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Step 3. Review federal and state regulations related to the care setting (ambulatory diabetes clinic), the type of provider (RDN), and the payment method (Centers for Medicare & Medicaid Services, private insurances). In this hypothetical example, there are no federal, state, or payer regulations that prohibit RDNs from providing this service.


Step 4. As the CNM, your next step is to determine which RDN currently on staff (or whom you will hire for this position) meets the minimum credentialing and competency standards to provide the requested services in the obstetrics clinic as documented in the job description. This can be accomplished by completion of quizzes or exams demonstrating didactic knowledge and performing chart reviews and observations of care provided.


Step 5. The RDN will perform a self-assessment of competency to determine whether they are confident and capable of providing safe, quality services in this clinic.


Step 6. Upon successful completion of steps 1 through 5, the RDN begins providing services. The CNM conducts initial and ongoing competency evaluation and documents the results in the RDN’s personnel file at least annually.


Statutory Scope of Practice


Professional scope of practice is established through CDR’s credentialing require- ments and the Academy of Nutrition and Dietetics SOP and SOP/SOPPs. In addition, RDNs and NDTRs must comply with statutory scopes of practice, which are estab- lished through state professional or occupational licensure or certification practice acts. The Academy of Nutrition and Dietetics provides a comprehensive analysis of state scope of practice laws and regulations on its professional website (www . eatright PRO . org / advocacy / licensure / professional - regulation - of - dietitians).


Defining “Qualified Dietitian”


When navigating the maze of what activities can or cannot be undertaken by the RDN or NDTR, CNMs must understand how the term qualified dietitian is defined by CMS, which provides the overarching guidance to other federal, state, and private agencies. In the CMS SOM Appendix PP: Guidance to Surveyors for Long Term Care Facilities, a qualified dietitian is one who is qualified based on either registration by the Commission on Dietetic Registration (CDR) or as permitted by state law on the basis of education, training, or experience in the identification of dietary needs, plan- ning, and implementation of dietary programs.20


This definition is also used by the


national accreditation organizations that have deeming authority from CMS. Many RDNs contend that people who do not hold the RDN credential through CDR cannot be defined as qualified dietitians. CNMs can work with the human resources depart- ment to craft position descriptions to stipulate that the RDN credential is required and whether other certifications that can only be obtained by RDNs are preferred or required. Nevertheless, if there are state regulations (such as professional licensing laws) that supersede such language, those regulations may preempt its inclusion. When writing facility-specific policies and procedures, CNMs should propose and advocate for wording that requires the RDN credential through CDR to provide ser- vices within that facility, which would then be enforceable at the facility level.


CHAPTER 10: Statutory and Regulatory Issues


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