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Setting the Standard: Including the RD and DTR in State and Facility Policies
practice applications
PUBLIC POLICY NEWS
Setting the Standard: Including the RD and DTR in State and Facility Policies
A
s with all health professions, dietetic practice is regulated. Health professionals from physicians to chiropractors are required to follow the letter of the law in every task they perform in order to protect the public by maintaining a minimum quality of service. The federal government dictates some of these standards through agencies within the US Department of Health and Human Services; however, states also regulate, and the states have the authority to implement higher standards than the federal government. This is a source of great opportunity for registered dietitians (RDs) and dietetic technicians, registered (DTRs) to be recognized as the qualified providers of nutrition and dietary services in programs and facilities in your state. Increasing the quality of nutrition and food services and supporting the employment of RDs and DTRs in health facilities nationwide must happen at the state administrative level, often through regulations. INCLUDING THE RD AND DTR States regulate health facilities licensed in their state, such as hospitals, nursing facilities, assisted living facilities, renal dialysis facilities, and home health programs. Several of these have a dietary services department that must be overseen by a foodservice supervisor. The federal government regulates most of these facilities, with the exception of assisted living facilities (which are regulated by the states). However, the federal government does not specify the qualifications for this staff in all cases. This article was written by Dana L. Whitley, member advocacy coordinator in ADA’s Washington, DC, office. doi: 10.1016/j.jada.2009.12.004
190
For example, federal regulations administered by the Center for Medicare and Medicaid Services require that hospitals must provide dietary services managed by a person, “qualified by experience or training” (1). However, the federal regulations do not specify what experience and training is necessary to be qualified. The state regulations or the hospital facility must define this. In addition to a foodservice manager, the Code of Federal Regulations continues by stating, “There must be a qualified dietitian, full-time, parttime, or on a consultant basis” (1). Again, the qualifications of the dietitian are not defined. These qualifications must be defined in state regulations or in facility policies. The federal requirements for hospitals establish a minimum standard for food and clinical dietary services in hospitals, but they do not define the qualifications necessary to meet these standards. Therefore, the states have the prerogative to define the qualifications for a foodservice manager and also to define the standards for a qualified dietitian. CHANGING STATE POLICY The state government agency that regulates health facilities (usually department of health) can define minimum education requirements and credentials for dietary services managers and qualified dietitians. This is where American Dietetic Association (ADA) members play an important role. Working with your state affiliate to present a request to the state regulatory agency, you can help write the standards by contributing to the decision process. Ideally, regulations should require the qualified dietitian to be an RD and/or state licensed/ certified (where applicable). If that’s not possible, the state should require the equivalent education standards of the RD written in the state regulations.
Journal of the AMERICAN DIETETIC ASSOCIATION
Knowing your state regulations is a powerful tool. In order to enter into a dialog with the state, you must first read and understand your own state regulations as they pertain to the profession and health facilities. All state governments post their statutes and regulations online for easy access by the general public. ADA provides members with the URLs so you can access your own state’s statutes and regulations. You can find these updated regularly on the Rules and Regulations page found at www.eatright. org/advocacy. At the time of this writing, state hospital regulations, state nursing facility regulations, and state regulations for assisted living had been posted. ADA is in the process of posting state regulations for home health and renal facilities. Each type of facility is regulated separately, so it is important to read and understand them as separate entities. A STATE EXAMPLE: LOUISIANA Some states have established high standards for dietary services staff, which results in a higher quality of care for patients and residents and increased opportunities for RDs and DTRs to be included on staff. Louisiana’s hospital regulations are particularly noteworthy. Section 9379 of Louisiana’s state hospital regulations specify that, “food and dietetic services shall be under the supervision of a registered dietitian, licensed to practice in Louisiana, who is employed either fulltime, part time, or on a consulting basis. If the registered dietitian is not full time, there shall be a full time dietary manager” (2). This provides specific clarification that a state licensed RD must be on staff. The Louisiana state regulations (section 9379) continue by defining the qualifications for the foodservice manager. It says that a person shall, “1. Be a qualified dietitian; or 2. Be a graduate of a dietetic technician program,
© 2010 by the American Dietetic Association
