SB1508 - 562R - Senate Fact Sheet

ARIZONA STATE SENATE

Fifty-Sixth Legislature, First Regular Session

AMENDED

FACT SHEET FOR s.b. 1508

~~vulnerable adult system; study committee~~

(NOW: licensure; dietitian nutritionists)

As passed by the Senate, S.B. 1508 established the Vulnerable Adult System Study Committee (Study Committee) and outlined Study Committee membership, duties and reporting requirements.

The House of Representatives adopted a strike-everything amendment that does the following:

Purpose

Establishes Department of Health Services (DHS) requirements and procedures relating to the licensure and regulation of nutritionists and dietitian nutritionists. Allows the Director of DHS (Director) to appoint an advisory committee to assist the Director in actions relating to licensure.

Background

Current statute allows a hospital to grant registered dietitians or qualified nutrition professionals the ability to order diets, enteral feeding, nutritional supplementation or parenteral nutrition if: 1) authorized by medical staff; 2) the hospital has written policies and procedures to allow registered dietitians or other qualified nutrition professionals to issue such orders; and 3) the hospital has written policies and procedures that address the hospital's response to adverse events, if any, that arise as a result of orders issued by a registered dietitian or other qualified nutrition professional.

Registered dietitian means a person who meets the qualifications of the credentialing agency for the American Academy of Nutrition and Dietetics (A.R.S. § 36-416).

The Academy of Nutrition and Dietetics defines registered dietitian nutritionists as food and nutrition experts with a minimum of a graduate degree from an accredited dietetics program and who completed a supervised practice requirement, passed a national exam and continue professional development throughout their careers (Academy of Nutrition and Dietetics).

If there is a cost associated with DHS licensure and regulation of dietitian nutritionists and nutritionists, there may be a fiscal impact to the state General Fund (state GF).

Provisions

Dietitian Nutritionist Licensure

1. Requires the Director to issue a two-year license to each applicant who meets licensure requirements.

2. Requires an applicant for an initial dietitian nutritionist license to submit a nonrefundable application fee and evidence satisfactory to the Director that the applicant:

a) holds a current and valid registration with the Commission on Dietetic Registration as a registered dietitian or registered dietitian nutritionist; or

b) meets all educational, supervised practice experience and examination requirements.

3. Requires an applicant to have earned a:

a) master's degree or doctoral degree from a college or university accredited at the time of the applicant's graduation by the appropriate regional accrediting agency recognized by the Council on Higher Education Accreditation and the U.S. Department of Education and a program of study accredited by the Accreditation Council for Education in Nutrition and Dietetics or its successor organization; or

b) foreign academic degree that is accredited by the Accreditation Council for Education in Nutrition and Dietetics, or its successor organization, and is determined by the Director to be equivalent to a master's or doctoral degree from an accredited American college or university.

4. Requires an applicant to have successfully completed a planned clinical program in the practice of dietetics and nutrition, as approved by the Director, that:

a) is accredited by the Accreditation Council for Education in Nutrition and Dietetics;

b) includes at least 1,000 hours under the supervision of a dietitian nutritionist who is either registered with the Commission on Dietetic Registration, licensed in Arizona or registered, certified or licensed in any other state with equivalent licensure requirements.

5. Requires an applicant to have passed the examination for registered dietitians administered by the Commission on Dietetic Registration.

6. Requires, if passage of the examination occurred more than five years before the license application, the applicant to demonstrate, for each five-year period after the examination, completion of 75 hours of continuing education that meets the Director's continuing education criteria.

7. Prohibits an applicant from:

a) having had a license, registration or certificate revoked or suspended by a state within the previous two years; and

b) being presently ineligible for licensure in any state because of a prior revocation or suspension.

8. Requires a licensee to renew the license every two years upon payment of a renewal fee.

9. Allows a licensee, within a 31-day grace period after the license expires, to renew the license upon payment of a late fee in addition to the renewal fee.

10. Requires the licensee, when renewing a license to:

a) attest to having completed required continuing professional education during the licensing period; and

b) provide documentation of completion upon DHS' request.

11. Requires the Director, by rule, to provide standards for required continuing professional education units.

12. Specifies that educational courses accepted by the Commission on Dietetic Registration or the Board for Certification of Nutrition Specialists are deemed to comply with DHS standards.

13. Requires a person who does not renew a license to reapply for a new license and provide proof of having completed the prescribed continuing professional education units within the previous 24 months before the reapplication date.

