BEFORE THE MEDICAL BOARD OF CALIFORNIA

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

In the Matter ofthe Accusation Against:

Purnima R. Sreenivasan, M.D.

Physician's and Surgeon's Certificate No. A 82039

Respondent

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File No. 12-2006-179350

DECISION

The attached Stipulated Settlement and Disciplinary Order is hereby adopted as the Decision and Order of the Medical Board of California, Department of Consumer Affairs, State of California.

This Decision shall become effective at 5:00p.m. on Apri123, 2010.

IT IS SO ORDERED March 26, 2010.

MEDICAL BOARD OF CALIFORNIA

EDMUND G. BROWN JR. Attorney (:Jenera! of Calif()rnia

; JOSE R. GUERRERO Supervising Deputy Attomey General

3 RUSSELL \V. LEE Deputy Attorney General

4 State Bar No. 94106 1515 Clay Street, 20th Floor

5 P.O. Box 70550 Oakland, CA 94612-0550

6 Telephone: (51 0) 622-2217 Facsimile: (510) 622-2121

7 Attorneysj(Jr Complainant

8 BEFORETHE MEDICAL BOARD OF CALIFORNIA

9 DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

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11 In the Matter of the Accusation Against:

12 PURNIMA RAVI SREENIVASAN, M.D.

13 120 La Casa Via, Ste. 205 Walnut Creek CA 94598

14 Physician's and Surgeon's Certificate No. A82039

15 Respondent.

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Case No. 12 2006 179350

STIPULATED SETTLEMENT AND DISCIPLINARY ORDER

18 In the interest of a prompt and speedy settlement of this matter, consistent with the public

19 interest and the responsibility of the Medical Board of California of the Department of Consumer

20 Affairs ("the Board''), the patiies hereby agree to the following Stipulated Settlement and

21 Disciplinary Order which will be submitted to the Board for its approval and adoption as the final

22 disposition of the Accusation.

23 PARTIES

24 1. Barbara Johnston (Complainant) is the Executive Director of the Medical Board of

25 Califcnnia. She brought this action solely in her official capacity and is represented in this matter

26 by Edmund G. Brown Jr., Attorney General ofthc State of California, by Russell W. Lee, Deputy

27 Attorney General.

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STIPULATED SETTLEMENT ( 12 2006 179350)

'J Respondent Pumima Ravi Sreenivasan, M.D. ("Respondent'' or "Dr. Sreenivasan") is

'J represented in this proceeding by attorney Geoffrey A. Mires, Esq., and Kevin R. Mintz, Esq.,

3 Rankin Spoat, Mires, Beaty & Reynolds, A Professional Corporation, 1970 Broadway, Suite

4 1150, Oakland, CA 94612, (51 0) 465-3922.

5 On or about February 21, 2003, the Medical Board of Califomia issued Physician's

6 and Surgeon's Certificate No. AS2039 to Respondent. The Physician's and Surgeon's Ce1iificate

7 was in full force and effect at all times relevant to the charges brought herein and will expire on

8 December 31,2010, unless renewed.

9 JURISDICTION

10 4. Accusation No. 12 2006 179350 was filed before the Board on July 14, 2009, and is

11 currently pending against Respondent. The Accusation, together with all other statutorily

12 required documents were properly served on Respondent in accordance with the Califomia

13 Administrative Procedure Act, and Respondent timely filed a Notice of Defense contesting the

14 Accusation. A copy of Accusation is attached as Exhibit A and incorporated herein by reference.

15 ADVISEMENT AND WAIVERS

16 5. Respondent has carefully read and understands the nature of the charges and

17 allegations in the Accusation and the effects ofthis Stipulated Settlement and Disciplinary Order.

18 6. Respondent is fully aware ofher legal rights in this matter, including the right to a

19 hearing on the charges and allegations in the Accusation; the right to be represented by counsel at

20 her own expense; the right to confront and cross-examine the witnesses against her; the right to

21 present evidence and to testify on her own behalf; the right to the issuance of subpoenas to

22 compel the attendance of witnesses and the production of documents; the right to reconsideration

23 and court review of an adverse decision; and all other rights accorded by the Califomia

24 Administrative Procedure Act and other applicable laws.

25 7. Respondent voluntarily, knowingly, and intelligently waives and gives up each and

26 every right set forth above.

27 Ill

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STIPU LA TFD SETTLEMENT ( 12 2006 179350)

CULPABILITY

') 8. Respondent understands and agrees that the charges and allegations in the

3 Accusation. if proven, constitute cause tor imposing discipline against her Physician's and

4 Surgeon's. Certificate No. A82039 pursuant to Business and Professions Code section 725, 2234

5 (c). and 2266.

6 9. For the purpose of resolving the Accusation without the expense and unceriainty of

7 an administrative hearing, Respondent acknowledges that these charges, if proven, provide a

8 factual basis for the imposition of discipline, gives up her right to contest those charges, and

9 agrees to be bound by the Board 's imposition of discipline as set forth in the Disciplinary Order

10 below.

11 RESERVATION

12 10. The admissions made by Respondent herein are only for the purposes of this

13 proceeding, or any other proceedings in which the Medical Board of Califomia or other

14 professional licensing agency is involved, and shall not be admissible in any other criminal or

15 civil proceeding.

16 805 REPORT

17 11. Respondent has been advised by the Medical Board and is otherwise aware that, in

18 September 2009, the Medical Board received a Business and Professions Code Section 805

19 Health Facility Reporting Fonn from John Muir Physician Network in Walnut Creek, Califomia,

20 (dated September 23, 2009) signed by Michael P. Kem, as Chief Executive Officer/Medical

21 Director/ Administrator, (hereinafter "805 Report"); that said 805 Report indicated that a summary

suspension of membership had been imposed on Respondent's membership with John Muir

Physician Network; that the 805 Repori contained allegations of substandard practice involving

24 inadequate recordkeeping, and prescribing of medications without adequate documentation or

25 justification with respect to five (5) patients identified by initials CW, LD, SA, EY, and AK, said

26 allegations of substandard practice being similar to those alleged in Accusation No. 12 2006

27 179350. It is stipulated and agreed that the discipline provided for in this Stipulated Settlement

28 and Disciplinary Order shall take into consideration the allegations set forih in said 805 Report,

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STIPULATED SETTLEMENT (12 2006 179350)

and that, if this Stipulated Settlement and Disciplinary Order is adopted by the Medical Board, the

2 Medical Board will not otherwise file an amended or supplemental Accusation based upon the

3 treatment of the patients spcci fied in said 805 Report.

4 CONTINGENCY

5 12. This Stipulated Settlement and Disciplinary Order shall be subject to approval by the

6 Board. Respondent understands and agrees that the Board's staff and counsel for Complainant

7 may communicate directly with the Board regarding this Stipulated Settlement and Disciplinary

8 Order, without notice to or pmiicipation by Respondent or her counsel. If the Board fails to adopt

9 this Stipulated Settlement and Disciplinary Order as its Order, the Stipulated Settlement and

10 Disciplinary Order, except for this paragraph, shall be of no force or effect. The Stipulated

11 Settlement and Disciplinary Order, shall be inadmissible in any legal action between the parties,

12 and the Board shall not be disqualified from further action by having considered this matter.

13 13. The pmiies agree that facsimile copies of this Stipulated Settlement and Disciplinary

14 Order, inc! uding facsimile signatures on it, shall have the same force and effect as the original.

15 14. In consideration of the foregoing admissions and stipulations, the parties agree that

16 the Board shall, without further notice or fom1al proceeding, issue and enter the following

1 7 Disciplinary Order:

18 DISCIPLINARY ORDER

19 IT IS HEREBY ORDERED that Physician's and Surgeon's Ce1iificate No. A82039 is

20 revoked. HOWEVER, the revocation of Respondent's Physician's and Surgeon's Ce1iificate No.

21 A82039 is stayed, and Respondent is placed on probation for three (3) years upon the following

22 terms and conditions.

23 1. PRESCRIBING PRACTICES COURSE Within 60 calendar days ofthe effective

24 date ofthis Decision, Respondent shall enroll in a course in prescribing practices, at Respondent's

25 expense, approved in advance by the Board or its designee. Failure to successfully complete the

26 course during the first 6 months of probation is a violation of probation.

27 A prescribing practice course taken after the acts that gave rise to the charges in the

28 Accusation, but prior to the effective date of the Decision may, in the sole discretion of the Board

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STIPULATED SETTLEMENT ( 12 2006 179350)

or its designee, be accepted towards the fulfillment of this condition if the course would have

2 been approved by the Board or its designee had the course been taken after the effective date of

3 this Decision.

4 Respondent shall submit a certiiication of successful completion to the Board or its

5 designee not later than 15 calendar days after successfully completing the course, or not later than

6 15 calendar days after the effective date of the Decision, whichever is later.

7 2. MEDICAL RECORD KEEPING COURSE Within 60 calendar days ofthe etTective

8 date ofthis Decision, Respondent shall enroll in a course in medical record keeping, at

9 Respondent's expense, approved in advance by the Board or its designee. Failure to successfully

1 0 complete the course during the first 6 months of probation is a violation of probation.