PUBLIC POLICY NEWS correspondence program or otherwise approved by the American [Dietetic] Association, or 3. Have successfully completed a course of study, by correspondence or classroom, which meets the eligibility requirements for certification by the Dietary Manager’s Association; or 4. Have successfully completed a training course at a state approved school, vocational or university, which includes course work in foods and food service, supervision and diet therapy” (2). These education standards essentially mean that there are four kinds of people who could be a qualified dietary manager in Louisiana hospitals: the RD, the DTR, a Certified Dietary Manager, or a properly trained dietary manager. In addition to defining the qualifications for the dietary services manager, the definitions section of the Louisiana regulations (section 9303) provide the definition of a registered dietitian as, “a dietitian who is qualified based on registration by the Commission on Dietetic Registration of the American Dietetic Association and licensing by the Louisiana Board of Examiners in Dietetics and Nutrition” (2). Remember that in hospital regulations, the federal government requires that facilities hire a dietary services manager and/or a qualified dietitian. Defining the qualifications to be eligible for these positions is written in state regulations. Louisiana is just one example among many states that have established strong standards for knowledgeable and educated managers of the dietary and nutrition services in hospitals. Examples such as this can be found for every facility, including nursing facilities, assisted living facilities, and home health agencies. IMPROVING FACILITY STANDARDS Some states have less rigorous standards in place at the state level. In many cases, this may be because the state’s regulations are out of date or because the state has a small population and has decided not to write its own regulations beyond the federal minimum requirements. Small states, such as Vermont, do not have their own regulatory requirements. There are also states with broad requirements, such as Kentucky, whose hospital regulations say, “The dietary department shall be directed on a full-
time basis by an individual who, by education or specialized training and experience, is knowledgeable in food service management” (3). This state asks for knowledge and education, but does not specify details of either. In all cases, hospital facilities have the prerogative to set their own standards when writing policies, procedures, and job descriptions for their hospital. RDs who work in states with broad, general standards should ensure that job descriptions include appropriate skill and education standards as qualification for working in the facility. Maintaining high standards in the hiring process through clear job descriptions is designed to ensure the quality of care in the facility and the inclusion of appropriately credentialed dietitians (registered and/or state licensed/certified) and DTRs on staff. There are three layers of regulations where registered and/or state licensed/certified dietitians and DTRs have the opportunity to be included as the minimum standard for dietary services staff: the federal regulations, the state regulations, and the facility policies. Changing regulations at the federal level is a slow process. However, state regulations are often more frequently revised, and facilities welcome standards that result in improved patient care and safety. As with most policy issues, it is easier to make changes and increase standards at the most local level. In the majority of situations, the local body is able to increase standards beyond the regulatory body above it (ie, facilities can have higher standards than the state government, and the state can have higher standards than the federal government). ADA members are encouraged to speak with their affiliate State Policy Representative to discuss the options in their state. Hospital regulations are just one example of facilities affected by federal and state regulations. In the case of assisted living facilities, the federal government does not have facility standards; instead, the states provide oversight. Without a national standard, the type of regulations states write and the level of standard they impose can vary substantially. This provides great opportunity for ADA members to work with their affiliate to upgrade the assisted living standards
in their state. ADA has posted URLs for the assisted living facility regulations in each state at www.eatright.org/ advocacy on the Rules and Regulations page. RDs, DTRs, and licensed/certified dietitians will be interested to know the dietary services standards for their state and may be interested in exploring the options of upgrading the standards. The same applies to nursing facilities, renal dialysis facilities, and home health agencies. With the leadership of the state affiliate, members can ask the state to update and change the state regulations to set higher requirements. You can even ask that the RD or the DTR be recognized as the qualified facility staff. Asking the state to make these changes requires collaboration with your affiliate State Policy Representative, as well as developing a trusted relationship with the state government agency that regulates the facility you are addressing. If you are interested in pursuing increased standards in your state or facility, work with your state affiliate leadership to develop your request and hone your message. ADA’s Policy Initiatives & Advocacy office in Washington, DC, is also able to provide assistance and support for your initiative. References 1. 42 CFR §482.28. Conditions of participation: Food and dietetic services. GPO Access Web site. http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c⫽ ecfr&sid⫽eace0246581f0e6276709d79fd17024d& rgn⫽div8&view⫽text&node⫽42:5.0.1.1.1.3.4.8& idno⫽42. Accessed October 19, 2009. 2. Louisiana Register, Vol 29, No. 11, Nov. 20, 2003. Louisiana Administrative Code; Title 48, Public Health, General. Part I. General Administration, Subpart 3. Licensing, Chapter 93. Hospitals, Subchapter G. Louisiana Office of the State Register Web site. http://www.doa.la. gov/osr/reg/0311/0311RUL.pdf#nameddest⫽c93. Accessed November 21, 2009. 3. Kentucky Administrative Regulations. KAR Title 902, Chapter 20:016, §4(3)(a)1. Kentucky Legislature Web site. http://lrc.ky.gov/ kar/902/020/016.htm. Accessed November 4, 2009.