14. Specifies that a license issued to any member of the National Guard or the U.S. Armed Forces Reserves does not expire while the member is serving on federal active duty.

15. Specifies that a license issued to any member of the National Guard, U.S. Armed Forces Reserves or the regular component of the U.S. Armed Forces is extended 180 days after the member returns from federal active duty if the member or the member's legal representative notifies the Director of the member's federal active duty status.

16. Allows a member of the National Guard, U.S. Armed Forces Reserves or the regular component of the U.S. Armed Forces to extend a license 180 days after the date the member is able to perform activities necessary under the license if the member:

a) is released from active duty service; and

b) suffers an injury resulting from active duty service that temporarily prevents the member from performing activities necessary under the license.

17. Prohibits, if a license is renewed during the applicable extended time period after a member returns from federal active duty, a member from being charged any additional costs such as late fees or delinquency fees beyond the normal fees and activities relating to the renewal of the license.

18. Requires a military member or the member's legal representative, in order to qualify for an extension, to present to the Director, before the end of the applicable extended time period, a:

a) copy of the member's official military orders;

b) redacted military identification card; or

c) written verification from the member's commanding officer.

Nutritionist Licensure

19. Requires an applicant for an initial nutritionist license to:

a) submit a nonrefundable application fee;

b) submit evidence satisfactory to the Director that the applicant meets all licensure requirements; and

c) not have had a license, registration or certificate revoked or suspended by a state within the previous two years or be presently ineligible for licensure in any state because of a prior revocation or suspension.

20. Requires an applicant to have completed a master's or doctoral nutrition degree, a doctoral clinical health care degree or validated accredited foreign equivalent, with a major, as it applies to nutrition degrees, in:

a) human nutrition;

b) foods and nutrition;

c) community nutrition;

d) public health nutrition;

e) nutrition education;

f) nutrition;

g) nutrition science;

h) clinical nutrition;

i) applied clinical nutrition;

j) nutrition counseling;

k) nutrition and functional medicine;

l) nutritional biochemistry;

m) nutrition and integrative health; or

n) a comparable titled major.

21. Requires an applicant to have completed coursework leading to competence in medical nutrition therapy, including at least:

a) 15 semester hours of clinical or life sciences, with at least 3 semester hours being in human anatomy and physiology or the equivalent; and

b) 15 semester hours of nutrition and metabolism, with at least 6 semester hours in biochemistry.

22. Requires an applicant to complete a Director-approved, planned, documented and continuous supervised practice experience demonstrating competence in providing nutrition care services and medical nutrition therapy:

a) within five years after completing education requirements, unless the Director grants an extension for a limited time due to extraordinary circumstances;

b) including at least 1,000 hours in nutrition assessment, nutrition intervention and nutrition monitoring evaluation, with a minimum of 200 hours in each practice area;

c) determined by the Director to have prepared the applicant to provide nutrition care services for various populations of diverse cultures and genders across the life cycle and to be able to competently formulate actionable medical nutrition therapies, interventions, education, counseling and ongoing care for the prevention, modulation and management of a range of acute and chronic medical conditions; and

d) under the supervision of a qualified supervisor.

23. Requires an applicant to complete the examination requirements by demonstrating that the applicant:

a) passed the certified nutrition specialist examination administered by the Board of Certification of Nutrition Specialists or its successor organization, or an equivalent examination on all aspects of the practice of nutrition that is accredited by the national commission for certifying agencies or its successor organization and approved by the Board for Certification of Nutrition Specialists; or

b) holds a valid current certification with the Board for Certification of Nutrition Specialists or its successor organization, that gives the applicant the right to use the title certified nutrition specialist.

24. Requires, if passage of the examination occurred more than five years before the license application, the applicant to demonstrate, for each five-year period after the examination, completion of 75 hours of approved continuing education.

25. Requires a qualified supervisor, if supervising a student who is providing medical nutrition therapy, to:

a) be a licensed dietitian nutritionist, licensed nutritionist or a health care provider licensed or certified in any state or territory whose scope of practice includes the provision of medical nutrition therapy;

b) meet other Director-established criteria, if the qualified supervisor is supervising a student in a state that does not provide for the licensure or certification of dietitians, dietitian nutritionists or nutritionists, including being a registered dietitian, certified nutrition specialist or a licensed health care provider whose scope of practice includes the provision of nutrition therapy; or

c) be an employee of the federal government authorized within the discharge of the employee's official duties to provide medical nutrition therapy.

