PURPOSE: This rule defines the terms used throughout this chapter as applicable to physician assistants, specifies the requirements for supervision agreements and practice of a physician assistant pursuant to a supervision agreement.

1. (1) As used in this rule, unless specifically provided otherwise, the term—

   1. (A) Supervising physician—shall mean a physician so designated pursuant to 4 CSR 150-7.100(4) who holds a permanent license to practice medicine in the state of Missouri and who is actively engaged in the practice of medicine, except that this shall not include physicians who hold a limited license pursuant to section 334.112, RSMo, or a temporary license pursuant to section 334.045 or 334.046, RSMo, or physicians who have retired from the practice of medicine. A physician meeting these requirements but not so designated may serve as a supervising physician, upon signing a physician assistant supervision agreement for times not to exceed fifteen (15) days, when the supervising physician is unavailable if so specified in the physician assistant supervision agreement;
   2. (B) Physician assistant supervision agreements—refers to written agreements, jointly agreed upon protocols, or standing orders between a supervising physician and a licensed physician assistant which provide for the delegation of health care services from a supervising physician to a licensed physician assistant and the review of such services;
   3. (C) Consultation—shall mean the process of seeking a supervising physician’s input and guidance regarding patient care including, but not limited to, the methods specified in the physician assistant supervision agreement;
   4. (D) Assistance—shall mean participation by a supervising physician in patient care; and
   5. (E) Intervention—refers to the direct management of a patient’s care by a supervising physician.
   6. (F) Actively engaged—as used in subsection (1)(A) of this rule shall mean a physician who, in addition to the patients being treated by the physician assistant, has an established practice of patients for whom they are responsible for their ongoing care.
2. (2) No physician assistant shall practice pursuant to the provisions of sections 334.735 through 334.748, RSMo or to the provisions of this rule unless licensed and pursuant to a written physician assistant supervision agreement.
3. (3) A supervising physician as designated pursuant to 4 CSR 150-7.100(4) or otherwise in the physician assistant supervision agreement shall at all times be immediately available to the licensed physician assistant for consultation, assistance, and intervention within the same office facility unless making follow-up patient examinations in hospitals, nursing homes and correctional facilities pursuant to section 334.735.1(8), RSMo or unless practicing under federal law. No physician assistant shall practice without physician supervision or in any location where a supervising physician is not immediately available for consultation, assistance and intervention, except in an emergency situation, pursuant to federal law, or as provided in section 334.735.9, RSMo.
4. (4) A physician assistant shall be limited to making follow-up patient examinations in hospitals, nursing homes and correctional facilities where the supervising physician as designated pursuant to 4 CSR 150-7.100(4) or otherwise in the physician assistant supervision agreement, is no further than thirty
5. (30) miles by road, using the most direct route available, or in any other fashion so distanced as to create an impediment to effective intervention, supervision of patient care or adequate review of services. Physician assistants practicing in federally designated health professional shortage areas (HPSAs), shall be limited to practice locations where the supervising physician as designated pursuant to 4 CSR 150-7.100(4) or otherwise in the physician assistant supervision agreement, is no further than fifty (50) miles by road, using the most direct route available.
6. (5) No physician may be designated to serve as supervising physician for more than three
7. (3) full-time equivalent licensed physician assistants. This limitation shall not apply to physician assistant supervision agreements of hospital employees providing in-patient care services in hospitals as defined in Chapter 197, RSMo.
8. (6) Upon entering into a physician assistant supervision agreement, the supervising physician shall be familiar with the level of skill, training and the competence of the licensed physician assistant whom the physician will be supervising. The provisions contained in the physician assistant supervision agreement between the licensed physician assistant and the supervising physician shall be within the scope of practice of the licensed physician assistant and consistent with the licensed physician assistant’s skill, training and competence.
9. (7) A licensed physician assistant practicing pursuant to a physician assistant supervision agreement shall work in the same office facility as the supervising physician except as provided in section 334.735.1(8), RSMo and 4 CSR 150-7.135(3) and (4).
10. (8) The delegated health care services provided for in the physician assistant supervision agreement shall be consistent with the scopes of practice of both the supervising physician and licensed physician assistant including, but not limited to, any restrictions placed upon the supervising physician’s practice or license. 20 CSR 2150-7

