[Federal Register Volume 89, Number 216 (Thursday, November 7, 2024)]
[Notices]
[Pages 88349-88351]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-25894]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Dental Hygienist Standard of Practice

AGENCY: Department of Veterans Affairs.

ACTION: Request for information.

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SUMMARY: The Department of Veterans Affairs (VA) is requesting 
information to assist in developing a national standard of practice for 
VA Dental Hygienists. VA seeks comments on various topics to help 
inform VA's development of this national standard of practice.

DATES: Comments must be received on or before January 6, 2025.

ADDRESSES: Comments must be submitted through https://www.regulations.gov/. Except as provided below, comments received 
before the close of the comment period will be available at https://www.regulations.gov/ for public viewing, inspection, or copying, 
including any personally identifiable or confidential business 
information that is included in a comment. We post the comments 
received before the close of the comment period on the following 
website as soon as possible after they have been received: https://www.regulations.gov/. VA will not post on https://www.regulations.gov/ 
public comments that make threats to individuals or institutions or 
suggest that the commenter will take actions to harm the individual. VA 
encourages individuals not to submit duplicative comments. We will post 
acceptable comments from multiple unique commenters even if the content 
is identical or nearly identical to other comments. Any public comment 
received after the comment period's closing date will not be 
considered.

FOR FURTHER INFORMATION CONTACT: Ethan Kalett, Office of Regulations, 
Appeals and Policy (10BRAP), Veterans Health Administration, Department 
of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 202-
461-0500. This is not a toll-free number.

SUPPLEMENTARY INFORMATION:

Authority

    Chapters 73 and 74 of 38 U.S.C. and 38 U.S.C. 303 authorize the 
Secretary to regulate VA health care professions to make certain that 
VA's health care system provides safe and effective health care by 
qualified health care professionals to ensure the well-being of those 
Veterans who have borne the battle.
    On November 12, 2020, VA published an interim final rule confirming 
that VA health care professionals may practice their health care 
profession consistent with the scope and requirements of their VA 
employment, notwithstanding any State license, registration, 
certification, or other requirements that unduly interfere with their 
practice. 38 CFR 17.419; 85 FR 71838. Specifically, this rulemaking 
confirmed VA's current practice of permitting VA health care 
professionals to deliver health care services in a State other than the 
health care professional's State of licensure,

[[Page 88350]]

registration, certification, or other requirement, and thereby, 
enhancing beneficiaries' access to critical VA health care services. 
The rulemaking also confirmed VA's authority to establish national 
standards of practice for its health care professionals, which would 
standardize a health care professional's practice in all VA medical 
facilities, regardless of conflicting State laws, rules, regulations, 
or other requirements.
    The rulemaking explained that a national standard of practice 
describes the tasks and duties that a VA health care professional 
practicing in the health care profession may perform and may be 
permitted to undertake. Having a national standard of practice means 
that individuals from the same VA health care profession may perform 
the same type of tasks and duties regardless of the State where they 
are located or the State license, registration, certification, or other 
requirement they hold. We emphasized in the rulemaking and reiterate 
here that VA will determine, on an individual basis, that a health care 
professional has the proper education, training, and skills to perform 
the tasks and duties detailed in the national standard of practice, and 
that they will only be able to perform such tasks and duties after they 
have been incorporated into the individual's privileges, scope of 
practice, or functional statement. The rulemaking explicitly did not 
create any such national standards and directed that all national 
standards of practice would be subsequently created through policy.

Preemption of State Requirements

    The national standard of practice will preempt any State laws, 
rules, regulations, or other requirements that are both listed and 
unlisted in the national standard as conflicting, but that do conflict 
with the tasks and duties as authorized in VA's national standard of 
practice. The term State, as applied here, means each of the several 
States, territories, and possessions of the United States and is 
consistent with the definition in 38 U.S.C. 101(20). If a State changes 
their requirements and places new limitations on the tasks and duties 
it permits in a manner that would be inconsistent with what is 
authorized under the national standard of practice, the national 
standard of practice will preempt such limitations and authorize the VA 
health care professional to continue to practice consistent with the 
tasks and duties outlined in the national standard of practice.
    In cases where a VA health care professional's license, 
registration, certification, or other requirement permits a practice 
that is not included in a national standard of practice, the individual 
may continue that practice so long as it is permissible under Federal 
law and VA policy; is not explicitly restricted by the national 
standard of practice; and is approved by the VA medical facility.

