This is important: Avoid making new license applications while you are under investigation

If your license to practice medicine, nursing, or pharmacy is under investigation and you know some form of discipline or sanction will soon be imposed, it is only human nature to consider your options. One common mistake, however, is to apply for a new license in a second state before the investigation in the first state closes. The rational may be that you need a fall back position, or that you are tired of the Oregon rain, or that it is time to move back home to be closer to family. These are all explanations I have heard.

What you need to know

What you need to know is that after you are disciplined by one state, that discipline will become public record, and it will become known to any other state in which you are licensed, and – this is important – the other states will open mirror image investigations, and may impose discipline. In effect, an investigation by one state will open an investigation in every other state in which you are licensed. Hopefully, these will be “small fires” to put out, but why risk it unless application for the new license is absolutely necessary.

There can be harsh consequences for making this mistake

As I write this post, I can think of two physicians who obtained new medical licenses in second states unaware of that the new state medical boards will open they own investigations. Yes, the problem can be managed, but it is painful to note that in each case, neither physician ever practiced or even applied for a position in the second state. It was simply a backup plan that was not given much thought, and was never implemented, but it cost the physician a second investigation.

My typical advice

In most cases, my typical advice is to not to apply for a new license in a second state unless and until the investigation in the first state is closed, or well under control, or the outcome is known, and the consequences of the second state’s investigation are understood. If there are extenuating circumstances, be sure to make your decision knowing all the possible legal consequences, and do not make this decision without first seeking competent legal advice.

Can my licensing Board really do that?

Licensing boards are administrative agencies acting pursuant to administrative law

In the past several years I have been approached by three physicians wanting to sue the Oregon Medical Board in a “real court,” usually meaning a state trial court. All three physicians were angry or frustrated, and all three were dismissive of the Oregon Medical Board’s authority and power. Earlier this year a pharmacist asked me if the Oregon Board of Pharmacy “can really do that?” The pharmacist seemed doubtful that the Board of Pharmacy had that kind of power over his license. All four licensees were frustrated by the strict sanctions threatened by their State licensing Boards.

The range of sanctions

In three of the four cases, the licensing Board was threatening substantial probation and/or revocation, which is at the “heavy end” on the sanction continuum. Sanctions include, for example, being reprimanded; being temporarily suspended, indefinitely suspended, or permanently suspended; or having your license revoked. Sanctions further include fines, continuing education, recurrent training, the imposition of a mentor and/or a monitor, and periods of probation (three to five years is not uncommon). One or more sanctions may be imposed in combination, as each individual case warrants, or the licensing Board sees fit.

The answer is “yes, for the most part, the Board really can do that”

The answer is “yes,” state licensing boards, whether it be the Oregon State Board of Nursing, Oregon Board of Pharmacy, or Oregon Medical Board, are all acting pursuant to State law and, when they are acting within the scope of their enabling legislation (legal authority), they really can do that. The scope of each Board’s legal authority is established by the Legislative Assembly in Salem, which passes statutes to create and empower each of the State licensing Boards. State law also includes the Oregon Administrative Rules (OARs) promulgated by each of the licensing Boards in the furtherance of their mission.

Exceptions

There are some exceptions. For example, if a State licensing Board is acting outside of its scope of its power (the agency’s enabling legislation), then the Board’s action may be challenged on that ground. Similarly, if you contest your case all the way to hearing and lose, you may appeal, seeking judicial review by the Oregon Court of Appeals, but you will not prevail unless you establish that your Board committed legal error, or took action that is not supported by “substantial evidence.” Neither type of challenge is a good bet, and it is not the place to start in any event.

Be smart – do not delay taking action

If you are prudent, you will not stake your case on state court legal challenges and appeals. Your first, best, and least expensive opportunity is to work directly with your State licensing Board. Get involved from the start. Unfortunately, too many licensees wait too long to obtain legal advice – until shortly before or after being interviewed by field investigators or licensing boards, or worse, after receiving written findings and proposed sanctions, i.e., a notice of proposed disciplinary action. At this point, your licensing Board has reached conclusions about your practice and your opportunity to participate and influence proposed findings and sanctions has been greatly lost. But even at this late date, there is still important work to do. For example, the next step may be to negotiate a settlement, or to proceed to an administrative hearing. No matter what you do, however, you will need legal counsel.

