physician assistant supervision agreement instructions sheet...forming a supervision agreement...

Last updated on April 23, 2017 by Chris Krummey - Managing Attorney-Transactions

Physician Assistant Supervision Agreement

Instructions Sheet

Outlined in this document the instructions for completing the “Physician Assistant Supervision Agreement” and

forming a supervision agreement between a Physician and Physician Assistant (PA). The instructions will help to address

questions that may arise regarding specific terms. For further questions regarding the form that are not answered here or in

the guide please contact SSM Health System Legal Affairs. Information governing a Physician Assistant’s collaboration

can be found in statute at Rev. Mo. Stat 334.735 and in Missouri Code at 20 CSR 2150-7.010 et. seq. or by visiting

http://pr.mo.gov/physicianassistants.asp.

1. : Using the Physician Assistant Supervision Agreement form fill in all fields appropriately. The effective date is

the date the collaboration is to commence between the Physician and Physician Assistant.

4. Page 8: Signatures Page – Complete all fields as they are required and outlined. The SSM Health Representative is

the applicable Hospital Chief Nursing Officer or SSM Health Medical Group Administrative Director for Nursing

Operations that oversees the applicable entity’s nursing operations.

5. Page 9: Exhibit 1, Protocols – Insert, using multiple pages if needed, the appropriate, pre-approved protocols andcontrolled substance authority that are to be delegated to the PA, taking into account both professionals’ skills and

experience. This section should also mirror privileges granted to PA under the applicable SSM Health Privileges

Form, and if any clinical privileges are granted to PA at SSM Health hospitals, it should be documented here.

a. Responsibilities of the PA – usually include an overview of the daily responsibilities of PA’s collaborative

practice including the ability to order tests, perform procedures, and prescribe medications.

b. Consultation – a overview of how and when PA will consult the Physician, or Designated Physician, to determine

appropriate care. Language here is often broad and written to include discretion of PA, however a Physician may

require consultation in certain instances.

c. Referrals – includes statements about how patients treated by the PA will follow up, usually by referral to their

primary care physician or specialists as needed.

d. Quality Review - includes statements on how the Physician will review the charts and services provided by the

PA.

6. Page 11: Exhibit 2, Designated Physicians - In the absence of, or in the event the Collaborating Physician is not

immediately available to the Physician Assistant for consultation, a back-up or Designated or Physician must fulfill the

responsibility of collaboration. Indicate all Designated Physician information in the appropriate row and have said

Designated Physician acknowledge their responsibilities on the following page via signature.

7. Page 12: Exhibit 3, Practice Locations – Indicate the address of all locations where an Physician Assistant has been

delegated authority to collaboratively practice by the Physician. Remember these practice locations must be consistent

with any delegation of Clinical Privileges at SSM Health Hospitals.

8. After the form is fully completed, obtain all necessary signatures and provide a copy to the Physician Assistant’s

manager and to the applicable Hospital Chief Nursing Officer or SSM Health Medical Group Administrative

Director for Nursing Operations that oversees the applicable entity’s nursing operations. Be sure the Physician

and Physician Assistant maintains the completed agreement for a minimum of eight (8) years and is readily available

for any agency inspection.

2. Page 2: Delegation of Controlled Substances - Check the appropriate boxes of Section 1.3(a),(b), and (c) todelegate or not delegate controlled substances. Any restrictions or specific schedules of controlled substances notdelegated should be included in the protocols of Exhibit 1.

3. Page 3: Delegation of Restraint Authority - Check the appropriate boxes in Section 1.6 for level of restraintauthority delegated by Physician to the Physician Assistant.

Version: 1/8/17

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PHYSICIAN ASSISTANT SUPERVISION AGREEMENT

The following terms defined below shall be applicable to this Agreement:

This PHYSICIAN ASSISTANT SUPERVISION AGREEMENT (“Agreement”) shall be effective on EFFECTIVE DATE by and between PHYSICIAN, a physician licensed to practice medicine in the State of Missouri and PHYSICIAN ASSISTANT, a Physician Assistant.

