BILL ANALYSIS �
SB 993
Page 1
Date of Hearing: June 24, 2014
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Susan A. Bonilla, Chair
SB 993 (Mitchell) - As Amended: April 21, 2014
SENATE VOTE : 32-0
SUBJECT : Healing arts: dietitians.
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.
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.
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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
prescribed 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 prescribing provider.
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
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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.
EXISTING LAW :
1)Establishes title protection and practice regulations for RDs
and DTRs. (Business and Professions Code (BPC) Sections 2585
et seq)
2) Requires an RD and DTR to possess prescribed academic,
examination and continuing education qualifications
recognized by the Department of Health Services. (BPC 2585
(a) et seq.)
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
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private office settings. (BPC 2586 (a))
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. (BPC 2586 (b))
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. (BPC 2586 (c))
6) Allows a DTR to assist 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. (BPC 2586 (d) (1))
7) Specifies that, upon referral by a physician and surgeon, an
RD may be reimbursed for nutritional advice or advice
concerning proper nutrition or for nutritional assessments,
counseling and treatments. (BPC 2585 (e))
8)Authorizes a person to assist in the implementation or
monitoring of specified services under the direct supervision
of an RD for six months from the date he or she completed the
supervised practice program for DTRs, or until the person
receives notice that he or she has failed the required
examination, whichever occurs first, if all of the following
conditions apply:
a) The person performs under the direct and immediate
supervision of a registered dietitian;
b) The person has completed supervised practice program
requirements;
c) The person has written verification, including the
program director's original signature, that the person has
completed the required supervised practice; and,
d) The person has applied to take the dietetic technician
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examination and is waiting for an examination date. (BPC
2586.6)
FISCAL EFFECT : Unknown
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.
"SB 993 updates the existing statutes governing RDs and DTRs
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 DHS and makes a number of
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conforming changes throughout the statute."
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
hospitals, HMOs, 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 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 9120 RDs and 532 DTRs in California.
4)Suggested technical amendments . The following are
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nonsubstantive, technical amendments:
On page 5, line 34, delete "prescribed"
On page 5, line 38, place a comma after "distribution" and
after "type."
On page 5, line 40, delete "prescribed"
On page 6, line 2, delete "prescribing provider" and insert
"physician responsible for the care of the patient"
5)Arguments in support . The California Dietetic Association
writes, "SB 993 is necessary for two main reasons. First, 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 perform medical
nutritional therapy in collaboration with the patient's
physician and multidisciplinary team and identify proper diet
and nutrition interventions to optimize patient outcomes and
reduce risks through patient-centered care.
"Currently, CPDH 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 as 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 for the patient's physician to modify the diet as long
as the changes are within the parameters of the
physician-prescribed diet order.
"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.
"SB 993 is consistent with recently released federal Center
for Medicare and Medicare Services (CMS) rules which
recognizes RDs as valued members of health care teams and will
help expedite and personalize patient care using the expertise
of registered dietitians."
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6)Previous legislation . AB 575 (Hayashi) of 2011 sought to
license and regulate RDs by creating the Dietitians Bureau
within the Department of Consumer Affairs. The measure was
held in the Assembly Business, Professions and Consumer
Protection Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
California Dietetic Association (sponsor)
California Hospital Association
24 Individuals
Opposition
None on file.
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301