[Federal Register Volume 88, Number 49 (Tuesday, March 14, 2023)]
[Notices]
[Pages 15860-15862]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-05143]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Registered Dietitian Nutritionists Standard of Practice

AGENCY: Department of Veterans Affairs.

ACTION: Request for information.

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SUMMARY: The Department of Veterans Affairs (VA) is requesting 
information to assist in developing a national standard of practice for 
VA Registered Dietitian Nutritionists (RDN). VA seeks comments on 
various topics to help inform VA's development of this national 
standard of practice.

DATES: Comments must be received on or before May 15, 2023.

ADDRESSES: Comments must be submitted through www.regulations.gov. 
Except as provided below, comments received before the close of the 
comment period will be available at www.regulations.gov for public 
viewing, inspection, or copying, including any personally identifiable 
or confidential business information that is included in a comment. We 
post the comments received before the close of the comment period on 
the following website as soon as possible after they have been 
received: https://www.regulations.gov. VA will not post on 
Regulations.gov public comments that make threats to individuals or 
institutions or suggest that the commenter will take actions to harm 
the individual. VA encourages individuals not to submit duplicative 
comments. We will post acceptable comments from multiple unique 
commenters even if the content is identical or nearly identical to 
other comments. Any public comment received after the comment period's 
closing date is considered late and will not be considered in a 
potential rulemaking.

FOR FURTHER INFORMATION CONTACT: Ethan Kalett, Office of Regulations, 
Appeals and Policy (10BRAP), Veterans Health Administration, Department 
of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 202-
461-0500. This is not a toll-free number.

SUPPLEMENTARY INFORMATION: 

Authority

    Chapters 73 and 74 of 38 U.S.C. and 38 U.S.C. 303 authorize the 
Secretary to regulate the professional activities of VA health care 
professions to make certain that VA's health care system provides safe 
and effective health care by qualified health care professionals to 
ensure the well-being of those Veterans who have borne the battle.
    On November 12, 2020, VA published an interim final rule confirming 
that VA health care professionals may practice their health care 
profession consistent with the scope and requirements of their VA 
employment, notwithstanding any State license, registration, 
certification, or other requirements that unduly interfere with their 
practice. 38 CFR 17.419; 85 FR 71838. Specifically, this rulemaking 
confirmed VA's current practice of allowing VA health care 
professionals to deliver health care services in a State other than the 
health care professional's State of licensure, registration, 
certification, or other State requirement, thereby enhancing 
beneficiaries' access to critical VA health care services. The 
rulemaking also confirmed VA's authority to establish national 
standards of practice for its health care professionals which would 
standardize a health care professional's practice in all VA medical 
facilities.
    The rulemaking explained that a national standard of practice 
describes the tasks and duties that a VA health care professional 
practicing in the health care profession may perform and may be 
permitted to undertake. Having a national standard of practice means 
that individuals from the same VA health care profession may provide 
the same type of tasks and duties regardless of the VA medical facility 
where they are located or the State license, registration, 
certification, or other State requirement they hold. We emphasized in 
the rulemaking and reiterate here that VA will determine, on an 
individual basis, that a health care professional has

[[Page 15861]]

the necessary education, training, and skills to perform the tasks and 
duties detailed in the national standard of practice and will only be 
able to perform such tasks and duties after they have been incorporated 
into the individual's privileges, scope of practice, or functional 
statement. The rulemaking explicitly did not create any such national 
standards and directed that all national standards of practice would be 
subsequently created via policy.

Need for National Standards of Practice

    As the Nation's largest integrated health care system, it is 
critical that VA develops national standards of practice to ensure 
beneficiaries receive the same high-quality care regardless of where 
they enter the system and to ensure that VA health care professionals 
can efficiently meet the needs of beneficiaries when practicing within 
the scope of their VA employment. National standards are designed to 
increase beneficiaries' access to safe and effective health care, 
thereby improving health outcomes. The importance of this initiative 
has been underscored by the COVID-19 pandemic. With an increased need 
for mobility in our workforce, including through VA's Disaster 
Emergency Medical Personnel System, creating a uniform standard of 
practice better supports VA health care professionals who already 
frequently practice across State lines. In addition, the development of 
national standards of practice aligns with VA's long-term deployment of 
a new electronic health record (EHR). National standards of practice 
are critical for optimal EHR implementation to enable the specific 
roles for each health care profession in EHR to be consistent across 
the Veterans Health Administration (VHA) and to support increased 
interoperability between VA and the Department of Defense (DoD). DoD 
has historically standardized practice for certain health care 
professionals, and VHA closely partnered with DoD to learn from their 
experience.

