[Federal Register Volume 88, Number 144 (Friday, July 28, 2023)]
[Notices]
[Pages 48963-48965]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-16007]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Recreation Therapists 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 Recreation Therapists. 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 September 26, 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: http://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 any 
potential future 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 the necessary 
education, training and skills to perform the tasks and duties detailed 
in the national standard of

[[Page 48964]]

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 
the 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 is comprised of VA 
employees who are health care professionals in the identified 
occupation; they 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 Recreation Therapists

    The proposed format for national standards of practice when there 
is a national certification, and some States require a license 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 certification needed to practice 
this profession at VA. The third paragraph confirms that this 
profession follows the standard set by the national certifying body. A 
final statement explains that while VA only requires a national 
certification, 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.
    Recreation Therapists systematically use recreation and activity-
based interventions for the specific purpose of improving the physical, 
social, emotional, cognitive and spiritual functioning of individuals; 
enhancing well-being; and enabling greater quality

[[Page 48965]]

of life through recreation participation for individuals with injury, 
illness or disability. VA qualification standards require Recreation 
Therapists to have an active, current, full and unrestricted 
certification as a Certified Therapeutic Recreation Specialist from the 
National Council for Therapeutic Recreation Certification (NCTRC). 
Although NCTRC is the certification body for Recreation Therapists, the 
American Therapeutic Recreation Association (ATRA) has developed the 
Standards for the Practice of Recreational Therapy, which is followed 
by all VA Recreation Therapists.
    VA reviewed whether there are any alternative registrations, 
certifications or State requirements that could be required for a 
Recreation Therapist and found that five States require a license to 
practice as a Recreation Therapist in that State. Of those, one State 
exempts Federal employees from its State license requirements. The 
standards set forth in the licensure requirements for all five States 
are consistent with what is permitted under the Standards of Practice 
for Recreational Therapy from the ATRA. Therefore, there is no variance 
in how any Recreation Therapists practice in any State.
    VA proposes to adopt a standard of practice consistent with the 
ATRA standards. Therefore, VA Recreation Therapists will continue to 
follow the same standard as set by their national certification. The 
ATRA standards can be found here: https://www.atra-online.com/general/custom.asp?page=SOP.
    Because the practice of Recreation Therapists 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 Recreation Therapists

    1. Recreation Therapists systematically use recreation and 
activity-based interventions for the specific purpose of improving the 
physical, social, emotional, cognitive and spiritual functioning of 
individuals; enhancing wellbeing; and enabling greater quality of life 
through recreation participation for individuals with injury, illness 
or disability. Recreation Therapists utilize treatment interventions, 
leisure education and recreation experiences to improve functional 
abilities, foster recovery, enhance health and wellness, promote the 
development and maintenance of a healthy leisure lifestyle and increase 
independent participation in activities of choice through activity 
modification, adaptation and facilitation.
    2. Recreation Therapists in VA possess the education and 
certification required by VA qualification standards. See VA Handbook 
5005, Staffing, Part II, Appendix G60, dated June 7, 2019.
    3. VA Recreation Therapists practice in accordance with the 
Standards for the Practice of Recreational Therapy from ATRA available 
at: https://www.atra-online.com/. VA reviewed license and certification 
requirements for this occupation in June 2023 and confirmed that all 
Recreation Therapists in VA follow the ATRA standards.
    4. Although VA only requires a certification, five States require a 
State license in order to practice as a Recreation Therapist in that 
State: New Hampshire, New Jersey, North Carolina, Oklahoma and Utah. Of 
those, the following State exempts Federal employees from its State 
license requirements: Oklahoma.
    VA reviewed license and certification requirements for this 
occupation in June 2023 and confirmed that there is no variance in how 
VA Recreation Therapists 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 and signed 
this document on July 12, 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.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
General Counsel, Department of Veterans Affairs.
[FR Doc. 2023-16007 Filed 7-27-23; 8:45 am]
BILLING CODE 8320-01-P