11 A medical record keeping course taken after the acts that gave rise to the charges in the

12 Accusation, but prior to the effective date of the Decision may, in the sole discretion of the Board

13 or its designee, be accepted towards the fulfillment of this condition if the course would have

14 been approved by the Board or its designee had the course been taken after the effective date of

15 this Decision.

16 Respondent shall submit a certification of successful completion to the Board or its

17 designee not later than 15 calendar days after successfully completing the course, or not later than

18 15 calendar days after the effective date ofthe Decision, whichever is later.

19 3. MONITORING- PRACTICE Within 30 calendar days of the effective date ofthis

20 Decision, respondent shall submit to the Board or its designee for prior approval as a practice,

21 monitor(s), the name and qualifications of one or more licensed physicians and surgeons whose

licenses are valid and in good standing, and who arc preferably American Board of Medical

Specialties (ABMS) certified. A monitor shall have no prior or current business or personal

24 relationship with respondent, or other relationship that could reasonably be expected to

25 compromise the ability of the monitor to render fair and unbiased reports to the Board, including,

26 but not limited to, any form ofbatiering, shall be in respondent's field of practice, and must agree

to serve as respondent's monitor. Respondent shall pay all monitoring costs.

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STIPULATED SETTLEMENT (12 2006 179350)

The Board or its designee shall provide the approved monitor with copies of the Decision

2 and Accusation, and a proposed monitoring plan. Within 15 calendar days of receipt of the

3 Decision and Accusation, and proposed monitoring plan, the monitor shall submit a signed

4 statement that the monitor has read the Decision and Accusation, fully understands the role of a

5 monitor, and agrees or disagrees with the proposed monitoring plan. If the monitor disagrees

6 with the proposed monitoring plan, the monitor shall submit a revised monitoring plan with the

7 signed statement.

8 Within 60 calendar days of the effective date of this Decision, and continuing throughout

9 probation, respondent's practice shall be monitored by the approved monitor. Respondent shall

10 make all records available for immediate inspection and copying on the premises by the monitor

11 at all times during business hours, and shall retain the records for the entire tenn of probation.

12 The monitor(s) shall submit a quarterly written report to the Board or its designee which

13 inCludes an evaluation ofrespondent's perfonnance, indicating whether respondent's practices are

14 within the standards of practice of medicine and whether respondent is practicing medicine

15 safely.

16 It shall be the sole responsibility of respondent to ensure that the monitor submits the

17 qumierly written repotis to the Board or its designee within 10 calendar days after the end of the

18 preceding quarter.

19 lfthc monitor resigns or is no longer available, respondent shall, within 5 calendar days of

20 such resignation or unavailability, submit to the Board or its designee, for prior approval, the

21 name and qualifications of a replacement monitor who \vill be assuming that responsibility within

22 15 calendar days. If respondent fails to obtain approval of a replacement monitor within 60 days

23 of the resignation or unavailability of the monitor, respondent shall be suspended from the

24 practice of medicine until a replacement monitor is approved and prepared to assume immediate

25 monitoring responsibility. Respondent shall cease the practice of medicine within 3 calendar

26 days after being so notified by the Board or designee.

27 ln lieu of a monitor, respondent may pmiicipate in a professional enhancement program

28 equivalent to the one offered by the Physician Assessment and Clinical Education Program at the

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STIPULATED SETTLEMENT (12 2006 1 79350)

University of California, San Diego School of Medicine, that includes, at minimum, quarterly

2 chart review, semi-annual practice assessment, and semi-annual review of professional growth

3 and education. Respondent shall participate in the professional enhancement program at

4 respondent's expense during the term of probation.

5 Failure to maintain all records, or to make all appropriate records available for immediate

6 inspection and copying on the premises, or to comply with this condition as outlined above is a

7 violation of probation.

8 STANDARD CONDITIONS

9 4. NOTIFICATION Prior to engaging in the practice of medicine, the respondent shall

I 0 provide a true copy of the Decision and Accusation to the Chief of Staff or the Chief Executive

11 Officer at every hospital where privileges or membership are extended to respondent, at any other

12 facility where respondent engages in the practice of medicine, including all physician and locum

13 tenens registries or other similar agencies, and to the Chief Executive Officer at every insurance

14 canier which extends malpractice insurance coverage to respondent. Respondent shall submit

15 proof of compliance to the Board or its designee within 15 calendar days.

16 This condition shall apply to any change(s) in hospitals, other facilities or insurance CatTier.

17 5. SUPERVISION OF PHYSICIAN ASSISTANTS During probation, respondent is

18 prohibited from supervising physician assistants.

19 6. OBEY ALL LAWS Respondent shall obey all federal, state and local laws, all rules

20 governing the practice of medicine in California, and remain in full comphance with any co uti

21 ordered criminal probation, payments and other orders.

22 7. QUARTERLY DECLARATIONS Respondent shall submit qumierly declarations

23 under penalty of pe1:j ury on forms provided by the Board, stating whether there has been

24 compliance with all the conditions of probation. Respondent shall submit qumierly declarations

25 not later than 1 0 calendar days after the end of the preceding quarter.

26 8. PROBATION UNIT COMPLIANCE Respondent shall comply with the Board's

27 probation unit. Respondent shall, at all times, keep the Board informed of respondent's business

28 and residence addresses. Changes of such addresses shall be immediately communicated in

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STIPULATED SETTLEMENT (I 2 2006 I 79350)

writing to the Board or its designee. Under no circumstances shall a post office box serve as an

,.., address of record, except as allowed by Business and Professions Code section 2021 (b).

3 Respondent shall not engage in the practice of medicine in respondent's place of residence.

4 Respondent shall maintain a current and renewed Califomia physician's and surgeon's license.

5 Respondent shall immediately inform the Board, or its designee, in writing, of travel to any

6 areas outside the jurisdiction of California which lasts, or is contemplated to last, more than 30

7 calendar days.

9. INTERVIEW WITH THE BOARD, OR ITS DESIGNEE Respondent shall be

9 available in person for interviews either at respondent's place of business or at the probation unit

10 office, with the Board or its designee, upon request at various intervals, and either with or without

11 prior notice throughout the tenn of probation.

12 10. RESIDING OR PRACTICING OUT-OF-STATE In the event respondent should

13 leave the State of California to reside or to practice, respondent shall notify the Board or its

14 designee in writing 30 calendar days prior to the dates of depm1ure and retum. Non-practice is

15 defined as any period of time exceeding 30 calendar days in which respondent is not engaging in

16 any activities defined in Sections 2051 and 2052 of the Business and Professions Code.

17 All time spent in an intensive training program outside the State of Califomia which has

18 been approved by the Board or its designee shall be considered as time spent in the practice of

19 medicine within the State. A Board-ordered suspension of practice shall not be considered as a

20 period of non-practice. Periods of temporary or pennanent residence or practice outside

21 California will not apply to the reduction of the probationary tem1. Periods of temporary or

22 permanent residence or practice outside California will relieve respondent of the responsibility to

comply with the probationary terms and conditions with the exception of this condition and the

24 following terms and conditions of probation: Obey All Laws; Probation Unit Compliance; and

25 Cost Recovery.

26 It shall be a violation ofprobation if Respondent's periods oftemporary or pem1anent

27 residence or practice outside California total two years. However, it shall not be a violation of

28 probation as long as respondent is residing and practicing medicine in another state of the United

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STIPULATED SETTLEMENT ( 12 2006 179350)

States and is on active probation with the medical licensing authority of that state, in which case

2 the two year period shall begin on the date probation is completed or tenninated in that state.

3 11. FAJLUI~~ TO PRACTICE MEDICINE- CALIFORNIA RESIDENT

4 In the event respondent resides in the State of Calif()mia and for any reason respondent

5 stops practicing medicine in California, respondent shall notify the Board or its designee in

6 writing within 30 calendar days prior to the dates of non-practice and return to practice. Any

7 period of non-practice within California, as defined in this condition, will not apply to the

8 reduction of the probationary tenn and does not relieve respondent of the responsibility to comply

9 witb the terms and conditions of probation. Non-practice is defined as any period of time

10 exceeding 30 calendar days in which respondent is not engaging in any activities defined in

11 sections 2051 and 2052 of the Business and Professions Code.

12 All time spent in an intensive training program which has been approved by the Board or its

13 designee shall be considered time spent in the practice of medicine. For purposes of this

14 condition, non-practice due to a Board-ordered suspension or in compliance with any other

15 condition of probation, shall not be considered a period of non-practice.

16 It shall be a violation of probation if respondent resides in Califomia and for a total of two

1 7 years, fails to engage in California in any of the activities described in Business and Professions

18 Code sections 2051 and 2052.

19 12. COMPLETION OF PROBATION Respondent shall comply with all financial

20 obligations (e.g., cost recovery, restitution, probation costs) not later than 120 calendar days prior

21 to the completion of probation. Upon successful completion of probation, respondent's certificate

22 shall be fully restored.

