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.

covid-19, On the Job, Scope of Practice

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, On the Job, Scope of Practice

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. 

delegation, On the Job, Scope of Practice

Permissible Delegation of Influenza Vaccination Administration in Michigan

Medical assistants are well-positioned to assist with vaccinations, but legal considerations may vary depending on state law. For example, I recently received the following question regarding when a medical assistant in Michigan can be delegated the administration of influenza vaccinations:

I have two medical assistants in our occupational health/employee health clinic who operate under a provider and can give injections. We are part of a hospital that is across the street from our clinic. Can the two medical assistants give influenza shots in the hospital setting without our provider actually on-site?

To answer this question, note the following from the Michigan Public Health Code, which is posted in the Michigan subsection of the State Scope of Practice Laws webpage on the AAMA website:

333.16215 Delegation of acts, tasks, or functions to licensed or unlicensed individual; supervision; rules; immunity; third party reimbursement or worker’s compensation benefits.

Sec. 16215.

(1) Subject to subsections (2) to (6), a licensee who holds a license other than a health profession subfield license may delegate to a licensed or unlicensed individual who is otherwise qualified by education, training, or experience the performance of selected acts, tasks, or functions where the acts, tasks, or functions fall within the scope of practice of the licensee’s profession and will be performed under the licensee’s supervision. A licensee shall not delegate an act, task, or function under this section if the act, task, or function, under standards of acceptable and prevailing practice, requires the level of education, skill, and judgment required of the licensee under this article. [Italics added.]

In this excerpt, the definition of “licensee” includes a licensed physician. Medical assistants are considered unlicensed individuals under Michigan law.

Furthermore, the definition of “supervision” in this part of the Michigan law is as follows:

(2) “Supervision”, except as otherwise provided in this article, means the overseeing of or participation in the work of another individual by a health professional licensed under this article in circumstances where at least all of the following conditions exist:

(a) The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.

(b) The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual’s functions.

Therefore, my legal opinion is that Michigan law permits physicians to delegate the administration of influenza vaccinations to knowledgeable and competent unlicensed individuals such as medical assistants as long as the delegating physician is accessible to the medical assistants by radio, telephone, or telecommunication.