and activity space [R 400.11149]
   • Health screening of staff and campers [R 400.11127(7)]
   • Appropriate safety equipment including personal protective equipment.
2. Responding to potential contagious disease
   • Safe handling and disposal of body fluids [R 400.11122 (1)]
   • Cleaning and sanitizing infected area [R 400.11149(1)]
   • Quarantine, isolation, and treatment of infected individuals [R 400.11123 (2)]
   • Notification and documentation of actions to guardians, appropriate personnel and authorities [R 400.11119(3)(h) and R 400.11127(9)

Consultation:

Some camps have developed “standing orders” which outline specific health procedures for illnesses and injuries typically experienced within the camp environment. These camps then include them within the health service policy. In the past, “standing orders” were required by prior versions of administrative rules from the State of Michigan. However, in 2009 the administrative rules removed the requirement to obtain the “standing health care orders from the camps consulting physician.” Camps need to be aware that if they use “standing orders” written within the health services policy and approved by their consulting physician, then these standing orders are considered policy and therefore are required to be followed.

Many camps develop two logbooks, one for the medical treatment and one for the documentation of medication dispensed. Electronic health logs are acceptable. R 400.11127(4) states that a camp shall maintain camper health records (camper health forms) for three years from the last day that camper is in attendance. Camp logbooks, whether written or electronic, are maintained for the life of the license.

Epinephrine Prescribed to a Camp

Public Act 221 of 2015 allows an authorized entity, as defined in MCL 333.17744a(5)(B), to acquire and stock a supply of auto-injectable epinephrine. Before providing or administering auto-injectable epinephrine, an employee, agent or other individual of the authorized entity must complete an initial anaphylaxis training program and a subsequent anaphylaxis training program every 2 years.

As used in this section, "authorized entity" means any of the following:

1. A school board for the purpose of meeting the requirements of section 1179a of the revised school code, 1976 PA 451, MCL 380.1179a.
2. A person or governmental entity that operates or conducts a business or activity at which allergens capable of causing anaphylaxis may be present, including, but not limited to, a recreation camp, youth sports league, amusement park, nonpublic school, religious institution, or sports arena.

For more information visit LARA's Auto-Injectable Epinephrine and Anaphylaxis Training website.

Epinephrine/Inhaler Provided by a Camper

According to Public Act 116 of 1973 [MCL 722.127a] if certain conditions apply a minor child may possess and use one or more of the following at a children's camp:

• A metered dosed inhaler or a dry powder inhaler to alleviate asthmatic symptoms or for use before exercise to prevent the onset of asthmatic symptoms.
• An epinephrine auto-injector or epinephrine inhaler to treat anaphylaxis.

Communicable Disease Containment

Camp operators are required to consider how to mitigate the infectious spread of communicable diseases within the camp programs and at the campsite. Information from the Center for Disease Control (CDC), State of Michigan Department of Health and Human Services (MDHHS), Michigan Occupational Safety and Health Administration (MIOSHA), Michigan Department of Licensing and Regulatory Affairs (LARA), and professional associations develop infectious control practices for businesses and organizations to operate safely.

The administrative rules require that camps consider, within their health services policy, contagious disease, and a procedure for preventing transmission. While camps have had to address the potential for contagious diseases within the camp environment for as long as camps have been operating, novel viruses and contagious diseases require the camp to stay up to date on threats to children’s health and wellness and to provide the necessary and reasonable precautions to reduce those threats.