TITLE 22.EXAMINING BOARDS

Part 24. TEXAS BOARD OF VETERINARY MEDICAL EXAMINERS

Chapter 575. PRACTICE AND PROCEDURE

22 TAC §575.25

The Texas Board of Veterinary Medical Examiners adopts amendments to §575.25 concerning Recommended Schedule of Sanctions without change to the proposed text as published in the Texas Register on March 10, 2006 (31 TexReg 1585). The amended section reflects the changes to the Veterinary Licensing Act made by the 79th Texas Legislature that raised the maximum amount of administrative penalties that the Board can impose from $2,500.00 for each violation not related to a controlled substance to $5,000.00 per day for each violation of any kind. Other minor changes were incorporated to assure full compliance with the legislative directives.

No comments were received regarding adoption of the amendments.

The amendments are adopted under the authority of §801.151(a) of the Veterinary Licensing Act, Occupations Code, which gives the Board authority to adopt rules necessary to administer the Act.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 27, 2006.

TRD-200603451

Julie A. Barker

Executive Assistant

Texas Board of Veterinary Medical Examiners

Effective date: July 17, 2006

Proposal publication date: March 10, 2006

For further information, please call: (512) 305-7555


22 TAC §575.27

The Texas Board of Veterinary Medical Examiners adopts amendments to §575.27 concerning Complaints--Receipt, Investigation and Disposition, with one change to the proposed text as published in the Texas Register on March 10, 2006 (31 TexReg 1586). The amended section reflects changes to the Veterinary Licensing Act made by the 79th Texas Legislature. Under the new procedures, two veterinarian members of the Board, instead of one, will initially review all complaints that potentially involve medical issues. For complaints that do not involve medical issues, a committee of the Board's staff will review those complaints and propose a settlement to the veterinarian who is subject to the complaint. An informal conference is available for those veterinarians who do not wish to accept the staff's settlement offer. For complaints involving medical issues, an informal conference is held to hear the case, and two veterinarian members of the Board and one public member must attend.

The purpose of the increased participation by Board members in the review of cases is to assure that cases are considered from more than one viewpoint, and thus increase the confidence of the public that the cases have been subject to a full and fair review.

Subsection (e) of the section has been amended to address the consideration of contested cases at the State Office of Administrative Hearings (SOAH). New language addresses the negative consequences of a licensee failing to respond to notice of scheduled SOAH hearings. This amended subsection clearly states that if a licensee fails to appear at a SOAH hearing, the Board may ask that the administrative law judge issue a default decision in favor of the Board.

In accordance with the legislative changes, the section is amended to allow restitution of expenses incurred by a complainant where a licensee is found to have improperly diagnosed and/or treated the complainant's animal. The amount of restitution may be in lieu of or in addition to other sanctions imposed on the licensee. The Board and public benefit by having another method of imposing sanctions.

One comment was received from a Board member, who asked that the amendments clarify what kind of violations do not involve "medical judgment or practice." Accordingly, subsection (c)(8)(B) is expanded to give two examples of non-medical practices: continuing education and controlled substances certificates. The addition is for clarification purposes.

The amendments are adopted under the authority of §801.151(a) of the Veterinary Licensing Act, Occupations Code, which gives the Board authority to adopt rules necessary to administer the Act.

§575.27.Complaints--Receipt, Investigation and Disposition.

(a) Complaints against licensees.

(1) All complaints filed by the public against board licensees must be in writing on a complaint form provided by the board and signed by the complainant. If a complaint is transmitted to the board orally or by means other than in writing and the complaint alleges facts showing a continuing or imminent threat to the public welfare, the requirement of a written complaint may be waived until later in the investigative process.

(2) Complaints by the board's enforcement section shall be initiated by the opening of a complaint file.

(3) The board shall maintain a log of complainants to whom the board sends a complaint form.

(4) Anonymous written complaints will not be investigated, but will be logged and filed for information purposes only.

(5) The board shall utilize violation code numbers to distinguish between categories of complaints.

(b) Complaints against non-licensees. Complaints against persons alleged to be practicing veterinary medicine without a license may be investigated and resolved informally by the executive director. Complaints not resolved by the executive director may be referred by the board to a local prosecutor or the attorney general for legal action.

(c) Investigation of complaints.

(1) The policy of the board is that the investigation of complaints shall be the primary concern of the board's enforcement program, and shall take precedence over all other elements of the enforcement program, including compliance inspections.

(2) The board shall investigate complaints based on the following allegations, in order of priority:

(A) acts or omissions, including those related to substance abuse, that may constitute a continuing and imminent threat to the public welfare;

(B) acts or omissions of a licensee that resulted in the death of an animal;

(C) acts or omissions of a licensee that contributed to or did not correct the illness, injury or suffering of an animal; and

(D) all other act and omissions that do not fall within categories (A) - (C) of this paragraph.

