Accommodating Campers with Diabetes: What Does the ADA Require?
Camps often ask about their ADA obligations to campers with diabetes. Based on how often camps run into these issues, it's not surprising that the Department of Justice (DOJ) has investigated and entered into settlement agreements with a number of camps concerning their treatment of campers with diabetes. Those agreements provide us with detailed guidance about what camps are expected to do.
The questions tend to arise in different forms: Can we require parents of campers with diabetes to provide a medical aide? Do our non-medical staff need to help administer insulin? What happens when a camper needs a counselor to respond to an insulin monitor in the middle of the night? And what if we're simply not comfortable assuming responsibility for these medical needs?
Fundamentally, camps often ask: Do we have to accept campers with diabetes?
In a guidance document for child care centers, the Department of Justice answered this question question as follows:
A: Generally, yes. Children with diabetes can usually be integrated into a child care program without fundamentally altering it, so they should not be excluded from the program on the basis of their diabetes. [Reasonable modifications include] monitor[ing] the child’s blood sugar – or “blood glucose” – levels before lunch and whenever the child appears to be having certain easy-to-recognize symptoms of a low blood sugar incident. While the process may seem uncomfortable or even frightening to those unfamiliar with it, monitoring a child’s blood sugar is easy to do with minimal training and takes only a minute or two. Once the caregiver has the blood sugar level, he or she must take whatever simple actions have been recommended by the child’s parents or guardians and doctor, such as giving the child some fruit juice if the child’s blood sugar level is low. The child’s parents or guardians are responsible for providing all appropriate testing equipment, training, and special food necessary for the child.
The general expectation is that camps and other youth programs will accommodate kids with diabetes.
Key Legal Considerations
Title III of the Americans with Disabilities Act prohibits most private, non-religious camps from discriminating against campers with disabilities, including diabetes. Camps are generally required to make reasonable modifications to their policies, practices, and procedures to accommodate campers with disabilities, unless doing so would fundamentally alter the nature of their programs.
This standard sets a relatively high bar for camps. An accommodation may be inconvenient, require additional staff training, or involve exceptions to longstanding policies -- all without fundamentally altering the camp program.
Another important ADA principle is that accommodation decisions must be based on an individualized assessment of each camper, rather than blanket rules about particular disabilities. A policy saying that camp doesn't accept campers with diabetes, or that all campers with diabetes must have a parent-provided medical aide, would violate the ADA. Instead, camp must determine what a particular camper needs and whether reasonable modifications would allow the camper to participate in the program. The DOJ has repeatedly emphasized this point in settlement agreements with camps.
Some Notable DOJ Settlements
For any camp wrestling with its approach to campers with diabetes, a useful starting point may be reading the DOJ's settlement actions with camps that have been the subject of complaints:
In a 2016 settlement with Camp Treetops, the DOJ addressed a complaint alleging that the camp rescinded a child's acceptance after learning that she had Type 1 diabetes. The settlement required the camp to evaluate accommodation requests individually and provide reasonable modifications, including assistance with diabetes monitoring and equipment.
Similarly, in a settlement with Rocky Run YMCA, the DOJ addressed a situation in which a parent was required to come to the program each day to supervise her child's insulin administration. The YMCA had also asked the parent to provide an aide at camp, offering to waive the registration fee to offset the expense. The DOJ determined that the YMCA had violated the ADA, and the resulting settlement required changes to its policies and procedures.
Another instructive example is the DOJ's 2009 settlement with Pine Hills. That matter involved a complaint that a camper with diabetes was not permitted to participate in field trips unless accompanied by a parent or a medically trained person hired by the parent. The settlement required individualized assessments and reasonable modifications for children with diabetes, including assistance with glucose monitoring, insulin pumps, and other diabetes-related equipment, both at the program and during off-site activities.
What does this mean in practice?
When a family seeks to enroll a camper with diabetes, the camp should work with the parents and, if needed, the camper's healthcare provider to understand the camper's specific, individualized needs. The goal is to develop an individualized diabetes management plan for the camper, which may include staff training for non-medical staff to be able to provide accommodations. For example, the Pine Hills settlement contains a detailed diabetes management policy, medical forms, and other documents in its appendices that camps can use as reference materials when developing their own procedures.
