BILL ANALYSIS Ó
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|Hearing Date:April 21, 2014 |Bill No:SB |
| |993 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Ted W. Lieu, Chair
Bill No: SB 993Author:Mitchell
As Amended: April 21, 2014 Fiscal: Yes
SUBJECT: Healing arts: dietitians.
SUMMARY: Revises the qualifications required for a registered
dietetic technician (DTR) and requires that a DTR complete his or her
course of study before assisting a registered dietitian (RD). Removes
the requirement for a RD to have physician authorization before making
changes to a medical nutrition therapy plan and instead permits a RD
to develop and recommend nutritional and dietary treatments and
provide medical nutrition therapy in accordance with a licensed health
care facility's approved policy and procedures. Also adds "registered
dietitian nutritionist" to the list of titles that can be utilized by
a RD.
Existing law:
1) Requires registered dietitians (RDs) to possess prescribed
academic, examination and continuing education qualifications
recognized by the Department of Health Services. (Business and
Professions Code (BPC) § 2585 (a) et seq.)
2) Specifies that the use of the name "registered dietitian" is
reserved for those persons who possess the prescribed
qualifications. (BPC § 2585 (a) (1))
3) Authorizes, upon referral from a health care provider authorized to
prescribe dietary treatments, a RD to provide nutritional and
dietary counseling, conduct nutritional and dietary assessments,
and develop nutritional and dietary treatments, including
therapeutic diets, for individuals or groups of patients in
licensed institutional facilities or in private office settings.
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(BPC § 2586 (a))
4) Permits a RD to accept or transmit verbal orders or electronically
transmitted orders from the referring physician consistent with an
established protocol to implement medical nutrition therapy. (BPC
§ 2586 (b))
5) Permits a RD to order medical laboratory tests related to
nutritional therapeutic treatments when authorized to do so by a
written protocol prepared or approved by the referring physician
and when, in the absence of the referring physician at a patient
visit, in a clinic where there is a registered nurse on duty, a
register nurse is notified that a medical laboratory test being
ordered and is afforded and opportunity to assess the patient.
(BPC § 2586 (c))
6) Specifies that the use of the name "dietetic technician" is
reserved for those persons who possess prescribed academic,
examination and continuing education qualifications recognized by
the Department of Health Services. (BPC § 2585 et seq.)
7) Allows a dietetic technician to assist a registered dietitian in
implementing or monitoring medical nutrition therapy services, but
may not develop nutritional or dietary therapy or treatments or
accept or transmit verbal orders. (BPC § 2586 (d) (1))
8) Specifies that upon referral by a physician and surgeon RDs may be
reimbursed for nutritional advice or advice concerning proper
nutrition or for nutritional assessments, counseling and
treatments. (BPC § 2585 (e))
9) Further specifies that nothing shall be construed to mandate direct
reimbursement of RDs as a separate provider type under the Medi-Cal
program, nor to mandate reimbursements where expressly prohibited
by federal law or regulation. (BPC § 2585 (f))
10)Specifies that any person who represents themselves as a dietitian,
but does not have the appropriate qualifications, is committing a
misdemeanor. (BPC § 2585 (c))
This bill:
1) Updates several references to the obsolete Department of Health
Services and replaces the term with the appropriate agency, the
Department of Public Health.
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2) Removes the requirement for satisfactory completion of the dietetic
technician program as a requisite for calling oneself a dietetic
technician, registered (DTR).
3) Adds the completion of the following as options for being
recognized as a DTR:
a) Receipt of an associate's degree or higher from a college or
university accredited by the Western Association of Schools and
Colleges or other regional accreditation agency and at least 450
hours of supervised practice experience or,
b) Appropriate academic requirements for the fields of
dietetics and related disciplines and receipt of a baccalaureate
or higher degree from a college or university accredited by WASC
or other regional accreditation agency.
4) Adds requirements for supervisors of practice including that they
must meet minimum qualifications established by public or private
agencies or institutions recognized by the State Department of
Public Health.
5) Adds "registered dietitian nutritionist" to the list of titles that
can be utilized by an individual who has met the prescribed
qualifications and academic requirements.