Process To Develop National Standards of Practice

    Consistent with 38 CFR 17.419, VA is developing national standards 
of practice via policy. There will be one overarching national standard 
of practice directive that will generally describe VHA's policy and 
have each individual national standard of practice as an appendix to 
the directive. The directive and all appendices will be accessible on 
VHA Publications website at: https://vaww.va.gov/vhapublications/ 
(internal) and https://www.va.gov/vhapublications/ (external) once 
published.
    To develop these national standards, VA is using a robust, 
interactive process that is consistent with the guidance outlined in 
Executive Order (E.O.) 13132 to preempt State law. The process includes 
consultation with internal and external stakeholders, including State 
licensing boards, VA employees, professional associations, Veterans 
Service Organizations, labor partners, and others. For each identified 
VA occupation, a workgroup comprised of health care professionals 
conducts State variance research to identify internal best practices 
that may not be authorized under every State license, certification, or 
registration, but would enhance the practice and efficiency of the 
profession throughout the agency. The workgroup may consult with 
internal stakeholders at any point throughout the process. If a best 
practice is identified that is not currently authorized by every State, 
the workgroup determines what education, training, and skills are 
required to perform such task or duty. The workgroup then drafts a 
proposed VA national standard of practice using the data gathered 
during the State variance research and incorporates internal 
stakeholder feedback to date.
    The proposed national standard of practice is internally reviewed, 
to include by an interdisciplinary workgroup consisting of 
representatives from Quality Management; Field Chief of Staff; Academic 
Affiliates; Field Chief Nursing Officer; Ethics; Workforce Management 
and Consulting; Surgery; Credentialing and Privileging; Field Chief 
Medical Officer; and EHR Modernization.
    Externally, the proposed national standard of practice is provided 
to our partners in DoD. In addition, VA labor partners are engaged 
informally as part of a pre-decisional collaboration. Consistent with 
E.O. 13132, a letter is sent to each State board and certifying 
organization that includes the proposed national standard and an 
opportunity to further discuss the national standard with VA. After the 
States and certifying organization have received notification, the 
proposed national standard of practice is published to the Federal 
Register for 60 days to obtain feedback from the public, including 
professional associations and unions. At the same time, the proposed 
national standard is published on an internal VA site to obtain 
feedback from VA employees. Feedback from State boards, professional 
associations, unions, VA employees, and any other person or 
organization who informally provides comments via the Federal Register 
will be reviewed. VA will make appropriate revisions in light of the 
comments, including those that present evidence-based practice and 
alternatives that help VA meet our mission and goals, and that are 
better for Veterans or VA health care professionals. We will publish a 
collective response to all comments at https://www.va.gov/standardsofpractice.
    After the national standard of practice is finalized, approved, and 
published in VHA policy, VA will implement the tasks and duties 
authorized by that national standard of practice. Any tasks or duties 
included in the national standard will be incorporated into an 
individual health care professional's privileges, scope of practice, or 
functional statement following any training and education necessary for 
the health care professional to perform those functions. Implementation 
of the national standard of practice may be phased in across all 
medical facilities, with limited exemptions for health care 
professionals as needed.

National Standard for Registered Dietitian Nutritionists

    The proposed format for national standards of practice when there 
are State licenses and a national registration is as follows. The first 
paragraph provides general information about the profession and what 
the health care professionals can do. The second paragraph references 
the education and registration needed to practice this profession at 
VA. The third paragraph confirms that this profession follows the 
standard set by the national registration body. A final statement 
explains that while VA only requires a national registration, some 
States also require licensure for this profession. The standard 
includes information on which States offer an exemption for Federal 
employees and where VA will preempt State laws, if applicable.
    We note that the proposed standards of practice do not contain an 
exhaustive list of every task and duty that each VA health care 
professional can perform. Rather, it is designed to highlight whether 
there are any areas of variance in how this profession can practice 
across States and how this profession will be able to practice within 
VA notwithstanding their State license, certification, registration, 
and other requirements.
    VA Registered Dietitian Nutritionists (RDNs) are experts in the 
disciplines of nutrition and food. They translate the complex science 
of nutrition into healthy, real-world solutions. VA qualification 
standards require

