CHAPTER 21
PHYSICIAN SUPERVISION OF A PHYSICIAN ASSISTANT
653—21.1(148,272C) Ineligibility determinants. A physician with an active permanent, special, or temporary Iowa license who is actively engaged in the practice of medicine in Iowa may supervise a physician assistant. A physician is ineligible to supervise a physician assistant for any of the following reasons:
	21.1(1) The physician does not hold an active, permanent, special or temporary Iowa medical license.
	21.1(2) The physician is subject to a disciplinary order of the board that restricts or rescinds the physician’s authority to supervise a physician assistant. The physician may supervise a physician assistant to the extent that the order allows.
	21.1(3) The physician does not have a written supervisory agreement in place with each physician assistant supervised by the physician.
	21.1(4) The physician is already supervising five physician assistants.
[ARC 3264C, IAB 8/16/17, effective 9/20/17; ARC 5252C, IAB 11/4/20, effective 12/9/20]
653—21.2(148,272C) Exemptions from this chapter. This chapter shall not apply to the following:
	21.2(1) A physician working in a federal facility or under federal authority when the provisions of this chapter conflict with federal regulations.
	21.2(2) A physician who supervises a physician assistant providing medical care created by an emergency or a state or local disaster pursuant to Iowa Code section 148C.4.
653—21.3(148) Board notification. A physician who supervises a physician assistant shall notify the board of the supervisory relationship within 60 days of the provision of initial supervision and at the time of the physician’s license renewal.
[ARC 3264C, IAB 8/16/17, effective 9/20/17]
653—21.4(148,272C) Supervisory agreements.
	21.4(1) A physician who supervises a physician assistant shall establish a written supervisory agreement prior to supervising a physician assistant. A sample supervisory agreement form is available from the board. The purpose of the supervisory agreement is to define the nature and extent of the supervisory relationship and the expectations of each party. The supervisory agreement shall take into account the physician assistant’s demonstrated skills, training and experience, proximity of the supervising physician to the physician assistant, and the nature and scope of the medical practice. The supervising physician shall maintain a copy of the supervisory agreement and provide a copy of the agreement to the board upon request. The supervisory agreement shall, at a minimum, address the following provisions.
	a. 	Review of requirements. The supervising physician and the physician assistant shall review all of the requirements of physician assistant licensure, practice, supervision, and delegation of medical services as set forth in Iowa Code section 148.13 and chapter 148C, these rules, and 645—Chapters 326 to 329.
	b. 	Assessment of education, training, skills, and experience. Each supervising physician shall assess the education, training, skills, and relevant experience of the physician assistant prior to providing supervision. Each supervising physician and physician assistant shall ensure that the other party has the appropriate education, training, skills, and relevant experience necessary to successfully collaborate on patient care delivered by the team. The method for assessing and providing feedback regarding the physician assistant’s education, training, skills, and experience shall be reflected in the supervisory agreement.
	21.4(2) The supervisory agreement between the physician assistant and the physician shall address all of the following:
	a. 	The medical services the supervising physician delegates to the physician assistant. The medical services and medical tasks delegated to and provided by the physician assistant shall be in compliance with 645—subrule 327.1(1). All delegated medical services shall be within the scope of practice of the supervising physician and the physician assistant.
	b. 	Methods for communication between the physician assistant and the physician and whether the physician assistant practices at the same site or a remote site. Each supervising physician and physician assistant shall conduct ongoing discussions and evaluation of the supervisory agreement, including supervision; expectations for both parties; assessment of education, training, skills, and relevant experience; review of delegated services; review of the medical services provided by the physician assistant; and the types of cases and situations when the supervising physician expects to be consulted.
	(1)	The plan for completing and documenting chart reviews. A licensed physician within the same facility or health care system as the physician assistant shall conduct an ongoing review of a representative sample of the physician assistant’s patient charts encompassing the scope of the physician assistant’s practice. The finding of the review shall be discussed with the physician assistant in a manner determined by the practice in consultation with the physician assistant’s primary supervising physician.
	(2)	 Remote medical site. “Remote medical site” means a medical clinic for ambulatory patients which is more than 30 miles away from the main practice location of the supervising physician and in which the supervising physician is present less than 50 percent of the time when the remote medical site is open. “Remote medical site” will not apply to nursing homes, patient homes, hospital outpatient departments, outreach clinics, or any location at which medical care is incidentally provided (e.g., diet center, free clinic, site for athletic physicals, jail facility). The supervisory agreement shall include a provision which ensures that the supervising physician visits the remote medical site, or communicates with a physician assistant at the remote medical site via electronic communications, at least every two weeks to provide additional medical direction, medical services and consultation specific to the medical services provided at the remote medical site. For purposes of this subparagraph, communication may consist of, but shall not be limited to, in-person meetings or two-way, interactive communication directly between the supervising physician and the physician assistant via the telephone, secure messaging, electronic mail, or chart review. The board shall only grant a waiver of this provision if substantially equal protection of public health, safety, and welfare will be afforded by a means other than that prescribed in this subparagraph.
	(3)	 The expectations and plan for alternate supervision. The supervising physician will ensure that the alternate supervising physician is available for a timely consultation and will ensure that the physician assistant is notified of the means by which to reach the alternate supervising physician.