23 13. VIOLATION OF PROBATION Failure to fully comply with any term or condition

24 of probation is a violation of probation. If respondent violates probation in any respect, the

25 Board, after giving respondent notice and the opportunity to be heard, may revoke probation and

26 carry out the disciplinary order that was stayed. If an Accusation, Petition to Revoke Probation,

27 or an Interim Suspension Order is filed against respondent during probation, the Board shall have

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STIPULATED SETTLEMENT (12 2006 179350)

continuing jurisdiction until the matter is final, and the period of probation shall be extended until

'> the matter is final.

3 14. LICENSE SURRENDER Following the effective date of this Decision, if

4 respondent ceases practicing due to retirement, health reasons or is otherwise unable to satisfy the

5 terms and conditions of probation, respondent may request the voluntary sunender of

6 respondent's license. The Board reserves the right to evaluate respondent's request and to

7 exercise its discretion whether or not to t,>rant the request, or to take any other action deemed

8 appropriate and reasonable under the circumstances. Upon formal acceptance of the surrender,

9 respondent shall within 15 calendar days deliver respondent's wallet and wall certificate to the

1 0 Board or its designee and respondent shall no longer practice medicine. Respondent will no

11 longer be subject to the ten11s and conditions of probation and the surrender of respondent's

12 license shall be deemed disciplinary action. If respondent reapplies for a medical license, the

13 application shall be treated as a petition for reinstatement of a revoked cetii ficate.

14 15. PROBATION MONITORING COSTS Respondent shall pay the costs associated

15 with probation monitoring each and every year of probation, as designated by the Board, which

16 may be adjusted on an annual basis. Such costs shall be payable to the Medical Board of

17 California and delivered to the Board or its designee no later than January 31 of each calendar

18 year. Failure to pay costs within 30 calendar days of the due date is a violation of probation.

19 ACCEPTANCE

20 I have carefully read the above Stipulated Settlement and Disciplinary Order and have fully

21 discussed the terms and conditions and other matters contained therein with my attorney,

22 Geoffrey A. Mires, Esq .. 1 understand the Stipulated Settlement and Disciplinary Order and the

23 effect it will have on my Physician's and Surgeon's Certificate No. A82039. 1 enter into this

24 Stipulated Settlement and Disciplinary Order voluntarily, knowingly, and intelligently, and agree

25 to be bound by the Decision and Order of the Medical Board of Califomia.

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27 DATED: \ I i

PURNIMA RA VI SREENIVASAN, M.D. Respondent

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STIPULATED SETTLEMENT (12 2006 179350)

l have read the above Stipulated Settlement and Disciplinary Order and approve of it as to

2 form and content. l have fully discussed the terms and conditions and other matters therein with

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5 DATED:

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8 ENDORSEMENT

9 The foregoing Stipulated Settlement and Disciplinary Order is hereby respectfully

10 submitted for consideration of the Medical Board of California, Department of Consumer Affairs.

11 Dated:

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Respectfully Submitted,

EDMUND G. BROWN JR. Attorney General of Califomia JOSE R. GUERRERO Supervising Deputy Attorney General

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RUSSELL W. LEE Deputy Attomey General Attorneysfor Complainant

STIPULATED SETTLEMEN 1 ( 12 2006 179350)

EXHIBIT A

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FILED STATE OF CALIFORNIA

MEDICAL BOARD F CALIFORNiA EDfv1UND G. BROW!\ JR. Attorney General of California JOSE R. GUERRERO

SACRAMENTO v I~ 20 0 9 /-· ,· ANALYST

Supervising Deputy Attorney General RUSSELL W. LEE Deputy Attorney General State Bar No. 94106

1515 Clay Street, 20th Floor P.O. Box· 70550 Oakland, CA 94612-0550 Telephone: (510) 622-2217 Facsimile: (510) 622-2121

Attorneysfor Complainant

BEFORE THE MEDICAL BOARD OF CALIFORNIA

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

In the Matter of the Accusation Against:

PURNIMA RA VI SREENIV ASAN, M.D.

120 La Casa Via, Ste. 205 Walnut Creek, CA 94598 Physician and Surgeon Certificate No. A82039

Case No. 12 2006 179350

ACCUSATION

Respondent.

Complainant alleges:

PARTIES

1. Barbara Johnston (Complainant) brings this Accusation solely in her official capacity

as the Executive Director of the Medical Board of California, Department of Consumer AfT airs.

2. On or about February 21. 2003, the Medical Board of California issued Physician and

Surgeon CeriificateNumber A82039 to Purnima Ravi Sreenivasan, M.D. (Respondent). Unless

renewed, it will expire on December 3 L 2010. There is no Board record of previous disciplinary

action having been taken against this certificate.

I I I

IIi

Accusation

JURlSDICTION

2 3. This Accusation is brought before the Medical Board of California (Board)1,

Department of Consumer A flairs, under the authority of the follC.l\Ving laws. All section

4 references are to the Business and Professions Code unless otherwise indicated.

5 4. Section 2004 of the Code states:

6 "The board shall have the responsibility for the following:

7 (a) The enforcement ofthe disciplinary and criminal provisions ofthe Medical Practice Act.

8 (b) The administration and hearing of disciplinary actions.

9 (c) Carrying out disciplinary actions appropriate to findings made by a panel or an

10 administrative law judge.

11 (d) Suspending, revoking, or otherwise limiting certificates after the conclusion of

12 disciplinary actions.

13 (e) Reviewing the quality of medical practice carried out by physician and surgeon

14 certificate holders under the jurisdiction of the board.

15 (f) Approving undergraduate and graduate medical education programs.

16 (g) Approving clinical clerkship and special programs and hospitals for the programs in

17 subdivision (f).

18 (h) Issuing licenses and certificates under the board's jurisdiction.

19 (i) Administering the board's continuing medical education program."

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5. Section 2227 of the Code provides that a licensee who is found guilty under the

Medical Practice. Act may have his or her license revoked, suspended for a period not to exceed

one year. placed on probation and required to pay the costs of probation monitoring, or such other

action taken in relation to discipline as the Division deems proper.

6. Section 2234 ofthc Code states:

1 The tern1 "board'' means the Medical Board of California. "Division of Medical Quality" shall also be deemed to refer to the board. (Bus. & Prof. Code §2002)

Accusation

"The Division of Medical Quality shall take action against any licensee who is charged with

2 unprofessional conduct. In addition to other provisions ofthis article, unprofessional conduct

includes, but is not limited to, the following:

4 (a) Violating or attempting to violate, directly or indirectly, assisting in or abetting the

5 violation oL or conspiring to violate any provision of this chapter [Chapter 5, the Medical

6 Practice Act].

7 (b) Gross negligence.

8 (c) Repeated negligent acts. To be repeated, there must bet wo or more negligent acts or

9 omissions. An initial negligent act or omission followed by a separate and distinct departure from

10 the applicable standard of care shall constitute repeated negligent acts.

11 (1) An initial negligent diagnosis followed by an act or omission medically appropriate for

12 that negligent diagnosis of the patient shall constitute a single neg! igent act.

13 (2) When the standard of care requires a change in the diagnosis, act, or omission that

14 constitutes the negligent act described in paragraph ( 1 ), including, but not limited to, a

15 reevaluation of the diagnosis or a change in treatment, and the licensee's conduct departs from the

16 applicable standard of care, each departure constitutes a separate and distinct breach of the

17 standard of care.

18 (d) Incompetence.

19 (e) The commission of any act involving dishonesty or corruption which is substantially

20 related to the qualifications, functions, or duties of a physician and surgeon.

21 (f) Any action or conduct which would have \Varranted the denial of a certificate."

22 7. Section 2266 of the Code states: "The failure of a physician and surgeon to maintain

23 adequate and accurate records relating to the provision of services to their patients constitutes

24 unprofessional conduct."

25 8. Section 725 of the Code states:

26 "(a) Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering

27 of drugs or treatment, repeated acts of clearly excessive usc of diagnostic procedures, or repeated

28 acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of

3 Accusatio~

the community of licensees is unprofessional conduct for a physician and surgeon, dentist,

podiatrist. psychologist. physical therapist. chiropractor. optometrist, speech-language

pathologist. or audiologist.

4 (b) Any person who engages in repeated acts of clearly excessive prescribing or

5 administering of drugs or treatment is guilty of a misdemeanor and shall be punished by a fine of

6 not less than one hundred dollars ($1 00) nor more than six hundred dollars ($600 ), or by

7 imprisonment for a term of not less than 60 days nor more than 1 80 days. or by both that fine and

8 imprisonment.

9 (c) A practitioner who has a medical basis for prescribing. furnishing, dispensing, or

10 administering dangerous drugs or prescription controlled substances shall not be subject to

11 disciplinary action or prosecution under this section.

12 (d) No physician and surgeon shall be subject to disciplinary action pursuant to this section

13 for treating intractable pain in compliance with Section 2241.5."

