[Federal Register Volume 89, Number 94 (Tuesday, May 14, 2024)]
[Notices]
[Pages 42057-42060]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-10528]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Nuclear Medicine Technologist 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 Nuclear Medicine Technologists. 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 July 15, 2024.

ADDRESSES: Comments must be submitted through https://www.regulations.gov/. Except as provided below, comments received 
before the close of the comment period will be available at https://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 https://www.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 will not be 
considered.

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 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 State 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, regardless of conflicting State laws, rules, regulations, 
or other State requirements.
    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

[[Page 42058]]

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 State 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 proper 
education, training, and skills to perform the tasks and duties 
detailed in the national standard of practice, and that they 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.

Preemption of State Requirements

    The national standard of practice will preempt any State laws, 
rules, regulations, or requirements that both are and are not listed in 
the national standard as conflicting, but that do in fact conflict with 
the tasks and duties as authorized in VA's national standard of 
practice. In the event that a State changes their requirements and 
places new limitations on the tasks and duties it allows in a manner 
that would be inconsistent with what is authorized under the national 
standard of practice, the national standard of practice will preempt 
such limitations and authorize the VA health care professional to 
continue to practice consistently with the tasks and duties outlined in 
the national standard of practice.
    In cases where a VA health care professional's license, 
registration, certification, or other State requirement allows a 
practice that is not included in a national standard of practice, the 
individual may continue that practice so long as it is permissible by 
Federal law and VA policy, is not explicitly prohibited by the national 
standard of practice and is approved by the VA medical facility.

Need for National Standards of Practice

    It is critical that VA, the Nation's largest integrated health care 
system, develops national standards of practice to ensure, first, that 
beneficiaries receive the same high-quality care regardless of where 
they enter the system and, second, 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 Coronavirus Disease 2019 (COVID-19) 
pandemic. The increased need for mobility in VA's workforce, including 
through VA's Disaster Emergency Medical Personnel System, highlighted 
the importance of creating uniform national standards of practice to 
better support VA health care professionals who practice across State 
lines. Creating national standards of practice also promotes 
interoperability of medical data between VA and the Department of 
Defense (DoD), providing a complete picture of a Veteran's health 
information and improving VA's delivery of health care to the Nation's 
Veterans. DoD has historically standardized practice for certain health 
care professionals, and VA has closely partnered with DoD to learn from 
their experience.

Process To Develop National Standards of Practice

    As authorized by 38 CFR 17.419, VA is developing national standards 
of practice via policy. There is one overarching directive to describe 
Veterans Health Administration (VHA) policy on national standards of 
practice. The directive is accessible on the VHA Publications website 
at https://vaww.va.gov/vhapublications/ (internal) and https://www.va.gov/vhapublications/ (external). As each individual national 
standard of practice is finalized, it is published as an appendix to 
the directive and accessible at the same websites.
    To develop these national standards, VA is using a robust, 
interactive process that adheres to the guidelines outlined in 
Executive Order (E.O.) 13132 to preempt conflicting State laws, rules, 
regulations, or other requirements. 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 VA occupation, a 
workgroup comprised of VA health care professionals in the identified 
occupation conducts 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 VA. 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 tasks and 
duties. The workgroup then drafts a proposed VA national standard of 
practice using the data gathered during the research and incorporates 
internal stakeholder feedback into the standard. The workgroup may 
consult with internal or external stakeholders at any point throughout 
the process.
    The proposed national standard of practice is then internally 
reviewed, to include by an interdisciplinary VA workgroup consisting of 
representatives from Quality Management, VA medical facility Chiefs of 
Staff, Academic Affiliates, Veterans Integrated Services Network (VISN) 
Chief Nursing Officers, Ethics, Workforce Management and Consulting, 
Surgery, Credentialing and Privileging, VISN Chief Medical Officers, 
and Electronic Health Record Modernization.
    Externally, VA hosts listening sessions for members of the public, 
professional associations, and VA employees to provide comments on the 
variance between State practice acts for specific occupations and what 
should be included in the national standard of practice for that 
occupation. The listening session for Nuclear Medicine Technologists on 
September 7, 2023, included five presenters, representing VA employees 
and the Nuclear Medicine Technology Certification Board. The presenters 
spoke about the qualifications of and scope of practice for Nuclear 
Medicine Technologists. Presenters were supportive of the national 
standard of practice. VA appreciates the thoughtful presentations and 
is considering the information presented at the listening session when 
drafting the proposed VA national standard of practice.
    VA has developed a robust process to engage with partners, members 
of the public, States, and employees on the proposed national standard 
of practice. VA provides the proposed national standard of practice to 
our DoD partners as an opportunity to flag inconsistencies with DoD 
standards. VA also engages with labor partners informally as part of a 
pre-decisional collaboration. Consistent with E.O. 13132, VA sends a 
letter to each State board and certifying organization or registration 
organization, as appropriate, which includes the proposed national 
standard and offers the recipient an opportunity to discuss the 
national standard with VA. After the State boards, certifying 
organizations, or registration organizations have received 
notification, the proposed national standard of practice is posted in 
the Federal Register for 60 days to obtain feedback from the public, 
professional associations, and any other interested parties. At the 
same time, the proposed national standard is posted to an