(3) Upon receipt of a complaint, a letter of acknowledgment will be promptly mailed to the complainant.

(4) Complaints will be reviewed every thirty (30) days to determine the status of the complaint. Parties to a complaint will be informed on the status of a complaint at least on a quarterly basis.

(5) Upon receipt of a complaint, a board investigator shall review it and may interview the complainant to develop additional information. If the investigator concludes that the complaint resulted from a misunderstanding, is outside the jurisdiction of the board, or is without merit, the investigator shall recommend through the director of enforcement to the executive director that the investigation be closed. If the executive director concurs with the recommendation, the complainant will be so notified, the investigation will be closed, and the complaint file will be maintained in a secure file in the board office. If the executive director does not concur with the recommendations, the investigation will proceed.

(6) If the executive director returns the complaint to the investigator with a notation of non-concurrence under paragraph (5) of this subsection, or if the executive director concurs with the investigator's determination that a potential violation exists, the licensee is furnished with a copy of the complaint, unless the executive director determines that an undercover investigation is required. If no undercover investigation is required, the investigator shall contact the licensee in writing, and request any patient records or other pertinent documents deemed necessary for the investigation. The investigator may schedule an interview with the licensee. The investigator may request a written narrative statement from the licensee.

(7) After the licensee's response to the complaint is received, further investigation may be necessary to corroborate the information provided by the complainant and the licensee. During the investigation, the investigator shall interview the complainant. The investigator may request additional medical opinions, supporting documents, and interviews with other witnesses.

(8) Upon the completion of an investigation, the director of enforcement shall present to the executive director a report of investigation (ROI) and a conclusion as to the probability that a violation(s) exists.

(A) If the executive director determines from the ROI that the probability of a violation involving medical judgment or practice exists, the director of enforcement shall forward a copy of the complaint file to the board secretary and another board member (the "veterinarian members") who will determine whether or not the complaint should be closed, further investigation is warranted, or if the licensee should be invited to respond to the complaint at an informal conference at the board offices.

(B) If the probable violation does not involve medical judgment or practice (example: administrative matters such as continuing education and federal and state controlled substances certificates), the executive director shall forward the complaint file to a committee of the executive director, director of enforcement, the investigator assigned to the complaint, and general counsel (the "staff committee"), which shall determine whether or not the complaint should be dismissed, investigated further, or settled.

(C) If the veterinarian members determine that a violation has not occurred, the executive director or director of enforcement shall notify the complainant and licensee in writing of the conclusion and that the complaint is dismissed.

(D) If the veterinarian members conclude that a probable violation(s) exists, the executive director shall invite the licensee in writing to an informal conference to discuss the complaint made against the licensee. If the veterinarian members cannot agree to dismiss or refer the complaint to an informal conference, the complaint will be automatically referred to an informal conference. The letter invitation to the licensee must include a list of the specific allegations of the complaint.

(E) A complaint considered by the staff committee shall be referred to an informal conference if:

(i) the staff committee determines that the complaint should not be dismissed or settled;

(ii) the staff committee is unable to reach an agreed settlement; or

(iii) the licensee who is the subject of the complaint requests that the complaint be referred to an informal conference.

(d) Informal conferences

(1) The informal conference is the last stage in the investigation of a complaint. The licensee has the right to waive his or her attendance at the conference. The licensee may be represented by counsel.

(2) The board may be represented at the informal conference by a conference committee of the executive director, the veterinarian members and a public member of the board (if the complaint involves medical judgment or practice), the director of enforcement, the investigator assigned to the complaint, and the board's general counsel. The complainant and the licensee and the licensee's legal counsel may attend the conference. Any other attendees are allowed at the discretion of the executive director. The executive director or the director of enforcement shall conduct the conference.

(3) Subject to the discretion of the executive director, the following procedure will be followed at the informal conference. The executive director shall explain the purpose of the conference and the rights of the participants, lead the discussion of the allegations of the complaint, and explain the possible courses of action at the conclusion of the conference. The licensee will be asked to respond to the allegations. The complainant will be allowed to make comments relevant to the allegations. Comments of the licensee and complainant must be addressed to the person conducting the conference and not to each other. In the interest of maintaining decorum, the licensee or complainant may be asked to leave the room while the other is talking with the committee. The committee may ask questions of the licensee and complainant in order to fully develop the complaint record.

(4) At the conclusion of the informal conference, the conference committee shall determine if a violation has occurred. If the conference committee determines that a violation has not occurred, the conference committee will dismiss the complaint, and will advise all parties of the decision and the reasons why the complaint was dismissed.