WHEREAS, PHYSICIAN is licensed in Missouri and employed by PHYSICIAN’S EMPLOYER to provide PHYSICIAN’S SPECIALITY services, and PHYSICIAN ASSISTANT is a registered physician assistant in the State of Missouri and employed by PHYSICIAN ASSISTANT’S EMPLOYER to provide professional physician assistant services in accordance with PHYSICIAN ASSISTANT’s, applicable job description, and as authorized by Missouri law; and

WHEREAS, in order to facilitate the provision of professional services in a collaborative fashion between PHYSICIAN and PHYSICIAN ASSISTANT, PHYSICIAN desires to delegate certain medical acts to PHYSICIAN ASSISTANT for services rendered at PRACTICE SITES in a manner consistent with PHYSICIAN ASSISTANT’S skill, training, competence and professional judgment and in accordance with Missouri law; and

WHEREAS, Missouri law requires physician assistants to enter into supervision agreements with licensed physicians to provide for the delegation of health care services from a supervising physician to a licensed physician assistant, and to provide for the review of such services; and

THEREFORE, for and in consideration of the covenants contained herein, the parties agree as follows:

EFFECTIVE DATE:

PHYSICIAN:

PHYSICIAN EMPLOYER:

PHYSICIAN’S SPECIALTY:

“PHYSICIAN ASSISTANT (PA)”

PHYSICIAN ASSISTANT EMPLOYER:

PRACTICE SITE(S) or HOSPITAL: Shall include all sites, as listed in Exhibit 3, where Physician Assistant is authorized by PHYSICIAN to collaboratively practice under the terms of this Agreement.

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1. Delegation of Authority. PHYSICIAN has considered and is familiar with PHYSICIANASSISTANT’s skill, training, education and competence and has determined that theresponsibilities delegated to PHYSICIAN ASSISTANT to deliver health care services andtreatment in accordance with Exhibit 1 are within the PHYSICIAN ASSISTANT’s scope ofpractice. Exhibit 1 is attached hereto and incorporated herein by reference. This Agreement andany Exhibits hereto shall be reviewed at least annually and revised as needed upon the mutualwritten consent of PHYSICIAN ASSISTANT and PHYSICIAN. The parties agree Exhibit 1 willat all times be written, signed and dated by PHYSICIAN and PHYSICIAN ASSISTANT prior toimplementation.

1.1 Clinical Privileges at SSM Health Hospitals .PHYSICIAN and PHYSICIAN ASSISTANT understand that SSM Health will

only grant privileges specified in the Clinical Privileges form, as amended and maintained by SSM Health. Any privileges specified in Exhibit 1 that exceed the scope of those privileges granted by SSM Health are not permitted under this Agreement.

1.2 Delegation of Prescriptive Authority.PHYSICIAN further delegates to PHYSICIAN ASSISTANT the authority to

administer, dispense and prescribe drugs in consultation with PHYSICIAN and pursuant to this Agreement within PHYSICIAN ASSISTANT’s and PHYSICIAN’s scope of practice, consistent with PHYSICIAN ASSISTANT’s skills, training, education and competence.

1.3 The authority to administer, dispense and prescribe drugs as delegated to PHYSICIAN ASSISTANT pursuant to Section 1.2 of this Agreement is subject to the following conditions: (a) PHYSICIAN ASSISTANT shall not, under any circumstances, prescribe controlled substances.

(c) The types of drugs, medications, devices or therapies prescribed or dispensed by PHYSICIAN ASSISTANT shall be consistent with the scopes of practice of PHYSICIAN ASSISTANT and PHYSICIAN. If Section 1.3(b) Applies, the following schedules of controlled substances are hereby delegated to PHYSICIAN ASSISTANT, and each individual substance shall be listed in Exhibit 1:

Schedule II: Authorized Not AuthorizedSchedule III: Authorized Not AuthorizedSchedule IV: Authorized Not AuthorizedSchedule V: Authorized Not Authorized

(d) All prescriptions shall conform with state and federal laws and regulations and shall include the name, address and telephone number of PHYSICIAN ASSISTANT and PHYSICIAN. (e) PHYSICIAN ASSISTANT may request, receive and sign for non-controlled professional samples and may distribute professional samples to patients. (f) PHYSICIAN ASSISTANT shall not prescribe any drugs, medicines, devices or therapies PHYSICIAN is not qualified or authorized to prescribe. (g) PHYSICIAN ASSISTANT may only dispense starter doses of medication to cover a period of time for seventy-two (72) hours or less.

(b) PHYSICIAN ASSISTANT may prescribe controlled substances pursuant to the provisions of this Agreement and under the authority given and requirements of Rev. Mo. Stat 334.747.1. The prescribing, administering or dispensing of controlled substances by PHYSICIAN ASSISTANT under this Agreement shall be accomplished only under the direction and supervision of PHYSICIAN. The PHYSICIAN and/or authorized PHYSICIAN ASSISTANT's directions for the prescribing, administering or dispensing of controlled substances shall be recorded in the patient’s chart and the appropriate dispensing log. These recordings shall be noted by PHYSICIAN ASSISTANT and shall be co-signed by PHYSICIAN following review of the records.

