DEPARTMENT OF HEALTH

[Filed April 30, 2024, 1:54 p.m.]

Supplemental Notice to WSR 23-22-131.

Preproposal statement of inquiry was filed as WSR 18-10-059.

Title of Rule and Other Identifying Information: Dietitians and nutritionists requirements in chapter 246-822 WAC. The department of health (department) is proposing amending, repealing, and creating new rule sections to clarify, streamline, update, and modernize rules for licensing dietitians and nutritionists. This supplemental proposal includes an additional definition in WAC 246-822-010, clarification of application and education requirements for dietitians and nutritionists in WAC 246-822-120, 246-822-130, 246-822-132, 246-822-135, 246-822-141, 246-822-145, and 246-822-160, updated requirements for dietitian qualified supervisors in WAC 246-822-147, and takes out unnecessary terms in WAC 246-822-175 Providing services.

Hearing Location(s): On June 5, 2024, at 2:30 p.m., at the Washington State Department of Health, 111 Israel Road S.E., Town Center 2, Room 166/167, Tumwater, WA 98501; or via Zoom. Register in advance for this webinar https://us02web.zoom.us/webinar/register/WN_zxoRGr0SQU-hPKcWI7SjVQ. After registering, you will receive a confirmation email containing information about joining the webinar. You may attend virtually or in person. You may also submit comments in writing.

Date of Intended Adoption: June 12, 2024.

Submit Written Comments to: Kim-Boi Shadduck, Office of Health Professions, P.O. Box 47852, Olympia, WA 98504-7852, email https://fortress.wa.gov/doh/policyreview, by June 5, 2024.

Assistance for Persons with Disabilities: Contact Kim-Boi Shadduck, phone 360-236-2912, TTY 711, email kimboi.shadduck@doh.wa.gov, by May 29, 2024.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Proposed amendments to chapter 246-822 WAC clarify, streamline, and modernize rules for dietitians and nutritionists. The proposed amendments include: (1) Updating rules to align with national professional standards for dietitians; (2) setting clear standards for education, experience, and supervision requirements; (3) updating rules to reflect current department processes; (4) removing redundant mandatory reporting language; and (5) making other updates and clarifications as appropriate.

Following the public rules hearing held on December 5, 2023, the department determined that the proposed rule language required amendments to multiple WAC sections to add definitions and clarifications that interested individuals felt were needed. Most amendments in the supplemental proposal are minor and were included to add further clarification of core curriculum requirements for nutritionists and dietitians, application requirements, qualified supervisor requirements for dietitians, and to include updated terms used in the practice of dietetics. Amendments that were more significant include adding content to the core curriculum requirements for dietitians, including skills and competency requirements for dietitian-coordinated programs, and removing unnecessary language from WAC 246-822-175 Providing services. The amendments and their impacts are explained in the supplemental significant analysis.

Reasons Supporting Proposal: Chapter 246-822 WAC has not been meaningfully updated in several decades. The proposed amendments will provide clear, accurate requirements for the regulated community. The proposed new rules reflect changes in professional standards, technology, and department processes.

The department determined that it would be beneficial to make thoughtful changes to the proposed rule language and further engage interested individuals after the December 5, 2023, public rules hearing due to the volume and nature of public comments from interested individuals. The department made changes based on feedback and sent out draft rules to interested individuals via GovDelivery for review and has received supportive comments on the supplemental proposal.

Statutory Authority for Adoption: RCW 18.138.070.

Statute Being Implemented: Chapter 18.138 RCW.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of health, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Kim-Boi Shadduck, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-2912.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Kim-Boi Shadduck, Office of Health Professions, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-2912, TTY 711, email kimboi.shadduck@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(4).

Explanation of exemptions: The proposed amendments impact rules regulating individual professional licenses, not businesses.

Scope of exemption for rule proposal:

Kristin Peterson, JD

for Umair A. Shah, MD, MPH

AMENDATORY SECTION(Amending WSR 91-02-049, filed 12/27/90, effective 1/31/91)

WAC 246-822-010Definitions.