(5) If the conference committee determines that a violation has occurred and that disciplinary action is warranted, the executive director will advise the licensee of the alleged violations and offer the licensee a settlement in the form of an agreed order that specifies the disciplinary action and monetary penalty. With the agreement of the licensee, the conference committee may recommend that the licensee refund an amount not to exceed the amount the complainant paid to the licensee instead of or in addition to imposing an administrative penalty on the licensee. The executive director must inform the licensee that the licensee has a right to a hearing before an administrative law judge on the finding of the occurrence of the violation, the type of disciplinary action, and/or the amount of the recommended penalty.

(6) Within 20 days after the date the licensee receives the settlement offer, the licensee must submit a written response to the board

(A) accepting the settlement offer and recommended disciplinary action, or

(B) requesting a hearing before an administrative law judge.

(7) If the licensee accepts the settlement offer by signing the agreed order, the agreed order will be docketed for board action at the next regularly scheduled board meeting. The board may approve the agreed order as docketed, approve the agreed order with amendments, or reject the agreed order. If the board approves the agreed order with amendments, the executive director shall mail the amended agreed order to the licensee and the licensee shall have fourteen (14) days from receipt to accept the amended agreed order by signing and returning it to the board. If a licensee does not sign an amended agreed order or does not respond within the fourteen (14) days, the complaint will be scheduled for a hearing before an administrative law judge. If the board rejects the agreed order, the complaint may be scheduled for a hearing before an administrative law judge, or the board may direct the executive director to take other appropriate action.

(e) Contested case hearing

(1) If the licensee declines the board's settlement offer, or if the licensee fails to respond timely to the offer, or if the board rejects a proposed agreed order, the investigator of the complaint shall prepare a complaint affidavit containing the allegations against the licensee. The signed and notarized complaint affidavit will then be reviewed by the board's legal counsel and signed by the executive director. The date the executive director signs the complaint affidavit is the official date of filing the complaint affidavit with the board. The complaint affidavit shall serve as the board's pleading in a contested case. At least ten (10) days prior to a scheduled hearing, the complaint affidavit and notice of hearing shall be served on the licensee as set out in subsection (e) (3) (A) of this section.

(2) The executive director shall submit to the State Office of Administrative Hearings (SOAH) a completed Request to Docket Case requesting SOAH to set a hearing and/or assign an administrative law judge to the contested case. The board shall provide notice of the time, date, and place of the hearing to the licensee. Following issuance of a proposal for decision by the administrative law judge, the board by order may find that a violation has occurred and impose disciplinary action, or find that no violation has occurred. The board shall promptly advise the complainant of the board's action.

(3) Notice of SOAH hearing; continuance and default

(A) The board shall send notice of a contested case hearing before SOAH to the licensee's last known address as evidenced by the records of the board. Notice shall be given by first class mail, certified or registered mail, or by personal service.

(B) If the licensee fails to timely enter an appearance or answer the notice of hearing, the board is entitled to a continuance at the time of the hearing. If the licensee fails to appear at the time of the hearing, the board may move either for dismissal of the case from the SOAH docket, or request that the administrative law judge issue a default proposal for decision in favor of the board.

(C) Proof that the licensee has evaded proper notice of the hearing may also be grounds for the board to request dismissal of the case or issuance of a default proposal for decision in favor of the board.

(f) Contingency. The board president shall appoint another licensee board member to assume the duties of the board secretary in the complaint process in the event the board secretary is unable to serve in the capacity set out in this section.

(g) Report to the board of dismissed complaints. The executive director or the director of enforcement shall advise the board at each scheduled meeting of the complaints dismissed since the last meeting. The information will consist of a summary of the allegations, investigation conducted, reasons for dismissal, and file number.

(h) Use of Private Investigators. The executive director may approve the use of private investigators to assist in investigation of complaints where the use of board investigators is not feasible or economical or where private investigators could provide valuable assistance to the board investigators. Private investigators may be utilized in cases involving honesty, integrity and fair dealing; reinstatement applications; solicitation; fraud; dangerous drugs and controlled substances; and practicing veterinary medicine without a license. Private investigators will be utilized in accordance with existing purchasing rules of the Texas Building and Procurement Commission.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 27, 2006.

TRD-200603453

Julie A. Barker

Executive Assistant

Texas Board of Veterinary Medical Examiners

Effective date: July 17, 2006

Proposal publication date: March 10, 2006

For further information, please call: (512) 305-7555


22 TAC §575.31

The Texas Board of Veterinary Medical Examiners ("Board") adopts new section §575.31 concerning Alternative Dispute Resolution (ADR) without change to the proposed text as published in the Texas Register on March 10, 2006 (31 TexReg 1588). The section reflects legislation passed by the 79th Legislature requiring the Board to adopt a policy encouraging the use of ADR in resolving internal and external disputes. The section clearly states this policy, appoints the Board's general counsel as the dispute resolution coordinator to assure that the policy is carried out, and informs the public of the steps that need to be taken to request ADR. Other issues are addressed to insure that the public is fully informed of the new procedures.

No comments were received regarding adoption of the new section.