Most physicians, many pharmacists, and some nurses have insurance that will cover fees incurred while defending board complaints

In my experience, most physicians, many pharmacists, and some nurses have insurance that will cover legal expenses incurred while defending a complaint to a professional licensing Board. Perhaps other licensed professional do too. Check your policy, and remember, time may be short to “tender” (file) a claim. Your insurance policy may contain a requirement that you notify the insurance carrier within so many days of the claim, often a short period of time. Although I have successfully tendered one claim many months late, by persuading the insurance carrier to provide a legal defense, late acceptance of an insurance claim should be considered the exception, not the rule, so do not count on it. Seek legal counsel and act swiftly to preserve your contractual rights to insurance coverage.

When in doubt, tender the claim

I am not a “coverage attorney,” but I can review your policy with you, tender claims for you, and refer you to a coverage attorney, when and if that becomes necessary. The important thing to do, however, is to determine what insurance policy may cover your claim, and to then tender your claim to the insurance carrier(s) right away. When in doubt, tender the claim, and let the carrier explain why you do not have coverage for a particular claim. If there is a disagreement with your insurance carrier, I can refer you to a coverage attorney.

Common mistakes licensees make when communicating with their licensing Boards – Part II

Last week, I explained that if you are under investigation, the record you are creating is a public record, and it will serve as the record should your case proceed to a contested case hearing. This is why the communications you receive from your investigator are formal, cogent, and professional. Similarly, your lawyer’s communications, sent on your behalf, should be coordinated, thoughtful, and legally strategic. In the most difficult of cases, this approach is absolutely necessary to succeed, and in the easiest cases, this approach is still necessary to prevent mistakes. Here are a few examples of real mistakes made by licensees when unrepresented by legal counsel.

Example #1 – Gloria

“Gloria,” a physician, was practicing under a restricted license, and she sought to have many of her restrictions lifted or modified. She sent frequent one or two sentence emails to her investigator, asking questions, often using her smart phone, which added the line, “sent from my smart phone.” Gloria would often send follow up emails without allowing the investigator adequate time to answer her first email. Other times, Gloria would fax material to the Board’s investigator, using only a facsimile cover page and the investigator’s name, without any explanation. All of Gloria’s communications would eventually make it into her file, but those communication were too frequent, too casual, and unprofessional. Gloria also appeared to have a “tin ear” for the investigators requests and concerns. She wanted relief from the Board, but she was not providing what the Board wanted from her. Not surprisingly, both Gloria and her investigator were frustrated, neither one able to understand the priorities of the other, bringing forward progress to a standstill.

Example #2 – Sam

“Sam,” a physician, did his own research, and would occasionally find literature helpful to his case. Sam would attach such articles to an email and send it off to the Board’s investigator, without much explanation, but intending to prove that he was meeting the applicable standard of care. In one unfortunate case, Sam found an article with a seemingly helpful introductory summary, and he sent it to the Board. A thorough reading of the article, however, suggested that Sam’s practice protocols did not meet the exacting standards required by the authors of the article, something Sam did not learn until he was harshly examined during his interview. Despite the time Sam put into his preparations, he never generated, much less provided, a single, cohesive, persuasive explanation of his standard of care.

Lessons to be learned

Perhaps half of Gloria’s communications were unnecessary, if not irritating, to the investigator, and the other half should have been consolidated into a few thoughtful, timely, and responsive communications, that would have placed Gloria in a professional light. More importantly, before Gloria could be in a good position to request relief from the Board, she needed to understand and comply with the Board’s requests. Once these mistakes were corrected, forward progress was immediate, and Gloria got the relief she sought.

Sam had the right idea, because he needed to establish that he was meeting the applicable standard of care. Sam’s approach, however, set Sam up for a big loss. Sam acted hastily. Sam’s defense was not persuasive, and, at times, harmful to him. Sam’s various communications should have been consolidated into one or two timely communications, complete with thoughtful analysis, including end notes, a bibliography, and enclosures of the most helpful articles. Inconsistent authority should have been distinguished. Using this approach, Sam’s mistakes would have been avoided, and the art of persuasion honored. Needless to say, the type of mistakes Sam made are not easy to correct.

