Delegation of COVID-19 Vaccinations in Oregon: Part I

I recently received the following question regarding the delegation of COVID-19 vaccinations in Oregon:

I am a public health registered nurse [RN]. I represent the Oregon Health Authority COVID-19 Recovery and Response Unit. Under Oregon law, may an RN delegate to medical assistants the administration of COVID-19 vaccinations? I found the following in Oregon nursing law which would seem to indicate that the answer is no:

Authorized Duties and Standards for Certified Medication Aide (CMA)

…

(4) A CMA may not administer medications by the following routes:

…

(c) Intramuscular;

[Another division of Oregon nursing law says something similar:]

Division 47

Standards for Community-Based Care Registered Nurse Delegation Process

…

(11) The Registered Nurse may not delegate the administration of medications by the intramuscular route

Certified medication aides are very different from medical assistants. The RN who contacted me is correct in stating that Division 47 of the Oregon Board of Nursing regulations does not permit RNs to delegate to certified medication aides the administration of intramuscular injections. Whether RNs are permitted by Oregon law to delegate to medical assistants the administration of intramuscular injections, however, is a different legal question.

Furthermore, Division 47 addresses community-based care settings. Note the following language from the Division 47 “Rule Summary, Statement of Purpose and Intent”:

(1) These rules apply only in settings where a Registered Nurse is not regularly scheduled and not available to provide direct supervision [italics added]. These are home and community-based settings as described in OAR 851-047-0010(6) and local corrections, lockups, juvenile detention, youth corrections, detoxification facilities, adult foster care and residential care, training and treatment facilities as described in ORS 678.150(9).

(2) These rules have no application in acute care or long-term care facilities or any setting where the regularly scheduled presence of a registered nurse is required by statute or administrative rule.

Therefore, my legal position is that Division 47 does not answer the question of whether RNs are permitted to delegate to medical assistants the administration of COVID-19 vaccinations in a vaccination clinic when the RNs are on the premises and immediately available.

Stay tuned for part II of this discussion, in which I will examine language in Oregon nursing law that allows RNs to delegate to medical assistants the administration of intramuscular injections.

Medical Assistants Deserve COVID-19 Vaccinations as Health Care Workers

I recently received notice of difficulties scheduling COVID-19 vaccinations appointments for health care professionals:

I had an appointment [to receive] a COVID-19 vaccine [in February] and was just notified today by Publix Pharmacy per their corporate office that frontline health care workers needed to have a Florida license number.

I tried to explain that [medical assistants] in the state of Florida are not required to have a medical license and that [medical assistants] work under the supervision of the physician.

Still, my appointment was canceled due to the fact that I do not have a state license. I have already sent an email to Publix’s customer care department and included a link that explains what a medical assistant is and does.

I am not certain if any other medical assistants (credentialed or not) have encountered this same issue with trying to obtain COVID-19 vaccination appointments as frontline health care workers at Publix or other pharmacies. I am simply passing this information on in the event that others have encountered the same issues.

This was the first medical assistant to report this issue to me, and they did all the right things. Medical assistants may use this as a model for what to do if denied the COVID-19 vaccination for not having a license number.

In this situation, medical assistants may also want to suggest to the pharmacy staff that they go to the AAMA website and navigate to the State Scope of Practice Laws webpage, where they will find the medical assisting law for all states.

COVID-19 Vaccination in New Jersey

On January 6, 2021, the New Jersey Department of Health issued an executive directive stating that health care providers, including ancillary health care personnel, are “authorized to administer COVID-19 vaccines that are approved or authorized by the FDA [U. S. Food and Drug Administration] at any vaccination site established within the state” as long as the health care providers are trained in and are competent in administering COVID-19 vaccinations. 

My legal opinion is that ancillary health care personnel, which fall within the directive’s definition of health care providers, include knowledgeable and competent medical assistants. 

COVID-19 Vaccination in Maryland

On January 1, 2021, the Maryland Department of Health issued an amended directive and order that, in part, permits certain individuals to administer COVID-19 vaccinations:

The following individuals may administer COVID-19 vaccines at vaccination sites: 

…

D. Other individuals provided that:

a. Each individual has successfully completed training on the administration ofCOVID-19 vaccines;

b. Qualified supervisory personnel at the vaccination site reasonably determine that each individual is able to administer COVID-19 vaccines under appropriate supervision; and

c. The individual administers the COVID-19 vaccine at the vaccination site under the reasonable supervision of qualified supervisory personnel. 

My legal opinion is that this category of individuals allowed to administer COVID-19 vaccinations includes knowledgeable and competent medical assistants who have completed training on the administration of COVID-19 vaccines. 

Connecticut COVID-19 Crisis Necessitates Medical Assistants Administering Vaccinations

On Monday, December 14, the AAMA and its Connecticut Society of Medical Assistants, in conjunction with the Fairfield and Hartford County Medical Associations, sent Connecticut Governor Ned Lamont a letter asking him to issue an executive order allowing knowledgeable and competent medical assistants to administer COVID-19 vaccinations under the authority and supervision of licensed providers. Read the full letter here: 

Dear Governor Lamont: 

I am writing on behalf of the American Association of Medical Assistants^® (AAMA), the national professional society representing over 80,000 members and CMAs (AAMA)^®, and the Connecticut Society of Medical Assistants, an affiliated state society of the AAMA. 