The section is adopted under the authority of §801.151(a) of the Occupations Code which gives the Board authority to adopt rules necessary to administer the Veterinary Licensing Act, and §801.162 of the Occupations Code which directs the Board to develop and implement a policy to encourage the use of ADR.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 27, 2006.

TRD-200603454

Julie A. Barker

Executive Assistant

Texas Board of Veterinary Medical Examiners

Effective date: July 17, 2006

Proposal publication date: March 10, 2006

For further information, please call: (512) 305-7555


22 TAC §575.32

The Texas Board of Veterinary Medical Examiners ("Board") adopts new §575.32 concerning Negotiated Rulemaking without change to the proposed text as published in the Texas Register on March 10, 2006 (31 TexReg 1589). The section reflects legislation passed by the 79th Legislature requiring the Board to adopt a policy encouraging the use of negotiated rulemaking in adopting Board rules. The section clearly states this policy, appoints the Board's general counsel as the negotiated rulemaking coordinator to assure that the policy is carried out, and informs the public of the steps that need to be taken to implement the policy in a given situation.

No comments were received regarding adoption of the new section.

The section is adopted under the authority of §801.151(a) of the Occupations Code which gives the Board authority to adopt rules necessary to administer the Veterinary Licensing Act, and §801.162 of the Occupations Code which directs the Board to develop and implement a policy to encourage the use of negotiate rulemaking.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 27, 2006.

TRD-200603455

Julie A. Barker

Executive Assistant

Texas Board of Veterinary Medical Examiners

Effective date: July 17, 2006

Proposal publication date: March 10, 2006

For further information, please call: (512) 305-7555


Chapter 577. GENERAL ADMINISTRATIVE DUTIES

Subchapter A. BOARD MEMBERS AND MEETINGS--DUTIES

22 TAC §577.2

The Texas Board of Veterinary Medical Examiners adopts amendments to §577.2 concerning Meetings without change to the proposed text as published in the Texas Register on March 10, 2006 (31 TexReg 1590). The amended section governs the conduct of the Board's meetings. The section is changed to allow the Board to efficiently conduct its meeting by allowing it to direct the location and placement of equipment in the meeting room, while ensuring the public's right to record or videotape a Board proceeding without undue restrictions.

No comments were received regarding adoption of the amended section.

The amendments are adopted under the authority of §801.151(a) of the Texas Occupations Code which gives the Board authority to adopt rules necessary to administer the Veterinary Licensing Act and §551.023 of the Government Code which authorizes agencies to adopt reasonable rules for the placement of recording equipment and the manner in which the recording is conducted.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 27, 2006.

TRD-200603456

Julie A. Barker

Executive Assistant

Texas Board of Veterinary Medical Examiners

Effective date: July 17, 2006

Proposal publication date: March 10, 2006

For further information, please call: (512) 305-7555


Part 29. TEXAS BOARD OF PROFESSIONAL LAND SURVEYING

Chapter 661. GENERAL RULES OF PROCEDURES AND PRACTICES

Subchapter D. APPLICATIONS, EXAMINATIONS, AND LICENSING

22 TAC §661.52

The Texas Board of Professional Land Surveying (TBPLS) adopts new §661.52, concerning Inactive Status, without changes to the proposed text as published in the February 3, 2006, issue of the Texas Register (31 TexReg 645) and will not be republished.

The new rule will clarify the procedures for implementing §1071.263 of the Professional Land Surveying Practices Act.

No comments were received regarding the new rule.

The new rule is adopted pursuant to §1071.151, Title 6, Occupations Code, Subtitle C, which authorizes the Board to adopt and enforce reasonable and necessary rules to perform its duties and to comply with Sunset Commission requirements.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 26, 2006.

TRD-200603444

Sandy Smith

Executive Director

Texas Board of Professional Land Surveying

Effective date: July 16, 2006

Proposal publication date: February 3, 2006

For further information, please call: (512) 239-5263


22 TAC §661.55

The Texas Board of Professional Land Surveying (TBPLS) adopts new §661.55, concerning Surveying Firms, without changes to the proposed text as published in the March 3, 2006, issue of the Texas Register (31 TexReg 1408) and will not be republished.

The new rule will clarify §1071.352 and §1071.353 regarding the responsibility of firms offering land surveying services.

No comments were received regarding the new rule.

The new rule is adopted pursuant to §1071.151, Title 6, Occupations Code, Subtitle C, which authorizes the Board to adopt and enforce reasonable and necessary rules to perform its duties and to comply with Sunset commission requirements.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 26, 2006.

TRD-200603445

Sandy Smith

Executive Director

Texas Board of Professional Land Surveying

Effective date: July 16, 2006

Proposal publication date: March 3, 2006

For further information, please call: (512) 239-5263


Subchapter E. CONTESTED CASES

22 TAC §661.63

The Texas Board of Professional Land Surveying (TBPLS) adopts a new rule §661.63, concerning Frivolous Complaints, without changes to the proposed text as published in the February 3, 2006, issue of the Texas Register (31 TexReg 646) and will not be republished.