14 9. Section 22412 of the Code states:

15 "(a) A physician and surgeon may prescribe, dispense, or administer prescription drugs,

16 inc] uding prescription controlled substances. to an addict under his or her treatment for a purpose

17 other than maintenance on, or detoxification from, prescription drugs or controlled substances.

18 (b) A physician and surgeon may prescribe, dispense, or administer prescription drugs or

19 prescription controlled substances to an addict for purposes of maintenance on, or detoxification

20 from. prescription drugs or controlled substances only as set forth in subdivision (c) or in Sections

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2 Prior to January L 2007, Section 2241 provided: Unless otherwise provided by this section, the prescribing, selling. furnishing, giving away, or administering or offering to prescribe, selL fumish. give away. or administer anyofthe drugs or compounds mentioned in Section 2239 to an addict or habitue constitutes unprofessional conduct. If the drugs or compounds are administered or applied by a licensed physician and surgeon or by a registered nurse acting under his or her instruction and supervision, this section shall not apply to any of the following cases:

(a) Emergency treatment of a patient whose addiction is complicated by the presence of incurable disease, serious accident or injury, or the infirmities attendant upon age.

(b) Treatment of addicts or habitues in state licensed institutions where the patient is kept under restraint and controL or in city or county jails or state prisons.

(c) Treatment of addicts as provided for by Section 11217.5 ofthe Health and Safety Code.

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Accusation

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11215, 1 1217, 11217.5. 11218, 1121 CJ, and 11220 of the Health and Safety Code. Nothing in this

subdivision shall authorize a physician and surgeon to prescribe, dispense, or administer

dangerous drugs or controlled substances to a person he or she kno\vs or reasonably believes is

using or will use the drugs or substances for a nonmedical purpose.

(c) Notwithstanding subdivision (a), prescription drugs or controlled substances may also

be administered or applied by a physician and surgeon, or by a registered nurse acting under his

or her instruction and supervision, under the following circumstances:

( 1) Emergency treatment of a patient whose addiction is complicated by the presence of

incurable disease, acute accident, illness, or injury, or the infirmities attendant upon age.

(2) Treatment of addicts in state-licensed institutions where the patient is kept under

restraint and controL or in city or county jails or state prisons.

(3) Treatment of addicts as provided for by Section 11217.5 of the Health and Safety Code.

( d)(l) For purposes of this section and Section 2241.5, "addict" means a person whose

actions are characterized by craving in combination with one or more of the following:

(A) Impaired control over drug use.

(B) Compulsive use.

(C) Continued use despite harm.

(2) Notwithstanding paragraph (1 ), a person whose drug-seeking behavior is primarily due

to the inadequate control of pain is not an addict within the meaning of this section or Section

2241.5."

10. Section 2241.5 3 ofthe Code states:

3 Prior to January 1, 2007, Section 2241.5 provided: Administration of controlled substances to person experiencing "intractable pain''

(a) Notwithstanding any other provision of law, a physician and surgeon may prescribe or administer controlled substances to a person in the course oftbe physician and surgeon's treatment of that person for a diagnosed condition causing intractable pain.

(b) ''Intractable pain," as used in this section, means a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts, including, but not limited to, evaluation by the attending physician and surgeon and one or more physicians and surgeons specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain.

(c) No physician and surgeon shall be subject to disciplinary action by the board for (continued ... )

5 I ~~~ Accusation \

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"(a) A physician and surgeon may prescribe for, or dispense or administer to. a person

under his or her treatment for a medical condition dangerous drugs or prescription controlled

substances for the treatment of pain or a condition causing pain. including. but not limited to,

intractable pain.

(b) No physician and surgeon shall be subject to disciplinary action for prescribing,

dispensing, or administering dangerous drugs or prescription controlled substances in accordance

with this section.

(c) This section shall not affect the power of the board to lake any action described in

Section 2227 against a physician and surgeon who does any of the following:

(1) Violates subdivision (b), (c), or (d) of Section 2234 regarding gross negligence, repeated

negligent acts, or incompetence.

prescribing or administering controlled substances in the course of treatment of a person for intractable pain.

(d) This section shall not apply to those persons being treated by the physician and surgeon for chemical dependency because of their use of drugs or controlled substances.

(e) This section shall not authorize a physician and surgeon to prescribe or administer controlled substances to a person the physician and surgeon knows to be using drugs or substances for nontherapeutic purposes.

(f) This section shall not affect the power ofthe board to deny, revoke, or suspend the license of any physician and surgeon who does any of the following:

( 1) Prescribes or administers a controlled substance or treatment that is nontherapeutic in nature or nontherapeutic in the manner the controlled substance or treatment that is administered or prescribed or is for a nontherapeutic purpose in a nontherapeutic manner.

(2) Fails to keep complete and accurate records of purchases and disposals of substances listed in the California Controlled Substances Act or of controlled substances scheduled in, or pursuant to, the federal Comprehensive Drug Abuse Prevention and Control Act of 1970. A physician and surgeon shall keep records of his or her purchases and disposals of these drugs, including the date of purchase, the date and records of the sale or disposal of the drugs by the physician and surgeon, the name and address of the person receiving the drugs, and the reason for the disposal of or the dispensing of the drugs to the person nd shall otherwise comply with all state recordkeeping requirements for controlled substances.

(3) Writes false or fictitious prescriptions for controlled substances listed in the California Controlled Substances Act or scheduled in the federal Comprehensive Drug Abuse Prevention ai1d Control Act of 1970.

( 4) Prescribes, administers, or dispenses in a manner not consistent with public health and welfare controlled substances listed in the California Controlled Substances Act or scheduled in the federal Comprehensive Drug Abuse Prevention and Control Act of 1970.

(5) Prescribes, administers, or dispenses in violation of either Chapter 4 (commencing with Section 11150) or Chapter 5 (commencing with Section 1121 0) of Division l 0 of the Health and Safety Code or this chapter.

(g) Nothing in this section shall be construed to prohibit the governing body of a hospital from taking disciplinary actions against a physician and surgeon, as authorized pursuant to Sections 809.05.809.4, and 809.5.

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Accusation

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(2) Violates Section 2241 regarding treatment of an addict.

(3) Violates Section 2242 regarding performing an appropriate prior examination and the

existence of a medical indication for prescribing, dispensing, or furnishing dangerous drugs.

( 4) Violates Section 2242.1 regarding prescribing on the Internet.

( 5) Fails to keep complete and accurate records of purchases and disposals of substances

listed in the California Uniform Controlled Substances Act (Division 10 (commencing with

Section 11 000) of the Health and Safety Code) or controlled substances scheduled in the federal

Comprehensive Drug Abuse Prevention and Control Act of 1970 (21 U.S.C. Sec. 801 et seq.), or

pursuant to the federal Comprehensive Drug Abuse Prevention and Control Act of 1970. A

physician and surgeon shall keep records of his or her purchases and disposals of these controlled

substances or dangerous drugs, including the date of purchase, the date and records of the sale or

disposal of the drugs by the physician and surgeon, the name and address of the person receiving

the drugs. and the reason for the disposal or the dispensing of the drugs to the person, and shall

otherwise comply with all state recordkeeping requirements for controlled substances.

(6) Writes false or fictitious prescriptions for controlled substances listed in the California

Uniform Controlled Substances Act or scheduled in the federal Comprehensive Drug Abuse

Prevention and Control Act of 1970.

(7) Prescribes, administers, or dispenses in violation of this chapter, or in violation of

Chapter 4 (commencing with Section 11150) or Chapter 5 (commencing with Section 1121 0) of

Division 1 0 of the Health and Safety Code.

(d) A physician and surgeon shall exercise reasonable care in determining whether a

particular patient or condition, or the complexity of a patient's treatment, including, but not

limited to, a cu1Tent or recent pattern of drug abuse, requires consultation with, or referral to, a

more qualified specialist.

(c) Nothing in this section shall prohibit the goveming body of a hospital from taking

disciplinary actions against a physician and surgeon pursuant to Sections 809.05, 809.4, and

809.5."

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Accusation

11. Section 2242 of the Code states:

2 "(a) Prescribing, dispensing. or furnishing dangerous drugs as defined in Section 4022

3 without an appropriate prior examination and a medical indication, constitutes unprofessional

4 conduct.

5 (b) No licensee shall be foLmd to have committed unprofessional conduct within the

6 meaning of this section iL at the time the drugs were prescribed. dispensed, or furnished. any of

7 the following applies:

8 (1) The licensee was a designated physician and surgeon or podiatrist serving in the absence

9 of the patient's physician and surgeon or podiatrist, as the case may be, and if the drugs were

10 prescribed, dispensed, or furnished only as necessary to maintain the patient until the return of his

11 or her practitioner, but in any case no longer than 72 hours.

12 (2) The licensee transmitted the order for the drugs to a registered nurse or to a licensed

13 vocational nurse in an inpatient facility. and if both of the following conditions exist:

14 (A) The practitioner had consulted with the registered nurse or licensed vocational nurse

15 who had reviewed the patient's records.

