BILL ANALYSIS Ó SB 993 Page 1 SENATE THIRD READING SB 993 (Mitchell) As Amended July 2, 2014 Majority vote SENATE VOTE :32-0 BUSINESS & PROFESSIONS 14-0 APPROPRIATIONS 17-0 ----------------------------------------------------------------- |Ayes:|Bonilla, Jones, |Ayes:|Gatto, Bigelow, | | |Bocanegra, Campos, | |Bocanegra, Bradford, Ian | | |Dickinson, Eggman, | |Calderon, Campos, | | |Gordon, Hagman, Holden, | |Donnelly, Eggman, Gomez, | | |Maienschein, Mullin, | |Holden, Jones, Linder, | | |Skinner, Ting, Wilk | |Pan, Quirk, | | | | |Ridley-Thomas, Wagner, | | | | |Weber | |-----+--------------------------+-----+--------------------------| | | | | | ----------------------------------------------------------------- SUMMARY : Modifies educational and training requirements for a dietetic technician, registered (DTR), authorizes a registered dietitian (RD) to perform additional duties, and makes additional changes to the practice authorizations for a DTR and RD, as specified. Specifically, this bill : 1)Revises the existing requirement and creates a second educational option for an individual to represent himself or herself as a DTR, as follows: a) 450 hours of supervised practice experience in addition to existing requirements mandating appropriate academic requirements for dietetic technicians, registered, and 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; or, b) Appropriate academic requirements for the field 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. SB 993 Page 2 2)States that it is a misdemeanor for any person not meeting the qualifications of an RD or DTR to use, in connection with his or her name or place of business, the words "registered dietitian nutritionist" or the letters "RDN," or any other words, letters, abbreviations, or insignia indicating or implying that the person is a registered dietitian nutritionist or to represent, in any way, orally, in writing, in print or by sign, directly or by implication, that he or she is a registered dietitian nutritionist. 3)Replaces the phrasing that a referral for medical nutrition therapy may include a "written protocol governing the patient's treatment" with the term "diet order." 4)Authorizes the following responsibilities for an RD or other nutritional professional, as specified, within the term "medical nutrition therapy": a) Recommend nutritional and dietary treatments; and, b) Perform nutritional assessments and initiate nutritional interventions within the parameters of the prescribed diet order pursuant to a licensed health care facility's approved nutrition screening policy and procedure. 5)Requires an RD, or other nutritional professional, as specified, to collaborate with a multidisciplinary team, which shall include the treating physician and the registered nurse, in developing the patient's nutrition care plan. 6)Authorizes an RD or other nutritional professional, as specified, 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 prescribed diet order, unless otherwise stated in the diet order by a patient's provider. 7)Requires any modification, and the rationale for the modification, to be documented in the patient's record for review by the physician responsible for the care of the patient. SB 993 Page 3 8)States that nothing in this bill shall be construed to authorize an RD, or other nutritional professional, as specified, to order or administer a central vein or peripheral vein nutrition. 9)Authorizes an RD or other nutritional professional, as specified, to accept or transmit verbal orders or electronically transmitted orders for medical nutrition therapy from the physician responsible for the care of the patient in a licensed health care facility. 10)Authorizes an RD or other nutritional professional, as specified, to order medical laboratory tests related to medical nutrition therapy services when approved by the physician responsible for the care of the patient and when, in the absence the physician responsible for the care of the patient at a patient visit, in a clinic where there is a registered nurse on duty, a registered nurse is notified that a medical laboratory test is being ordered and is afforded an opportunity to assess the patient. 11)Clarifies that nothing in this bill prohibits a DTR from providing nutritional advice, as specified. 12)Requires a person to have completed, not just be enrolled in, a course of study for a DTR to assist in the implementation or monitoring of specified services under the direct supervision of an RD. 13)Authorizes a person to assist in the implementation or monitoring of specified services, as specified, after completing the academic requirements for DTRs and providing written verification thereof, rather than after completing a supervised practice program. 14)States that no reimbursement is required by this bill because the only costs that may be incurred by a local agency will be incurred because this bill creates a new crime or infraction, eliminates a crime or infraction, changes the penalty for a crime or infraction, or changes the definition of a crime. 15)Makes clarifying and technical amendments. FISCAL EFFECT : According to the Assembly Appropriations SB 993 Page 4 Committee, potential minor and absorbable fiscal impact to the Licensing and Certification Division within the Department of Public Health (DPH) to revise policies governing the activities of RDs and DTRs in health facilities regulated by DPH. COMMENTS : 1)Purpose of this bill. This bill updates educational, title protection, and practice provisions for DTRs and RDs to align more closely with the practice environment. This bill is sponsored by the California Dietetic Association. 2)Author's statement. According to the author's office, "Neither RDs nor DTRs are licensed by the state, but RDs are considered 'registered' ?. However, the institutions in which they are employed and practice are licensed and regulated by the Department of Public Health (DPH). 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. The violations involve very simple and logical actions by RDs which are entirely consistent with the training RDs receive and the services for which they are responsible. "The most significant example is the following. Currently, DPH asserts that, based on a plain reading of the statute, RDs must receive physician approval before making minor modifications to a patient's diet plan (such changing the texture of the diet when a patient has poor-fitting dentures, or adding calories at lunch when the patient was not able to have breakfast). [Asking] the treating physician to approve such changes is not the best use of the physician's time, does not require any medical judgment, and ultimately, the delay in addressing the patient's needs is not 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 for the patient's physician to modify the diet as long as the changes are within the parameters of the physician-prescribed diet order." 3)RDs and DTRs. RDs are trained health care professionals who provide dietetic and nutrition services. The majority of RDs work in the treatment and prevention of disease through the practice of evidence-based medical nutrition therapy, often in SB 993 Page 5 hospitals, health maintenance organizations, private practice, and other healthcare facilities. RDs must have a bachelor's degree, complete dietetics coursework specified by the Accreditation Council for Education in Nutrition and Dietetics, complete an internship, pass a national registration examination, and complete continuing education requirements. Some RDs hold additional certifications in specialty areas (e.g. pediatrics, renal, oncology, and diabetes) awarded by the Commission on Dietetic Registration or other medical or health care organizations or certifying boards. DTRs are authorized to assist RDs while under direct supervision of an RD, but may not develop nutritional or dietary therapy or treatments or accept or transmit verbal orders. To be a DTR, an individual must be 18 years of age or older, complete an approved dietetic technician program including at least 450 hours of supervised practice, have an associate's degree or higher, pass an examination, and complete continuing education requirements. This bill modifies existing educational requirements for DTRs by requiring either an associate's degree and practice experience or a bachelor's degree. This bill also updates provisions of law regarding the role of DTRs and RDs in licensed institutional settings and addresses specific issues regarding the modification of medically prescribed diets. California law provides title-protection and a non-exclusionary scope of practice for RDs and DTRs. Current law also recognizes the ability of other nutritional professionals with a master's or higher degree in a field covering clinical nutrition sciences, from a college or university accredited by a regional accreditation agency, to provide nutritional advice, nutritional assessments, counseling, and treatments. There are 9,120 RDs and 532 DTRs in California. Analysis Prepared by : Sarah Huchel / B., P. & C.P. / (916) 319-3301 SB 993 Page 6 FN: 0004569