11. (9) The physician assistant supervision agreement between a supervising physician and a licensed physician assistant shall—

    1. (A) Include consultation, transportation and referral procedures for patients needing emergency care or care beyond the scope of practice of the licensed physician assistant if the licensed physician assistant practices in a setting where a supervising physician is not continuously present;
    2. (B) Include the method and frequency of review of the licensed physician assistant’s practice activities;
    3. (C) Be reviewed at least annually and revised as the supervising physician and licensed physician assistant deem necessary;
    4. (D) Be maintained by the supervising physician and licensed physician assistant for a minimum of eight (8) years after the termination of the agreement;
    5. (E) Be signed and dated by the supervising physician and licensed physician assistant prior to its implementation; and
    6. (F) Contain the mechanisms for input for serious or significant changes to a patient.
12. (10) It is the responsibility of the supervising physician to determine and document the completion of at least a one (1)-month period of time during which the licensed physician assistant shall practice with a supervising physician continuously present before making follow-up visits in hospitals, nursing homes and correctional facilities.
13. (11) It is the responsibility of the supervising physician and licensed physician assistant to jointly review and document the work, records, and practice activities of the licensed physician assistant at least once every two (2) weeks. For nursing home practice, such review shall occur at least once a month. The supervising physician and the licensed physician assistant shall conduct this review at the site of service except in extraordinary circumstances which shall be documented. The documentation of this review shall be available to the Board of Registration for the Healing Arts for review upon request.
14. (12) If any provisions of these rules are deemed by the appropriate federal or state authority to be inconsistent with guidelines for federally funded clinics, individual provisions of these rules shall be considered severable and supervising physicians and licensed physician assistants practicing in such clinics shall follow the provisions of such federal guidelines in these instances. However, the remainder of the provisions of these rules not so affected shall remain in full force and effect for such practitioners. FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

AUTHORITY: section 334.735, RSMo 2000.* This rule originally filed as 4 CSR 150-7.135. Original rule filed Jan. 3, 1997, effective July 30, 1997. Rule Action Notice filed: July 7, 1998, effective July 21, 1999. Amended: Filed July 30, 1999, effective Feb. 29, 2000. Amended: Filed March 1, 2005, effective Aug. 30, 2005. Amended: Filed June 1, 2005, effective Dec. 30, 2005. Moved to 20 CSR 2150-7.135, effective Aug. 28, 2006.

*Original authority: 334.735, RSMo 1989, amended 1996, 1997, 1998. Rule Action Notice: On July 16, 1999, the Cole County Circuit Court, Case No. CV198-196CC, ordered that the definition of “same office facility” set forth in 4 CSR 150- 7.135(1)(F) be terminated from the rule as being promulgated without statutory rulemaking authority. The Court further ordered the suspension of the following sections of the rule: the portion of subsection (1)(E) which states “either personally or via telecommunications”; the portion of section (3) which states “either personally or via telecommunications”; the portion of section (4) which states “A physician assistant shall be limited to practice locations where the supervising physician as designated pursuant to 4 CSR 150-7.100(4) or otherwise in the physician assistant supervision agreement, is no further than thirty (30) miles by road, using the most direct route available, or in any other fashion so distanced as to create an impediment to effective intervention, supervision of patient care or adequate review of services.”; the portion of section (7) which states “as defined in subsection (4)(F)”; and section (10) in its entirety. The Judgment and Order of the Court was entered on July 6, 1999. The Court provided that the effective date of the voiding of 4 CSR 150-7.135(1)(F), and the suspension of portions of 4 CSR 150- 7.135(1)(E), (3), (4), (7), and 4 CSR 150- 7.135(10) shall be fifteen (15) days from the entry of the Court Order. After July 21, 1999, 4 CSR 150-7.135(1)(F) shall be terminated and of no further force and effect and portions of 4 CSR 150-7.135(1)(E), (3), (4), and (7), and section (10) in its entirety shall be suspended until modified through the rulemaking process. No appeal is taken.