The definitions in this section and RCW 18.138.010 apply throughout this chapter unless the context clearly requires otherwise.

(1) "Accreditation council for education in nutrition and dietetics" or "ACEND" means a national organization that accredits dietetics education programs.

(2) "Accredited college or university" means a college or university accredited by a national or regional accrediting body recognized by the ((council on))office of postsecondary education at the time the applicant completed the required education.

(((2) "Continuous preprofessional experience" means a minimum of 900 hours of supervised competency-based practice in the field of dietetics accumulated over a maximum of thirty-six months. This competency-based practice should include, but not be limited to the following:

(a) Assuring that food service operations meet the food and nutrition needs of clients and target markets.

(b) Utilization of food, nutrition, and social services in community programs.

(c) Providing nutrition care through systematic assessment, planning, intervention, and evaluation of groups and individuals.

(d) Providing nutrition counseling and education to individuals and groups for health promotion, health maintenance, and rehabilitation.

(e) Applying current research information and methods to dietetic practice.

(f) Utilizing computer and other technology in the practice of dietetics.

(g) Integrating food and nutrition services in the health care delivery system.

(h) Promoting positive relationships with others who impact on dietetic service.

(i) Coordinating nutrition care with food service systems.

(j) Participating in the management of cost-effective nutrition care systems.

(k) Utilizing menu as the focal point for control of the food service system.

(l) Participating in the management of food service systems, including procurement, food production, distribution, and service.

(m) Participating in the management of human, financial, material, physical, and operational resources.

(n) Providing education and training to other professionals and supportive personnel.

(o) Engaging in activities that promote improved nutrition status of the public and advance the profession of dietetics.

(p) Recognizing the impact of political, legislative, and economic factors on dietetic practice.

(q) Utilizing effective communication skills in the practice of dietetics.

(r) Participating in the management of a quality assurance program.

(3) "Supervision" means the oversight and responsibility for the dietitian's or nutritionist's continued practice by a qualified supervisor. Methods of supervision may include face-to-face conversations, direct observation, or review of written notes or tapes.

(4) "Qualified supervisor" means a dietitian who is certified under this chapter or who is qualified for certification under this chapter.

(5) "Coordinated undergraduate program" means supervised dietetic practice that is part of a course of study.))(3) "Client" means a person who receives services from a certified dietitian or certified nutritionist; this term may be used interchangeably with "patient."

(4) "Commission on dietetic registration" or "CDR" means the credentialing organization of the academy of nutrition and dietetics, a professional organization for nutrition and dietetics practitioners.

(5) "Coordinated program" means supervised dietetic practice that is part of a course of study under WAC 246-822-145.

(6) "Dietitian" or "certified dietitian" means a person certified to practice dietetics under this chapter and chapter 18.138 RCW.

(7) "Nutritionist" or "certified nutritionist" means a person certified to provide general nutrition services under this chapter and chapter 18.138 RCW.

(8) "Nutrition care process" includes all the following concepts:

(a) "Nutrition assessment" means assessing and evaluating the nutritional needs of individuals and groups using anthropometric, biochemical, nutrigenomic, clinical, metabolic, physiologic, dietary, and behavioral, social and demographic data for clinical, research and program planning purposes; and, determining resources in the practice setting, including ordering laboratory tests to check and track nutrition status and monitor effectiveness of nutrition plans or orders.

(b) "Nutrition care services" means and involves nutrition care, medical nutrition therapy, and nutrition-related services using knowledge, evidence-based practices, and clinical judgment to address health promotion and wellness, and prevention and management of acute or chronic diseases and conditions for individuals and groups. Nutrition care services involves using the four interrelated steps of the nutrition care process including nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.