Mistakes are often easier to prevent that to correct

Overall, Gloria and Sam both communicated too freely, too casually, and too often with their licensing Boards. Gloria and Sam’s mistakes would have been prevented by experienced legal counsel. Experienced legal counsel will communicate less often, but more thoroughly and persuasively on your behalf.

Common mistakes licensees make when communicating with their licensing Boards – Part I

Knowing that you are under investigation by your licensing Board will, in the best of cases, create a sense of unease, and, in the worst of cases, create a sense of panic. How you respond when you are under investigation is crucial. If you are represented by experienced licensure counsel, your lawyer will take control of the communications and the deadlines. In doing so, your licensure lawyer will create a “comfort zone,” sparing you much grief and anxiety, while serving the greater purpose of providing you with legal representation.

What you need to know

If you are under investigation, the record you are creating is a public record, and it will be the record that is litigated should your case proceed to hearing. This is why the communications you receive from your investigator are formal, cogent, and professional – your investigator knows what he or she is doing. Similarly, your licensure lawyer’s communications, sent on your behalf, will be coordinated, thoughtful, and legally strategic. In the most difficult of cases, this is absolutely necessary to succeed, and in the easiest cases, this is still necessary to help you prevent mistakes.

Where the trouble starts

All too often, however, licensees defend their cases on their own, usually until one or more common mistakes become apparent, compelling the licensee to retain licensure counsel. Such mistakes often fall into two broad categories. Licensees in the first category, not sure what to do, but feeling the need to do something, communicate too freely, too casually, and too often, with their licensing Boards. Conversely, licensees in the second category, feeling overwhelmed, if not threatened, are slow to respond, or fail to respond at all. Next week I will share a few examples of common mistakes.

For pharmacists: What you need to know about reporting a drug loss or theft

Once you discover a drug loss or theft, time is short. The applicable Oregon Administrative Rule (OAR) requires that you report a “significant” drug loss or violation related to theft to the Board of Pharmacy within “one business day.” OAR 855-041-1030(2) & (3) (Reporting Drug Loss) provides as follows:

(2) The outlet shall notify the Board in the event of a significant drug loss or violation related to drug theft within one (1) business day.

(3) At the time a Report of Theft or Loss of Controlled Substances (D.E.A. Form 106) is sent to the Drug Enforcement Administration, a copy shall be sent to the Board.

To notify the Drug Enforcement Administration (DEA), go online and complete and submit a DEA Form 106. Print a copy and send it to the Oregon Board of Pharmacy, as required by OAR 855-041-1030(3), quoted immediately above. Never forget, however, that you are creating a public record. You are also reporting to the DEA and your licensing Board, both of which have significant enforcement powers. Consequently, you will be well served to have a competent attorney advise you throughout the reporting process. It is my preference to review, if not prepare, both reports.

A significant drug loss or theft will prompt an investigation by the Oregon Board of Pharmacy, and perhaps the DEA as well, depending upon the circumstances. The pharmacist(s), and especially the pharmacist in charge responsible for the pharmacy’s annual audits, perpetual inventories, and security of the pharmacy, will be exposed to additional scrutiny by the Oregon Board of Pharmacy and by the DEA. You will want competent legal counsel from the onset. If you proceed without competent legal counsel, you do so at your own peril.

What you should expect

If the cause of the drug loss or drug theft is not clear from the beginning, an investigation will certainly follow, and that investigation will continue until the cause of the drug loss or drug theft is fully known and understood by the Oregon Board of Pharmacy and, perhaps, the DEA as well. You will be interviewed. You should expect that one, or more, Board of Pharmacy inspectors will be involved until the case is resolved.

You should further expect that your pharmacy’s relevant annual audits and perpetual inventories will be requested and reviewed by pharmacy inspectors. Any shortcomings in your pharmacy’s inventory systems will prompt further review by the pharmacy inspectors. More will be required of the pharmacist in charge, as compared to a staff pharmacist, but all will need to be proactive in the investigation and resolution of any perceived lapse in pharmacy security. If the pharmacy’s inventory systems and procedures are legally inadequate, the responsible pharmacist(s), and especially the pharmacist in charge, will face additional scrutiny, and may face disciplinary proceedings.