As part of this process, you can request that parents provide medical instructions, necessary equipment and supplies, and training regarding their camper's specific needs. You can also ask parents to be available to participate on the first day of a session and by telephone during the program to answer questions about their child's care.
The idea is that accommodating a camper with diabetes should be a cooperative effort between camp, the family, and the appropriate medical professionals -- all with the goal of assessing each camper individually and meeting their particular needs with reasonable modifications to the camp's program.
How should we approach nighttime monitoring?
Let's consider a camper who needs an adult to respond to a glucose-monitoring alarm overnight. While I haven't seen specific guidance on this point, my takeaway from the DOJ settlement actions and general ADA principles is that having a counselor sleep near the camper and listen for the monitor at night is a reasonable modification. As already discussed, camps don't need to provide reasonable modifications that would fundamentally alter the program, but responding to nighttime needs doesn't seem to rise to that level (although unusually frequent interruptions may warrant further consideration). By analogy, counselors are not-infrequently woken up by campers with nighttime needs, and it's just considered part of the job.
How about medication administration?
Another recurring question concerns medication administration. Some states allow trained, non-medical personnel to assist with medication administration, while others require that medication can only be administered by medical staff. We previously wrote about that topic in this post.
Camps must therefore consider both their ADA obligations and applicable state law. In a 2014 settlement, the DOJ stated that the program would need to use its best efforts to seek a waiver from the state allowing non-medical staff to administer medication if this would be necessary to accommodate campers with diabetes.
Where state law prohibits non-medical staff from administering medications, it could very well constitute a fundamental alteration for a small program for have to hire a nurse. As the DOJ has written: "[I]f a child requires complicated medical procedures that can only be done by licensed medical personnel, and the center does not normally have such personnel on staff, the center would not be required to provide the medical services under the ADA."
Can camps charge families extra for providing these accommodations?
Camps generally cannot charge families extra for modifications that the ADA requires. If staff can reasonably assist with glucose monitoring or other necessary diabetes care, the camp cannot impose a special fee on the family to cover that expense. However, in the same FAQ linked above, the DOJ explained that if a program chooses to go above and beyond its ADA obligations -- such as by providing an accommodation that's a fundamental alteration of the camp program -- then it can charge families. Note, however, that this only applies in the case of an accommodation that the camp wouldn't otherwise be required to provide under the ADA.
What about the risks to camp and the camper?
When a camp provides reasonable modifications, the experience may entail medical risks. For example, we all know that, even some of our best counselors simply sleep through their alarm clock. Likewise, a well-intentioned counselor may not hear an overnight insulin alarm -- that's a real risk. As part of the interactive process, camps should communicate openly with families about these risks, explore ways to mitigate them, and ensure that everyone understands the diabetes management plan and its limitations.
Perhaps this is an area where camps use a specific set of disclosures explaining the inherent risks of the experience to parents. However, camps should tread cautiously when using anything that looks like a waiver in this context. In at least one DOJ settlement agreement (see section on Yavapai Regional Medical Center), the DOJ stated that signing a waiver should not be a condition to the organization providing an accommodation. By contrast, in other settlement agreements, the DOJ allows families of campers with diabetes to sign the camp's general waiver that all families sign (but this is different from imposing a special liability waiver solely because a camper has diabetes).
Conclusion
Camps have a substantial obligation to accommodate campers with diabetes, but that obligation is not unlimited. The ADA does not require camps to fundamentally alter their programs, but it sets a high bar for providing reasonable accommodations. Camps often find that accommodations are challenging to implement and burdensome on staff, but they're still required unless they are a fundamental alteration of the program; and it takes a lot to show a fundamental alteration. Camps should approach each camper with diabetes individually and make a meaningful effort to identify reasonable modifications and meet their needs. If, after completing that individualized process, a camp believes it cannot reasonably accommodate a camper's needs, I would strongly recommend discussing the circumstances with counsel before communicating a denial to the family.
Useful Resources
For camps interested in exploring these obligations further, several resources are especially useful:
the DOJ's Title III Technical Assistance Manual,
this collection of DOJ settlement agreements involving camps, and
the American Diabetes Association's fact sheet on the rights of children with diabetes at camp.