February 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
191
PUBLIC POLICY NEWS
Setting the Standard: Including the RD and DTR in State and Facility Policies
A
s with all health professions, dietetic practice is regulated. Health professionals from physicians to chiropractors are required to follow the letter of the law in every task they perform in order to protect the public by maintaining a minimum quality of service. The federal government dictates some of these standards through agencies within the US Department of Health and Human Services; however, states also regulate, and the states have the authority to implement higher standards than the federal government. This is a source of great opportunity for registered dietitians (RDs) and dietetic technicians, registered (DTRs) to be recognized as the qualified providers of nutrition and dietary services in programs and facilities in your state. Increasing the quality of nutrition and food services and supporting the employment of RDs and DTRs in health facilities nationwide must happen at the state administrative level, often through regulations. INCLUDING THE RD AND DTR States regulate health facilities licensed in their state, such as hospitals, nursing facilities, assisted living facilities, renal dialysis facilities, and home health programs. Several of these have a dietary services department that must be overseen by a foodservice supervisor. The federal government regulates most of these facilities, with the exception of assisted living facilities (which are regulated by the states). However, the federal government does not specify the qualifications for this staff in all cases. This article was written by Dana L. Whitley, member advocacy coordinator in ADA’s Washington, DC, office. doi: 10.1016/j.jada.2009.12.004
190
For example, federal regulations administered by the Center for Medicare and Medicaid Services require that hospitals must provide dietary services managed by a person, “qualified by experience or training” (1). However, the federal regulations do not specify what experience and training is necessary to be qualified. The state regulations or the hospital facility must define this. In addition to a foodservice manager, the Code of Federal Regulations continues by stating, “There must be a qualified dietitian, full-time, parttime, or on a consultant basis” (1). Again, the qualifications of the dietitian are not defined. These qualifications must be defined in state regulations or in facility policies. The federal requirements for hospitals establish a minimum standard for food and clinical dietary services in hospitals, but they do not define the qualifications necessary to meet these standards. Therefore, the states have the prerogative to define the qualifications for a foodservice manager and also to define the standards for a qualified dietitian. CHANGING STATE POLICY The state government agency that regulates health facilities (usually department of health) can define minimum education requirements and credentials for dietary services managers and qualified dietitians. This is where American Dietetic Association (ADA) members play an important role. Working with your state affiliate to present a request to the state regulatory agency, you can help write the standards by contributing to the decision process. Ideally, regulations should require the qualified dietitian to be an RD and/or state licensed/ certified (where applicable). If that’s not possible, the state should require the equivalent education standards of the RD written in the state regulations.
Journal of the AMERICAN DIETETIC ASSOCIATION
Knowing your state regulations is a powerful tool. In order to enter into a dialog with the state, you must first read and understand your own state regulations as they pertain to the profession and health facilities. All state governments post their statutes and regulations online for easy access by the general public. ADA provides members with the URLs so you can access your own state’s statutes and regulations. You can find these updated regularly on the Rules and Regulations page found at www.eatright. org/advocacy. At the time of this writing, state hospital regulations, state nursing facility regulations, and state regulations for assisted living had been posted. ADA is in the process of posting state regulations for home health and renal facilities. Each type of facility is regulated separately, so it is important to read and understand them as separate entities. A STATE EXAMPLE: LOUISIANA Some states have established high standards for dietary services staff, which results in a higher quality of care for patients and residents and increased opportunities for RDs and DTRs to be included on staff. Louisiana’s hospital regulations are particularly noteworthy. Section 9379 of Louisiana’s state hospital regulations specify that, “food and dietetic services shall be under the supervision of a registered dietitian, licensed to practice in Louisiana, who is employed either fulltime, part time, or on a consulting basis. If the registered dietitian is not full time, there shall be a full time dietary manager” (2). This provides specific clarification that a state licensed RD must be on staff. The Louisiana state regulations (section 9379) continue by defining the qualifications for the foodservice manager. It says that a person shall, “1. Be a qualified dietitian; or 2. Be a graduate of a dietetic technician program,
© 2010 by the American Dietetic Association
