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[Federal Register Volume 89, Number 249 (Monday, December 30, 2024)]
[Notices]
[Pages 106762-106765]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-31205]

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DEPARTMENT OF VETERANS AFFAIRS

Notice of Request for Information on the Department of Veterans 
Affairs Rehabilitation Counselor Standard of Practice

AGENCY: Department of Veterans Affairs.

ACTION: Request for Information.

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SUMMARY: The Department of Veterans Affairs is requesting information 
to assist in developing a national standard of practice for VA 
Rehabilitation Counselors. 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 February 28, 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

[[Page 106763]]

services in a state other than the health care professional's state of 
licensure, registration, certification, or other requirement, 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 via policy.

Preemption of State Requirements

    The national standard of practice will preempt any state laws, 
rules, regulations, or other requirements that both are and are not 
listed 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, possessions of the United States, and the district 
of Columbia, and the Commonwealth of Puerto Rico and is consistent with 
the definition in 38 U.S.C. 101(20). In the event that 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, develops 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 via policy. There is one overarching directive to describe 
Veterans Health Administration (VHA) policy on national standards of 
practice, VHA Directive 1900(5), 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 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 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 Rehabilitation Counselors was held on September 
21, 2023. No one provided comments on Rehabilitation Counselors 
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 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

[[Page 106764]]

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 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 who provides comments via the Federal 
Register--will be reviewed. VA will make appropriate revisions in light 
of the comments, including those that present evidence-based practice 
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. 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 Rehabilitation Counselors

    The format for the proposed national standards of practice when 
there is a national certification body is as follows. The first 
paragraph provides general information about the profession and what 
the health care professionals can do. For this national standard, 
Rehabilitation Counselors help patients with disabilities to achieve 
their personal career, independent living, social, and psychological 
goals. 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 will be able to practice within VA.
    The second paragraph references the education and certification 
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 the VA qualification standards even if the requirements 
conflict with or differ from a state requirement. National standards of 
practice do not affect those requirements. For Rehabilitation 
Counselors, VA qualification standards require an active, current, 
full, and unrestricted certification from the Commission on 
Rehabilitation Counselor Certification (CRCC). For Rehabilitation 
Counselors, VA qualification standards require an active, current, 
full, and unrestricted certification from the certification body: 
complete qualifications standards details for Rehabilitation Counselors 
are found: https://www.va.gov/OHRM/QualificationStandards/HT38/0101-RehabilitationCounselor.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 requirements prior to 
revisions to 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 Rehabilitation Counselors 
have grandfathering provisions included within their qualification 
standards, and VA proposes to have those individuals not be authorized 
to follow the Rehabilitation Counselor national standard of practice. 
Instead, VA proposes its medical facilities will determine the tasks 
and duties for Rehabilitation Counselors who are grandfathered under 
the qualification standards. Such determinations are determined at the 
VA medical facility based on the Rehabilitation Counselor's education, 
training, and credentialing.
    The third paragraph establishes what the national standard of 
practice will be for the occupation in VA. For this national standard, 
VA Rehabilitation Counselors follow the standard set by the CRCC, found 
at: https://crccertification.com, with the exception of, the listed 
task or duty VA proposes to restrict even though the certification 
otherwise permits the profession to perform those tasks or duties.
    The final paragraph provides justification for VA's proposal to 
restrict the specified tasks and duties. It explains why VA is 
restricting those tasks or duties and the clinical basis for this 
proposed decision.
    This national standard of practice does not address training 
because it will not authorize VA Rehabilitation Counselors to perform 
any tasks and duties not already authorized under their national 
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 Rehabilitation Counselors

    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. Rehabilitation Counselors are professional counselors educated 
and trained at the graduate level who possess the specialized 
knowledge, skills, and attitudes to work collaboratively with patients 
with disabilities. Through a professional counseling process, 
Rehabilitation Counselors help patients with disabilities to achieve 
their personal career, independent living, social, and psychological 
goals.
    2. Rehabilitation Counselors in the Department of Veterans Affairs 
(VA) possess the education and certification required by VA 
qualification standards, available at: https://www.va.gov/OHRM/QualificationStandards/HT38/0101-RehabilitationCounselor.pdf.

    Note:  This national standard of practice does not apply to 
Rehabilitation Counselors who were grandfathered into the position 
on July 21, 2020, the effective date for the VA qualification 
standards for Rehabilitation Counselors. Tasks and responsibilities 
for Rehabilitation Counselors who are grandfathered under the 
qualification standards are determined at the VA medical facility 
based on their education, training, and credentialing.

    3. VA Rehabilitation Counselors practice in accordance with the 
Certified Rehabilitation Counselor scope of practice from the 
Commission on Rehabilitation Counselor Certification (CRCC), available 
at: https://crccertification.com/, except as noted in paragraph 3.a. VA 
reviewed certification requirements for this occupation in October 2024 
and confirmed that all Rehabilitation Counselors in VA followed this 
national certification.
    a. VA Rehabilitation Counselors, practicing within scope of their 
VA employment and consistent with this standard, cannot diagnose mental 
health disorders (F Codes in the International Classification of 
Diseases 11th Revision) unless they have a license in a mental health 
discipline, in addition to their CRCC certification and qualify as 
licensed providers through the Medical

[[Page 106765]]

Staff Bylaws of their VA medical facility.

    Note:  VA Rehabilitation Counselors meet CRCC certification 
eligibility criteria of a master's degree in rehabilitation 
counseling or a qualifying related mental health field with 
additional graduate-level core rehabilitation coursework and 
supervised experience. All Rehabilitation Counselors with CRCC 
certification can diagnose ``Other Conditions That May Be a Focus of 
Clinical Attention'' as outlined in the Diagnostic and Statistical 
Manual of Mental Disorders Fifth Edition (Z codes in the 
International Classification of Diseases 11th Revision).

4. Justification

    a. VA Rehabilitation Counselors who only maintain a CRCC 
certification are restricted from diagnosing mental health disorders 
because VA has licensed mental health personnel with the specific 
education, training, and expertise that VA would rely on to diagnose. 
VA Rehabilitation Counselors who possess a CRCC certification, hold a 
state license in a mental health field (e.g., Licensed Professional 
Counselor, Licensed Clinical Professional Counselor, Licensed Clinical 
Social Worker, Licensed Independent Social Worker, Licensed 
Psychologist), and qualify as a licensed provider based on the medical 
facility bylaws will be permitted to diagnose mental health disorders 
because their education, training, and expertise provides the necessary 
competency to diagnose.

Request for Information

    1. Is VA's assessment of what the state and CRCC certification 
permits, and prohibits, accurately represented?
    2. Are there any other areas of variance of any state license, 
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 December 6, 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 & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2024-31205 Filed 12-27-24; 8:45 am]
BILLING CODE 8320-01-P
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