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internal VA site to obtain feedback from VA employees. Responses 
received through all vehicles--from State boards, professional 
associations, unions, VA employees, and any other individual or 
organization who 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. VA 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 properly incorporated into an 
individual health care professional's privileges, scope of practice, or 
functional statement once it has been determined by their VA medical 
facility that the individual has the proper education, training, and 
skills to perform the task or duty. Implementation of the national 
standard of practice may be phased in across all VA medical facilities, 
with limited exemptions for health care professionals, as needed.

Format for the Proposed National Standard for Nuclear Medicine 
Technologists

    The format for the proposed national standards of practice when 
there are national certification bodies and State licenses is described 
as follows. The first paragraph provides general information about the 
profession and what the health care professionals can do. For this 
national standard, Nuclear Medicine Technologists administer 
radionuclides, radiopharmaceuticals, and adjunct medications under the 
direction of a Nuclear Medicine Physician or Radiologist. We reiterate 
that the proposed standard of practice does not contain an exhaustive 
list of every task and duty that each VA health care professional can 
perform. Rather, it is designed to highlight generally what tasks and 
duties the health care professionals perform and how they will be able 
to practice within VA notwithstanding their State license, 
certification, registration, or other State requirements.
    The second paragraph references the education and certification 
needed to practice this profession at VA. Qualification standards for 
employment of health care professionals by VA are outlined in VA 
Handbook 5005, Staffing, dated April 8, 2024. VA follows the 
requirements outlined in the VA qualification standards even if the 
requirements conflict with or differ from a State requirement. National 
standards of practice do not affect those requirements. This includes, 
but is not limited to, when a State requires a license to practice a 
specific occupation, but VA does not require a State license as part of 
the qualification standards. For Nuclear Medicine Technologists, VA 
qualification standards require an active, current, full, and 
unrestricted certification from the Nuclear Medicine Technology 
Certification Board (NMTCB) or the American Registry of Radiologic 
Technology (ARRT).
    The second paragraph also notes whether the national standard of 
practice explicitly excludes individuals who practice under 
``grandfathering'' provisions. Qualification standards may include 
provisions to permit employees who met all requirements prior to 
revisions to the qualification standards to maintain employment at VA 
even if they no longer meet the new qualification standards. This 
practice is referred to as grandfathering. Nuclear Medicine 
Technologists have grandfathering provisions included within their 
qualification standards, and VA proposes to have those individuals be 
authorized to follow the Nuclear Medicine Technologist national 
standard of practice. Therefore, there would be no notation regarding 
grandfathered employees in the national standard of practice as they 
would be required to adhere to the national standard as would any other 
VA Nuclear Medicine Technologist who meets the current qualification 
standards.
    The third paragraph establishes what the national standard of 
practice will be for the occupation in VA. For this national standard, 
VA Nuclear Medicine Technologists follow the standard set by Society of 
Nuclear Medicine and Molecular Imaging (SNMMI), which can be found at: 
https://www.snmmi.org/Technologists. For Nuclear Medicine 
Technologists, VA confirmed that all individuals, whether certified by 
NMTCB or ARRT, followed the Nuclear Medicine Technologist Scope of 
Practice and Performance Standards from SNMMI.
    The fourth paragraph identifies if there are additional 
registrations, regulations, certifications, licenses, or Federal 
exemptions for the profession. It explains if VA is preempting any 
conflicting State laws, rules, regulations, or requirements. For this 
national standard of practice, VA reviewed if there are any required 
alternative registrations, certifications, licenses, or other State 
requirements for Nuclear Medicine Technologists. VA found that 34 
States require a State license for Nuclear Medicine Technologists.
    The fourth paragraph also includes information on which States 
offer an exemption for Federal employees and whether VA is preempting 
any conflicting State laws, rules, regulations, or requirements. Of 
those 34 States that require a license, 24 States exempt Federal 
employees from their State license requirements. Furthermore, the tasks 
and duties set forth in the State license requirements for all 34 
States are consistent with what is permitted under the national 
certification. Therefore, there is no variance in how Nuclear Medicine 
Technologists practice in any State. VA thus proposes to adopt a 
standard of practice consistent with the national certification. VA 
Nuclear Medicine Technologists will continue to follow this standard.
    This national standard or practice does not address training 
because it will not authorize VA Nuclear Medicine Technologists to 
perform any tasks or duties not already authorized under their national 
certification and State license.
    Following public and VA employee comments and revisions, each 
national standard of practice that is published in policy will also 
include the date for recertification of the standard of practice and a 
point of contact for questions or concerns.

