Between aging Baby Boomers and obesity in school children, there appears to be no shortage of work for dietitians in the coming years. However, hospitals may need to take a closer look at how these employees write diet orders in order to comply with national regulations.
In 2008, word spread among registered dietitians (RD) that CMS was citing hospitals that allowed RDs to prescribe diet orders. The therapeutic diet regulation that required diet orders to be prescribed by the patient's practitioner (i.e., a licensed independent practitioner [LIP]), had been on the books since 1986. It wasn't until October 2008, when the issue was featured in the Medicare State Operations Manual Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals, that surveyors began strongly enforcing the regulation.
However, some in the California dietitian community believed this regulation was unduly restrictive and slowed patient care. Some RDs successfully petitioned their medical staffs to grant them privileges so that they could write their own diet orders. When the state department of public health surveyed these organizations, they faulted them for privileging a non-LIP practitioner.
Today, California RDs continue to seek clinical privileges, along with an LIP status that would ease the path to their primary goal. Because the CMS regulation affects RDs nationwide, other states are likely to face similar hurdles.
Mary Hager, PhD, RD, FADA, director of regulatory affairs in the ADA's Washington, DC, office, says the organization supports the efforts of RDs nationwide to gain clinical privileges so facilities can privilege those who qualify to write diet orders.
"The pursuit and development of such advance skills also raises some legal considerations that must be addressed in the context of the broad range of patient care for which, in virtually every aspect, the physician practitioner is legally accountable," Hager says. "The diet order and related orders are the specific legal responsibility of the medical practitioners—namely medical doctors and doctors of osteopathic medicine—and their delegation to other providers does not eliminate that responsibility."
Heidi Kiehl, MS, RD, CNSC, member of the professional practice task force of the California Dietetic Association's (CDA) public policy counsel, says the CDA became aware of CMS' diet order rules after RDs in the field approached the CDA with questions. When CMS began telling RDs they needed privileges to practice, the RDs weren't familiar with the regulatory terminology. "It was like a foreign language to us a couple of years ago," says Kiehl.
The CDA plans to rewrite its business and professions code and address licensure to make changes. To achieve that goal, CDA is working with a healthcare lawyer specializing in scope of practice and the organization maintains a working relationship with the Department of Public Health.
"We're also working with the American Dietetic Association, who has a licensing work group to help states that don't have licensure," says Kiehl. "We're not the only state that doesn't have licensure for dietitians, so there's a cluster of us who are working to move this."
Emily Berry is an associate editor for Briefings on Credentialing and Credentialing Resource Center Connection, and manages CredentialingResourceCenter.com. You can reach her at eberry@hcpro.com.