[ARC 3264C, IAB 8/16/17, effective 9/20/17; ARC 4213C, IAB 1/2/19, effective 2/6/19; ARC 5252C, IAB 11/4/20, effective 12/9/20]
653—21.5(148,272C) Grounds for discipline. A physician may be subject to disciplinary action for supervising a physician assistant in violation of these rules or the rules found in 653—Chapter 23 or 645—Chapters 326 and 327, which relate to duties and responsibilities for physician supervision of physician assistants. Grounds for discipline also include:
	21.5(1) The physician supervises a physician assistant when the physician does not have sufficient training or experience to supervise a physician assistant in the area of medical practice in which a physician assistant is to be utilized.
	21.5(2) A physician supervises more than five physician assistants at the same time.
	21.5(3) The physician fails to ensure that the physician assistant is adequately supervised, including being available in person or by telecommunication to respond to the physician assistant.
	21.5(4) The physician fails to adequately direct and supervise a physician assistant or fails to comply with the minimum standards of supervision in accordance with this chapter, Iowa Code section 148.13 and chapter 148C, and 645—Chapters 326 to 329.
[ARC 0870C, IAB 7/24/13, effective 8/28/13; ARC 2532C, IAB 5/11/16, effective 6/15/16; see Rescission note at end of chapter; ARC 3264C, IAB 8/16/17, effective 9/20/17]
653—21.6(148,272C) Disciplinary sanction. The board may restrict or rescind a physician’s authority to supervise a physician assistant as part of a disciplinary sanction following a contested case proceeding, if the reason for the disciplinary action impacts the ability of the physician to supervise a physician assistant. The board shall notify the board of physician assistants when it takes a disciplinary action against a physician’s license that affects the physician’s authority to supervise a physician assistant.
[ARC 2532C, IAB 5/11/16, effective 6/15/16; see Rescission note at end of chapter; ARC 3264C, IAB 8/16/17, effective 9/20/17]
653—21.7(148,272C) Communication with physician assistant supervisees. The physician shall notify all physician assistant supervisees within one workday upon receiving disciplinary action from the board or any other change in status that affects the physician’s eligibility to supervise a physician assistant.
[ARC 2532C, IAB 5/11/16, effective 6/15/16; see Rescission note at end of chapter; ARC 3264C, IAB 8/16/17, effective 9/20/17]
653—21.8(17A,147,148,272C) Waiver or variance requests. Waiver or variance requests shall be submitted in conformance with 653—Chapter 3.
[ARC 2532C, IAB 5/11/16, effective 6/15/16; see Rescission note at end of chapter; ARC 3264C, IAB 8/16/17, effective 9/20/17]
These rules are intended to implement Iowa Code sections 148.13 and 272C.3.
[Filed 1/4/89, Notice 11/16/88—published 1/25/89, effective 3/1/89]123
[Filed 8/31/89, Notice 5/31/89—published 9/20/89, effective 10/25/89]
[Filed 2/23/96, Notice 1/3/96—published 3/13/96, effective 4/17/96]4
[Filed emergency 10/4/96—published 10/23/96, effective 10/4/96]
[Filed 9/29/00, Notice 8/23/00—published 10/18/00, effective 11/22/00]
[Filed 12/4/03, Notice 8/20/03—published 12/24/03, effective 1/28/04]5
[Filed emergency 3/9/04—published 3/31/04, effective 3/9/04]
[Filed ARC 0870C (Notice ARC 0692C, IAB 4/17/13), IAB 7/24/13, effective 8/28/13]
[Filed ARC 2532C (Notice ARC 2372C, IAB 1/20/16), IAB 5/11/16, effective 6/15/16]6
[Filed ARC 3264C (Notice ARC 3069C, IAB 5/24/17), IAB 8/16/17, effective 9/20/17]
[Filed ARC 4213C (Notice ARC 3992C, IAB 9/12/18), IAB 1/2/19, effective 2/6/19]
[Filed ARC 5252C (Notice ARC 5133C, IAB 8/12/20), IAB 11/4/20, effective 12/9/20]
1	Effective date of 3/1/89 delayed 70 days by Administrative Rules Review Committee at its February 13, 1989, meeting.
2	Effective date of 3/1/89 delayed until adjournment of the 1990 Session of the General Assembly at its May 9, 1989, meeting.
3	Delay until adjournment of the 1990 G.A. lifted by the Administrative Rules Review Committee at its August 3, 1989, meeting which allowed the rules to become effective August 4, 1989.
4	Effective date of 4/17/96 delayed 70 days by the Administrative Rules Review Committee at its meeting held April 16, 1996. Effective date delayed until adjournment of the 1997 General Assembly by the Administrative Rules Review Committee at its meeting held June 11, 1996.
5	Effective date of 1/28/04 delayed 70 days by the Administrative Rules Review Committee at its January 6, 2004, meeting; at its meeting held March 8, 2004, the Committee lifted the delay, effective March 9, 2004.
6	Amendments to ch 21 in ARC 2532C, which included the renumbering of 21.4 to 21.7 as 21.5 to 21.8 (Item 1), the adoption of new 21.4 (Item 2), and the amendment to the implementation sentence (Item 3), rescinded by 2017 Iowa Acts, House File 591, section 2, paragraph “a,” on 4/12/17 and, pursuant to paragraph “b,” prior language restored IAC Supplement 5/10/17.