Supervisory Role of DOs for APRNs & PAs in Florida

This article addresses the supervisory role of a licensed DO in Florida, when supervising a Physician Assistant (PA) or an Advanced Practice Registered Nurse (APRN).

Supervision required for the APRN and PA

1. APRN – SUPERVISORY RELATIONSHIPS IN MEDICAL OFFICE SETTINGS.—An osteopathic physician who supervises an advanced practice registered nurse or physician assistant at a medical office other than the osteopathic physician’s primary practice location, where the advanced practice registered nurse or physician assistant is not under the onsite supervision of a supervising osteopathic physician, must comply with the standards set forth in this subsection. For the purpose of this subsection, an osteopathic physician’s “primary practice location” means the address reflected on the physician’s profile published pursuant to s. 456.041.

459.025(3)(a) An osteopathic physician who is engaged in providing primary health care services may not supervise more than four offices in addition to the osteopathic physician’s primary practice location. For the purpose of this subsection, “primary health care” means health care services that are commonly provided to patients without referral from another practitioner, including obstetrical and gynecological services, and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.

(b) An osteopathic physician who is engaged in providing specialty health care services may not supervise more than two offices in addition to the osteopathic physician’s primary practice location. For the purpose of this subsection, “specialty health care” means health care services that are commonly provided to patients with a referral from another practitioner and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.

(c) An osteopathic physician who supervises an advanced practice registered nurse or physician assistant at a medical office other than the osteopathic physician’s primary practice location, where the advanced practice registered nurse or physician assistant is not under the onsite supervision of a supervising osteopathic physician and the services offered at the office are primarily dermatologic or skin care services, which include aesthetic skin care services other than plastic surgery, must comply with the standards listed in subparagraphs 1.-4. Notwithstanding s. 459.022(4)(e)6., an osteopathic physician supervising a physician assistant pursuant to this paragraph may not be required to review and cosign charts or medical records prepared by such physician assistant.

1. The osteopathic physician shall submit to the Board of Osteopathic Medicine the addresses of all offices where he or she is supervising or has a protocol with an advanced practice registered nurse or a physician assistant which are not the osteopathic physician’s primary practice location.

2. The osteopathic physician must be board certified or board eligible in dermatology or plastic surgery as recognized by the Board of Osteopathic Medicine pursuant to s. 459.0152.

3. All such offices that are not the osteopathic physician’s primary place of practice must be within 25 miles of the osteopathic physician’s primary place of practice or in a county that is contiguous to the county of the osteopathic physician’s primary place of practice. However, the distance between any of the offices may not exceed 75 miles.

4. The osteopathic physician may supervise only one office other than the osteopathic physician’s primary place of practice.

(d) An osteopathic physician who supervises an office in addition to the osteopathic physician’s primary practice location must conspicuously post in each of the osteopathic physician’s offices a current schedule of the regular hours when the osteopathic physician is present in that office and the hours when the office is open while the osteopathic physician is not present.

(e) This subsection does not apply to health care services provided in facilities licensed under chapter 395 or in conjunction with a college of medicine or college of nursing or an accredited graduate medical or nursing education program; offices where the only service being performed is hair removal by an advanced practice registered nurse or physician assistant; not-for-profit, family-planning clinics that are not licensed pursuant to chapter 390; rural and federally qualified health centers; health care services provided in a nursing home licensed under part II of chapter 400, an assisted living facility licensed under part I of chapter 429, a continuing care facility licensed under chapter 651, or a retirement community consisting of independent living units and either a licensed nursing home or assisted living facility; anesthesia services provided in accordance with law; health care services provided in a designated rural health clinic; health care services provided to persons enrolled in a program designed to maintain elderly persons and persons with disabilities in a home or community-based setting; university primary care student health centers; school health clinics; or health care services provided in federal, state, or local government facilities. Fla. Stat. s. 459.025.