The new rule will clarify the definition of frivolous and harassment as used in §1071.204(f) of the Professional Land Surveying Practices Act.

No comments were received regarding the new rule.

The new rule is adopted pursuant to §1071.151, Title 6, Occupations Code, Subtitle C, which authorizes the Board to adopt and enforce reasonable and necessary rules to perform its duties and to comply with Sunset Commission requirements.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 26, 2006.

TRD-200603442

Sandy Smith

Executive Director

Texas Board of Professional Land Surveying

Effective date: July 16, 2006

Proposal publication date: February 3, 2006

For further information, please call: (512) 239-5263


Chapter 663. STANDARDS OF RESPONSIBILITY AND RULES OF CONDUCT

Subchapter B. PROFESSIONAL AND TECHNICAL STANDARDS

22 TAC §663.18

The Texas Board of Professional Land Surveying (TBPLS) adopts an amendment to §663.18, concerning Certification, without changes to the proposed text as published in the February 3, 2006, issue of the Texas Register (31 TexReg 647) and will not be republished. This section identifies what the registered land surveyor can certify to.

The amendment will further clarify what the surveyor may certify to.

No comments were received regarding adoption of the amendment.

The amendment is adopted pursuant to §1071.151, Title 6, Occupations Code, Subtitle C, which authorizes the Board to adopt and enforce reasonable and necessary rules to perform its duties.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 26, 2006.

TRD-200603443

Sandy Smith

Executive Director

Texas Board of Professional Land Surveying

Effective date: July 16, 2006

Proposal publication date: February 3, 2006

For further information, please call: (512) 239-5263


Part 31. TEXAS STATE BOARD OF EXAMINERS OF DIETITIANS

Chapter 711. DIETITIANS

22 TAC §§711.1 - 711.3, 711.6 - 711.8, 711.12, 711.14, 711.17, 711.19

The Texas State Board of Examiners of Dietitians (board) adopts amendments to §§711.1 - 711.3, 711.6 - 711.8, 711.12, 711.14, 711.17, and 711.19, concerning the licensure and regulation of dietitians. Section 711.3 is adopted with changes to the proposed text as published in the January 13, 2006, issue of the Texas Register (31 TexReg 231). Sections 711.1, 711.2, 711.6 - 711.8, 711.12, 711.14, 711.17, and 711.19 are adopted without changes, and the sections will not be republished.

The amendments are adopted pursuant to statutory changes to the Occupations Code, Chapter 701, regarding House Bill 1155, passed during the 79th Legislature, 2005. Each section was reviewed in order to ensure clarity; to ensure that the rules reflect current legal, policy, and operational considerations; to ensure accuracy; to improve draftsmanship; and to make the rules more accessible, understandable, and usable, to the extent possible.

SECTION BY SECTION SUMMARY

The amendment to §711.1 reflects the current name of the agency.

The amendment to §711.2 clarifies travel reimbursement for board members and the process for the election of presiding officers of the board.

The amendment to §711.3 adds new language that allows hospital dietitians to take/transcribe dietary and parental nutrition orders under the provision of protocols approved by the governing bodies of these institutions.

The amendment to §711.6(g)(3) specifies the examination is the "licensing" examination.

Section 711.6(h) was deleted because the subsection is a duplicate rule to §711.6(b).

The amendment to §711.7 adds new language to require the Texas Jurisprudence Exam.

The amendment to §711.8 adds language regarding failure to show proof of the Texas Jurisprudence exam will be reason for disapproval of a license. Also, procedures for processing applications increased from 14 working days to 20 working days.

Regarding §711.12(7), new language was added to allow refusal to renew for non-payment of an administrative penalty imposed under the Act.

The amendment to §711.14 clarifies the maximum amount an administrative penalty may be per violation, per day and the ability to issue a cease and desist order.

The amendment to §711.17 adds new language to require the Texas Jurisprudence Exam for licensure renewal.

New language was added to §711.19 to allow the board to order a license holder to issue a refund to a consumer resulting from an informal conference instead of or in addition to an administrative penalty.

COMMENTS

Comment: Regarding §711.3, sixty commenters support the rule because they believe that the rule is within a licensed dietitian's scope of practice and that it clearly defines the settings, situations, and circumstances in which a licensed dietitian may accept a physician's verbal order and order lab tests consistent with medical direction or authorization.

Response: The board agrees with the commenters that §711.3(c)(2) and (3) should be adopted in that the rule serves to more clearly define a licensed dietitian's scope of practice, not expand it. The board also notes that several of the commenters originally proposed the rule to the committee through a Petition for Rulemaking. No change was made as a result of this comment.