If you are reporting a drug theft, and the theft was accomplished due to a security lapse, the Board of Pharmacy will pursue the security lapse until the cause of the security lapse is known. If the drug theft was accomplished after hours by someone other than a pharmacist, the pharmacy inspectors and the Board of Pharmacy will further want to know how, or why, a non-pharmacist had access to pharmacy keys and/or pass codes. OAR 855-041-1020 (Security of Prescription Area) requires the following:

(1) The area in a registered pharmacy where legend and/or controlled substances are stored, possessed, prepared, manufactured, compounded, or repackaged shall be restricted in access, in such a manner as to ensure the security of those drugs.

(2) The pharmacist-in-charge and each pharmacist while on duty shall be responsible for the security of the prescription area including provisions for adequate safeguards against theft or diversion of prescription drugs, and records for such drugs.

(3) When there is no pharmacist present, the pharmacy shall be secured to prevent entry. All entrances to the pharmacy shall be securely locked and any keys to the pharmacy shall remain in the possession of the pharmacist-in-charge and other employee pharmacists as authorized by the pharmacist-in-charge. When there is no pharmacist present, and it is necessary for non-pharmacist employees or owners to have access to the pharmacy, the prescription area shall be secured from entry as described in OAR 855-041-2100.

(4) Prescription drugs and devices and non-prescription Schedule V controlled substances shall be stored within the prescription area or a secured storage area.

(5) Any security system deviating from the requirements of this section, except as provided in OAR 855-041- 6310, shall be approved by the Board prior to implementation. Requests for such approval shall be in writing and provide a detailed description of the proposed system. A written description of such security system, as approved by the Board, shall be maintained in the pharmacy.

Finally, you should expect that the Board of Pharmacy investigation will continue until all discrepancies in inventory and systems have been understood and corrected. To the extent you are pro-active and take charge (if you don’t lead the investigation, a pharmacy inspector will), you will improve your chances of a positive and quick resolution. I would be remiss not to add that you will need legal counsel to guide you through the process.

Medical board complaints

The medical board investigates complaints asserting violations of state law. Most often, complaints assert one or more violations of the standard of care, inappropriate prescribing, inappropriate relationships with patients, physician impairment, and/or criminal activity.

How will I learn that a complaint has been filed against me?

If you are fortunate, you will have learned about the complaint on your own, usually from a colleague, the patient, or a family member of the patient making the complaint. Other times, you will first learn about a complaint when you receive a letter from the medical board, asking you to provide a written explanation. When you learn about the complaint either way, it may be a blessing in disguise, because you have a small amount of time to collect your thoughts, consult a lawyer, and generally prepare yourself to participate in the board’s investigation, which is something you will want and need to do.

If you are unfortunate, however, you will learn about the complaint when you receive a telephone call from the board’s investigator, or worse, an in person surprise visit by the board’s investigator. These surprise calls and visits are most uncomfortable for the physician, they seldom go well, and, in my experience, it means that the medical board believes the complaint is of a more serious type, and that certain desired evidence may best be gained by surprise.

What should I do if I receive a surprise call or visit from a medical board investigator?

I advise my clients to be cooperative, but always decline a surprise interview, and never sign anything without your lawyer’s approval. Instead, request that the interview be scheduled in the next five business days, and offer a time or two. This will usually be adequate for the investigator. If the investigator persists, explain that your calendar cannot accommodate a spontaneous interview and that you are uncomfortable under the circumstances. If the investigator still persists, explain that you want to consult your lawyer and, if necessary, call your lawyer in the investigator’s presence.

Do not be seduced

Friendly questions, or a “few simple questions,” will lead to progressively more difficult questions. Although the investigator is entitled to investigate, and you will want to cooperate with the medical board’s investigation to protect your license and ability to practice, the bottom line is that no physician, and no lawyer, is so skilled and knowledgeable that he/she is prepared for a surprise interview by a skilled investigator. Only the investigator is prepared in that situation, while you are not.

For Pharmacists: Three medication errors could mean probation and loss of PIC

It is well accepted that dispensing or medication errors occur with some regularity in the practice of pharmacy. While most dispensing errors are never reported to the Board of Pharmacy, once they are, there are consequences for the dispensing pharmacist. For a first and second reported dispensing error, the dispensing pharmacist is at risk of professional discipline by the Board of Pharmacy, most likely a reprimand, and a fine ranging from $1,000 to $5,000.