2. PA – PERFORMANCE OF SUPERVISING PHYSICIAN.—Each physician or group of physicians supervising a licensed physician assistant must be qualified in the medical areas in which the physician assistant is to perform and shall be individually or collectively responsible and liable for the performance and the acts and omissions of the physician assistant. A physician may not supervise more than 10 currently licensed physician assistants at any one time. A physician supervising a physician assistant pursuant to this section may not be required to review and cosign charts or medical records prepared by such physician assistant. A supervisory physician may delegate to a licensed physician assistant, pursuant to a written protocol, the authority to act according to s. 154.04(1)(c). Such delegated authority is limited to the supervising physician’s practice in connection with a county health department as defined and established pursuant to chapter 154. The boards shall adopt rules governing the supervision of physician assistants by physicians in county health departments.

(e) A supervising physician may delegate to a fully licensed physician assistant the authority to prescribe or dispense any medication used in the supervising physician’s practice unless such medication is listed on the formulary created pursuant to s. 458.347. A fully licensed physician assistant may only prescribe or dispense such medication under the following circumstances:

1. A physician assistant must clearly identify to the patient that she or he is a physician assistant.

2. The supervising physician must notify the department of her or his intent to delegate, on a department-approved form, before delegating such authority and of any change in prescriptive privileges of the physician assistant. Authority to dispense may be delegated only by a supervising physician who is registered as a dispensing practitioner in compliance with s. 465.0276.

3. A fully licensed physician assistant may procure medical devices and drugs unless the medication is listed on the formulary created pursuant to s. 458.347(4)(f).

4. The physician assistant must complete a minimum of 10 continuing medical education hours in the specialty practice in which the physician assistant has prescriptive privileges with each licensure renewal. Three of the 10 hours must consist of a continuing education course on the safe and effective prescribing of controlled substance medications which is offered by a provider that has been approved by the American Academy of Physician Assistants and which is designated for the American Medical Association Physician’s Recognition Award Category 1 credit, designated by the American Academy of Physician Assistants as a Category 1 credit, or designated by the American Osteopathic Association as a Category 1-A credit.

5. The prescription may be in paper or electronic form but must comply with ss. 456.0392(1) and 456.42(1) and chapter 499 and must contain the physician assistant’s name, address, and telephone number and the name of each of his or her supervising physicians. Unless it is a drug or drug sample dispensed by the physician assistant, the prescription must be filled in a pharmacy permitted under chapter 465, and must be dispensed in that pharmacy by a pharmacist licensed under chapter 465.

6. The physician assistant must note the prescription or dispensing of medication in the appropriate medical record.

(f) A supervisory physician may delegate to a licensed physician assistant the authority to, and the licensed physician assistant acting under the direction of the supervisory physician may, order any medication for administration to the supervisory physician’s patient in a facility licensed under chapter 395 or part II of chapter 400, notwithstanding any provisions in chapter 465 or chapter 893 which may prohibit this delegation.

(g) A licensed physician assistant may perform services delegated by the supervising physician in the physician assistant’s practice in accordance with his or her education and training unless expressly prohibited under this chapter, chapter 458, or rules adopted under this chapter or chapter 458.

The same supervision requirements come into play as stated above for a PA if the supervising physician is not supervising at their own medical office. Further, if the supervision includes the PA performing specialty health care services. The issues relate to the type of supervision required for the services provided by each extender (i.e. PA and APRN). If the procedures are outside of the medical office setting, then a review of the above is paramount before entering into any supervisory role for a PA or APRN. Finally, the type of services provided, if it is aesthetic skin care or dermatologic, limits the number of offices a DO can supervise, but the number of APRN’s or PA’s within each practice location.

If there is no on-site supervision and the services are primarily dermatologic or skin care services, then complying with the below, is MANDATORY: a physician supervising a physician assistant pursuant to this paragraph may not be required to review and cosign charts or medical records prepared by such physician assistant.

1. The physician shall submit to the board the addresses of all offices where he or she is supervising an advanced practice registered nurse or a physician assistant which are not the physician’s primary practice location.

2. The physician must be board certified or board eligible in dermatology or plastic surgery as recognized by the board pursuant to s. 458.3312.

3. All such offices that are not the physician’s primary place of practice must be within 25 miles of the physician’s primary place of practice or in a county that is contiguous to the county of the physician’s primary place of practice. However, the distance between any of the offices may not exceed 75 miles.

4. The physician may supervise only one office other than the physician’s primary place of practice.

For additional information regarding the framework in Florida for DOs supervising APRNs and PAs, please contact Jason Winn at jwinn@panzamaurer.com.