Section 1.3(a): Applies Does NOT Apply

Section 1.3(b): Applies Does NOT Apply

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1.4 At all times while this Agreement is in effect, PHYSICIAN shall maintain accountability for authority granted in this Agreement and accept responsibility for oversight of the activities of, and health care services rendered by PHYSICIAN ASSISTANT.

1.5 The parties may amend the PHYSICIAN(S) who are parties to this Agreement by designating in writing any new physician who agrees to be bound to the terms of this Agreement.

2. Geographic Restrictions.

2.1 PHYSICIAN’s and PHYSICIAN ASSISTANT’s practice is located at the Practice Site. Notwithstanding anything to the contrary herein, at all times while this Agreement is in effect, PHYSICIAN ASSISTANT and PHYSICIAN shall practice within fifty (50) miles by road of one another.

3. Oversight and Review.

3.1 PHYSICIAN responsibilities for oversight and review are governed by Missouri state statutes and regulations contained in §334.735 R.S.Mo. and 20 CSR 2150-7.135. SSM Health requires that oversight and review provided in this Section is in compliance with all applicable state laws.

3.2 PHYSICIAN ASSISTANT and PHYSICIAN acknowledge and shall document that PHYSICIAN ASSISTANT has practiced at the Practice Site with PHYSICIAN being continuously present for a period of at least one month before PHYSICIAN ASSISTANT may practice in a setting where PHYSICIAN is not continuously present. For purposes of this Section 3.1, one month shall be defined as a minimum of one hundred (100) hours in a consecutive thirty (30) day period.

3.3 PHYSICIAN shall work within the same facility as the PHYSICIAN ASSISTANT for at least four hours within one calendar day for every fourteen days on which the PHYSICIAN ASSISTANT provides patient care. The requirement of appropriate supervision shall be applied so that no more than thirteen calendar days in which a PHYSICIAN ASSISTANT provides patient care shall pass between the PHYSICIAN’s four hours working within the same facility.

3.4 PHYSICIAN must be readily available either in person or via telecommunications during the time PHYSICIAN ASSISTANT is providing patient care. PHYSICIAN ASSISTANT shall not otherwise practice without the supervision of PHYSICIAN if PHYSICIAN is not readily available for consultation, assistance and intervention, except in the event of an emergency situation.

3.5 PHYSICIAN ASSISTANT shall consult with PHYSICIAN and/or refer patients to PHYSICIAN or a designated health facility for services or emergency care that is beyond the education, training, competence or scope of practice of PHYSICIAN ASSISTANT in accordance with Practice Site guidelines and polices and as appropriate to serve the immediate needs of the patient.

3.6 In the event PHYSICIAN ASSISTANT provides health care services for conditions other than acute self-limited or well-defined problems, PHYSICIAN shall see the patient for evaluation and approve or formulate the plan of treatment for new or significantly changed

1.6 PHYSICIAN hereby delegates the following authority regarding the usage of restraints: Authority to order restraints and/or seclusion for patients with violent or self-destructive behavior in a

dedicated psychiatric unit:Applies (Only allowed at SSM Health DePaul Hospital - St. Louis, Does NOT ApplySSM Health St. Joseph Hospital - St. Charles, and

SSM Health St. Mary's Hospital - St. Louis)

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conditions as soon as practical, but in no case more than two (2) weeks after the patient has been seen by PHYSICIAN ASSISTANT. In all circumstances, PHYSICIAN ASSISTANT shall promptly notify PHYSICIAN of any serious or significant change in any patient’s condition.

3.7 PHYSICIAN, in collaboration with PHYSICIAN ASSISTANT, shall jointly review and document the work records and practice activities of the PHYSICIAN ASSISTANT at least every two (2) weeks regarding the quality and appropriateness of professional services provided pursuant to this Agreement. In the event PHYSICIAN ASSISTANT provides health care services in the nursing home setting, such review shall occur at least once a month. PHYSICIAN and PHYSICIAN ASSISTANT shall conduct all reviews at the Practice Site of service, except in extraordinary circumstances which shall be documented. PHYSICIAN shall review a minimum of ten percent (10%) of PHYSICIAN ASSISTANT’s patient’s records and shall document each review. The review process and documentation of the review process implemented by PHYSICIAN and PHYSICIAN ASSISTANT shall be on file and maintained by PHYSICIAN at the appropriate Practice Site. The documentation of this review shall be available to the Missouri State Board of Registration for the Healing Arts for review upon request.

