delegation, Scope of Practice

Permissible Delegation to Montana Medical Assistants

I recently received the following appeal from a licensed practical nurse working in Montana:

I’m requesting something in writing that states that CMAs (AAMA) can still administer immunizations. The verbiage that my bosses are reading has [caused them to change] what our medical assistants can and can’t do. I depend on [medical assistants] being able to give shots (i.e., immunizations) when working with me.

For documentation related to this issue, go to the State Scope of Practice Laws webpage on the AAMA website to find the medical assisting laws of all states, including Montana.

Note the following from the Montana Code Annotated (MCA):

37-3-104. Medical assistants — guidelines. (1) The board shall adopt guidelines by administrative rule for:

(a) the performance of administrative and clinical tasks by a medical assistant that are allowed to be delegated by a physician, physician assistant, or podiatrist, including the administration of medications; and

(b) the level of physician, physician assistant, or podiatrist supervision required for a medical assistant when performing specified administrative and clinical tasks delegated by a physician, physician assistant, or podiatrist. However, the board shall adopt a rule requiring onsite supervision of a medical assistant by a physician, physician assistant, or podiatrist for invasive procedures, administration of medication, or allergy testing. [Italics added.]

Further, note the following from the Administrative Rules of Montana (ARM):

24.156.401    MEDICAL ASSISTANT – DELEGATION AND SUPERVISION

(1) A health care provider authorized by 37-3-104, MCA, may delegate administrative and clinical tasks which are within the delegating health care provider’s scope of practice to medical assistants who:

(a) work in the delegating health care provider’s office under the general supervision of the delegating health care provider; and

(3) A health care provider delegating administrative and/or clinical tasks to a medical assistant shall:

(c) personally provide onsite direct supervision as defined by ARM 24.156.501 to a medical assistant to whom the health care provider has delegated:

(i) injections other than immunizations;

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication [Italics added.]

The definition for direct supervision is in ARM “Definitions”:

(7) “Direct supervision” means the supervising physician is:

(a) physically present in the same building as the person under supervision; or

(b) in sufficiently close proximity to the person under supervision to be quickly available to the person under supervision. [Italics added.]

Given this language from the Montana statutes and regulations, my legal opinion is that Montana law permits physicians to delegate to medical assistants—who have the knowledge and competence outlined in the Montana rules—the administration of immunizations under the physician’s general supervision. My opinion is also that Montana law requires the delegating physician to be exercising direct supervision when medical assistants are performing the following tasks outlined in ARM:

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication

covid-19, delegation, Scope of Practice

Delegation of COVID-19 Vaccinations in Oregon: Part II

In part I of this topic, I responded to a registered nurse (RN) who questioned whether language in the regulations of the Oregon Board of Nursing might prevent RNs from delegating to medical assistants the administration of COVID-19 vaccinations. The RN followed up with an additional question:

What language in the Oregon nursing law permits RNs to delegate to medical assistants the administration of intramuscular injections—including COVID-19 vaccinations?

Medical assistants are classified as unregulated assistive personnel (UAP) under the Oregon nursing law. Division 45 of the regulations of the Oregon Board of Nursing, “Standards and Scope of Practice for the Licensed Practical Nurse and the Registered Nurse,” contains the key information on medical assistants’ scope of practice:

(11) Standards related to the RN who delegates the performance of a nursing procedure to a UAP.

(e) The RN’s authorization of a UAP to perform a nursing procedure shall only occur when the following delegation process steps are met:

(A) Based on nursing judgment, the RN determines that:

(i) The procedure does not require interpretation or independent decision making during its performance on the client;

(ii) The results of performing the procedure are reasonably predictable;

(B) The RN teaches the nursing procedure to the UAP and competency validates the UAP in the safe and accurate performance of the procedure on the client.

(f) The RN shall provide clinical supervision of the UAP to whom the procedure has been delegated.  The clinical supervision shall include:

(A) Monitoring of the UAP’s performance of the procedure to verify the UAP’s adherence to written directions; and

(B) Engaging in ongoing evaluation of the client and associated data to determine the degree to which client outcomes related to performance of the procedure are being met.

My legal opinion is that Division 45—not Division 47, which was discussed in Part I—is the applicable Oregon nursing law for determining what tasks may be delegated by RNs to UAP such as medical assistants in outpatient settings, including vaccination clinics. Division 45 states that RNs are permitted to delegate to UAP nursing procedures as long as all of the conditions delineated in Division 45 are satisfied.

An intramuscular injection such as a COVID-19 vaccination is a nursing procedure. Therefore, my legal conclusion is that Oregon nursing law allows RNs to delegate to knowledgeable and competent medical assistants working under direct or on-site RN supervision the administration of COVID-19 vaccinations in outpatient vaccination clinics as long as all the requirements of nurse delegation in Division 45 are met.

covid-19, delegation, Scope of Practice

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.

delegation, Scope of Practice

Nebraska Amendment Clarifies Medical Assisting Scope of Practice

Beginning in 2018, a particular interpretation of Nebraska law has cast doubt on the legal authority of physicians to delegate to medical assistants the performing of certain tasks under direct/on-site physician supervision in outpatient settings.

In response, the Nebraska Medical Association drafted an amendment to the Medicine and Surgery Practice Act to eliminate any ambiguity about medical assistants’ scope of practice. The American Association of Medical Assistants® and the Nebraska Society of Medical Assistants submitted written testimony supporting this legislation, and the amendment was enacted into law.

The new language clarifies the authority of physicians to delegate—and the right of medical assistants to perform—tasks within the standard scope of practice for medical assistants throughout the United States. I have incorporated this new language into my legal opinion letter for Nebraska, which is available on the AAMA State Scope of Practice webpage.

delegation, Scope of Practice

What Tasks Are Delegable to—and Performable by—Medical Assistants? Part II

The COVID-19 pandemic has created many changes in health care. Notably, medical assistants’ roles have shifted and expanded to help ensure patients continue to receive high-quality care.

The January/February 2021 Public Affairs article—adapted from the handout for my presentation of the same title for the 2020 American Academy of Ambulatory Care Nursing Annual (Virtual) Conference— discusses medical assistants’ scope of practice in terms of state law. Specifically, I examine the legality of delegating certain tasks to medical assistants:

  • Performing injections and venipuncture
  • Executing verbal and standing orders from licensed providers
  • Enter­ing orders under the Medicaid Promoting Interoperability Program and its meaningful use provisions for electronic order entry

Review details by reading “What Tasks Are Delegable to—and Performable by—Medical Assistants? Part II” on the AAMA website. And check out “Part I,” which was published in the November/December 2020 issue of CMA Today.