[Federal Register Volume 88, Number 144 (Friday, July 28, 2023)]
[Notices]
[Pages 48955-48958]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-16008]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Creative Arts Therapists (Art) 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 Creative Arts Therapists (Art). 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.

[[Page 48956]]

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 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 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.

[[Page 48957]]

    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 registration 
organization that includes the proposed national standard and an 
opportunity to further discuss the national standard with VA. After the 
States and registration 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 Creative Arts Therapists (Art)

    The proposed format for national standards of practice when there 
is a national registration 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 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 national 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.
    Art Therapists integrate psychotherapeutic principles and art 
interventions to evaluate, diagnose and treat individuals with various 
clinical mental health and rehabilitation issues that impact their 
health, function and quality of life. VA qualification standards 
require Art Therapists to have an active, current, full and 
unrestricted registration as a Registered Art Therapist (ATR) from the 
Art Therapy Credentials Board (ATCB). Please note that while VA 
Handbook 5005, Part II, Appendix G60 refers to this position as 
Creative Arts Therapists (Art), this position is commonly referred to 
as Art Therapists, and we will use that terminology throughout. 
Although ATCB is the registration body for Art Therapists, the American 
Art Therapy Association (AATA) has developed the Ethical Principles for 
Art Therapists, which is followed by all VA Art Therapists.
    VA reviewed whether there are any alternative registrations, 
certifications or State requirements that could be required for an Art 
Therapist and found that 14 States require a license to practice as an 
Art 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 14 States are consistent with 
what is permitted under the Ethical Principles for Art Therapists 
standards from the AATA. Therefore, there is no variance in how Art 
Therapists practice in any State.
    VA proposes to adopt a standard of practice consistent with the 
Ethical Principles for Art Therapists by the AATA. The AATA standards 
can be found here: https://arttherapy.org/wp-content/uploads/2017/06/Ethical-Principles-for-Art-Therapists.pdf.
    Because the practice of Art 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 Art Therapists

    1. Art Therapists integrate psychotherapeutic principles and art 
interventions to evaluate, diagnose and treat individuals with various 
clinical mental health and rehabilitation issues that impact their 
health, function and quality of life. Art Therapists use art-making and 
the creative process to improve cognitive and sensorimotor functions, 
foster self-esteem and emotional resilience, promote insight, enhance 
social skills and reduce and resolve conflicts and distress in order to 
ameliorate biopsychosocial conditions.
    2. Art Therapists in VA possess the education and registration 
required by VA qualification standards. See Handbook 5005, Staffing, 
Part II, Appendix G60, dated June 7, 2019.
    3. VA Art Therapists practice in accordance with the Ethical 
Principles for Art Therapists from the American Art Therapy Association 
(AATA), available at: https://arttherapy.org. VA reviewed license and 
certification requirements for this occupation in June 2023 and 
confirmed that all Art Therapists in VA follow the AATA standards.
    4. Although VA only requires a registration, 14 States require a 
State license in order to practice as an Art Therapist in that State: 
Connecticut, Delaware, District of Columbia, Kentucky, Maryland, 
Mississippi, New Jersey, New Mexico, New York, Oregon, Pennsylvania, 
Tennessee, Texas and Virginia. Of those, the following State exempts 
Federal employees from its State license requirements: Virginia.
    VA reviewed license and certification requirements for this 
occupation in June 2023 and confirmed that there is no variance in how 
VA Art 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?

[[Page 48958]]

    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 10, 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. 2023-16008 Filed 7-27-23; 8:45 am]
BILLING CODE 8320-01-P