16 (B) The practitioner was designated as the practitioner to serve in the absence of the

17 patient's physician and surgeon or podiatrist, as the case may be.

18 (3) The licensee was a designated practitioner serving in the absence of the patient's

19 physician and surgeon or podiatrist, as the case may be, and was in possession of or had utilized

20 the patient's records and ordered the renewal of a medically indicated prescription for an amount

21 not exceeding the original prescription in strength or amount or for more than one refill.

22 ( 4) The licensee was actii1g in accordance vvith Section 1205 8:2 of the Health and Safety

23 Code."

24 12. Section2242.1 oftheCodcstates:

25 "(a) No person or entity may prescribe, dispense, or furnish, or cause to be prescribed,

26 dispensed, or furnished, dangerous drugs or dangerous devices, as defined in Section 4022, on the

27 Internet for delivery to any person in this state, without an appropriate prior examination and

28 medical indication, except as authorized by Section 2242.

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Accusation

(b) Notwithstanding any other provision of law, a violation of this section may subject the

2 person or emity that has committed the violation to either a fine of up to twenty-five thousand

3 dollars ($25.000) per occurrence' pursuant to a citation issued by the hoard or a civil penalty of

4 twenty-five thousand dollars ($25,000) per occurrence.

5 (c) The Attorney General may bring an action to enforce this section and to collect the fines

6 or civil penalties authorized by subdivision (b).

7 (d) For notifications made on and after .January 1, 2002, the Franchise Tax Board, upon

8 notification by the Attorney General or the board of a final judgment in an action brought under

9 this section, shall subtract the amount of the fine or awarded civil penalties from any tax refunds

1 0 or lottery winnings due to the person who is a defendant in the action using the offset authority

11 under Section 12419.5 of the Government Code, as delegated by the Controller, and the processes

12 as established by the Franchise Tax Board for this purpose. That amount shall be forwarded to

13 the board for deposit in the Contingent Fund of the Medical Board of California.

14 (e) If the person or entity that is the subject of an action brought pursuant to this section is

15 not a resident of this state, a violation of this section shall, if applicable. be reported to the

16 person's or entity's appropriate professional licensing authority.

17 (f) Nothing in this section shall prohibit the board from commencing a disciplinary action

18 against a physician and surgeon pursuant to Section 2242."

19 DRUGS

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13. The following drugs are classified as follows:

A. Hydrocodone Bitartrate (generic for Vicodin. Lortab. Vicoprofen. and others):

Hydrocodonc bitartrate is produced by several drug manufacturers. Hydrocodone with Tylenol

(acetaminphcn) is known by the trade name "Tylenol #3 or #4." Hydrocodone 5 mg with

acetaminophen 500 mg is known by the trade name "Vicodin" (''5/500"). Hydrocodone 7.5 mg

with acetaminophen 750 mg is known by the trade name "Vicodin ES'" ("7.5/750''), and it is

known as "Vicodin HP'" and "Norco'· at 10 mg strength. Hydrocodone Bitartrate 7.5 mg \Vith

ibuprofen 200 mg is known as Vicoprofen. Hydrocodone is semisynthetic narcotic analgesic, a

dangerous drug as defined in section 4022 ofthe Code, a Schedule lil controlled substance and

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Accusation

narcotic as defined by section 11056 (e) (4) of the Health and Safety Code [not more than 15 mg

2 dihydrocudeinone (an early pharmaceutical term currently known as hydrocodone) per dosage

3 unit \·Vith a nonnarcotic ingredient],

4 Suboxone. commonly known as buprenorphine HCl, is an opioid medicine

5 similar to morphine, codeine, and heroin. It targets the same places in the brain that opioids do.

6 It relieves drug cravings without inducing the same high as other opioid drugs. Buprenorphine

7 can cause side effects similar to other opioids and also can cause physical dependence.

8 Buprenorphine can help treat addiction to opioid drugs, including heroin and narcotic painkillers.

9 It prevents or reduces withdrawal symptoms caused by quitting these drugs.

10 Under the Drug Addiction Treatment Act of 2000 (DATA) codified at 21 U .S.C. 823(g),

11 prescription use of this product in the treatment of opioid dependence is limited to physicians who

12 meet certain qualifying reg uirements, and have notified the Secretary of Health and Human

13 Services (HHS) of their intent to prescribe this product for the treatment of opioid dependence.

14 It is a dangerous drug as defined in section 4022 of the Code and a schedule V controlled

15 substance as defined by section 1105 8 (d) of the Health and Safety Code.

16 C. Am bien is a non-benzodiazepine hypnotic of the imidasopyridine class. lt is a

17 dangerous drug as defined in section 4022 ofthe Code, and a schedule IV controlled substance as

18 defined by section 11057 of the Health and Safety Code. It is indicated for the short-term

19 treatment of insomnia. It is a central nervous system depressant and should be used cautiously in

20 combination with other central nervous system depressants. Any central nervous system

21 depressant could potentially enhance the CNS depressive effects of Ambien. lt should be

22 administered cautiously to patients exhibiting signs or symptoms of depression because of the risk

23 of suicide. Because of the risk of habituation and dependence, individuals with a history of

24 addiction to or abuse of drugs or alcohol should be carefully monitored while receiving Ambien.

25 D. Xanax is a trade name for alprazolam tablets. Alprazolam is a psychotropic

26 triazolo analogue of the 1 ,4 hcnzodiazepine class of central nervous system-active compounds.

27 Xanax is used for the management of anxiety disorders or for the short-term relief of the

28 symptoms of anxiety. lt is a dangerous drug as defined in section 4022 of the Code, and a

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Accusation

schedule IV controlled substance and narcotic as defined by section 11057 ofthe Health and

2 Safety Code. Xanax has a central nervous system depressant effect and patients should be

")

-' cautioned about the simultaneous ingestion of alcohol and otl1er CNS depressant drugs during

4 treatment with Xanax. Addiction-prone individuals (such as drug addicts or alcoholics) should be

5 under careful surveillance when receiving alprazolam because of the predisposition of such

6 patients to habituation and dependence.

7 Depakote, a trade name for valproic acid and its derivative, divalproex, are oral

8 drugs that are used for the treatment of convulsions, migraines and bipolar disorder. The active

9 ingredient in both products is valproic acid or valproate. Scientists do not knov. the mechanism

J 0 of action of valproate. The most popular theory is that valproate exerts its effects by increasing

11 the concentration of gamma-aminobutyric acid (GABA) in the brain. Gamma-aminobutyric acid .

12 is a neurotransmitter. a chemical that nerves use to communicate with one another. It is a

13 dangerous drug as defined in section 4022 of the Code.

14 F. Effexor, a trade name for venlafaxine. is in a new class of anti-depressant

15 medications that affects chemical messengers within the brain. These chemical messengers are

16 called neurotransmitters, and some examples are serotonin, dopamine, and norepinephrine.

17 Neurotransmitters are manufactured by nerve cells and are released by the cells. The

18 neurotransmitters travel to nearby nerve cells and cause the cells to become more or less active.

19 Many experts believe that an imbalance in these neurotransmitters is the cause of depression and

20 also may play a role in anxiety. Venlafaxine is believed to work by inhibiting the release or

21 affecting the action of these neurotransmitters. lt is a dangerous drug as defined in section 4022

22 of the Code.

G. Prozac, a trade name for iluoxetine hydrochloride, is used for treating

24 depression. It is in a class of drugs called selective serotonin reuptake inhibitors (SSRis), a class

that also contains citalopram (Celexa), paroxctine (Paxil) and sertraline (Zoloft). Fluoxetine

26 affects neurotransmitters, the chemicals that nerves within the brain usc to communicate with

27 each other. Fluoxetine works by preventing the reuptake of one neurotransmitter, serotonin, by

28 nerve cells after it has been released. Since uptake is an important mechanism for removing

11

Accusation

released neurotransmitters and terminating their actions on adjacent nerves, the reduced uptake

2 caused by fluoxetine increases free serotonin that stimulates nerve cells in the brain. 11 is a

3 dangerous drug as defined in section 4022 of the Code.

4 H. Soma is a trade name for carisoprodol tablets: carisoprodol is a muscle-relaxant

5 and sedative. 11 is a dangerous drug as defined in section 4022 ofthe Code. Since the eiTects of

6 carisoprodol and alcohol or carisoprodol and other central nervous system depressants or

7 psychotropic drugs may be additive. appropriate caution should be exercised with patients who

8 take more than one ofthese agents simultaneously. Carisoprodol is metabolized in the liver and

9 excreted by the kidneys. To avoid its excess accumulation. caution should be exercised in

10 administration to patients with compromised liver or kidney functions.

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I. Lexapro, a trade name for escitalopram, is an oral drug that is used for treating

depression and generalized anxiety disorder. Chemically, escitalopram is similar to citalopram

(Celexa). Both are in the class of drugs called selective serotonin reuptake inhibitors (SSRls), a

class that also includes fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). SSRls work

by affecting neurotransmitters in the brain, the chemical messengers that nerves use to

communicate with one another. It is a dangerous drug as defined in section 4022 ofthe Code.