PUBLIC POLICY NEWS correspondence program or otherwise approved by the American [Dietetic] Association, or 3. Have successfully completed a course of study, by correspondence or classroom, which meets the eligibility requirements for certification by the Dietary Manager’s Association; or 4. Have successfully completed a training course at a state approved school, vocational or university, which includes course work in foods and food service, supervision and diet therapy” (2). These education standards essentially mean that there are four kinds of people who could be a qualified dietary manager in Louisiana hospitals: the RD, the DTR, a Certified Dietary Manager, or a properly trained dietary manager. In addition to defining the qualifications for the dietary services manager, the definitions section of the Louisiana regulations (section 9303) provide the definition of a registered dietitian as, “a dietitian who is qualified based on registration by the Commission on Dietetic Registration of the American Dietetic Association and licensing by the Louisiana Board of Examiners in Dietetics and Nutrition” (2). Remember that in hospital regulations, the federal government requires that facilities hire a dietary services manager and/or a qualified dietitian. Defining the qualifications to be eligible for these positions is written in state regulations. Louisiana is just one example among many states that have established strong standards for knowledgeable and educated managers of the dietary and nutrition services in hospitals. Examples such as this can be found for every facility, including nursing facilities, assisted living facilities, and home health agencies. IMPROVING FACILITY STANDARDS Some states have less rigorous standards in place at the state level. In many cases, this may be because the state’s regulations are out of date or because the state has a small population and has decided not to write its own regulations beyond the federal minimum requirements. Small states, such as Vermont, do not have their own regulatory requirements. There are also states with broad requirements, such as Kentucky, whose hospital regulations say, “The dietary department shall be directed on a full-
time basis by an individual who, by education or specialized training and experience, is knowledgeable in food service management” (3). This state asks for knowledge and education, but does not specify details of either. In all cases, hospital facilities have the prerogative to set their own standards when writing policies, procedures, and job descriptions for their hospital. RDs who work in states with broad, general standards should ensure that job descriptions include appropriate skill and education standards as qualification for working in the facility. Maintaining high standards in the hiring process through clear job descriptions is designed to ensure the quality of care in the facility and the inclusion of appropriately credentialed dietitians (registered and/or state licensed/certified) and DTRs on staff. There are three layers of regulations where registered and/or state licensed/certified dietitians and DTRs have the opportunity to be included as the minimum standard for dietary services staff: the federal regulations, the state regulations, and the facility policies. Changing regulations at the federal level is a slow process. However, state regulations are often more frequently revised, and facilities welcome standards that result in improved patient care and safety. As with most policy issues, it is easier to make changes and increase standards at the most local level. In the majority of situations, the local body is able to increase standards beyond the regulatory body above it (ie, facilities can have higher standards than the state government, and the state can have higher standards than the federal government). ADA members are encouraged to speak with their affiliate State Policy Representative to discuss the options in their state. Hospital regulations are just one example of facilities affected by federal and state regulations. In the case of assisted living facilities, the federal government does not have facility standards; instead, the states provide oversight. Without a national standard, the type of regulations states write and the level of standard they impose can vary substantially. This provides great opportunity for ADA members to work with their affiliate to upgrade the assisted living standards
in their state. ADA has posted URLs for the assisted living facility regulations in each state at www.eatright.org/ advocacy on the Rules and Regulations page. RDs, DTRs, and licensed/certified dietitians will be interested to know the dietary services standards for their state and may be interested in exploring the options of upgrading the standards. The same applies to nursing facilities, renal dialysis facilities, and home health agencies. With the leadership of the state affiliate, members can ask the state to update and change the state regulations to set higher requirements. You can even ask that the RD or the DTR be recognized as the qualified facility staff. Asking the state to make these changes requires collaboration with your affiliate State Policy Representative, as well as developing a trusted relationship with the state government agency that regulates the facility you are addressing. If you are interested in pursuing increased standards in your state or facility, work with your state affiliate leadership to develop your request and hone your message. ADA’s Policy Initiatives & Advocacy office in Washington, DC, is also able to provide assistance and support for your initiative. References 1. 42 CFR §482.28. Conditions of participation: Food and dietetic services. GPO Access Web site. http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c⫽ ecfr&sid⫽eace0246581f0e6276709d79fd17024d& rgn⫽div8&view⫽text&node⫽42:5.0.1.1.1.3.4.8& idno⫽42. Accessed October 19, 2009. 2. Louisiana Register, Vol 29, No. 11, Nov. 20, 2003. Louisiana Administrative Code; Title 48, Public Health, General. Part I. General Administration, Subpart 3. Licensing, Chapter 93. Hospitals, Subchapter G. Louisiana Office of the State Register Web site. http://www.doa.la. gov/osr/reg/0311/0311RUL.pdf#nameddest⫽c93. Accessed November 21, 2009. 3. Kentucky Administrative Regulations. KAR Title 902, Chapter 20:016, §4(3)(a)1. Kentucky Legislature Web site. http://lrc.ky.gov/ kar/902/020/016.htm. Accessed November 4, 2009.
February 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
191