Need for National Standards of Practice

    It is critical that VA, the Nation's largest integrated health care 
system, develop national standards of practice to ensure, first, that 
beneficiaries receive the same high-quality care regardless of where 
they enter the system and, second, that VA health care professionals 
can efficiently meet the needs of beneficiaries when practicing within 
the scope of their VA employment. National standards are designed to 
increase beneficiaries' access to safe and effective health care; 
thereby, improving health outcomes. The importance of this initiative 
has been underscored by the Coronavirus Disease 2019 (COVID-19) 
pandemic. The increased need for mobility in VA's workforce, including 
through VA's Disaster Emergency Medical Personnel System, highlighted 
the importance of creating uniform national standards of practice to 
better support VA health care professionals who practice across State 
lines. Creating national standards of practice also promotes 
interoperability of medical data between VA and the Department of 
Defense (DoD), providing a complete picture of a Veteran's health 
information and improving VA's delivery of health care to the Nation's 
Veterans. DoD has historically standardized practice for certain health 
care professionals, and VA has closely partnered with DoD to learn from 
their experience.

Process To Develop National Standards of Practice

    As authorized by 38 CFR 17.419, VA is developing national standards 
of practice through policy. The overarching directive to describe 
Veterans Health Administration (VHA) policy on national standards of 
practice is VHA Directive 1900(3), VA National Standards of Practice, 
August 30, 2023. The directive is accessible on VHA's publications 
website at https://www.va.gov/vhapublications. As each individual 
national standard of practice is finalized, it is published as an 
appendix to the directive and is accessible at the same website.
    To develop these national standards, VA is using a robust, 
interactive process that adheres to the requirements of Executive Order 
(E.O.) 13132, Federalism, to preempt conflicting State laws, rules, 
regulations, or other requirements. For each health care occupation, a 
workgroup comprised of VA health care professionals in the identified 
occupation conducts research to identify internal best practices that 
may not be authorized under every State license, certification, or 
registration, but would enhance the practice and efficiency of the 
profession throughout VA. If a best practice is identified that is not 
currently authorized by every State, the workgroup determines what 
education, training, and skills are required to perform such tasks and 
duties. The workgroup then drafts a proposed VA national standard of 
practice using the data gathered and any internal stakeholder feedback 
received. The workgroup may consult with internal or external 
stakeholders at any point throughout the process.
    The process to develop VA national standards of practice includes 
listening sessions for members of the public, professional 
associations, and VA employees to provide comments on the variance 
between State practice acts for specific occupations and what should be 
included in the national standard of practice for that occupation. The 
listening session for dental hygienists was held on September 7, 2023. 
No comments were provided on the dental hygienists standard of 
practice.
    After the proposed standard is developed, it is first internally 
reviewed. This includes a review from an interdisciplinary VA workgroup 
consisting of representatives from the following offices: Quality 
Management, VA medical facility Chief of Staff, Academic Affiliates, 
Veterans Integrated Services Network (VISN) Chief Nursing Officer, 
Ethics, Workforce Management and Consulting, Surgery, Credentialing and 
Privileging, VISN Chief Medical Officer, and Electronic Health Record 
Modernization.
    After the internal review, VA provides the proposed national 
standard of practice to our DoD partners as an opportunity to flag 
inconsistencies with DoD standards. VA also engages with labor partners 
informally as part of a pre-decisional collaboration. Consistent with 
E.O. 13132, VA sends a letter to each State board and certifying 
organization or registration organization, as appropriate, which 
includes the proposed national standard and offers the recipient an 
opportunity to discuss the national standard with VA. After the State 
boards, certifying organizations, or registration organizations have 
received notification, the proposed national standard of practice is 
posted in the Federal Register for 60 days to obtain feedback

[[Page 88351]]

from the public, professional associations, and any other interested 
parties. At the same time, the proposed national standard is posted to 
an internal VA site to obtain feedback from VA employees. Responses 
received through all vehicles--from State boards, professional 
associations, unions, VA employees, and any other individual or 
organization that provides comments through the Federal Register--will 
be reviewed. VA will make appropriate revisions in light of the 
comments, including those that present evidence-based practices and 
alternatives that help VA meet our mission and goals. VA will publish a 
collective response to all comments at https://www.va.gov/standardsofpractice/.
    The national standard of practice is then finalized, approved, and 
published in VHA policy. Any tasks or duties included in the national 
standard will be properly incorporated into individual VA health care 
professionals' privileges, scope of practice, or functional statement 
once it has been determined by their VA medical facility that the 
individual has the proper education, training, and skills to perform 
the task or duty. The implementation of the national standard of 
practice may be phased in across all VA medical facilities, with 
limited exemptions for health care professionals as needed.