During one recent case, however, it was revealed to me that the Board of Pharmacy is of the view that for a third reported dispensing error, the presumptive sanction is a fine, plus five-years of probation, and loss of pharmacist-in-charge (PIC) privileges. This is true even when pharmacy workload is a factor, and the prescription involves a look-alike or sound-alike drug.

What you need to know

You need to know that the Board of Pharmacy is imposing discipline upon pharmacists for dispensing errors even though pharmacists know, and the literature establishes, that dispensing errors cannot be fully prevented. For example, according to one study cited by the Institute of Medicine’s 2007 report, 1.7 percent of new and refill prescriptions are dispensed in error:

This more recent, large-scale study of both new prescriptions and prescription refills found an error rate of 1.7 percent (Flynn, et al., 2003). This dispensing error rate translates to approximately 4 errors per 250 prescriptions per pharmacy per day, or an estimated 51.5 million errors during the filling of 3 billion prescriptions each year. One study of medication errors at Medco Health Solutions, Inc., a large mail order pharmacy, carried out by Medco employees, found a dispensing error rate of 0.075 percent—16 dispensing errors among 21,252 prescriptions (Teagarden, et al., 2005).

Preventing Medication Errors: Quality Chasm Series (2007). Retrieved from: http://books.nap.edu/openbook.php?record_id=11623&page=113.

Applying the above error rate of 1.7% to a pharmacy filling 1,500 prescriptions per week indicates that 25 dispensing errors occur each week in that pharmacy. Dispensing errors are not, however, fully preventable, due to what has been described by Stuart R. Levine, et al., as a “latent failure” in the practice of pharmacy:

“Medication errors rarely occur from the failure of a single element or because of mistakes from a single practitioner. Rather medication errors are the result of the combined effects of ‚Äòlatent failures’ in the system and ‚Äòactive failures’ by individuals. Latent failures are weaknesses in the structure of the organization, * * * . By themselves, latent failures are often subtle and may cause no problems. Their consequences are hidden, becoming apparent only when they occur in proper sequence and are combined with active failures of individuals to penetrate or bypass the system’s safety nets. Many of the latent and active failures that were at the root of medication errors are not apparent until a root cause analysis is performed. [Footnote omitted] For this reason, providing an optimal level medication safety requires both recognition and correction of latent failures in the system. * * * . It is unrealistic to expect absolute perfection or error free performance from any person. * * * .”

Stuart R. Levine, et al., Guidelines for Preventing Mediation Errors in Pediatrics, p. 427.

The Department of Human Services (DHS) and findings of patient abuse

Two nurses face allegations by DHS of patient abuse but only one nurse hires a lawyer soon enough avoid a finding of abuse

As a lawyer representing nurses before the Department of Human Services (DHS), I was recently hired by two Certified Nursing Assistants (CNAs), each facing finding of patient abuse by DHS. Both cases involved allegations of rough treatment of a patient and, in both cases, DHS went the next step and issued a notice of intent to publish the findings of patient abuse in the registry maintained by the Oregon State Board of Nursing (OSBN), typically a career-ending event for the nurse.

The first case – a good outcome – DHS reverses finding of patient abuse

The factual records were similar in each case, but in the first case, the nurse hired me as soon as she received her notice from DHS, while the nurse in the second waited to hire a lawyer until the DHS finding of abuse was “finalized.” The defense in both cases was essentially the same, and both cases required that the nurse be interviewed by the investigators from DHS and the Board of Nursing.

In this first case, our preparations were extensive, including preparation of written statements well in advance of the DHS and OSBN interviews. At the DHS interview, we persuaded DHS investigators to withdraw their finding of patient abuse, a tremendous victory. Our success at DHS naturally influenced the mirror-image case pending before the Board of Nursing, and the Board of Nursing likewise chose to close its file without disciplining the nurse, a “double victory.”

The second case – off to a bad start – DHS defends its finding of patient abuse.

In sharp contrast, the nurse in the second case did not hire a lawyer, and she was unprepared when she attended the so-called “informal interview” at DHS. Although DHS characterizes this interview as “informal,” it is anything but; it is a very important interview. At the informal interview, the nurse will face the very same investigators who previously found that she committed patient abuse. This interview is also the last opportunity for the nurse to convince the DHS investigators that they got it wrong.

