In a 2015 Public Affairs column, I argued that The Joint Commission Standards for Ambulatory Care did not dictate medical assisting scope of practice and did not supersede or override state and federal medical assisting law.1 Because many ambulatory care delivery centers are affiliated with, and on the premises of, hospitals, I am starting to receive questions about whether Joint Commission standards for hospitals limit the scope of practice for medical assistants. The answer to this question is that The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH)2 (January 2016) contains essentially the same language as The Joint Commission Standards for Ambulatory Care (SAC)3 in regard to delegation to unlicensed allied health professionals such as medical assistants. Therefore, the scope of practice for medical assistants under state and federal law is not altered in any way by the provisions of CAMH.

Note the following from Standard HR.01.02.07 of the CAMH2:

Standard HR.01.02.07—

The hospital determines how staff function within the organization.

Elements of Performance for HR.01.02.07

1. All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation.

2. Staff who provide patient care, treatment, and services practice within the scope of their license, certification, or registration and as required by law and regulation.

Also note the following from Standard HR.01.02.052:

Standard HR.01.02.05—

The hospital verifies staff qualifications.

Elements of Performance for HR.01.02.05

1. When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed.

As was the case with The Joint Commission Standards for Ambulatory Care, the CAMH does not add to or subtract from any state or federal requirements or restrictions on medical assistants’ scope of practice or credentialing. Thus, if state law permits providers to delegate to knowledgeable and competent unlicensed allied health professionals—such as medical assistants working under their direct/on-site supervision in outpatient settings—the administration of intramuscular (IM), intradermal (ID), and subcutaneous (subq) injections, the CAMH does not interfere with the provider’s right to delegate, and the medical assistant’s right to perform, an IM, ID, or subq injection.

Similarly, because the Centers for Medicare & Medicaid Services (CMS) rules for the Medicaid Electronic Health Record (EHR) Incentive Program indicate that only “credentialed medical assistants” (in addition to licensed health care professionals) are permitted to enter medication, laboratory, and diagnostic imaging orders into the computerized provider order entry (CPOE) system for meaningful use calculation purposes, nothing in the CAMH diminishes or alters this CMS requirement.

If a Joint Commission auditor, during an accreditation visit, takes the position that medical assistants are forbidden from performing certain tasks because of language in the CAMH, I would suggest that you immediately request written documentation of the citation, with a reference to the CAMH provision that is being violated. I also recommend that you contact me as soon as possible.

General questions about The Joint Commission Comprehensive Accreditation Manual for Hospitals, or specific questions that arise about medical assisting scope of practice during an audit by TJC, should be directed to Donald A. Balasa, JD, MBA, chief executive officer and legal counsel, at, or 800/228-2262.