Clinical Task Delegation in Iowa

I received the following question from a clinical quality practice leader in Iowa regarding medical assistants performing clinical tasks in inpatient settings. These types of questions are increasing because of the need to use medical assistants more extensively during the COVID-19 crisis.

I am a registered nurse [RN] and the clinical quality practice leader at a multi-clinic system in Iowa. We are accredited under The Joint Commission accreditation standards for hospitals. In working through pandemic surge planning, the question surfaced regarding the use of medical assistants in a supporting role in the inpatient setting. Would it be within the scope of a medical to perform certain clinical tasks based on a physician’s order and under the supervision of an RN?

To answer this question, note the following from the rules of the Iowa Board of Nursing (Chapter 6: “Nursing Practice for Registered Nurses/Licensed Practical Nurses”):

655—6.2(152) Minimum standards of nursing practice for registered nurses.

…

6.2(5) The registered nurse shall recognize and understand the legal implications of accountability. Accountability includes but need not be limited to the following:

…

c. Using professional judgment in assigning and delegating activities and functions to unlicensed assistive personnel. Activities and functions which are beyond the scope of practice of the licensed practical nurse may not be delegated to unlicensed assistive personnel.

Unlicensed assistive personnel (UAP) are defined in the Iowa nursing law as follows:

655—6.1(152) Definitions.

…

“Unlicensed assistive personnel” is an individual who is trained to function in an assistive role to the registered nurse and licensed practical nurse in the provision of nursing care activities as delegated by the registered nurse or licensed practical nurse.

Medical assistants are considered UAP when functioning in an assistive role to RNs, often in inpatient settings.

The legality of RNs delegating clinical tasks to medical assistants is determined by the answers to the following two questions:

1. Are these tasks within the scope of practice of licensed practical nurses (LPNs) under Iowa law? If not, the tasks are not delegable to any UAP, including medical assistants.
2. Does the performance of these tasks require the exercise of independent clinical judgment or the making of independent clinical assessments or evaluations? If so, the tasks are not delegable to any UAP, including medical assistants.

If the medical assistant is competent and knowledgeable in these tasks, my legal opinion is that Iowa law does not forbid the delegation of these tasks to competent medical assistants working under RN direct/on-site supervision.

It may also be prudent to ask the malpractice insurance carrier for the health system whether it would cover any negligence by a UAP (such as a medical assistant) in performing these tasks.

The clinical quality practice leader followed my advice and asked the malpractice insurance carrier. This was the insurer’s response:

Tasks legally delegable to unlicensed assistive personnel may be delegated to medical assistants by the chief nursing officer, and supervision would have to be exercised by a registered nurse. The list of delegated tasks, the required competencies, and the dates the competencies were assessed and periodically reassessed must be in writing.

The medical assistants must report to the supervising RN if there is an emergency.

Our insurance will provide coverage for medical assistants performing these tasks, but we request the role be clearly delegated and documented as above.

Permissible Delegation to Medical Assistants in Response to COVID-19

In light of COVID-19, I am receiving many questions about changes in the scope of practice of medical assistants resulting from executive orders of governors and emergency legislation. The following example of a state-based question (New Hampshire) on medical assisting scope of practice serves as a blueprint for other state-based scope of practice questions.

“My employer is sending me to the hospital to work as an aid under the direction of nurses given the COVID-19 crisis. Is this going to get me in trouble? Can they do this?”

Medical assistants are “unlicensed assistive personnel” under the New Hampshire nursing law, and according to the rules of the New Hampshire Board of Nursing:

(b)  For nursing related tasks involving assistance with or the administration of medication, the following persons shall be eligible to be delegatees:

(1)  Any currently licensed RN [registered nurse] and APRN [advanced practice registered nurse];

(2)  Any currently licensed LPN [licensed practical nurse], only when:

a.  The method of medication administration is not intravenous; or

b.  The method of medication administration is intravenous and the LPN is in compliance with Nur 604.01 (b) and (c);

(3)  Unlicensed assistive personnel who have competency to perform the specific task to be delegated; [emphasis added]

If your state has similar legislation, then this New Hampshire example can apply to you too. For instance, Arizona nursing law says that medical assistants are permitted to work as “unlicensed assistive personnel” who can be delegated tasks by an RN or LPN.

