Proposed Delaware Regulation Expands APRN Delegation to Medical Assistants

On June 9, 2022, I sent a letter to the executive director of the Delaware Board of Nursing regarding proposed regulations that would allow advanced practice registered nurses (APRNs), including nurse practitioners, to delegate to educated and credentialed medical assistants the administration of medication.

Read the full letter here:

I am writing on behalf of the American Association of Medical Assistants® (AAMA), the national professional society for medical assistants, in regard to the following proposed addition to the regulations of the Delaware Board of Nursing (BON):

8.7.15.1 APRNs are authorized to assign and supervise medication administration to a medical assistant if the medical assistant has successfully completed a medical assistant training program and possesses current national medical assistant certification.

8.7.15.1.1 If a practice is solely operated by APRNs, the APRN must be present in the building when the medical assistant is administering medications and assumes liability for the actions of the medical assistant.

8.7.15.2 When a physician delegates to a medical assistant, and an organizational policy exists to allow the APRN to assign and supervise the medical assistant, the physician retains responsibility and accountability for the actions of the medical assistant and will be notified of unsafe or improper practices.

It is the position of the AAMA that medical assistants who have completed a medical assistant training program that includes medication administration theory and technique, and who have a current national medical assistant certification such as the CMA (AAMA)® that tests knowledge needed to safely administer medication, should be permitted to administer medication under the authority of APRNs—including nurse practitioners—and other licensed independent practitioners such as physicians.

The AAMA commends the Delaware BON for increasing the availability of safe and accessible health care for the residents of Delaware by proposing this revision to the BON regulations.

Clarification of Medication Administration Delegation to Medical Assistants in Oklahoma

I had the opportunity to present at the Medical Group Management Association (MGMA) Medical Practice Excellence: Leaders Conference in October 2021. The title of my presentation was “Utilizing Medical Assistants to the Top of Their Training: How Recent Law Changes Have Expanded Their Scope of Work.” After this presentation, I received the following question from an osteopathic physician practicing in Oklahoma:

I am writing to you to get a follow-up opinion on the delegatory ability of advanced practice registered nurses (APRNs) to medical assistants under Oklahoma law. I have seen your opinion letter on the AAMA website about the delegatory role of physicians to medical assistants and understand that you believe that the verbiage from the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act authorizes physicians (both MDs [doctors of medicine] and DOs [doctors of osteopathic medicine]) to delegate tasks to a medical assistant through licensed nonphysician providers, such as physician assistants and nurse practitioners.

How can your opinion be reconciled with the Oklahoma Board of Nursing (BON) statement on delegation of tasks by licensed nurses (including APRNs) to unlicensed allied health professionals such as medical assistants? Section F of the Oklahoma BON statement specifically mentions the administering of medications as not eligible for delegation by nurses to unlicensed persons.

The physician’s understanding of my legal opinion letter is correct. The relevant language I cite from the Oklahoma Medical and Surgical Licensure and Supervision Act is as follows:

E. Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall prohibit:

1. The service rendered by a physician’s unlicensed trained assistant [which would include a medical assistant] if such service is rendered under the supervision and control of a licensed physician pursuant to Board rules, provided such rules are not in conflict with the provisions of any other healing arts licensure act or rules promulgated pursuant to such act

I am familiar with the statement of the Oklahoma BON regarding delegation to unlicensed persons. I agree that the position of the Oklahoma BON is that nurses are not permitted to delegate to unlicensed professionals such as medical assistants the administration of medication.

In terms of reconciling my letter and the position of the Oklahoma Board of Nursing, my legal opinion is that a physician is permitted to assign to a registered nurse (as well as an APRN such as a nurse practitioner) the supervision of a medical assistant who is administering medication as delegated to the medical assistant by the physician as long as the delegating/overseeing physician is on the premises and immediately available, although not necessarily in the same room. However, my opinion is also that—based on the policy of the Oklahoma BON—a nurse practitioner is not permitted to delegate to an unlicensed professional such as a medical assistant the administration of medication.

Preparation and Administration of Injections by Medical Assistants

In the current ambulatory care environment, medical assistants are being delegated the preparation of injectable substances, as well as the administration of injections. I often receive questions about legal restrictions on medical assistants preparing injectable substances. In some states, there are specific laws that address this question. In general, it is my legal opinion that, if there is a likelihood of significant harm to a patient if an injectable substance is prepared improperly, the delegating provider must verify the identity and the dosage of the injectable substance before it is administered by the medical assistant.

Massachusetts Law Outlines Delegation of Immunizations

In 2016 the Massachusetts legislature passed legislation that permits primary care providers to delegate the administration of immunizations to a medical assistant who is the following:

… is a graduate of a post-secondary medical assisting education program accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association, or its successor, the Accrediting Bureau of Health Education Schools, or its successor or such other certificate program as the commissioner of public health shall approve; (ii) is employed in the medical practice of a licensed primary care provider; and (iii) who performs basic administrative, clerical, and clinical duties upon the specific authorization and under the direct supervision of a licensed primary care provider.

Note the following definitions from the legislation:

Direct supervision: “Oversight of a certified medical assistant exercised by a primary care provider who is present in the facility and immediately available to furnish assistance and direction throughout the course of the performance of a delegated procedure but is not required to be present in the room when the procedure is being performed.”

Primary care provider: “A health care professional qualified to provide general medical care for common health care problems who: (i) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (ii) initiates referrals for specialist care; and (iii) maintains continuity of care within the scope of practice.”

The legislation directs the Massachusetts Department of Public Health to promulgate regulations regarding the specifics of the delegation of immunizations. The full text of the legislation can be found on the AAMA website, under State Scope of Practice Laws.

Medical Assistants as Pharmacy Technicians

I have been receiving an increasing number of questions similar to the following:

Can a CMA (AAMA) work as a pharmacy technician in my state?  And, if so, can that CMA (AAMA) administer injections and take blood pressures under the supervision of a pharmacist?

Here is my response:

Thank you for this question.  A medical assistant—even a CMA (AAMA)—would have to meet the state law requirements and become a pharmacy technician in order to work in that capacity under the supervision of a pharmacist.  Once a CMA (AAMA) is registered by the state as a pharmacy technician, the scope of practice for this individual would be the same as all other pharmacy technicians as specified by the laws of that state.