(c) "Nutrition counseling" means the provision of dietary and nutrition counseling and education with the goal of facilitating knowledge, skill, and ability including concerning disease pathophysiology, clinical and biochemical data and data patterns, health-related behaviors, lifestyle choices, environmental factors, food and dietary patterns, nutrient and prescription drug interactions; provision of education and training on nutrition-related medical devices; and the development and administration of nutrition care standards.

(d) "Nutrition diagnosis" means identifying and labeling nutrition problems managed and treated by a certified dietitian or certified nutritionist. It does not include the medical differential diagnosis of the health status of an individual.

(e) "Nutrition intervention" means purposefully planned actions and counseling intended to positively change a nutrition-related behavior, risk factor, environmental condition or aspect of the health status for an individual, including education and training on nutrition-related medical devices.

(i) Nutrition intervention includes using approved clinical privileges, physician/nonphysician practitioner-driven orders (i.e., delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, or organizational policy.

(ii) Nutrition intervention involves implementing, initiating, or modifying orders for therapeutic diets, medication and nutrition interactions, management, or nutrition-related services (e.g., medical foods/nutrition dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous infusions, laboratory tests, medications, and education and counseling).

(f) "Nutrition monitoring and evaluation" means identifying patient outcomes using data sources and technology-based applications relevant to the nutrition diagnosis and comparing the outcomes with the patient's previous health status, interventions, goals or reference standards to determine the progress made in achieving desired outcomes or nutrition care and whether planned interventions should be continued or revised.

(9) "Qualified supervisor" means a dietitian who is credentialed by the department under this chapter or registered by the commission on dietetic registration as a registered dietitian.

(10) "Registered dietitian," "registered dietitian nutritionist," "RD," or "RDN" means a person registered as such with the commission on dietetic registration.

(11) "Supervision" means the oversight and responsibility for an individual's supervised preprofessional experience or coordinated program by a qualified supervisor under WAC 246-822-147.

(12) "Supervised preprofessional experience" means at least 900 hours of supervised competency-based practice in the field of dietetics under WAC 246-822-141.

AMENDATORY SECTION(Amending WSR 21-02-002, filed 12/23/20, effective 1/23/21)

WAC 246-822-120Nutritionist application requirements.

(((1) Individuals applying for certification as a certified dietitian must submit:

(a) A completed application form with fee; and

(b) Verification of current registration status with the commission on dietetic registration.

(2) Individuals applying for certification as a certified dietitian who have not passed the required written examination or who are not registered with the commission on dietetic registration must:

(a) Provide transcripts forwarded directly from the issuing college or university showing completion of a baccalaureate degree or higher in a major course of study in human nutrition, foods and nutrition, dietetics, or food management;

(b) Provide evidence of completion of a continuous preprofessional experience or coordinated undergraduate program in dietetics under the supervision of a qualified supervisor; and

(3) Individuals applying))An applicant for certification as a ((certified)) nutritionist ((must submit))shall:

(1) Submit to the department:

(a) A completed application on forms((with fee; and

(b) Documentation that the applicant meets the application requirements for certified dietitians, as set forth in subsection (1) or (2) of this section; or

(c)))provided by the department;

(b) The applicable fee in WAC 246-822-990; and

(2) Provide one of the following:

(a) Transcripts forwarded directly to the department from the issuing accredited college or university showing completion of a ((masters))master's or doctorate degree in one of the following subject areas: Human nutrition, nutrition education, foods and nutrition, or public health nutrition with demonstration of meeting the nutritionist minimum core curriculum under WAC 246-822-130; or

(b) Documentation to the department of meeting requirements for certified dietitians in WAC 246-822-132.

AMENDATORY SECTION(Amending WSR 91-02-049, filed 12/27/90, effective 1/31/91)

WAC 246-822-130Nutritionist minimum core curriculum.

((Training for certified nutritionist should include))To be eligible for certification as a nutritionist, an applicant shall:

(1) Successfully complete a master's or doctorate degree in one of the following subject areas: Human nutrition, nutrition education, foods and nutrition, or public health nutrition, as required in RCW 18.138.030 (4)(b).