Comment: Regarding §711.3(c)(2) and (3), one commenter, the Texas Medical Association, opposed the rule claiming that the rule is not based upon current authority contained in the Act that regulates dietitians. Additionally, the commenter notes that the fact that the Texas Legislature failed to pass similar legislation is evidence that the legislature did not intend for dietitians to have such authority.

With regard to §711.3(c)(2), the commenter complains that medication orders and medical protocols are not within the realm of the dietitian and should not be added by rule.

With regard to §711.3(c)(3), the commenter argues that the term "medical nutrition therapy" is not defined and that the definition appears on its face to permit the exercise of medical act and judgment neither of which are permitted the dietitian by statute.

Response: The board disagrees and believes that the rule provides greater clarity and definition to the scope of practice of licensed dietitians as contemplated by Occupations Code, Chapter 701, as well as, mirrors current health care practice settings which involve therapeutic diet orders are being issued in one of three ways: physician delegation; verbal orders; or hospital nutrition order writing protocol or policy.

Additionally, the board believes that it has the general legal authority under Occupations Code, §701.152 to adopt rules to clarify and further define the statutory provisions for which it is responsible notwithstanding the failure of the legislature to pass similar legislation during the 79th legislative session.

The board believes that §711.3(c)(2) which would allow a dietitian to "accept, transcribe into a patient's medical record, and transmit to another authorized health care professional, the verbal or electronically transmitted orders of a physician relating to the implementation or provision of medical nutrition therapy or other related protocols for an individual patient or group of patients" is within the scope of practice of a licensed dietitian, and has in fact been common practice in this state and the nation in ESRD facilities and hospitals. Such practice is approved by other credentialing and regulatory bodies such as the Joint Commission on Accreditation of Health Organization ("JCAHO") and the Centers for Medicare and Medicaid Services ("CMS"). Second, all of the acts by a licensed dietitian under this rule are to be performed only in accordance with the Medical Practice Act and the rules of the Texas Medical Board, and consistent with medical direction or authorization. Third, the rule has the additional limitations in that it relates only to "the acts of "accepting, transcribing...and transmitting, and, only to those orders relating to "the implementation or provision of medical nutrition therapy." Fourth, the Texas Board of Nurses does not consider it a violation of the Nurse Practice Act for a nurse to receive and act upon a physician's medication treatment order when that order is relayed to the nurse through another person acting as the agent of the physician.

The board believes that §711.3(c)(3) which would allow a licensed dietitian, "acting within the scope of his or her license and consistent with medical direction or authorization, to order medical laboratory tests relating to the implementation or provision of medical nutrition therapy and related medical protocols for individual patients or groups of patients", is within the scope of practice of a licensed dietitian. Contrary to the commenter's suggestion that the rule would allow a licensed dietitian to diagnose and treat patients without a physician ever seeing the patient, the subsection has a built-in safeguard in that the medical direction or authorization shall be provided through "a physician's order, or a standing medical order; or standing delegation order; or medical protocol."

Although the subsection does not define the term "medical nutrition therapy", the term is understood in the profession and in the medical fields in nutrition as a commonly used form of therapy, such as in end stage renal disease facilities. Significantly, the term is defined in the federal Social Security Act, which authorizes Medicare reimbursement of registered dietitians for "medical nutrition therapy" in the treatment of certain diseases.

Section 711.3(c)(3) speaks only to the performance of specific acts, which are to be performed only upon the authorization of a physician(s) in accordance with the Medical Practice Act and Texas Medical Board rules. No change was made as a result of this comment.

The Department of State Health Services staff, on behalf of the board, provided a comment concerning the proposal.

Change: Concerning §711.3(c)(2), first sentence, the word "patent" was corrected to the word "patient" to read "an individual patient".

STATUTORY AUTHORITY

The amendments are authorized by Occupations Code, §701.152, which authorizes the board to adopt rules necessary for the performance of the board's duties.

§711.3.The Profession of Dietetics.

(a) The rules relating to the profession of dietetics shall be to establish the standards of professional and ethical conduct required of a licensee.

(b) Dietetics. The profession of dietetics includes six primary areas of expertise: clinical, educational, management, consultation, community and research; and includes without limitation the development, management, and provision of nutrition services, as follows:

(1) planning, developing, controlling, and evaluating food service systems;

(2) coordinating and integrating clinical and administrative aspects of dietetics to provide quality nutrition care;

(3) establishing and maintaining standards of food production, service, sanitation, safety, and security;

(4) planning, conducting, and evaluating educational programs relating to nutrition care;

(5) developing menu patterns and evaluating them for nutritional adequacy;

(6) planning layout designs and determining equipment requirements for food service facilities;

(7) developing specifications for the procurement of food and food service equipment and supplies;

(8) developing and implementing plans of nutrition care for individuals based on assessment of nutrition needs;

(9) counseling individuals, families, and groups in nutrition principles, dietary plans, and food selection and economics;

(10) communicating appropriate diet history and nutrition intervention data through medical record systems;

(11) participating with physicians and allied health personnel as the provider of nutrition care;

(12) planning, conducting or participating in, and interpreting, evaluating, and utilizing pertinent current research related to nutrition care;

(13) providing consultation and nutrition care to community groups and identifying and evaluating needs to establish priorities for community nutrition programs;

(14) publishing and evaluating technical and lay food and nutrition publications for all age, socioeconomic, and ethnic groups;

(15) planning, conducting, and evaluating dietary studies and participating in nutrition and epidemiologic studies with a nutrition component.

