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###### Department of Veterans Affairs

# AGENCY:

Department of Veterans Affairs.

# ACTION:

Request for information.

# SUMMARY:

The Department of Veterans Affairs (VA) is requesting information to assist in developing a national standard of practice for VA Blind Rehabilitation Specialists (BRS) and Visual Impairment Services Team (VIST) Coordinators. 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 August 30, 2022.

# ADDRESSES:

                        Comments may be submitted through                         *www.regulations.gov*. Comments received will be available at                         *www.regulations.gov*                         for public viewing, inspection or copies.                    

# 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, at 202-461-0500. This is not a toll-free number.

# SUPPLEMENTARY INFORMATION:

## Authority

Chapters 73 and 74 of the title 38 of the U.S.C. and 38 U.S.C. 303 authorize the Secretary to regulate the professional activities of 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 allowing VA health care professionals to deliver health care                           ( print page 39596)                        services in a State other than the health care professional's State of licensure, registration, certification, or other State 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.                

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 provide the same type of tasks and duties regardless of the VA medical facility where they are located or the State license, registration, certification, or other State requirement they hold. We emphasized in the rulemaking and reiterate that VA will determine, on an individual basis, that a health care professional has the necessary education, training and skills to perform the tasks and duties detailed in the national standard of practice and 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.

## Need for National Standards of Practice

As the Nation's largest integrated health care system, it is critical that VA develop national standards of practice to ensure beneficiaries receive the same high-quality care regardless of where they enter the system and to ensure 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 COVID-19 pandemic. With an increased need for mobility in our workforce, including through VA's Disaster Emergency Medical Personnel System, creating a uniform standard of practice better supports VA health care professionals who already frequently practice across State lines. In addition, the development of national standards of practice aligns with VA's long-term deployment of a new electronic health record (EHR). National standards of practice are critical for optimal EHR implementation to enable the specific roles for each health care profession in EHR to be consistent across the Veterans Health Administration (VHA) and to support increased interoperability between VA and the Department of Defense (DoD). DoD has historically standardized practice for certain health care professionals, and VHA closely partnered with DoD to learn from their experience.

## Process To Develop National Standards of Practice

                    Consistent with 38 CFR 17.419, VA is developing national standards of practice via policy. There will be one overarching national standard of practice directive that will generally describe VHA's policy and have each individual national standard of practice as an appendix to the directive. The directive and all appendices will be accessible on VHA Publications website at:                     *https://vaww.va.gov/​vhapublications/​*                     (internal) and                     *https://www.va.gov/​vhapublications/​*                     (external) once published.                

To develop these national standards, VA is using a robust, interactive process that is consistent with the guidance outlined in Executive Order (E.O.) 13132 to preempt State law. The process includes consultation with internal and external stakeholders, including State licensing boards, VA employees, professional associations, Veterans Service Organizations, labor partners and others. For each identified VA occupation, a workgroup comprised of health care professionals conducts State variance 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 the agency. The workgroup may consult with internal stakeholders at any point throughout the process. 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 task or duty. The workgroup then drafts a proposed VA national standard of practice using the data gathered during the State variance research and incorporates internal stakeholder feedback to date.

The proposed national standard of practice is internally reviewed, to include by an interdisciplinary workgroup consisting of representatives from Quality Management; Field Chief of Staff; Academic Affiliates; Associate Director Patient Care Services; Ethics; Workforce Management and Consulting; Surgery; Credentialing and Privileging; Field Chief Medical Office; and Electronic Health Record Modernization.

                    Externally, the proposed national standard of practice is provided to our partners in DoD. In addition, VA labor partners are engaged informally as part of a pre-decisional collaboration. Consistent with E.O. 13132, a letter is sent to each State board and certifying organization that includes the proposed national standard and an opportunity to further discuss the national standard with VA. After the States have received notification, the proposed national standard of practice is published to the                     **Federal Register**                     for 60 days to obtain feedback from the public, including professional associations and unions. At the same time, the proposed national standard is published on an internal VA site to obtain feedback from VA employees. Feedback from State boards, professional associations, unions, VA employees and any other person or organization who informally 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, and that are better for Veterans or VA health care professionals. We will publish a collective response to all comments at                     *https://www.va.gov/​standardsofpractice*.                

After the national standard of practice is finalized, approved and published in VHA policy, VA will implement the tasks and duties authorized by that national standard of practice. Any tasks or duties included in the national standard will be incorporated into an individual health care professional's privileges, scope of practice, or functional statement following any training and education necessary for the health care professional to perform those functions. Implementation of the national standard of practice may be phased in across all medical facilities, with limited exemptions for health care professionals as needed.

## National Standard for BRS and VIST Coordinators

                    The proposed format for national standards of practice when there is a national certifying body is as follows. The first paragraph provides general information about the profession and what the health care professionals can do. The second paragraph references the education, certification, license, registration, or other requirement needed to practice this profession at VA                           ( print page 39597)                        and confirms that this profession follows the standard of practice set by the national certifying body. A final statement confirms that as of the date of the workgroup's research into requirements, all individuals in this profession follow the same standard of practice.                

We note that proposed standards of practice do not contain an exhaustive list of every task and duty that each VA health care professional can perform. Rather, it is designed to highlight whether there are any areas of variance in how this profession can practice across States and how this profession will be able to practice within VA notwithstanding their State license, certification, registration and other requirements.