Check with the AAMA State Scope of Practice Laws webpage to find key legislative materials for your state.

Medical Assistants’ Role in RPM Services

Medical assistants meet the criteria for clinical staff for several well-known programs (the Medicare Chronic Care Management (CCM) and Transitional Care Management (TCM) programs and the Medicare appropriate use criteria program for advanced diagnostic imaging services). But what is medical assistants’ scope of practice for other services, such as remote physiologic monitoring (RPM) services?

To answer this question, review relevant information from the Centers for Medicare & Medicaid Services (CMS) on Current Procedural Terminology (CPT) code structure and several general legal principles presented in the March/April 2020 Public Affairs article, “Medical Assistants’ Role in Remote Physiologic Monitoring Services,” on the AAMA website.

Meeting the Standard of Care

Whether you are a referral coordinator or a medical assisting professional, knowing when the standard of care has been met within the process of a referral from a primary care physician to a specialist is valuable. I recently received the following question on that matter:

When referrals are processed in an [outpatient] setting from a patient’s [primary care physician] to a specialist, at what point is the legal standard of care met? Is it when [the primary care physician] gets a written response from [the specialist] ([e.g., “the patient] is scheduled on this date at this time”)? Or [is the standard of care met] when the [primary care physician] receives an actual chart note from the referred specialist?

… Also, are the rules the same for follow-up [on] diagnostic orders?

My legal opinion is that the standard of care for the primary care physician has not been met until (1) the primary care physician receives official notice that the patient has been seen by the specialist or (2) the specialist has declined the referral. As I see it, the primary care physician has a legal duty to take appropriate action vis-à-vis the patient if the specialist does not agree to see the patient.

Moreover, until actual results are obtained, the order is still considered to be in process.

The same legal principles would apply to diagnostic orders.

The AAMA Protects the Medical Assisting Right to Practice

The American Association of Medical Assistants® (AAMA) engages in state and federal advocacy to protect patients from substandard medical assisting services. This objective is achieved by drafting legislation and regulations that ensure that potentially patient-jeopardizing tasks are delegable to only knowledgeable and competent medical assistants who meet the following three standards:

• Have completed education of appropriate and adequate depth, breadth, and rigor
• Have been awarded an accredited credential—such as the CMA (AAMA)®—that measures required medical assisting knowledge and its application
• Have demonstrated continuing competence by periodic recertification

As a result of accomplishing this objective, knowledgeable and competent medical assistants are differentiated in law from other medical assistants.

As part of the AAMA mission, AAMA staff monitor and pursue advocacy opportunities on the federal and state levels that are most strategically advantageous. The following are some examples of AAMA advocacy that have increased patient protection by requiring medical assistants to have appropriate as well as adequate education and/or credentialing.

Arizona

In 2017, AAMA staff urged the Arizona Medical Board (AMB) to more precisely define approved medical assistant program in its delegation rules. The AMB saw the wisdom of the AAMA position and changed the wording of its regulations.

North Dakota

Because of a 2004 ruling by the North Dakota attorney general, medical assistants were no longer permitted to be delegated and perform medication administration. Partly through the efforts of AAMA staff, medication assistant regulations were amended to permit medical assistants who had completed an accredited program and held an accredited medical assisting credential to be delegated certain types of medication administration.

CMS meaningful use requirements of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs

The initial set of proposed rules published by the Centers for Medicare & Medicaid Services (CMS) in 2010 to implement the computerized provider order entry (CPOE) requirements of the Medicare and Medicaid EHR Incentive Programs allowed only “licensed health care professionals” to enter orders into the CPOE system for meaningful use calculation purposes. Staff of the AAMA petitioned CMS to recognize “credentialed medical assistants,” as well as licensed professionals, for meaningful use order entry. In 2012, CMS was persuaded and changed the wording of its final rule to include “credentialed medical assistants.” This was the first time that credentialed medical assistants were distinguished from noncredentialed medical assistants in federal law.

For more information on these achievements, read the Public Affairs articles “Comments to the Arizona Medical Board” (November/December 2017), “North Dakota CMAs regain injections” (September/October 2005), and “AAMA triumphs in CMS order entry rule” (November/December 2012) in past CMA Today issues.