MEDICAL BOARD INVESTIGATION

18 14. The Medical Board received a Consumer Complaint from a former employee of

19 Respondent indicating that she worked for Respondent for 4 months and observed, among other

20 things. that Respondent approved excessive refills of medications :for two patients.

21 15. The Medical Board thereafter conducted an investigation into Respondents treatment

22 of the two patients, hereinafter referred to as Patient A. and Patient B~.

23 FIRST CAUSE FOR DISCIPLINE

24 (Rc: Patient A.)

25 16. Respondent is subject to disciplinary action for unprofessional conduct under

26 Business and Professions Code sections: 2234 (general unprofessional conduct): and/or 2234(b)

27

28 4 Full names of patients \Vill be provided upon Request for Discovery.

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Accusation

(gross negligence); and/or 2234(c) (repeated negligent acts) and/or 2234(d) (incompetence);

2 and/or 725 (repeated acts of clearly excessive prescribing); and/or 2241 in conjunction with

3 section 2234(a) (improper prescribing tl' addict): and/or section 2241.5(d) in conjunction with

4 section 2234(a) (failure to exercise reasonable care); and/or 2266 (failure to maintain adequate

5 and accurate records); in connection with the treatment of Patient A The circumstances are as

6 follows:

7 Events Rc: Patient A.

8 17. Respondent ·s treatment of Patient A, (female born 1983), based upon Patient A.'s

9 treatment records, includes, but is not limited to the following:

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B.

Patient A. received care from Respondent from 7/15/05 through 9/26/06.

In an office visit on 7/15/05, Patient A. completed a three-page medical history

12 form, which covered her past medical history and present medical situation. She denied any

13 significant past medical history including any history of alcoholism or drug dependency and her

14 review of symptoms was significant only for occasional back pain and difficulty concentrating.

15 She denied taking any prescription medications. Respondent's notes for this visit were written in

16 the margins and blank spaces on Patient A.'s self assessment form and were handwritten and

17 difficult to read. Respondent's notes were very brief and lacking in pertinent information. There

18 was a comment of "ADD," back pain, a history of scoliosis, that Patient A. had a recent injury to

19 the nose and that she appeared depressed. There was a cursory physical examination of the chest,

20 abdomen, and extremities. which were all normal. There was no assessment. problem list or

21 documentation of a plan, or a note that any medications were prescribed. The examination or

22 documentation did not include a back examination or psychiatric evaluation. Respondent

23 typically did not list the medications that Patient A. was taking at each visit and did not document

24 in the chmi what medications were prescribed. Occasionally, in the chart there were photocopies

25 of prescriptions which were written, but there was no such documentation at this visit. However,

26 the pharmacy prescription records obtained independently by Medical Board investigators

27 indicate that Respondent wrote a prescription for hydrocodone, with 4 refills which Patient A.

28 Jilled, on this date. (When interviewed by the Medical Board in a later Physician Conference on

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Accusation

.2/.25/2008, Respondent indicated that she recommended TylenoL presumably for the complaint of

2 back pain.)

C. A chart entry dated 81]5/05, indicates that Patient A. was hilled $30.00 for the

4 initiation of a new prescription medication. There was no chart documentation regarding this new

5 medication and no indication that Respondent spoke with Patient A. by telephone or otherwise.

6 D. ln an off]ce visit on 9/30/05, Patient A complained of tooth problems. She had

7 recent dental work, which was still troubling her. Respondent charted that Patient A ''has

8 chronic back problems" and "\vants pain medicine" There \vas a very brief physical examination

9 including the mouth, chest and the abdomen, but not the back. The assessment was acute

1 0 toothache and gingivitis status post root canal treatment. There was no plan nor any prescriptions

11 documented, but later that day, pharmacy records obtained independently by Medical Board

12 investigators indicate Patient A. filled a prescription from Respondent for 60 tablets of Vicodin

13 5/325. This was refilled one week later on (1017/05).

14 E. In an office visit on 11/25/05, Patient A's chief complaint was a toothache,

15 with "highly severe pain." Respondent charted that the "tooth is killing her" that she had been

16 seeing a specialist for this problem. Physical examination concentrated on the mouth, the chest

17 and the abdomen, which were unremarkable. Respondent rendered a diagnosis of ''acute

18 toothache'' and "gingivitis." Patient A was given an injection of 2 grams of the antibiotic

19 Ceftriaxone (cephalosporin) (charge: $100.00) and a prescription for the antibiotic Augmentin

20 (amoxycillin). She also was given a prescription for Vicodin 5/500. The Vicodin prescription

21 was refilled 5 days later on 1/18/06. The chart documentation did not specif)' the quantity of

22 medication or the number of refills.

23 F. In an ofiice visit on 1 /13/06, Respondent charted that the dental work had been

24 done and the symptoms seemed to have improved, but Patient A. was complaining of severe pain.

25 It was not clear to what the pain complaints refer. Examination of chest, abdomen and

26 extremities was unremarkable. There was no documented oral examination. Assessment was

27 acute gingivitis and toothache status post root canal, also chronic back pain and obesity. There is

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Accusation

no plan clearly documented. Patient A. was given a prescription for an amibiotic and 45 tablets

2 of Yicodin 5/500.

(]. Jn ;:m ot1ice- visit on 1/26/06, Respondent commented that Patient A. had

4 problems with depression and that she still had chronic back pain, but also she was

5 "noncompliant and not paying the amount owed.'. Respondent issued another prescription for 45

6 tablets ofVicodin 5/500 which Patient A. had filled on 1/26,2/4.2/13,2/23 and 3/5,2006. This

7 translates into 225 tablets provided over 5 weeks or about 6 Y2 tablets daily.

8 H. ln an oflice visit on 4/1 0/06, the chief complaint is stated as a '·follow-up for

9 back problems,'· also increasingly severe panic anacks. Respondent commented that Patient A.

1 0 was having panic attacks, which were becoming worse. There is also one brief comment about

11 back pain. The physical examination was again very cursory, and did not include the back or

12 neurological system. The assessment was low back pain, panic attacks, and obesity. There was

13 no back examination or documented plan or psychiatric assessment. Prescriptions for controlled

14 substances Vicodin, Xanax and Soma were rendered, each with 4 refills.

15 I. In an office visit on 6/9/06, Respondent also addressed back problems and

16 panic attacks. There was no documented back examination beyond the notation "tenderness."

17 . The plan was to obtain "labs,'· an MRI of the LIS spine (lower back) and refer Patient A. for

18 physical therapy. Prescriptions were provided for Soma and Vicodin, each with 2 refills.

19 J. ln an office visit on 6/22/06, Respondent noted a chief complaint of ''pain in the

20 back." Respondent commented that there was ''unbearable sharp pain in the upper back". Patient

21 A. had not yet obtained previously requested labs, x-rays, or visit to physical therapy. Review of

22 system and physical examination (again not including the back). were unremarkable. Assessment

23 was back pain, obesity. There was a photocopy of a prescription for Vicodin Extra Strength

24 (1-Iydrocodone/APAP 7.5/750) with 3 refills.

25 K. Jn an office visit on 7/25/06, there was no documentation of a chief complaint

26 or any status revinv of Patient A. at this visit. A very cursory examination of the chest abdomen,

27 and extremities. was indicated as normal. There is no clearly documented back examination

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Accusation

although the diagnosis is chronic back pain and back muscle spasms. A prescription for 60

2 tablels of Vicodin (3 refills) and 30 tablets of Soma ( 4 refills) was provided.

3 L ln an office visit on 8/21/06, the patient chart is notable for a new progress note

4 template on which there are multiple ambiguous marks corresponding to elements ofthe history

5 and physical examination. Complaints of anxiety and panic attacks appear central to this visit and

6 an antidepressant (Eifexor) was prescribed. Though not documented, according to pharmacy

7 records obtained independently by Medical Board investigators, Soma (90 tablets) and Vicodin

8 ( 1 00 tablets) were again prescribed. Patient A. refilled the V icodin four times in the ensuing

9 month, on 8/25, 9/8, 9115 & 9/19. This means Patient A. accessed 500 Vicoclin tablets in the

10 course of a month which implies an intake of over 16 tablets a day.

11 M. In a final office visit on 9/26/06, Patient A. reported that she couldn't afford to

12 fill the Effexor prescription and that the requested MRI was too expensive. There were extensive

13 check marks on the history and examination template suggesting an entirely normal physical

14 examination. Dr. Sreenivasan noted that she spent 45 minutes with Patient A. although no

15 diagnosis was documented. In a subsequent Physician Conference of 2/25/00 with the Board, Dr.

16 Sreenivasan indicated that she discharged Patient A. from her practice on this visit, but there was

17 no documentation regarding this. Instead, the plan included a prescription for the generic form of

18 Effexor, X-rays (instead ofMRI) and a prescription for 60 tablets ofVicodin 7.5/500 with 1 refill.

19 18. ln the Physician Conference of2/25/08 with the Board, Respondent stated that she

20 confronted Patient A. about her overuse of pain medication and discharged her from the practice

21 but there was no documentation of any such discussion or action. She stated that she had

22 received a call from the Safeway Pharmacy in Walnut Creek expressing concern about Patient

23 A.· s overuse of hydrocodone, but this was not documented. Respondent indicated that on

24 1 ()102106. she notified the Sateway Pharmacy to cancel any remaining prescriptions for Patient A.