3.8 PHYSICIAN and PHYSICIAN ASSISTANT have determined an appropriate process for the review and management of abnormal test results.

3.9 PHYSICIAN ASSISTANT and PHYSICIAN agree, and PHYSICIAN hereby designates the following physicians set forth on Exhibit 2, attached hereto and incorporated herein by reference, to consult, direct or supervise PHYSICIAN ASSISTANT in the event PHYSICIAN is unavailable for consultation due to temporary illness, injury or absence.

4. Term and Termination.

4.1 The term of this Agreement shall commence on the Effective Date and shall continue until terminated herein. This Agreement shall be reviewed annually by both the PHYSICIAN and PA.

4.2 This Agreement can be terminated at any time by either PHYSICIAN or PHYSICIAN ASSISTANT upon sixty (60) days written notice to the other. The terminating party shall concurrently forward a copy of the notice of termination to the Practice Site.

4.3 In addition, this Agreement terminates automatically and immediately without written notice upon:

(a) termination of the employment relationship between either EMPLOYER and PHYSICIAN ASSISTANT or PHYSICIAN;

(b) suspension, revocation, nonrenewal or other adverse action taken with respect to the professional license, BNDD or DEA certifications of PHYSICIAN or PHYSICIAN ASSISTANT as applicable;

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(c) nonrenewal, expiration or termination of professional liability insurance of PHYSICIAN or PHYSICIAN ASSISTANT as required under the provisions of Section 6, below; or

(d) suspension or exclusion of PHYSICIAN or PHYSICIAN ASSISTANT from any federal or state health care reimbursement program.

4.4 This Agreement shall terminate immediately upon notice to PHYSICIAN ASSISTANT (verbal or written) if PHYSICIAN, after consultation with HOSPITAL, determines that PHYSICIAN ASSISTANT:

(a) has materially breached any term of this Agreement; or

(b) has committed an act which is determined to be gross or professional misconduct.

5. Insurance.

5.1 At all times during the term of this Agreement, PHYSICIAN and PHYSICIAN ASSISTANT shall maintain insurance consistent with the requirements of the parties’ respective employment agreements.

5.2 The obligations of PHYSICIAN and PHYSICIAN ASSISTANT under this Section 5 shall survive the expiration or termination of this Agreement for any reason.

6. Miscellaneous.

6.1 Bylaws.

All services performed pursuant to this Agreement shall be performed in a manner consistent with HOSPITAL Medical Staff Bylaws and related Manuals and HOSPITAL policies and procedures.

6.2 Document Retention.

PHYSICIAN and PHYSICIAN ASSISTANT each agree to maintain copies of this Agreement, any and all amendments, exhibits, protocols, standing orders and modifications thereto, and any notice of termination of this Agreement for a minimum of eight (8) years after termination of this Agreement.

6.3 Documentation of Quality Reviews. The process and documentation of review of health care services described in Section 3 above shall be maintained by PHYSICIAN at the Practice Site, and shall be made available to any of the parties upon request.

6.4 Assignment and Subcontracting.

The purpose of this Agreement is to secure the services of PHYSICIAN in the performance of supervisory services of PHYSICIAN ASSISTANT as more fully set forth hereunder. Accordingly, neither PHYSICIAN nor PHYSICIAN ASSISTANT may assign their rights

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or obligations under this Agreement nor otherwise subcontract for, or delegate, the performance of his/her obligations under this Agreement to any other person or entity.

6.5 Independent Contractors.

For purposes of this Agreement, PHYSICIAN and PHYSICIAN ASSISTANT are independent contractors, and this Agreement shall not constitute the formation of a partnership, joint venture, employment or master-servant relationship.

6.6 Entire Agreement.

This Agreement contains the entire understanding between the parties hereto and supersedes all prior proposals, negotiations, representations, communications, writings and agreements between the parties with respect to the subject matter hereof, whether oral or written. No amendment, change, modification or alteration of the terms and conditions hereof shall be binding unless evidenced by a subsequent writing signed by the parties hereto. This Agreement shall be binding on the parties, their successors, and permitted assigns.

6.7 Governing Law; Change in Law.

This Agreement and any disputes arising hereunder shall be governed by the substantive laws of the State of Missouri without regard to Missouri’s conflict of laws provisions. The parties agree that this Agreement is subject to all applicable state, local and federal laws and regulations, as well as the standards of the Joint Commission and any amendments thereto, during the term of this Agreement. In the event any provision in this Agreement shall be deemed, by either party, to be a violation of law or regulation, enacted after the execution of this Agreement, or to be inconsistent with the laws or regulations existing as of the date of this Agreement but interpreted by a court or regulatory authority of competent jurisdiction after the execution of this Agreement, then the parties shall proceed in good faith to renegotiate this Agreement to eliminate such violation upon written notice of such violation to the other party hereto. If an amended agreement cannot be reached by the parties within thirty (30) days from the receipt of the written notice, then this Agreement shall be subject to termination by either party upon ten (10) days written notice to the other party.