6) Indicates that it is a misdemeanor for any person to use the title
"registered dietitian nutritionist" or the letters "RDN" who has
not met prescribed qualifications and academic requirements.
7) Deletes the requirement for a referring physician and surgeon to
establish or approve a written protocol governing the patient's
treatment.
8) Adds "medical nutrition therapy" as a type of therapy that a
physician and surgeon can make a referral for.
9) Adds language that will allow a health care facility's approved
nutrition screening policy and procedure to guide the practice of a
registered dietitian to perform nutritional assessments and
initiate nutritional interventions within the parameters of the
diet order.
10)Requires the registered dietitian to collaborate with a
multidisciplinary team including the treating physician and
registered nurse in developing the patient's nutrition care plan.
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11)Allows the registered dietitian to individualize the patient's
nutritional or dietary treatment when necessary by modifying the
distribution, type or quantity of food and nutrients within the
parameters of the diet order.
12)Requires that modifications and rationale be documented in the
patient's record for review by the prescribing provider.
13)Specifies that a registered dietitian or other nutritional
professional is unauthorized to administer central vein or
peripheral vein nutrition.
14)Removes the term "nutritional therapeutic treatments" and adds
"medical nutrition therapy services" in describing the types of
medical laboratory tests that a registered dietitian or other
nutritional professional may order.
15)Removes the requirement for a written protocol from the referring
physician, or a registered nurse on duty when the referring
physician is not present, to permit a dietitian to order a medical
laboratory test.
16)Adds "the physician responsible for the care of the patient" as a
person who is permitted to approve the ordering of medical
laboratory tests, verbal or electronic orders related to medical
nutrition therapy services.
17)Removes the option for a person to be enrolled in a course of study
to fulfill the educational requirements of a dietetic technician
and instead requires that a person have completed course of study
for a registered dietetic technician.
18)Removes the requirement that an individual complete the supervised
practice program requirements for a dietetic technician and instead
only requires that the person complete an educational program and
possess an associate's degree or higher.
FISCAL EFFECT: Unknown. This bill has been keyed fiscal by
Legislative Counsel.
COMMENTS:
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1. Purpose. This bill is sponsored by the California Dietetic
Association . According to the Author, "SB 993 updates existing
statute governing registered dietitians and dietetic technicians,
registered, by clarifying the scope of practice of RDs working in
licensed health care institutions and by updating the pathways by
which and individual can become a DTR. Additionally, the measure
corrects obsolete references to the Department of Health Services."
The Author also notes, "As a result of the narrow and confusing
language in the code sections that set forth the authority of RDs,
DPH has imposed citations alleging violations of law by these
institutions employing RDs. RDs have the training and expertise to
make minor changes within the existing nutrition/diet orders
without waiting for the patient's physician to modify the diet as
long as the changes are within the parameters of the
physician-prescribed diet order."
2. Background. RD Scope of Practice . Dietitians are allied health
care professionals who provide a range of medical nutrition therapy
(MNT) services to patients. MNT involves:
1) nutrition assessment (e.g. examination of the patient's medical
history and possible drug-nutrition interactions), and 2) provision
of nutrition therapy (e.g. development of nutrition care plans for
individuals or groups of patients). The nutrition plans RDs create
are utilized to help patients manage chronic disease, food
allergies, sensitivities and intolerances and weight loss. Work
environments for RDs include hospitals, nursing care facilities,
schools, community and public health settings and private practice.
A RD may refer to themselves as a dietitian, registered dietitian,
RD or any other terms or initials that imply they are registered.
Requirements for RD Registration . Forty six states have enacted
legislation regulating the practice of dietetics. State regulation
is entirely separate and distinct from credentialing by the
Commission on Dietetic Registration. In California, dietitians
must register with the California Department of Public Health. In
order to meet the requirements for registration, an individual must
satisfy specific academic, examination and supervision
pre-requisites.
Academic . Must possess a Baccalaureate or
post-Baccalaureate degree from a regionally accredited
institution of higher learning with a program in dietetics or a
related discipline such as dietetics, foods and nutrition or
food service systems management.