25 19. In December of 2006, Respondent was notified by the Department of Justice [via

26 letter of December 8. 2006] that Patient A. had been obtaining hydrocodonc prescriptions from

27 multiple providers.

16 ---~--~----~----- I Ace us~

20. The prescription for Patient A indicates that over the period of 3 Y: months, from

2 5/5/06 through 9/19/06, Respondent prescribed 1620 tablets of combination narcotic analgesics

3 for Patient A On average, Patient A obtained 15 tablets daily. This translates to a daily

4 hydrocodone dose of between 75mg to l 00 mg. Since each tablet also contained 500-750 mg of

5 acetomenophen, Respondent's prescriptions conceivably led to Patient A ingesting over 7 grams

6 of acetomenophen daily. This far exceeds the recommended maximum daily dose of

7 acetomenophen of 4 grams.

8 Standard of Practice Re: Patient A.

9 21. When evaluating a patient for the first time, it is customary to have the patient iill out

1 0 a lengthy health questionnaire in advance, and review this with them. Any current problems are

11 addressed in more detail and the physical examination customarily focuses on these chief

12 complaints. A diagnosis is subsequently rendered, and a diagnostic and/or treatment plan

13 developed. The foregoing is documented in the patient's medical record, and it is the standard of

14 practice to document in the form of a SOAP note,

15 (S=subjective,O=objective,A=assessment,P=plan).

16 Acts or Omissions Re: Patient A.

17 22. Respondent committed the following acts or omissions in the treatment of Patient A.:

18 A. In her initial evaluation of Patient A. on 7115/05, Respondent did not perform

19 nor adequately document an examination of the back although she rendered treatment

20 recommendations regarding back pain. The sparse notes were not in the form of a SOAP note

21 and there was no documented medical assessment or treatment plan;

22 B. Respondent failed to adequately· document the reason for the billing of a $30.00

23 charge to Patient A on 8/15/05. If Patient A. called the office requesting a change in medication,

24 the standard of practice would have been to document the receipt of this calL and for Respondent

25 to document the reason for altering the treatment plan. l1 would be standard of practice to

26 document in the chart which medication \Vas prescribed, the dose, directions and amount

27 dispensed;

28

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Accusation

C. Respondent failed to document performance of a physical examination that

2 focused on the chief complaint (no examination pertaining to chief complaint or subsequently

3 1 rendered diagnoses on 1 113106, 4/1 Q/06, 6l22/06, 7 /25106; examinations that only partially

4 addressed chief complaints and subsequently rendered diagnoses on 9/30/05, 6/9/06 ); and/or

5 D. Respondent failed to document in the oiTice record that medications were

6 prescribed (9/30/05, 8/21/06);

7 E. Respondent failed to document in the office record the amount of medication

8 prescribed or the number of authorized refills (9/30/05, 10/7/05, 11/25/05);

9 F. Respondent failed to document a diagnostic impression (7/15/05, 7/26/06);

10 G. Respondent rendered a diagnosis unsupported by clinical findings (11 /25/05 );

11 H. Respondent authorized excessive prescription refills when treating acute pain

12 complaints (9/30/05, 1/13/06, 1/26/06, 4/1 0106);

1'"' j.) l l. Respondent provided escalating doses or quantities of controlled substances

14 without a documented treatment plan, pain contract, or any documentation that she recognized or

15 discussed with Patient A. the overuse of controlled substances ( 6/22/06, 7/25/06, 8/21 /06);

16 J. Respondent failed to document a treatment plan (7115/05, 9/30/05, 9/26/06);

17 K. Respondent prescribed and/or failed to recognize that Patient A. received

18 potentially toxic doses of acetaminophen;

19 L. Respondent specifically failed to properly address Patient A.· s pain

20 management issues, including the following:

21 ( 1) Respondent failed to document and/or perform an adequate initial

22 assessment \vhich should include a thorough history and physical examination, leading to

23 identification of the pain problem to be treated and development of a treatment plan with defined

24 objectives and a metric to evaluate the outcome of treatment. Pain was not even specified among

25 the initial problems to be treated, and there is inadequate indication in the chart to indicate what

26 Respondent was doing:

27

28

18

Accusation I I

(2) Respondent failed to perform and/or document ongoing review to

2 evaluate the efficacy of treatment with pain medications and documentation of reasons for

3 changes in the treatment plan;

4 (3) Respondent failed to employ an adequate system to keep track of the

5 medication Patient A. was obtaining along with careless prescription practices such as authorizing

6 multiple refills of opiates, authorizing prescriptions without seeing Patient A. in person at

7 appropriate intervals, writing overlapping prescriptions and continuing to write prescriptions in

8 spite of escalating demand, without objective findings but with signals of addiction, resulting in

9 Patient A. obtaining prescriptions for the excessive amounts of medication noted above:

10 ( 4) Respondent exhibited a lack of ability to identify and manage Patient A

11 with addictive disease evident. With this knowledge, Respondent might have been able to avoid

12 being drawn in to this situation;

13 (5) Respondent failed to exercise reasonable care in consulting with and/or

14 referring Patient A. to addiction specialists and/or pain management specialists. and/or

15 documenting such a consultation or referral with Patient A., and/or in recognizing that such a

16 consultation/referral was indicated;

17 ( 6) Respondent failed to consult or document consultation with Patiem A.'s

18 other treating practitioners, case manager( s ), counselor( s ), or dispensing pharmacies;

19 (7) Respondent failed to adequately recognize and/or document and/or treat

20 (by intervention. referraL or otherwise) the signs and symptoms of Patient A.'s abuse and/or

21 dependence to opiates, including, but not limited to. Patient A.'s resistance in other aspects of her

22 therapy, and in specifically coming up with rationales for requesting additional amounts of

23 specific medications;

24 ( 8) Respondent committed repeated acts of clearly excessive prescribing, as

25 large amounts of controlled substances were prescribed without properly documented medical

26 indication.

27

28

19

Accusation I

Violations Rc: Patient A

2 Respondent's conduct as set forth in the Events and Acts or Omissions as set forth

3 lltTeinahove constitutes grounds for disciplinary action as follows:

4 A. Respondent's conduct constitutes general unprofessional conduct and is cause

5 for disciplinary action pursuant to section 2234 of the Code.

6 B. Respondent's conduct constitutes gross negligence and is cause for disciplinary

7 action pursuant to section 2234(b) of the Code.

8 r ~. Respondent's conduct constitutes repeated negligent acts and is cause for

9 disciplinary action pursuant to section 2234( c) of the Code.

10 D. Respondent" s conduct constitutes incompetence and is cause for disciplinary

11 action pursuant to section 2234(d) of the Code.

12 E. Respondent's conduct constitutes unprofessional conduct in that she failed to

1 '1 lJ maintain adequate and accurate records relating to the provision of services to the patient and is

14 cause for discipline pursuant to section 2266 of the Code.

15 F. Respondent's conduct constitutes repeated acts of clearly excessive prescribing

16 or administering of drugs or treatment as determined by the standard of the community of

17 licensees and is cause for disciplinary action pursuant to section 725 of the Code .

18 G. Respondent's conduct constitutes the failure to exercise reasonable care in

19 consulting with and/or referring Patient A. to addiction specialists and/or pain management

20 specialists, and therefore is cause for disciplinary action pursuant to section 2234(a) in

21 conjunction with section 2241.5(d) ofthe Code.

22 SECOND CAUSE FOR DISCIPLINE

23 (Rc: Patient B.)

24 24. Respondent is subject to disciplinary action for unprofessional conduct pursuant to

25 Business and Professions Code sections: 2234 (general unprofessional conduct); and/or

26 2234(b)(gross negligence); and/or 2234(c) (repeated negligent acts) and/or 2234(d)

27 (incompetence); and/or 725 (repeated acts of clearly excessive prescribing); and/or 2241 in

28 conjunction with section 2234(a) (improper prescribing to addict); and/or section 2241.5(d) in

20

Accusation

conjunction with section 2234(a) (failure to exercise reasonable care); and/or 2266 (failure to

2 maintain adequate and accurate records); in connection with the treatment of Patient B. The facts

3 and circumstances are as se1 forth hereinafter in this Accusation. The circumstances are as

4 follows:

S Events Re: Patient B

6 25. Respondent's treatment of Patient B., (female, born 1972), based upon Patient B.'s

7 treatment records, includes, but is not limited to, the following:

8 A. In an office visit on 1/10/06, Patient B., a recently unemployed college graduate

9 presented to Respondent with several chief complaints including back pain, post nasal drip,

10 anxiety, depression and insomnia. Patient B. reported that seven years earlier (1989) she "broke

11 my back" and sustained a fracture of the first lumbar vertebrae. She carried the diagnosis of

12 "Bipolar disorder with mania" for which a psychiatrist had prescribed Depakote (500mg at

13 bedtime) and Lexapro. Respondents notes on this visit are penned in the margins of the extensive

14 patient questionnaire and there is no documented examination, list of diagnoses or treatment plan.