(2) Successfully complete coursework at the ((collegiate level or equivalent))college or graduate level from an accredited college or university in the following areas:

(((1)))(a) Basic science(( - Which should include)), including courses in one or more of the following:

(((a)))(i) Physiology.

(((b)))(ii) Biochemistry.

(((2)))(b) Foods(( - Which should include)), including courses in one or more of the following:

(((a)))(i) Selection.

(((b)))(ii) Composition.

(((c)))(iii) Food science.

(((3)))(iv) Nutritional science.

(((4)))(c) Applied nutrition(( - Which should include)), including courses in one or more of the following:

(((a)))(i) Diet therapy.

(((b)))(ii) Nutrition of the life cycle.

(((c)))(iii) Cultural/anthropological nutrition.

(((d)))(iv) Public health nutrition.

(((5)))(d) Counseling/education(( - Which should include)), including courses in one or more of the following:

(((a)))(i) Psychological counseling.

(((b)))(ii) Educational psychology.

(((c)))(iii) Communication.

(((d)))(iv) Psychology.

(((e)))(v) Education.

WAC 246-822-132Dietitian application requirements.

An applicant for certification as a dietitian shall:

(1) Submit to the department:

(a) A completed application on forms provided by the department;

(b) The applicable fee in WAC 246-822-990; and

(2) Provide to the department verification of current RDN registration or provide the following documentation:

(a) Transcripts sent directly from the issuing accredited college or university showing completion of a bachelor's degree or higher with a major course of study in human nutrition, foods and nutrition, dietetics, or food systems management and demonstration of meeting the dietitian minimum core curriculum under WAC 246-822-135;

(b) Evidence of completing either supervised preprofessional experience under WAC 246-822-141 or a coordinated program under WAC 246-822-145; and

WAC 246-822-135Dietitian minimum core curriculum.

(1) To apply for certification as a dietitian by completing a core curriculum, an applicant shall successfully complete a bachelor's degree or higher from an accredited college or university with coursework that includes at least the following topics:

(a) Research skills, including methodology and interpretation or research literature;

(b) Science of nutrition and dietetics, including organic chemistry, biochemistry, anatomy, physiology, pharmacology, genetics, microbiology, nutrient metabolism, and nutrition across the lifespan;

(d) Food science, food safety and sanitation, and recipe and menu development;

(e) Effective education and counseling techniques;

(f) Public health policy, including legislative and regulatory structures, and health equity; and

(g) Professional practice skills, including professional ethics, client communication, documentation standards, coding and billing practices, and health care delivery systems.

(2) A didactic program in dietetics accredited by ACEND satisfies the requirements of this section.

WAC 246-822-141Dietitian supervised preprofessional experience.

(1) To apply for certification as a dietitian by completing supervised preprofessional experience, an applicant shall complete at least 900 hours of competency-based practice in the field of dietetics, supervised by a qualified supervisor. This must include practical experience that meets the competency standards of an ACEND accredited dietetic internship.

(a) Exhibiting professionalism in attitudes and interactions with clients;

(b) Understanding scientific research and incorporating new, evidence-based information into practice;

(d) Developing knowledge of health systems and referring clients to other professionals and services as appropriate.

(2) A dietetic internship accredited by ACEND satisfies the requirements of this section.

WAC 246-822-145Dietitian coordinated program.

(1) To apply for certification as a dietitian by completing a dietitian coordinated program, an applicant shall complete a coordinated program in dietetics that includes concurrent completion of:

(a) A dietetics education program that meets curriculum requirements in WAC 246-822-135; and

(b) A supervised preprofessional experience that meets the requirements in WAC 246-822-141.

(2) A coordinated program accredited by ACEND that satisfies the requirements of this section.

WAC 246-822-147Supervision and qualified supervisors.

(1) A qualified supervisor provides oversight and takes responsibility for an individual working to meet experience requirements. To be a qualified supervisor, an individual must be a dietitian certified by the department or registered as a registered dietitian nutritionist by CDR.