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Examination . Must have evidence of satisfactory
completion of an examination administered by a public or
private agency or institution recognized by the State
Department of Public Health as qualified to administer the
examination. The California Department of Public Health has
recognized the Commission on Dietetic Registration as the
vendor that administers the examination.
Supervised Experience . Must have completed 900 hours
under a supervisor who meets the minimum qualifications
established by the public or private agencies.
RD Credentials . In addition to state registration, RDs are
credentialed by the Commission on Dietetic Registration (CDR), the
credentialing agency for the Academy of Nutrition and Dietetics.
RDs may renew their registration with CDR annually or every five
years. The CDR maintains an online verification system that tracks
the registration status of credentialed practitioners. In
addition, the CDR creates the code of ethics for RDs and also
maintains a database of continuing professional education
providers.
Although not required, some dietitians may also seek Board
Certification as a Specialist in Renal Nutrition (RD, CSR) or
Pediatric Nutrition (RD, CSP). Dietitians with the Fellow of the
American Dietetic Association (FADA) certification must have earned
a master's or doctoral degree and have at least eight years of work
experience.
The following chart illustrates the current pathways for an
individual to become a RD in California.
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|STEP 1 |STEP 2 |STEP 3 |STEP 4 |STEP 5 |STEP 6 |
| | | | | | |
|Degree | | | | | |
|Programs | | | | | |
|-----------+------------+--------+-------------+--------+--------|
|Didactic |"Verificatio|Apply |Successful | | |
|Program in |n |for |Completion | | |
|Dietetics |Statement" |Dietetic|of Dietetic | | |
|(DPD), |from DPD | |Internship |RD EXAM | |
|BS or MS |Program |Internsh|Full Time or | | |
|Local |Director |ips |Part Time | | |
|University |required | |(approximatel| | |
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|or Distant |for |GPA? |y 900-1200 | | |
|Program |Dietetic |Cost? |hours) | | |
| |Internship |Time? | | | |
| | |Location| | | |
| | |? | | | |
|-----------+------------+--------+-------------+--------+--------|
|Coordinated|Successful | | | | |
| Dietetics |Completion | | | | |
|Program |of CDP |RD EXAM | | | |
|(CDP) |Undergraduat| | | | |
|Local |e or | | | | |
|University |Graduate | | | | |
|or Distant |Program | | | | |
|Program | | | | | |
|-----------+------------+--------+-------------+--------+--------|
|BS/MS |Additional |"Verific|Apply for |Successf| |
|Nutrition |DPD |ation |Dietetic |ul | |
|or other |Classes, |Statemen|Internships |Completi| |
|non- DPD |Local |t" from | |on of |RD EXAM |
|approved |University |DPD |GPA? |Dietetic| |
|program |or online |Program |Cost? | | |
| |DPD Classes |Director|Time? |Internsh| |
| | | |Location? |ip | |
| | |required| | | |
| | | for | | | |
| | |Dietetic| | | |
| | | | | | |
| | |Internsh| | | |
| | |ip | | | |
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Chart retrieved from the California Department of
Public Health website April 14, 2014.
Registered Dietetic Technicians . Registered Dietetic Technicians
(DTRs) work under the supervision of a RD. A DTR assists a RD in
implementing or monitoring medical nutrition therapy services, but
may not develop nutritional or dietary therapy or treatments or
accept or transmit verbal orders. Under current law, a RD is
required to receive an associate's degree or higher from a Western
Association of schools and Colleges accredited institution. They
must complete the dietetic technician program requirements by an
accredited public or private agency recognized by the Department of
Public Health and complete examination and continuing education
requirements. The California Department of Public Health has
recognized the Commission on Dietetic Registration as the vendor
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that administers the examination and continuing education
requirements.
Referrals and Authorization . Current law requires a referral by a
patient's physician or other health care provider authorized to
prescribe dietary treatments before medical nutrition therapy can
begin. The referral must be accompanied by a written prescription
signed by the health care provider detailing the patient's
diagnosis and including a statement of the desired objective of
dietary treatment, unless a referring physician has established or
approved a written protocol governing the patient's treatment.