(c) Provider of nutrition services.

(1) A person licensed by the board is designated as a health care provider of nutrition services.

(2) A licensed dietitian, acting within the scope of his or her license and consistent with medical direction or authorization as provided in this section, may accept, transcribe into a patient's medical record or transmit verbal or electronically-transmitted orders, including medication orders, from a physician to other authorized health care professionals relating to the implementation or provision of medical nutrition therapy and related medical protocols for an individual patient or group of patients. In a licensed health facility, the medical direction or authorization shall be provided, as appropriate, through a physician's order, or a standing medical order, or standing delegation order, or medical protocol issued in accordance with Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter. In a private practice setting, the medical direction or authorization shall be provided, as appropriate, through the physician's order, standing medical order, or standing delegation order of a referring physician, in accordance with Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter.

(3) A licensed dietitian, acting within the scope of his or her license and consistent with medical direction or authorization as provided in this section, may order medical laboratory tests relating to the implementation or provision of medical nutrition therapy and related medical protocols for individual patients or groups of patients. In a licensed health facility, the medical direction or authorization shall be provided, as appropriate, through a physician's order, or a standing medical order, or standing delegation order, or medical protocol, issued in accordance with Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter. In a private practice setting, the medical direction or authorization shall be provided through the physician's order, standing medical order, or a standing delegation order of the referring physician, in accordance with Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter.

(d) Code of ethics. These rules shall constitute a code of ethics as authorized by the Act, §701.151.

(1) Professional representation and responsibilities.

(A) A licensee shall conduct himself/herself with honesty, integrity and fairness.

(B) A licensee shall not misrepresent any professional qualifications or credentials. A licensee shall not knowingly or recklessly make any false or misleading claims about the efficacy of any nutrition services or dietary supplements.

(C) A licensee shall not permit the use of his/her name for the purpose of certifying that nutrition services have been rendered unless that licensee has provided or supervised the provision of those services.

(D) A licensee shall not promote or endorse products in a manner that is false or misleading.

(E) A licensee shall disclose to a client, a person supervised by the licensee, or an associate any personal gain or profit from any item, procedure, or service used by the licensee with the client, supervisee, or associate.

(F) A licensee shall maintain knowledge and skills required for professional competence. A licensee shall provide nutrition services based on scientific principles and current information. A licensee shall present substantiated information and interpret controversial information without bias.

(G) A licensee shall not abuse alcohol or drugs in any manner which detrimentally affects the provision of nutrition services.

(H) A licensee shall comply with the provisions of the Texas Controlled Substances Act, the Health and Safety Code, Chapter 481 and Chapter 483 relating to dangerous drugs; and any rules of the department or the Texas State Board of Pharmacy implementing those chapters.

(I) A licensee shall have the responsibility of reporting alleged misrepresentations or violations of board rules to the board's executive secretary.

(J) A licensee shall comply with any order relating to the licensee which is issued by the board.

(K) A licensee shall not aid or abet the practice or misrepresentation of an unlicensed person when that person is required to have a license under the Act.

(L) A licensed dietitian shall supervise a provisional licensed dietitian in accordance with §711.9 of this title (relating to Provisional Licensed Dietitians).

(M) A licensee shall not make any false, misleading, or deceptive claims in any advertisement, announcement, or presentation relating to the services of the licensee, any person supervised by the licensee or any dietary supplement.

(N) A licensee shall conform to generally accepted principles and standards of dietetic practice which are those generally recognized by the profession as appropriate for the situation presented, including those promulgated or interpreted by or under the association or commission, and other professional or governmental bodies. A licensee shall recognize and exercise professional judgement within the limits of his/her qualifications and collaborate with others, seek counsel, or make referrals as appropriate.

(O) A licensee shall not interfere with an investigation or disciplinary proceeding by willful misrepresentation of facts to the board or its authorized representative or by the use of threats or harassment against any person.

(2) Professional relationships.

(A) A licensee shall make known to a prospective client the important aspects of the professional relationship including fees and arrangements for payment which might affect the client's decision to enter into the relationship. A licensee shall bill a client or a third party in the manner agreed to by the licensee and in accordance with state and federal law.

(B) A licensee shall not receive or give a commission or rebate or any other form of remuneration for the referral of clients for professional services.