26. Requires a qualified supervisor supervising a student who is providing medical nutrition therapy to an individual in Arizona to be licensed in Arizona, unless the supervisor is an employee of the federal government authorized within the discharge of the employee's official duties to provide medical nutrition therapy.

27. Requires a qualified supervisor to:

a) only supervise a clinical activity or nutrition care service for which the supervisor is qualified and is authorized to perform;

b) develop and carry out a program, for advancing and optimizing the quality of care provided by the student being supervised, that requires the supervisor and student to identify and document goals for the supervised practice experience, the assignment of clinical tasks as appropriate to the student's evolving level of competence, the student's relationship and access to the supervisor and a process for evaluating the student's performance;

c) oversees the activities of and approves and accepts responsibility for the nutrition care services rendered by the student;

d) be, at a minimum, physically on-site and present where the student is providing nutrition care services, or is immediately and continuously available to the student by means of two-way real-time audiovisual technology that allows for direct, contemporaneous interaction by sight and sound between the supervisor and the student;

e) ensure, if the supervisor assigns a nutrition care service to a student that is to be provided in a setting where the supervisor is not routinely present, that the means and methods of supervision are adequate to ensure appropriate patient care, which may include synchronous videoconferences or another method of communication and oversight that is appropriate to the care setting and the education and experience of the student;

f) review, on a regular basis, the charts, records and clinical notes of the supervised student and maintains responsibility for the student's clinical recordkeeping;

g) be available to render assistance during the provision of nutrition care services when requested by the patient, or arrange for another qualified practitioner lawfully able to render nutrition care services to be available in the absence of the qualified supervisor; and

h) limit the assignment of nutrition care services to services within the training and experience of the student and customary to the practice of the supervisor.

Nutrition Professional Orders

28. Authorizes a hospital to allow a licensed dietitian nutritionist or other qualified nutrition professional, if initially authorized or granted standing ordering privileges by medical staff, to order:

a) diets;

b) a change in diet orders;

c) enteral feeding;

d) durable nutrition-related medical equipment;

e) nutritional supplementation;

f) parenteral nutrition;

g) medical nutrition therapy;

h) laboratory tests to check and track nutrition status; and

i) prescription drug dose adjustments under a medical staff-approved protocol.

29. Allows a licensed dietitian nutritionist or other qualified nutrition professional that is either an employee of a nonhospital health care institution or an independent contractor to order:

a) diets;

b) a change in diet orders;

c) enteral feeding;

d) durable nutrition-related medical equipment;

e) nutritional supplementation;

f) parenteral nutrition;

g) medical nutrition therapy; and

h) laboratory tests to check and track nutrition status.

30. Requires a hospital's or nonhospital health care institution's written policies and procedures related to dietary nutrition to:

a) allow licensed dietitian nutritionists to issue nutrition-related orders or perform medical nutrition therapy;

b) prescribe the qualifications necessary for qualified nutrition professionals to issue orders;

c) list any additional restrictions on qualified nutrition professionals' abilities to issue orders; and

d) address the hospital's response to adverse events, if any arise as a result of nutrition-related orders.

License Denial, Revocation or Suspension and Administrative Proceedings

31. Allows the Director to deny, revoke or suspend a license if the applicant or licensee:

a) has been convicted of or entered into a plea of no contest to any crime that is directly related to the duties and responsibilities of a dietitian nutritionist or nutritionist or that was violent or sexual in nature, with sufficient evidence of conviction, including a record of the conviction, a certified copy from the clerk of the court where the conviction occurred or a copy from the judge of that court;

b) secures a license through fraud or deceit;

c) engages in unprofessional conduct or incompetence in the conduct of practice;

d) uses a false name or alias in the practice of the applicant's or licensee's profession; or

e) violates statutes relating to nutritionists and dietitian nutritionists.

32. Allows DHS to deny a license without holding a hearing.

33. Allows an applicant, after receiving notification of a license denial, to request a hearing to review the denial.

34. Allows, if the Director determines that grounds for license revocation or suspension exist, the Director to make the revocation or suspension permanent or for a fixed period, and to impose rule-prescribed conditions on this action.