Format for the Proposed National Standard for Dental Hygienist

    The format for the proposed national standards of practice when 
there are State licenses is as follows. The first paragraph provides 
general information about the profession and what the VA health care 
professionals can do. For this national standard, Dental Hygienists 
perform oral prophylaxis and other therapeutic or preventive procedures 
for periodontal disease, caries control, or other dental problems. We 
reiterate that the proposed standard of practice does not contain an 
exhaustive list of every task and duty that each VA health care 
professional can perform. Rather, it is designed to highlight generally 
what tasks and duties the health care professionals perform and how 
they practice within VA.
    The second paragraph references the education and license, or other 
requirement, needed to practice this profession at VA. Qualification 
Standards for employment of health care professionals by VA are 
available at: https://www.va.gov/OHRM/QualificationStandards/. VA 
follows the requirements outlined in its qualification standards even 
if the requirements conflict with or differ from a State requirement. 
The national standards of practice do not affect those requirements. 
For dental hygienists, VA requires an active, current, full, and 
unrestricted State license, and that the dental hygienists meet 
credentialing standards in 42 CFR part 75, Standards for the 
Accreditation of Educational Programs for the Credentialing of 
Radiologic Personnel. The dental hygienists VA qualification standards 
are available at: https://www.va.gov/OHRM/QualificationStandards/HT38/0682-DentalHygienist.pdf.
    The second paragraph also notes whether the national standard of 
practice explicitly excludes individuals who practice under 
``grandfathering'' provisions. Qualification standards may include 
provisions to permit employees who met all the requirements prior to 
revisions of the qualification standards to maintain employment at VA 
even if they no longer meet the new qualification standards. This 
practice is referred to as grandfathering. VA dental hygienists have 
grandfathering provisions included within their qualification 
standards, and VA proposes to have those individuals authorized to 
follow the dental hygienists national standard of practice. Therefore, 
there would be no notation regarding grandfathered employees in the 
national standard of practice as they would be required to adhere to 
the same standard as would any other VA dental hygienist who meets the 
current qualification standards.
    The third paragraph establishes what the national standard of 
practice will be for the occupation in VA. It includes whether the 
professional can practice all duties covered by their license. For 
dental hygienists, VA proposes that VA dental hygienists can practice 
all duties covered by their license and the credentialing standards. VA 
reviewed State laws and practice acts for dental hygienists in March 
2024 and did not identify any conflicts that impact practice of this 
profession in VA.
    This national standard of practice does not address training 
because it will not authorize VA dental hygienists to perform any tasks 
or duties not already authorized under their State license or 
certification.
    Following public and VA employee comments and revisions, each 
national standard of practice that is published in policy will also 
include the date for recertification of the standard of practice and a 
point of contact for questions or concerns.

Proposed National Standard of Practice for Dental Hygienists

    Note: All references herein to VA and VHA documents incorporate 
by reference subsequent VA and VHA documents on the same or similar 
subject matter.

    1. Dental hygienists perform oral prophylaxis and other therapeutic 
or preventive procedures for periodontal disease, caries control, or 
other dental problems.
    2. Dental Hygienists in the Department of Veterans Affairs (VA) 
possess the education, license, and certification required by VA 
qualification standards, available at: https://www.va.gov/OHRM/
QualificationStandards/HT38/0682-dentalhygienist.pdf.
    3. VA Dental Hygienists can practice all duties covered by their 
license, and practice in accordance with the credentialing standards in 
42 CFR part 75, Standards for the Accreditation of Educational Programs 
for the Credentialing of Radiologic Personnel, available at: https://www.ecfr.gov/. VA reviewed State laws and practice acts for Dental 
Hygienists in March 2024 and did not identify any conflicts that impact 
practice of this profession in VA.

Request for Information

    1. Is VA's assessment of what your State permits and prohibits 
accurate?
    2. Are there any areas of variance between State licenses, 
certification, registration, or other requirement that VA should 
preempt that are not listed?
    3. Is there anything else you would like to share with us about 
this VA national standard of practice?

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved and signed 
this document on October 22, 2024, and authorized the undersigned to 
sign and submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy and 
Management (00REG), Office of General Counsel, Department of Veterans 
Affairs.
[FR Doc. 2024-25894 Filed 11-6-24; 8:45 am]
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