15 Medications prescribed on this visit without documented justification included the antibiotic

16 Zithromax, sedative Ambien, antidepressant Prozac, and mood stabilizer Depakote. The

17 antibiotic presumably was prescribed to treat a suspected bacterial infection of the sinuses, but

18 inexplicably there were 2 refills on this prescription. Dosing of Patient B.'s Depakote was

19 inexplicably changed from 500 mg at bedtime (which is standard) to 250 mg twice daily. It is

20 unclear why Prozac was prescribed instead of the previously prescribed antidepressant Lexapro.

21 The Prozac prescription included 2 refills, meaning a 3 month supply was provided. The Ambicn

22 prescription included 4 refills, meaning a total of 150 tablets were authorized. The pharmacy

23 records obtained by Medical Board investigators indicate that prior to coming to see Respondent,

24 Patient A. had been prescribed the drug Suboxone, commonly used to treat opiate dependency.

25 B. On 1115/06, Respondent referred Patient B. to a psychologist. In the

26 subsequent Physician Conference with the board, Respondent explained that she did not refer

27 Patient B. to a psychiatrist because she anticipated that the medical insurer would not cover care

28 provided by a psychiatrist.

21

Accusation

C. ln an office visit on 1/19/06, laboratory and spine MRl results were reviewed

2 and a limited physical examination performed. Patient B.'s laboratory tests revealed elevation of

3 some lipid components, but ratios that placed her below average risk of heart disease. There was

4 no documented examination of the back and no objective assessment of Patient B.'s mood, affect

5 or other elements of the psychiatric examination. Patient B. reported having stopped taking

6 Depakote, but said that she was taking Prozac. The diagnoses were ''Chronic back pain!L 1

7 compression deformity, GAD (Generalized Anxiety Disorder) and "Hyperlip-"(elevated lipids).

8 D. ln an office visit on 2/1/06, Patient B. was recorded as having trouble sleeping.

9 The diagnostic assessment was" l. Insomnia 2. Chronic Back Pain 3 .Anxiety/Depression." The

10 treatment plan was ''d/c (discontinue) Depakote-Prozac is enough." A new sedative medication

11 Restoril was prescribed. There is no note regarding the previously prescribed sleeping aid

12 Am bien. Additional prescriptions for 45 tablets of Vicodin were filled on 2/6/06, 2/16/06 and

13 3/1106.

14 E. ln an office visit on 5/15/06, Patient B. reported "manic episodes" and

15 "hallucinating." The examination does not include an assessment of mood or affect beyond

16 "NAD'' (No Acute Distress). There is no examination ofthe back. The documented diagnoses

17 were anxiety/depression/mania/hallucinations and fatigue. Pem1ed in the margins Respondent

18 wrote "Told Patient B. I \Vill not order too many or refill meds if not indicated ... There is no

19 treatment plan beyond "F/U" (follow-up). Photocopies of prescriptions written on this day

20. included Prozac i 0 mg. Trazodone 50 mg. Flexeril (i 0 mg, 60 tablets and 4 refills authorized)

21 and Vicoprofen (7 .5 mg hydrocodone and 200 mg ibuprofen tablets, 90 tablets, unclear number of

22 refills). On this same day, a separate prescription was written for Prozac with 4 refills, to which

23 was added in the same hand but different ink "Vi co din 60 tablets."

24 F. In an office visit on (J/15/06, Patient B. reported having sustained a fall and was

25 bruised. Inexplicably, she reported novv taking the antidepressant Effexor XR 75 mg daily. The

26 physical examination is notable for the absence of documented bruises or formal psychiatric

examination. There are ambiguous notations in the margins concerning Lorazepam and the

28 maximun; dose of Vicodin. The dose of EiTexor \Vas doubled without documented jllStification.

22

Accusation

Patient B. was again provided a prescription for Flexeril (1 Omg, 60 tablets, and 4 refills

2 authorized l. A prescription for Vicoprofen 90 tablets was filled on 6/15106, and an early refill

3 1 request occurred on 6/26/06.

4 G. On 7/19/06, Respondent authorized a Los Angeles pharmacist to refill 10

5 tablets of Vicodin with no refills, the next day on 7/20/06 she again authorized 1 0 tablets, now

6 with one refill . Three days later, on 7/22/06 there was another approval for 10 tablets of Vicodin.

7 1-I. In an office visit on 7/25/06, there are no notes regarding these multiple refill

8 requests. The diagnoses include ''clinical depression, insomnia, chronic back pain" and plan is

9 unclear but seems to involve sleep hygiene and lab work.

10 I. On 8/15/06, a prescription for one hundred tablets ofVicodin 7.5/500 \Nith 4

11 refills (=500 tablets; 3750 mg hydrocodone) was written by Respondent.

12 J. On 9/5/06, a prescription for 60 tablets of Vicodin 10/500 with 2 refills (=180

13 tablets; 1800 mg hydrocodone) was written by Respondent.

14 K. On 10/23106, a prescription for 100 tablets of Lortab 10/500 ( 1 000 mg

15 hydro cod one) was written by Respondent.

16 L. On 12/4/06, Respondent faxed to a Los Angeles pharmacy a prescription for 30

17 tablets of Ambien with 2 refills (=90 tablets total) with the notation "patient needs to make appt

18 (appointment) with doctor."

19 Standard of Practice Re: Patient B.

20 26. When presented with a patient with an extensive past medical history, physicians

21 often are compelled to defer aspects of the evaluation to a future visit. In the case of Patient B.,

22 the physical examination was not accomplished until the second visit and this was reasonable.

However, any acute medical problem, in this case the suspicion of a sinus infection, warrants a

24 focused history (regarding the duration of symptoms, associated fevers, description of nasal

25 discharge) and physical examination of the head, ears, nose and throat.

26

27 Acts or Omissions Re: Patient B.

28 27. Respondent committed the following acts or omissions in the treatment of Patient B.:

23

A. Respondent failed to obtain and/or document, an adequate history of Patient

'! B.'s acute sinus infection complaint, an examination of the afJected part of the body and/or a

3 diagnostic assessmen1 and treatment plan:

4 B. Respondent provided refills for the antibiotic Zithromax without documented

5 medical justification;

6 c. Respondent initiated the prescribing of Prozac instead of continuing the

7 previously prescribed Lexapro, without adequate justification in the record. Prozac is an

8 activating antidepressant which conceivably could worsen insomnia:

9 D. Respondent altered the dosing of Depakote from 500 mg at night to 250 mg

1 0 twice daily, notwithstanding Patient B.'s insomnia, without adequate justification in the record.

11 A mood stabilizer such as Depakote is required when treating bipolar patients with anti-

12 depressants. Depakote has a sedative effect which is why it is usually dosed at nighttime. Th~re

13 was no documented reason to change the dosing of Depakote from 500 mg at night to 250 mg

14 twice daily, especially given Patient B.'s insomnia;

15 E. Respondent failed to perform and/or document an objective evaluation of

16 Patient B.'s psychiatric illness. When following a patient with a history of mental illness over

1 7 time, the usual practice is to document at each visit the patient's function, inquire about and

18 document any manifestations of the disease and evaluate the patient's mood. affect and cognition;

19

20

21

22

!'"' _ _)

24

25

26

27

28

F. Respondent failed to consider or document consideration of the risks of

prescribing Prozac knowing that Patient B. was no longer taking Depakote. Treatment of a

patient with bipolar disease usually involves a mood stabilizer such as Depakote. When patient's

stop taking mood stabilizers, especially when they are also taking medications such as Prozac,

there is a risk that they will shift into the manic phase of their disease. Respondent's rendering

of diagnoses such as '"GAD'' (generalized anxiety disorder). "anxiety/depression'· and "clinical

depression" indicates that Respondent failed to consider the history of bipolar disease as she

continued to provide care to this Patient B .. Had she documented or formulated a problem list on

the first or second visit it is less likely that she would have overlooked this crucial piece of

medical history;

24

Accusation

G. Respondent's failure to appreciate the risk of mania in Patient B. indicates a

2 lack of knowledge regarding the treatment of bipolar;

,., J H. Respondent failed to consider or document consideration that the insomnia was

4 a manifestation of Patient B.'s bipolar mental illness. The treatment of insomnia usually involves

5 patient education regarding sleep hygiene, attention to underlying diagnoses and, sometimes,

6 brief courses of sedative medication. In prescribing a 5 month course of the sedative Am bien at

7 the first visit with Patient B., Respondents conduct fell outside the standard of care. When

8 insomnia presents in a patient with mental illness, the usual approach is to optimize treatment of

9 the psychiatric condition;

10 I. Respondent failed to adequately treat and/or document adequate treatment of

11 Patient B.'s back pain. The accepted appr