VA qualification standards require BRSs to have at least one active, current, full, and unrestricted certification granted by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP). The following four national certifications from the ACVREP correspond with four distinct specialties within the occupation:

1. Certified Low Vision Therapist (CLVT);

2. Certified Orientation and Mobility Specialist (COMS);

3. Certified Assistive Technology Instructional Specialist for People with Visual Impairments (CATIS); and

4. Certified Vision Rehabilitation Therapist (CVRT).

BRSs can practice under any of these four ACVREP certifications. BRSs who provide orientation and mobility training, communication and daily living therapy, low vision therapy, or assistive technology must possess the corresponding ACVREP certification for the type of service they provide. For example, a BRS who provides low vision therapy must be certified as a CLVT. VA reviewed whether there are any alternative certifications or requirements from any State that could be required for a BRS and found that there were none. Therefore, VA proposes to adopt a standard of practice consistent with these four national certifications; therefore, VA BRSs in each of these four specialties will continue to follow the same standard as set by their national certifications. Standards of practice for each of the four certifications can be found at the following websites:
    - CLVT: https://www.acvrep.org/​certifications/​clvt-scope ;                
    - COMS: https://www.acvrep.org/​certifications/​coms-scope ;                
    - CATIS: https://www.acvrep.org/​certifications/​catis-scope ; and                
    - CVRT: https://www.acvrep.org/​certifications/​cvrt-scope .                

This national standard of practice for BRSs includes VIST Coordinator because all VIST Coordinator positions are appointed as BRSs. BRS VIST Coordinators may be drawn from traditional blind/vision rehabilitation backgrounds or from counseling backgrounds. There is no national or State license or certification for VIST Coordinators; therefore, there is no variance with a State in the standard of practice for VIST Coordinators. VA VIST Coordinators must be licensed, certified, or registered as BRSs, Social Workers, Certified Rehabilitation Counselors, or other health care professionals. VIST Coordinators who are licensed, certified, or registered as BRSs, Social Workers, Certified Rehabilitation Counselors, or in other health care occupations must adhere to the VA national standard of practice for that specific occupation.

Because the practice of Blind Rehabilitation Specialists and VIST Coordinators is not changing, there will be no impact on the practice of this occupation when this national standard of practice is implemented. However, national standards of practice for other occupations may impact practice of those occupations at VA once they are implemented.

## Proposed National Standard of Practice for BRSs

BRSs use assessments, therapies and technologies to improve the independent function, quality of life and adjustment for Veterans who are blind or visually impaired. BRSs evaluate Veterans through interviews, tests and measurements and use such findings either solely or as a part of an interdisciplinary team to develop and implement blind and vision rehabilitation programs for individual Veterans. Instructional activities are directed toward achieving therapeutic objectives for Veterans who are blind or visually impaired. These activities include effective communication and visual skills; instruction on optical low vision devices; orientation to and management of the environment; safe ambulation and travel; access to information through the use of assistive technologies; manual skills; proficiency and understanding in activities of daily living; pursuit of avocational and vocational skills; and education and adjustment to visual impairment.

                    BRSs in VA possess the required education and certification from ACVREP in accordance with VA qualification standards, as more specifically described in VA Handbook 5005, Staffing, Part II, Appendix G41. This national standard of practice confirms BRSs practice in accordance with the ACVREP standards based on the certification they hold, including CLVT, COMS, CATIS and CVRT, available at:                     *www.acvrep.org*. As of August 2021, BRSs in all States follow these national certifications.                

## Proposed National Standard of Practice for VIST Coordinators

VIST Coordinators provide adjustment counseling, coordination of services, assure adequate compensation and benefits and conduct complex negotiations with the medical and benefit systems as well as non-VA service delivery systems for Veterans who are blind or visually impaired.

There is no national or State license or certification for VIST Coordinators; therefore, there is no variance with a State in the standard of practice for VIST Coordinators. VA VIST Coordinators must be licensed, certified, or registered as BRSs, Social Workers, Certified Rehabilitation Counselors, or other health care professionals as outlined in VA Handbook 5005, Staffing, Part II, Appendix G41. More specifically, VIST Coordinators must be credentialed or certified through the following:

a. Any certification via ACVREP, including CLVT, COMS, CATIS and CVRT;

b. License or certification by a State to independently practice social work at the master's degree level;

c. Certification via the Commission on Rehabilitation Counselor Certification, Certified Rehabilitation Counselor; or

d. License or certification by a State to independently practice in other health care occupations.

VIST Coordinators licensed, certified, or registered as BRSs, Social Workers and Certified Rehabilitation Counselors, or in other health care occupations, must adhere to the VA national standard of practice for that specific occupation.

## Request for Information

1. Are there any required trainings for the aforementioned practices that we should consider?

2. Are there any factors that would inhibit or delay the implementation of the aforementioned practices for VA health care professionals in any States?

3. Is there any variance in practice that we have not listed?

                    4. What should we consider when preempting conflicting State laws, regulations, or requirements regarding supervision of individuals working toward obtaining their license or unlicensed personnel?                          ( print page 39598)    

5. Is there anything else you would like to share with us about these national standards of practice?

## Signing Authority

Denis McDonough, Secretary of Veterans Affairs, approved this document on June 14, 2022, 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.

Jeffrey M. Martin,

Assistant Director, Office of Regulation Policy & Management, Office of General Counsel, Department of Veterans Affairs.

[FR Doc. 2022-14033 Filed 6-30-22; 8:45 am]

BILLING CODE 8320-01-P