6.8 Waiver of Breach.

The failure of any party to this Agreement to object or take affirmative action with respect to any conduct of the other party which is in violation of the provisions of this Agreement shall not be construed as a waiver of that violation or of any future violations of the provisions of this Agreement.

6.9 Notices.

Any notices or other communications required or contemplated under the provisions of this Agreement shall be in writing, delivered in person, evidenced by a signed receipt or sent by certified mail, return receipt requested, postage pre-paid, to the addresses indicated below or to such other persons or addresses as the parties may provide by notice to the

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other. The date of notice shall be the date of delivery if personally delivered or the date of mailing if the notice is mailed by certified mail.

6.10 Counterparts, Facsimile or Electronic Signature.

This Agreement may be signed in one or more counterparts including via facsimile or email, or by electronic signature in accordance with Missouri law, all of which shall be considered one and the same agreement, binding on all parties hereto, notwithstanding that both parties are not signatories to the same counterpart. A signed facsimile or photocopy of this Agreement shall be binding on the parties to this Agreement.

[Remainder of Page Intentionally Left Blank - Signature Page to Follow]

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IN WITNESS WHEREOF, each person signing below represents and warrants that he or she is fully authorized to sign and deliver this Agreement in the capacity set forth beneath his or her signature and the parties hereto have signed this Agreement as of the date and year written below.

PHYSICIAN:

By:____________________________________

Date: __________________________________

Home Address:

Home No.:

Work Address:

Work No.:

Pager No.:

Cell No.:

Email:

PHYSICIAN ASSISTANT:

By:____________________________________

Date: __________________________________

Home Address:

Home No.:

Work Address:

Work No.:

Pager No.:

Cell No.:

Email:

ACKNOWLEDGED BY SSM HEALTH REPRESENTATIVE:

By:____________________________________

Date: __________________________________

Title:

Email:

License Number: License Number:

Physician / Date:_________ PA / Date:_________





ANNUAL REVIEW (Please initial and date):

Name

Name: Name:

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EXHIBIT 1

DELEGATION OF PHYSICIAN ASSISTANT DUTIES

PHYSICIAN delegates to PHYSICIAN ASSISTANT (PA) the authority to deliver those health care services and treatments and to administer, dispense and prescribe drugs within the scope of practice and consistent with the skill, training, education and competence of both the PHYSICIAN and PHYSICIAN ASSISTANT and which are specific to the clinical conditions to be treated by PHYSICIAN ASSISTANT and PHYSICIAN, including, but not limited to the following:

Responsibilities of the PA:

(1) Taking patient histories; (2) Performing physical examinations of a patient; (3) Performing or assisting in the performance of routine office laboratory and patient screening(4) Performing routine therapeutic procedures;(5) Recording diagnostic impressions and evaluating situations calling for attention of a physician to institute treatement procedures. (6) Instructing and counseling patients regarding mental and physical health using procedures reviewed and approved by a licensed physician;(7) Assisting PHYSICIAN in institutional settings, including reviewing of treatment plans,ordering of tests and diagnostic laboratory and radiological services, and ordering of therapies, using procedures reviewed and approved by a licensed physician;(8) Assisting in surgery as applicable; (9) Performing such other tasks not prohibited by law under the supervision of a licensed physician as PHYSICIAN ASSISTANT has been trained and is proficient to perform;(10) PHYSICIAN ASSISTANT shall not perform abortions.

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Consultation:

Referrals:

Quality Review:

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EXHIBIT 2

ALTERNATE SUPERVISING PHYSICIANS

The following physicians shall provide consultation, direction and supervision to PHYSICIAN ASSISTANT in the event that PHYSICIAN is unavailable due to temporary illness, injury or absence. The following physicians by signing below further agree to be bound by the terms of this Agreement when consulting, directing or supervising PHYSICIAN ASSISTANT as described herein.

AGREED:

____________________________________________ ____________________________________________ Name Date Name Date











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EXHIBIT 3

PRACTICE LOCATIONS

Please designate Collaboration Practice Site with an asterisk (*) or other identifying mark.

physician assistant supervision agreement instructions sheet...forming a supervision agreement...

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