Proposed National Standard of Practice for Nuclear Medicine 
Technologists

    1. Nuclear Medicine Technologists perform technical work in support 
of the Diagnostic Imaging Service's Nuclear Medicine section under the 
direction of a Nuclear Medicine Physician or Radiologist. Nuclear 
Medicine Technologists administer radionuclides, radiopharmaceuticals, 
and adjunct medications. They also operate radiation detectors, 
scanning apparatus, and related equipment for patients having General 
Nuclear Medicine, Nuclear Cardiology, Positron Emission Tomography and 
Computerized Tomography (PET/CT), and Positron Emission Tomography and 
Magnetic Resonance Imaging (PET/MRI) exams. Under the supervision of an 
authorized user, Nuclear Medicine Technologists are responsible for the 
safe use of ionizing and non-ionizing radiation and molecular imaging 
for diagnostic, therapeutic, and research purposes. Nuclear Medicine 
Technologists review patients' medical histories to understand their 
illnesses, medical issues, and pending diagnostic or treatment 
procedures; instruct

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patients before, during, and following procedures; evaluate the 
satisfactory preparation of patients before beginning procedures; 
complete documentation within electronic health records as necessary; 
and recognize and respond appropriately to emergency situations.
    2. Nuclear Medicine Technologists in the Department of Veterans 
Affairs (VA) possess the education and certification required by VA 
qualification standards. See VA Handbook 5005, Staffing, part II, 
appendix G19, dated December 10, 2019.
    3. VA Nuclear Medicine Technologists practice in accordance with 
the Nuclear Medicine Technologist Scope of Practice and Performance 
Standards from the Society of Nuclear Medicine and Molecular Imaging 
(SNMMI), available at https://www.snmmi.org/Technologists. Nuclear 
Medicine Technology Certification Board and the American Registry of 
Radiologic Technology, the two national certifying bodies of Nuclear 
Medicine Technologists, follow the SNMMI standards. VA reviewed license 
and certification requirements for this occupation in September 2023 
and confirmed that all Nuclear Medicine Technologists in VA followed 
SNMMI standards.
    4. Although VA only requires a certification, 34 States require a 
State license in order to practice as a Nuclear Medicine Technologist 
in that State: Alaska, Arizona, Arkansas, California, Delaware, 
Florida, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, 
Maine, Maryland, Massachusetts, Mississippi, Nevada, New Hampshire, New 
Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Puerto Rico, 
Rhode Island, South Carolina, Texas, Utah, Vermont, Virginia, West 
Virginia, and Wyoming.
    Of those, 24 States exempt Federal employees from their State 
license requirements: Alaska, Arizona, California, Delaware, Florida, 
Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, 
Nevada, New Hampshire, New Jersey, New York, North Dakota, Ohio, 
Oregon, Texas, Utah, Vermont, Virginia, and West Virginia.
    VA reviewed license and certification requirements for this 
occupation in September 2023 and confirmed there was no variance in how 
VA Nuclear Medicine Technologists practice in any State.

Request for Information

    1. Are there any additional trainings for the aforementioned tasks 
and duties where VA is preempting States that we should consider?
    2. Are there any factors that would inhibit or delay the 
implementation of the aforementioned tasks and duties for VA health 
care professionals in any States?
    3. Is there any variance in tasks and duties that we have not 
listed?
    4. What should we consider when preempting conflicting State laws, 
rules, 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 April 25, 2024, 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. 2024-10528 Filed 5-13-24; 8:45 am]
BILLING CODE 8320-01-P