delegation, On the Job, Scope of Practice

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.

14 thoughts on “Clinical Task Delegation in Iowa”

  1. Not to be a devils advocate, but I’m just curious. I’ve been retired many years. In regard to the above situation…..many Medical Assistants are IV trained and state allowed. LPNs are not always IV certified. In the above situation would the properly trained medical assistant be allowed to do an IV when a given LPN was not qualified? Being in the RN supervised scenario.

    Thank you
    Susan Mattern
    New Mexico

      1. I have a MA student who is working in a urology clinic. She is asking if she received proper training, Would it be permissible for her straight cath patients in the clinic setting. I didn’t know the answer to this. Can you help?

  2. So the rule is we can not delegate to CMA if a LPN can not perform the task. My question is, if we have specific standing orders that state a CMA can refill these HTN etc medications if these certain parameters are met otherwise it needs sent to provider or RN to fill, Can we legally do this?

    1. Thank you for your question. It is my legal opinion that the delegating/overseeing licensed provider (or another licensed provider or licensed health professional) should verify the medication/prescription order before it becomes actionable and may be transmitted—even if the standing order contains parameters that must be met for the order to be drafted.

      I hope this is helpful.

      Donald A Balasa JD MBA
      CEO and House Legal Counsel
      American Association of Medical Assistants

    1. I have done the necessary research of the Iowa statutes, and the regulations and policies of the Iowa Board of Nursing. I cannot find language that specifically addresses which individuals are permitted to supervision nurses.

      Absent specific language, I invoke common law principles to render an opinion. It is my legal opinion that, under Iowa common law, medical assistants are not permitted to perform clinical supervision over RNs and LPNs. However, it is also my opinion that Iowa common law would permit medical assistants to exercise administration and non-clinical supervision over nurses, such as in the areas of scheduling, dress code, punctuality, and abiding by administrative policies.

      I hope this is helpful.

      Donald A Balasa JD MBA
      CEO and House Legal Counsel
      American Association of Medical Assistants

  3. I have tried to find direct language, but am failing. Is it possible to for an RN to delegate enteral feeding of formula via a PEG tube to a UAP in a home setting. Not a long term care or group home setting. Thanks for your feedback.

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