(2) Methods of supervision may include face-to-face supervision, direct supervision, distance supervision, and review of written notes or recordings.

(a) "Direct supervision" means the supervisor is on the premises and available for immediate consultation.

(b) "Distance supervision" means supervision provided through remote technology, used when a qualified supervisor and an applicant are not working in the same physical location.

(3) Distance supervision is not appropriate when an individual is providing direct client services where a provider's physical presence is necessary.

AMENDATORY SECTION(Amending WSR 92-02-018, filed 12/23/91, effective 1/23/92)

WAC 246-822-150Examinations.

(((1) A written examination will be given at least once annually to qualified applicants at a time and place determined by the secretary.

(2) Applications must be received sixty days in advance of the scheduled examination.

(3) Applicants who fail the examination shall submit the appropriate fee for reexamination.))(1) The department requires passage of the CDR registered dietitian examination. To register for the examination, an applicant must meet the CDR's eligibility requirements.

(2) The department must receive the passing examination results directly from the testing organization.

AMENDATORY SECTION(Amending WSR 91-02-049, filed 12/27/90, effective 1/31/91)

WAC 246-822-160Foreign degree equivalency.

((Applicants who obtained their education outside of the United States and its territories must have their academic degree(s) validated as substantially equivalent to the baccalaureate, master's, or doctorate degree conferred by a regionally accredited college or university recognized by the council on postsecondary education at the time the applicant completed the required degree.))(1) To become credentialed as a nutritionist in Washington, an applicant educated outside the United States and its territories shall:

(a) Have their academic degree assessed by a credential evaluation service to be validated as substantially equivalent to the education requirements in WAC 246-822-120 or 246-822-130 and submit the assessment with the application or become credentialed by CDR as a registered dietitian; and

(b) Apply to the department under WAC 246-822-120.

(2) To become credentialed as a dietitian in Washington, an applicant educated outside the United States and its territories shall:

(a) Become credentialed by CDR as a registered dietitian; and

(b) Apply to the department under WAC 246-822-132.

WAC 246-822-175Providing services.

(1) A certified dietitian may provide services as defined in RCW 18.138.010.

(2) A certified nutritionist may provide services as defined in RCW 18.138.010.

(3) A certified dietitian or nutritionist may provide services in person or through telehealth, to residents of Washington, as appropriate, based on the needs of the client.

AMENDATORY SECTION(Amending WSR 15-19-149, filed 9/22/15, effective 1/1/16)

WAC 246-822-990Dietitian and nutritionist fees and renewal cycle.

(1) ((Certificates))A certification must be renewed every year on the practitioner's birthday as provided in chapter 246-12 WAC((, Part 2)).

(2) The following nonrefundable fees will be charged:

Title		Fee
Original application
	Application	$65.00
	HEAL-WA* surcharge	16.00
Renewal
	Renewal	45.00
	HEAL-WA* surcharge	16.00
	Late renewal penalty	45.00
Expired certificate reissuance		50.00
Duplicate certificate		30.00
Verification of certificate		30.00

*	HEAL-WA is the health resources for Washington online library. See RCW 43.70.110.

The following sections of the Washington Administrative Code are repealed:

Mandatory reporting.

Health care institutions.

Dietitian or nutritionist associations or societies.

Health care service contractors and disability insurance carriers.

Professional liability carriers.

State and federal agencies.

Certification for dietitians—Grandfathering.

WAC 246-822-020	General provisions.
WAC 246-822-030	Mandatory reporting.
WAC 246-822-040	Health care institutions.
WAC 246-822-050	Dietitian or nutritionist associations or societies.
WAC 246-822-060	Health care service contractors and disability insurance carriers.
WAC 246-822-070	Professional liability carriers.
WAC 246-822-080	Courts.
WAC 246-822-090	State and federal agencies.
WAC 246-822-170	Certification for dietitians—Grandfathering.