(C) A licensee shall disclose to clients any interest in commercial enterprises which the licensee promotes for the purpose of personal gain or profit.

(D) A licensee shall take reasonable action to inform a client's physician and any appropriate allied health care provider in cases where a client's nutritional status indicates a change in medical status.

(E) A licensee shall provide nutrition services without discrimination based on race, creed, gender, religion, national origin, or age.

(F) A licensee shall not violate any provision of any federal or state statute relating to confidentiality of client communication and/or records. A licensee shall protect confidential information and make full disclosure about any limitations on his/her ability to guarantee full confidentiality.

(G) A licensee shall not engage in sexual contact with a client. The term "sexual contact" means any type of sexual behavior described in the Texas Penal Code, Chapters 21, 22, or 43, and includes sexual intercourse. A licensee shall not engage in sexual harassment in connection with professional practice.

(H) A licensee shall terminate a professional relationship when it is reasonably clear that the client is not benefiting from the services provided.

(I) A licensee shall not provide services to a client or the public if by reason of any mental or physical condition of the licensee, the services cannot be provided with reasonable skill or safety to the client or the public.

(J) A licensee shall not provide any services which result in mental or physical injury to a client or which create an unreasonable risk that the client may be mentally or physically harmed.

(K) A licensee shall provide sufficient information to enable clients and others to make their own informed decision.

(L) A licensee shall be alert to situations that might cause a conflict of interest or have the appearance of a conflict. A licensee shall make full disclosure when a real or potential conflict of interest arises.

(3) Supervision of provisional licensed dietitian. A licensed dietitian shall adequately supervise a provisional licensed dietitian or a temporary licensed dietitian for whom the licensee has assumed supervisory responsibility.

(4) Billing information required; prohibited practices.

(A) On the written request of a client, a client's guardian, or a client's parent, if the client is a minor, a licensee shall provide, in plain language, a written explanation of the charges for client nutrition services previously made on a bill or statement for the client. This requirement applies even if the charges are to be paid by a third party.

(B) A licensee may not persistently or flagrantly overcharge or overtreat a client.

(5) Sanctions. A licensee shall be subject to disciplinary action by the board if under the Crime Victims Compensation Act, Texas Code of Criminal Procedure, Article 56.31, the licensee is issued a public letter of reprimand, is assessed a civil penalty by a court, or has been convicted and ordered to pay court costs under the Crime Victims Compensation Act, Texas Code of Criminal Procedure, Chapter 56, Subchapter B, Article 56.55.

(e) Disclosure.

(1) A licensee shall make a reasonable attempt to notify each client of the name, mailing address, and telephone number of the board for the purpose of directing complaints to the board by providing notification:

(A) on each written contract for services of a licensee;

(B) on a sign prominently displayed in the primary place of business of each licensee; or

(C) in a bill for service provided by a licensee to a client or third party.

(2) A provisional licensed dietitian must include the name and telephone number of his or her supervisor in all advertising and announcements of services including business cards and applications for employment.

(f) Unlawful, false, misleading, or deceptive advertising.

(1) A licensee shall use factual information to inform the public and colleagues of his/her services. A licensee shall not use advertising that is false, misleading, or deceptive or that is not readily subject to verification.

(2) False, misleading, or deceptive advertising or advertising that is not readily subject to verification includes advertising that:

(A) makes a material misrepresentation of fact or omits a fact necessary to make the statement as a whole not materially misleading;

(B) makes a representation likely to create an unjustified expectation about the results of a health care service or procedure;

(C) compares a health care professional's services with another health care professional's services unless the comparison can be factually substantiated;

(D) contains a testimonial;

(E) causes confusion or misunderstanding as to the credentials, education, or licensure of a health care professional;

(F) advertises or represents that health care insurance deductibles or copayments may be waived or are not applicable to health care services to be provided if the deductibles or copayments are required;

(G) advertises or represents that the benefits of a health benefit plan will be accepted as full payment when deductibles or copayments are required;

(H) makes a representation that is designed to take advantage of the fears or emotions of a particularly susceptible type of patient; or

(I) advertises or represents in the use of a professional name a title or professional identification that is expressly or commonly reserved to or used by another profession or professional.

(3) A "health care professional" includes a licensed dietitian, provisional licensed dietitian, temporary licensed dietitian, or any other person licensed, certified, or registered by the state in a health-related profession.

(g) Applicants. A violation of any provision of subsection (d) of this section by a person who is an applicant or who subsequently applies for a license (even though the person was not a licensee at the time of the violation) may be a basis for disapproval of the application under §711.8(e)(7) of this title (relating to Determination of Eligibility).

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 3, 2006.

TRD-200603581

Ralph McGahagin

Chair

Texas State Board of Examiners of Dietitians

Effective date: July 23, 2006

Proposal publication date: January 13, 2006

For further information, please call: (512) 458-7111 x6972