[[Page 15862]]

Registered Dietitian Nutritionists (RDNs) to have an active, current, 
full, and unrestricted registration from the Commission on Dietetic 
Registration, the credentialing branch of the Academy of Nutrition and 
Dietetics. VA reviewed whether there are any alternative registrations, 
certifications, or State requirements that could be required for a RDN 
and found that 46 States require a license to practice as a RDN in that 
State. Of those, 34 States exempt Federal employees from their State 
license requirements. The standard set forth in the licensure 
requirements for all 46 States are consistent with what is permitted 
under the national registration. Therefore, there is no variance in how 
any RDN practices in any State.
    VA proposes to adopt a standard of practice consistent with the 
national registration; therefore, VA RDNs will continue to follow the 
same standard as set by their national registration. Standard of 
practice for the registration can be found here: Academy of Nutrition 
and Dietetics: Revised 2017 Scope of Practice for the Registered 
Dietitian Nutritionist--Journal of the Academy of Nutrition and 
Dietetics (jandonline.org).
    Because the practice of RDN is not changing, there will be no 
impact on the practice of this occupation when this national standard 
of practice is implemented.

Proposed National Standard of Practice for Registered Dietitian 
Nutritionist

    RDNs are experts in the disciplines of nutrition and food. They 
translate the complex science of nutrition into healthy, real-world 
solutions. RDNs within the Department of Veterans Affairs (VA) are 
fully integrated into a health care team and work within a variety of 
settings including inpatient, outpatient, long term care, food 
operations, and community clinics. Clinical RDNs are responsible for 
utilizing the nutrition care process framework to provide patient-
centered care using evidence-based guidelines to make decisions. RDNs 
in the food service setting are responsible for scientific preparation 
and service of high-quality food by selection, requisition, receipt, 
storage, issuance, and transportation of food and supplies. They assure 
sanitation, safety, competency, and training programs are robust and 
effective.
    RDNs employed by VA possess the education and registration from the 
Commission on Dietetic Registration (CDR) required by VA qualification 
standards, as more specifically described in VA Handbook 5005, 
Staffing, Part II, Appendix G20.
    This national standard of practice confirms RDNs practice in 
accordance with the Registered Dietitian Nutritionist standards from 
the Academy of Nutrition and Dietetics, available at: www.eatright.org. 
As of March 2022, RDNs in VA follow the standards associated with this 
national registration.
    Although VA only requires a registration, 46 States require a State 
license in order to practice as RDNs in that State: Alabama, Alaska, 
Arkansas, Delaware, District of Columbia, Florida, Georgia, Guam, 
Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, 
Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, 
Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North 
Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto 
Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, 
Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming.
    Of those, the following States exempt Federal employees from its 
State license requirements: Alabama, Alaska, Arkansas, Delaware, 
District of Columbia, Florida, Georgia, Guam, Hawaii, Illinois, Iowa, 
Kansas, Kentucky, Louisiana, Maine, Maryland, Minnesota, Mississippi, 
Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, 
North Dakota, Ohio, Oklahoma, Puerto Rico, Rhode Island, South 
Carolina, South Dakota, Tennessee, Wisconsin, and Wyoming.
    As of May 2022, there is no variance in how VA RDNs practice in any 
State.

Request for Information

    1. Are there any required trainings for the aforementioned 
practices that we should consider?
    2. Are there any factors that would inhibit or delay the 
implementation of the aforementioned practices for VA health care 
professionals in any States?
    3. Is there any variance in practice that we have not listed?
    4. What should we consider when preempting conflicting State laws, 
regulations, or requirements regarding supervision of individuals 
working toward obtaining their license or unlicensed personnel?
    5. Is there anything else you would like to share with us about 
this national standard of practice?

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on February 21, 2023, and authorized the undersigned to sign 
and submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2023-05143 Filed 3-13-23; 8:45 am]
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