Disclaimer: The information is based on what is currently known and is subject to change and further enhancements as developments are incurred from regulators, facilities, legal authorities and others. Future FAQs are anticipated and subsequent training in being planned for the NYSDA annual meeting 5/18-19/2015 in Albany, NY.
1. With the CMS ruling on writing Therapeutic Diet Orders issued in July 2014, is it okay for a RD/RDN in New York State to now write orders for patients in a hospital?
New York is categorized as a “yellow state” by the Academy. There are a number of steps that must be completed before a RD/RDN in New York can include writing nutrition orders in their practice at a hospital. To be in regulatory compliance to do this, changes will need to be made in two NY State Departments i.e. Health and Education. Once these regulatory changes are achieved, each hospital’s medical staff will need to approve the privilege of writing nutrition orders to include a RD/RDN.
2. If you are a RD/RDN in a hospital in New York State, do you need to have your CDN in order to have the CMS order writing privilege?
In New York the CDN credential is required in order to obtain a Medicare Provider number. This would strongly suggest that the individual should have the CDN credential and is one of the regulatory clarifications that will need to be determined.
3. Where can I find information about obtaining the CDN credential?
Details about certification are at: www.op.nysed.gov/prof/diet/dietlic.htm
4. If I do not have my CDN now should I pursue it now or should I wait?
Obtaining the CDN can take some time so you should start the process now. Although licensure is a goal for dietitians in New York, it has not yet been achieved. It is anticipated that when it occurs, qualified dietitians that have the CDN, will have the opportunity to be “grandfathered” into the anticipated LDN credential.
5. What are the implications of the CMS ordering writing privilege with respect to the Nursing Scope of Practice in New York?
The Nursing Scope of Practice defines, in New York State, the licensed disciplines from which Registered Nurses can process or enact orders. RDs/RDNs are neither licensed in NYS nor included in the list of disciplines. This is one of the regulatory and possibly statutory changes that will need to be made before this CMS ruling can be implemented in New York for RDs/RDNs.
6. Is it recommended that we move forward on seeking RD/RDN order writing privilegs, within each hospital, despite the current inability in NY State to implement this CMS privilege?
While you should not currently move forward with seeking order writing privileges, you should be communicating that NYSDA conversations with the Department of Education (NYSED) and the Department of Health (NYDOH) are "in process". NYSDA has not been given a definite "No" so will continue with the conversations. The goal is to have these two departments support the change so that when a hospital is reviewed for regulatory compliance; RD/RDN order writing is not a "finding" that results in a citation.
7. If you are working in a hospital that already had approved RD/RDN order writing privileges prior to the 2014 ruling – are there any actions you should take at this time?
Review this with your Quality/Regulatory Department for guidance. Until New York State regulations allow RD/RDN nutrition order writing, continuing to allow such practice can put your institution in regulatory jeopardy.
8. Are there any facilities that have already implemented this change that can be contacted for advice?
There are hospitals in New York that had put this in place prior to the CMS ruling - due to responding to a brief time period where it was "ok" with a 2007 ruling, that unfortunately was rescinded. Eventually the change was approved which is the 2014 CMS ruling. We have not been advised of any New York State hospital that has proceeded with making the change in 2014 nor would this be advisable at this time as currently the New York State regulations do not support RD/RDN order writing.
9. Is there anything I can do – while waiting for the regulatory changes that have been described to be approved?
Review your current practice and develop a clear plan to assure and describe why you are competent to write nutrition orders. Build your relationships with the medical staff to be a consistent, helpful resource to meet the nutritional needs of patients. Pursue additional training and/or credentials that are valued by medical staff to assure your competence.
10. Are there any suggestions for getting the process stared within the hospital?
Determine strategic collaborations within the hospital that will help you achieve this change such as: the medical staff credentialing office, quality department, human resources and/or the facility regulatory official. Titles may vary depending on the facility.
11. If approval is received from New York State that a RD/RDN may request the CMS nutrition order writing privilege within the hospital where they work, what specific orders will they be able to write?
This is the list that we are using in our discussions with the New York State Departments of Education and Health: Nutrition orders, including but not limited to orders for diets, enteral nutrition, parenteral nutrition, oral nutrition supplements, medical nutrition foods, dietary supplements, vitamins, minerals, texture modifications and heights/weights. Laboratory tests to monitor the effectiveness of the nutrition care plan.
12. What information should I be ready to provide to help build an understanding of the request to obtain the nutrition order writing privilege?
Information such as delayed update of orders, i.e., change from a regular diet to a consistent carbohydrate that delays provision of care, meal service and/or discharge and patient dissatisfaction related to delayed nutrition orders.
13. Is it okay for dietitians to take a verbal order from a Provider (MD, DO, PA, NP) to change a nutrition order?
CMS does not allow any staff including nurses or health care professional to take verbal orders unless it is an emergency situation and then that emergency must be documented. It is highly unlikely that a nutrition order would be deemed as an emergency situation.
14. CMS made this change in July-2014, I find it frustrating that there are always barriers to implementing what was a long overdue change. What can we do to overcome these barriers?
This was a landmark advisory that the Academy has sought for years and yet it is not perfect. The process of change takes time due to the number of details. One of the components of facilitating any change is to have hospital dietitians clearly describe situations (with attention to HIPPA) that result in harm to the patient, increase costs or delay discharge because this ruling was not in effect. Stories are very important to describing the work that a RD/RDN does to someone that does not understand their work. As a profession, we are hesitant to speak negatively and yet a description of a real patient story can be of value to change things. Please take the time to record your stories so that you can share them when the moment arrives to present your “case” to the medical staff. Also, please share you stories with other NYSDA members at firstname.lastname@example.orgNYSDA
15. I work in a long-term care facility and heard CMS may change the regulations to allow RDN to nutrition orders writing privileges. Should I get the CDN?
The Academy is addressing therapeutic order writing by a qualified dietitian with CMS in long-term care, however, no timeline can ever be projected. Obtaining the CDN can take some time so you should start the process now. 16. Based on the current CDN credentialing in NYS, is there oversight for reporting improper dietetics practice at the state level? Yes – The NYSED – Office of the Professions – under the authority of the Board of Regents - outlines a plethora of unprofessional conduct descriptors. If there is a (unprofessional conduct) concern an electronic complaint form is available to complete and submit. This form may be found at www.op.nysed.gov/opd/complain - or you may call 1-800-442-8106
This information is property of NYSDA and has been taken with permission from the NYSDA CMS Task Force