Whenever an RD desires to make a change to the medical nutrition
therapy plan, they must receive authorization from the referring
physician.
CDPH Citations . According to information provided by the sponsor
of this bill, several hospitals have cited by CDPH for dietitians
for making modifications to the dietary plans of patients without
obtaining approval from the referring physician.
1. Arguments in Support. The California Dietetic Association supports
the bill and writes, "The measure seeks to clarify the existing
confusing and outdated scope of practice which has resulted in CA
Department of Public Health (CDPH) citations against the hospitals
in which RDs are employed. This language enhances patient safety
and increases efficiency by allowing RDs to perform medical
nutritional therapy in collaboration with the patient's physician
and multidisciplinary team and identify proper diet and nutrition
interventions within the scope of the physician diet order which
will optimize patient outcomes and reduce risks through
patient-centered care?Second, SB 993 aligns the statute with
national standards for the DTR by updating the eligibility
requirements for a dietetics student to become a credentialed DTR."
The California Hospital Association supports the bill and writes,
"SB 993 is necessary for two primary reasons: (1) eliminate
regulatory citations that result from confusing scope of practice
language in the existing law and 2) Align the CA B&P Code 2585 with
national standards for the Dietetic Technician Registered."
The California State Council of the Service Employees International
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also supports the bill and writes, "Currently, the California
department of Public Health asserts that RDs must receive physician
approval before making minor modifications to a patient's diet plan
(for example, changing the texture of the diet when a patient has
poor-fitting dentures) which is not the best use of the physician's
time or in the best interest of the patient. RDs have the training
and expertise to make those minor changes within the existing
nutrition/diet orders without waiting on the patient's physician to
modify the diet as long as the changes are within the parameters of
the physician-prescribed diet order."
2. Oppose Unless Amended. The California Nurses Association has an
"oppose unless amended" position on this measure. In their letter
they write, "We are opposed to the changes that undermine a patient
centered team approach to care led by the admitting practitioner or
practitioners. While dietitians are valuable members of the
health care team, they do not have the depth and breadth of medical
knowledge that physicians have and do not have full responsibility
for patient care that would allow for the independent modification
of a patient's diet without clear physician notification and/or
authorization. From a nursing perspective, the flexibility for
dietitians to modify a patient diet without specific authorization
from a physician will result in therapeutic diet modifications
being made through two different providers. Registered nurses are
there with patients 24 hours a day and physicians are available
directly or via telephone 24 hours a day. Dietary services in
general, and registered dietitians services specifically, are very
time limited in the acute care setting."
The Center for Nutrition Advocacy also opposes the bill unless
amended. In their letter they write, "We would like to express our
continued opposition to the existing Registration regulation, which
does arbitrarily give government imprimatur to one professional
group while excluding other qualified nutrition professionals from
the same recognition. This statute also recognizes bachelor's
level Registered Dietitians while other trained nutrition
professionals are required to have a minimum of a Masters level
degree. We recognize SB 933 is designed to implement independent
authority for Medical Nutrition Therapy services within licensed
health care facilities and that at a later time a broader
regulation for nutrition and dietetics is likely to be considered.
We have been assured by lobbyists for the California Dietetic
Association/Academy of Nutrition and Dietetics that any such effort
will only be undertaken collaboratively with other nutrition
professional stakeholders at the table. We respectfully request
that the record reflect we accept SB 993 as amended solely based on
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this commitment that has been made."
3. Related Legislation. AB 575 (Hayashi, 2011) sought to license and
regulate RDs by creating the Dietitians Bureau within the
Department of Consumer Affairs. ( Status : AB 575 was set for
hearing in the Assembly Business, Professions and Consumer
Protection Committee but was not heard at the request of the
Author.)
SUPPORT AND OPPOSITION:
Support:
California Dietetic Association (Sponsor)
SEIU California
California Hospital Association
Kaiser Permanente
22 registered dietitians
1 dietetics graduate student
Oppose Unless Amended:
California Nurses Association
Center for Nutrition Advocacy
Alliance for Natural Health
Opposition:
None received as of April 17, 2014
Consultant:Le Ondra Clark, Ph.D.