BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 993|
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THIRD READING
Bill No: SB 993
Author: Mitchell (D), et al.
Amended: 4/21/14
Vote: 21
SENATE BUSINESS, PROF. & ECON. DEV. COMM. : 5-0, 4/21/14
AYES: Wyland, Berryhill, Hernandez, Hill, Padilla
NO VOTE RECORDED: Lieu, Block, Corbett, Galgiani
SENATE APPROPRIATIONS COMMITTEE : Senate Rule 28.8
SUBJECT : Healing arts: dietitians
SOURCE : California Dietetic Association
DIGEST : This bill revises the qualifications required for a
dietetic technician, registered (DTR), and requires that a DTR
complete his/her course of study before assisting a registered
dietitian (RD); defines medical nutritional therapy; allows an
RD to make modifications to a diet order within the parameters
of the physician prescribed order; permits an 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; and adds "registered
dietitian nutritionist" to the list of titles that can be
utilized by an RD.
ANALYSIS :
Existing law:
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1. Requires RDs to possess prescribed academic, examination and
continuing education qualifications recognized by the
Department of Health Services (DHS).
2. Specifies that the use of the name "registered dietitian" is
reserved for those persons who possess the prescribed
qualifications.
3. Authorizes, upon referral from a health care provider
authorized to prescribe dietary treatments, an 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.
4. Permits an 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.
5. Permits an 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.
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 DHS.
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.
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
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and treatments.
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.
10.Specifies that any person who represents themselves as a
dietitian, but does not have the appropriate qualifications,
is committing a misdemeanor.
This bill:
1. Updates several references to the obsolete DHS and replaces
the term with the appropriate agency, the Department of
Public Health (DPH).
2. Removes the requirement for satisfactory completion of the
dietetic technician program as a requisite for calling
oneself a 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 (WASC) 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.
1. Adds requirements for supervisors of practice including that
they must meet minimum qualifications established by public
or private agencies or institutions recognized by DPH.
2. 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.
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3. 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.
4. Deletes the requirement for a referring physician and
surgeon to establish or approve a written protocol governing
the patient's treatment.
5. Adds "medical nutrition therapy" as a type of therapy that a
physician and surgeon can make a referral for.
6. 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.
7. 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.
8. 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.
9. Requires that modifications and rationale be documented in
the patient's record for review by the prescribing provider.
10.Specifies that a registered dietitian or other nutritional
professional is unauthorized to administer central vein or
peripheral vein nutrition.
11.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.
12.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.
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13.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.
14.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.
15.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.
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 that
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. An 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 (CDR). In
California, dietitians must register with DPH. 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
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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.
Examination . Must have evidence of satisfactory completion
of an examination administered by a public or private agency
or institution recognized by DPH as qualified to administer
the examination. DPH has recognized the CDR 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 CDR, the credentialing agency for the
Academy of Nutrition and Dietetics. RDs may renew their
registration with the 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.
DTRs . DTRs work under the supervision of an RD. A DTR assists
an 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 existing
law, a DTR is required to receive an associate's degree or
higher from a WASC accredited institution. They must complete
the dietetic technician program requirements by an accredited
public or private agency recognized by the DPH and complete
examination and continuing education requirements. The DPH has
recognized the CDR as the vendor that administers the
examination and continuing education requirements.
Referrals and authorization . Existing 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
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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.
DPH citations . According to information provided by this bill's
sponsor, the California Dietetic Association, several hospitals
have been cited by DPH for dietitians making modifications to
the dietary plans of patients without obtaining approval from
the referring physician.
Comments
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 an individual can become a DTR. Additionally,
the measure corrects obsolete references to the now disbanded
Department of Health Services." The author also notes, "As a
result of RD's confusing and outdated scope of practice, DPH has
imposed citations alleging scope of practice violations by
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."
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
SUPPORT : (Verified 5/6/14)
California Dietetic Association (source)
California Hospital Association
Kaiser Permanente
SEIU California
SEIU-United Healthcare Workers West
OPPOSITION : (Verified 5/6/14)
Alliance for Natural Health
California Nurses Association
Center for Nutrition Advocacy
Certification Board for Nutrition Specialists
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ARGUMENTS IN SUPPORT : The California Dietetic Association
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 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."
SEIU California 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."
ARGUMENTS IN OPPOSITION : The California Nurses Association
writes, "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
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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 writes, "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 this commitment that
has been made."
MW:k 5/7/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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