[Federal Register Volume 89, Number 148 (Thursday, August 1, 2024)]
[Notices]
[Pages 62868-62870]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-16944]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Massage Therapist 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 Massage 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 30, 2024.

ADDRESSES: Comments must be submitted through http://www.regulations.gov/. Except as provided below, comments received 
before the close of the comment period will be available at http://www.regulations.gov/ for public viewing, inspection, copying, or 
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 http://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 Governance, 
Regulations, Appeals, and Policy (10B-GRAP), 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 requirements that unduly interfere with their 
practice. 38 CFR 17.419; 85 FR 71838. Specifically, this rulemaking 
confirmed VA's current practice of permitting 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 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 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 a national standard of practice means 
that individuals from the same VA health care profession may perform 
the same type of tasks and duties regardless of the state where they 
are located or the state license, registration, certification, or other 
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.

[[Page 62869]]

Preemption of State Requirements

    The national standard of practice will preempt any state laws, 
rules, regulations, or other requirements that both are and are not 
listed in the national standard as conflicting, but that do 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 permits 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 consistent 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 requirement permits a practice 
that is not included in a national standard of practice, the individual 
may continue that practice so long as it is permissible under Federal 
law and VA policy, is not explicitly restricted 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, VHA Directive 1900(5), VA National Standards of Practice, 
August 30, 2023. The directive is accessible on VHA's publications 
website at https://www.va.gov/vhapublications/. As each individual 
national standard of practice is finalized, it is published as an 
appendix to the directive and accessible at the same website.
    To develop these national standards, VA is using a robust, 
interactive process that adheres to the requirements of Executive Order 
(E.O.) 13132 to preempt conflicting state laws, rules, regulations, or 
other requirements. For each health care 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 and any internal stakeholder feedback received. The 
workgroup may consult with internal or external stakeholders at any 
point throughout the process.
    The process to develop VA national standards of practice includes 
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 Massage Therapists was held on August 31, 2023. 
No professional associations presented comments on the Massage 
Therapist standard of practice.
    After the proposed standard is developed, it is first internally 
reviewed. This includes a review from an interdisciplinary VA workgroup 
consisting of representatives from Quality Management, VA medical 
facility Chief of Staff, Academic Affiliates, Veterans Integrated 
Services Network (VISN) Chief Nursing Officer, Ethics, Workforce 
Management and Consulting, Surgery, Credentialing and Privileging, VISN 
Chief Medical Officer, and Electronic Health Record Modernization.
    After the internal review, 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 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/.
    The national standard of practice is then finalized, approved, and 
published in VHA policy. Any tasks or duties included in the national 
standard will be properly incorporated into individual VA health care 
professionals' 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 Massage Therapist

    The format for the proposed national standards of practice when 
there are state licenses, registrations, or certifications is as 
follows. The first paragraph provides general information

[[Page 62870]]

about the profession and what the VA health care professionals can do. 
For this national standard, Massage Therapists skillfully assess and 
manipulate the soft tissues of the human body for therapeutic purposes. 
Massage Therapists assess patients, develop evidence-based, 
individualized massage therapy treatment plans, and participate as 
members of interdisciplinary health care teams. 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 practice within VA.
    The second paragraph references the education and license, 
registration, or 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 July 8, 2024. 
VA follows the requirements outlined in its qualification standards 
even if the requirements conflict with or differ from a state 
requirement. National standards of practice do not affect those 
requirements. For Massage Therapists, VA qualification standards 
require an active, current, full, and unrestricted state license, 
registration, or certification.
    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. Massage Therapists have 
grandfathering provisions included within their qualification 
standards, and VA proposes to have those individuals authorized to 
follow the Massage Therapist 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 any other VA Massage Therapist who meets the 
current qualification standards.
    The third paragraph establishes what the national standard of 
practice will be for the occupation in VA. It includes whether the 
profession can practice all duties covered by their license, 
certification, or registration. For Massage Therapists, they can 
perform all tasks and duties authorized under their applicable license, 
registration, or certification. VA reviewed the state laws and practice 
acts for Massage Therapists on November 2023 and did not identify any 
conflicts that impact practice of this profession in VA.
    This national standard of practice does not address training 
because it will not authorize VA Massage Therapists to perform any 
tasks or duties not already authorized under their state license, 
registration, or certification.
    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 Massage Therapist

    Note: All references herein to VA and VHA documents incorporate 
by reference subsequent VA and VHA documents on the same or similar 
subject matter.

    1. Massage Therapists skillfully assess and manipulate the soft 
tissues of the human body for therapeutic purposes. Massage Therapists 
assess patients, develop evidence-based, individualized massage therapy 
treatment plans, and participate as members of interdisciplinary health 
care teams. They use their hands, arms, knees, and feet to perform soft 
tissue manipulation. Massage Therapists incorporate active and passive 
range of motion exercise. They also utilize devices and tools to mimic 
or enhance manual therapy; incorporate adjunctive modalities; educate 
patients in health promotion, disease prevention and holistic self-care 
methods; and facilitate mind-body awareness to achieve healing.
    2. Massage Therapists in the Department of Veterans Affairs (VA) 
possess the education and license, registration, or certification 
required by VA qualification standards. See VA Handbook 5005, Staffing, 
Part II, Appendix G56, dated March 12, 2019.
    3. VA Massage Therapists can practice all duties covered by their 
license, local registration, or local certification; or practice in 
accordance with the National Certification Board for Therapeutic 
Massage and Bodywork certification, available at: https://ncbtmb.org/. 
VA reviewed the state laws and practice acts for Massage Therapists on 
November 2023 and did not identify any conflicts that impact practice 
of this profession in VA.

Request for Information

    1. Is VA's assessment of what states permit and restrict accurate?
    2. Are there any areas of variance between state licenses, 
certification, registration, or other requirement that VA should 
preempt that are not listed?
    3. Is there anything else you would like to share with us about 
this VA national standard of practice?

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved and signed 
this document on July 17, 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.

Michael P. Shores,
Director, Office of Regulation Policy & Management, Office of General 
Counsel, Department of Veterans Affairs.
[FR Doc. 2024-16944 Filed 7-31-24; 8:45 am]
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