With COVID-19 vaccinations beginning in the United States, the Centers for Disease Control and Prevention (CDC) published the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. The purpose of this publication is to assist state and local public health programs “to plan and operationalize a vaccination response to COVID-19 within their jurisdictions.” Note the reference to medical assistants as “vaccinators” on page 22 of this CDC publication: 

Verify COVID-19 vaccination providers have active, valid licensure/credentials to possess and administer vaccine. This licensure verification is needed only for those with prescribing authority [e.g., MD, DO, RPh, NP, PA] who will oversee COVID-19 vaccine administration. Credential verification is not required for vaccinators who work under the authority of someone with a higher level of licensure (i.e., not required for pharmacy techs/interns, RNs, LPNs, medical assistants, etc.). [emphase​s added] 

As demand for allied health professionals to administer the COVID-19 vaccines has started to increase rapidly, state governors have issued executive orders waiving certain elements of their state law to enable knowledgeable and competent medical assistants to be delegated, and to perform, COVID-19 vaccinations. For example, on December 4, 2020, Tennessee governor Bill Lee issued Executive Order No. 68: An Order to Facilitate the Continued Response to COVID-19 By Increasing Health Care Resources and Capacity. In part, this order authorizes “medical assistants certified by the American Association of Medical Assistants [to be delegated] tasks that would normally be within the practical nurse scope of practice, including, but not limited to, administration of COVID-19 vaccinations.” Tasks delegable to certified medical assistants “are required to have been ordered and authorized by a Tennessee licensed practitioner with prescriptive authority” and “performed under the supervision of the delegating registered nurse.” 

Also, state departments of health have clarified (as necessary) the fact that COVID-19 vaccinations may be delegated to, and may be administered by, knowledgeable and competent medical assistants. For example, the Washington State Department of Health published a list of health professionals permitted to administer the COVID-19 vaccine under licensed provider authority and supervision. Note the following: 

Medical assistant-certified 

Can administer vaccines? Yes 

Requires supervision? Yes 

Task must be delegated by a provider with the activity in their scope of practice: MD/DO, RN, ARNP, Naturopathic Physician, PA/DOPA. The requirements for the supervising health care practitioner to be physically present and immediately available in the facility are waived under Governor Inslee’s Proclamation 20-32. The supervisor only has to be immediately available, which may be by remote means. 

Issuing executive orders allowing medical assistants to administer COVID-19 vaccinations is consistent with similar measures that have been taken under federal and state law in regard to medical assistants performing nasopharyngeal swabbing for COVID-19 testing. 

The Centers for Medicare & Medicaid Services (CMS) published an interim final rule with comment period entitled “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” (85 FR 19247 through 19253) in the April 6, 2020, Federal Register. Its language supports the legal position that medical assistants are permitted to perform nasopharyngeal swabbing to test for COVID-19. Note the following excerpts from this CMS rule: 

Even if the patient is confined to the home because of a suspected diagnosis of an infectious disease as part of a pandemic event … a nasal or throat culture … could be obtained by an appropriately-trained medical assistant or laboratory technician … Services furnished by auxiliary personnel (such as nurses, medical assistants, or other clinical personnel acting under the supervision of the [rural health clinic] or [federally qualified health center] practitioner) are considered to be incident to the visit and are included in the per-visit payment. [emphases added] 

The New York State Board of Medicine has taken the position that unlicensed allied health professionals such as medical assistants may not be delegated by physicians certain invasive procedures. In response to the early crisis period of the COVID-19 pandemic, New York Governor Andrew Cuomo declared a state disaster emergency that included the following provisions: 

I hereby temporarily suspend or modify … the following: 

… 

Sections 6521 and 6902 of the Education Law, to the extent necessary to permit unlicensed individuals, upon completion of training deemed adequate by the Commissioner of Health, to collect throat or nasopharyngeal swab specimens from individuals suspected of being infected by COVID-19, for purposes of testing; and to the extent necessary to permit non-nursing staff, upon completion of training deemed adequate by the Commissioner of Health, to perform tasks, under the supervision of a nurse, otherwise limited to the scope of practice of a licensed or registered nurse; 

In light of the aforementioned federal and state precedents, and the great need to deploy competent unlicensed allied health professionals to supplement the current licensed allied health workforce in administering COVID-19 vaccinations, the American Association of Medical Assistants and the Connecticut Society of Medical Assistants urge you to issue an executive order permitting medical assistants to administer COVID-19 vaccinations under the authority of licensed providers such as physicians (MDs/DOs), nurse practitioners, physician assistants, and pharmacists. 

Thank you for your consideration, Governor Lamont. Feel free to direct questions to me at dbalasa@aama-ntl.org and 800/228-2262.