BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                  SB 993
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          SENATE THIRD READING
          SB 993 (Mitchell)
          As Amended  July 2, 2014
          Majority vote 

           SENATE VOTE  :32-0  
           
           BUSINESS & PROFESSIONS         14-0                  
          APPROPRIATIONS      17-0        
           
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          |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.   








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          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. 









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          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  








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          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  








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            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 










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