35. Requires DHS to conduct a hearing before revoking or suspending a license or imposing a civil penalty.

36. Requires hearings to be conducted in accordance with uniform administrative hearing procedures.

37. Allows the Director, instead of denying, revoking or suspending a license, to file a letter of concern, issue a degree of censure, prescribe a probation period or restrict or limit the practice of a licensee.

38. Requires the Director, if the Director initiates a disciplinary action against a licensee, to promptly notify the licensee's employer.

39. Allows the Director to enforce statute by injunction or any other appropriate proceeding.

40. Prohibits enforcement proceedings from being barred by any prior completed proceeding, pending proceeding or the imposition of any fine, civil penalty or term of imprisonment resulting thereof.

DHS Director and Advisory Committee

41. Requires the Director to:

a) license persons who apply for and possess all qualifications required for licensure;

b) authorize all necessary disbursements; and

c) ensure the public's health and safety by adopting and enforcing qualification standards and a scope of practice for licensees and applicants;

42. Allows the Director to:

a) appoint an advisory committee to collaborate with, receive assistance from and perform Director duties;

b) inform the advisory committee to regarding disciplinary actions;

c) issue and renew licenses;

d) deny, suspend, revoke or refuse to renew a license;

e) file a letter of concern, issue a degree of censure, prescribe probation, impose a civil penalty or restrict or limit the practice of a licensee;

f) make or publish necessary rules; and

g) require a licensee to produce records of patients involved in complaints on file with DHS.

43. Requires that the advisory committee consist of:

a) the Director;

b) one licensed physician;

c) three licensed dietitian nutritionists;

d) one licensed nutritionist; and

e) one public member.

44. Requires licensed committee members to have at least five years of experience in their respective field of practice in Arizona, immediately preceding their appointment.

45. Allows the advisory committee to provide recommendations to the Director, on which the Director must act within a reasonable amount of time, regarding:

a) license issuance and renewal;

b) disciplinary procedures;

c) necessary rules that are consistent with statute; and

d) licensee production of records of patients involved in complaints on file with DHS.

46. Requires the Director to prescribe and collect fees from licensed persons for a:

a) license application;

b) license issuance;

c) license renewal;

d) issuance of a duplicate license; and

e) late fee.

47. Requires, of monies collected through the licensing and regulation of nutritionists and dietary nutritionists, the Director to deposit:

a) 10 percent of all monies collected into the state GF;

b) 90 percent of all monies collected into the Health Services Licensing Fund; and

c) all monies collected from imposed civil penalties into the state GF.

48. Requires the Director to keep a record of licensees' locations of practice.

49. Allows the Director to mail, to the address last given by a licensee to the Director, any notice that the Director is required to give the licensee.

Miscellaneous

50. Requires licensees to notify the Director, in writing, of the address of the location where the licensee engages in the practice of dietetics or nutrition, along with any change of address.

51. Allows a person to use the title:

a) certified nutrition specialist or any alternative spelling or abbreviation of the title if the person holds a valid current certification with the Board for Certification of Nutrition Specialists that authorizes the person to use the title of the abbreviation CNS.

b) dietitian, registered dietitian, registered dietitian nutritionist, any alternative spelling of these titles or the abbreviations RD or RDN, if the person is currently credentialed as a registered dietitian or registered dietitian nutritionist by the Commission on Dietetic Registration;

c) licensed dietitian, licensed dietitian nutritionist or any alternative spelling or abbreviation if the person is a licensed dietitian nutritionist; and

d) licensed nutritionist or any alternative spelling or abbreviation if the person is a licensed nutritionist.

52. Specifies that violations of statute regarding title usage constitutes an unlawful practice, which the Attorney General may investigate and take appropriate action against.

53. Exempts DHS from statutory rulemaking requirements for one year after the effective date for purposes of licensing and regulating nutritionists and dietitian nutritionists.

54. Declares the Legislature's intent that the total fees for acquiring an initial dietitian nutritionist license do not exceed $200.

55. Modifies the definition of prescription order to:

a) include an order initiated by a licensed dietitian nutritionist, rather than a registered dietitian; and

b) exclude diet orders.

56. Defines terms.

57. Makes technical and conforming changes.

58. Becomes effective on the general effective date.

Amendments Adopted by the House of Representatives

· Adopted the strike-everything amendment relating to licensure for dietitian nutritionists.

House Action

APPROP 3/25/24 DPA/SE 14-3-0-0

3^rd Read 4/4/24 41-18-1

Prepared by Senate Research

April 8, 2024

MM/KS/DM/slp