Without a lawyer, the nurse in the second case did not appreciate the importance of the informal interview, and she did not know how to prepare. She also mistakenly chose to attend the interview by telephone. Making matters worse, the nurse spoke broken English with a heavy accent, so it is doubtful that her concerns were properly understood by the DHS investigators on the other end of the phone during the informal interview. In sum, the informal interview by DHS investigators requires careful preparations and a near-perfect presentation, but without an experienced DHS lawyer, it is unlikely you will know how to prepare yourself. I believe that had the second nurse been represented by an experienced DHS lawyer, DHS would have withdrawn its findings of abuse in that case too.

It gets worse. Because the second nurse, without a lawyer and unprepared by a lawyer, failed to persuade DHS to reconsider and withdraw its finding of patient abuse, her only remaining choice was to give up, or to proceed forward, to a contested case hearing. A contested case proceeding is essentially a trial before an Administrative Law Judge (ALJ). The nurse in this second case chose to keep fighting. She had no practical alternative if she wanted to continuing working as a CNA. For the hearing, the second nurse finally hired a lawyer and she was well represented by that lawyer at hearing, and she made a good record. Although she won most of the factual disputes relevant to DHS’ finding of patient abuse, she did not win them all, and, in the end, the ALJ affirmed DHS’s finding of patient abuse. I was then hired to take her case up on appeal.

What was the difference between these two cases with similar findings of patient abuse?

I do not believe the facts of the two cases are much different. Both cases involved a CNA, allegations of rough treatment of a resident, and findings of patient abuse by DHS. Both cases include extenuating circumstances that explain what had happened, at least in part. Indeed, if I had to predict which case had the better odds of success at an informal interview with DHS, or at a hearing before an ALJ, I would be hard pressed to pick one case over the other. This is because the difference between these two cases is not so much the individual fact patterns, but instead the quality of the nurse’s early preparations, guided by an experienced lawyer.

The moral of the story

The moral of the story is that when defending against allegations or findings of patient abuse, hire a experienced DHS lawyer at the onset. Do not wait to hire a lawyer until you are faced with a hearing or, worse, you have lost your hearing and the only choice remaining is to take an appeal. The best results are almost always obtained well before that, during the early stages of the investigation. Retain and experienced attorney at the beginning, before you do anything else.

I just received a notice of proposed discipline – what does this mean?

If you have received a notice of proposed disciplinary action, it most likely means that your licensing board, whether it be the Oregon Medical Board, the Oregon Board of Pharmacy, or the Oregon State Board of Nursing (or any of the other state licensing boards in Oregon), has concluded its investigation, reached certain conclusions about your practice standards, and is now proposing to discipline you for one or more deficiencies, by imposing one or more sanctions upon you.

The range of sanctions

Sanctions include being reprimanded; having your license to practice medicine, pharmacy, or nursing temporarily suspended, indefinitely suspended, or permanently suspended; or having your license to practice medicine, pharmacy, or nursing permanently revoked. Sanctions further include monetary fines, continuing education, recurrent training, the imposition of a mentor and monitoring, and periods of probation (five years is not uncommon). One or more sanctions, in combination, may be imposed by your licensing board, as the board sees fit.

Illicit drug use; impairment; fitness to practice your profession

If illicit drug use or abuse is involved, then you should further expect to complete an assessment and the drug treatment necessary to restore your health. If you are impaired, or your fitness to practice as a physician, pharmacist, or nurse is at issue, these assessments may be extensive and expensive, and may require travel to an approved facility.

The board’s concerns

The general concern of all healthcare licensing boards is to ensure patient safety and the competency of the individual practitioner. If a pharmacy is involved, the board will further want to ensure the security of the drug inventory.

What are the next steps?

If you haven’t been represented by licensure counsel thus far, the next step is to retain legal counsel. Too many health care providers wait to obtain legal advice until shortly before or after being interviewed by field investigators or licensing boards, or worse, after receiving written findings and proposed sanctions, i.e., a notice of proposed disciplinary action. At this point, your licensing board has reached conclusions about your practice, and at this late date, your opportunity to participate and influence proposed findings and sanctions has been greatly diminished, but there is still important work to do. The next step is to negotiate a settlement, or to proceed to an administrative hearing. No matter what you do, you need legal counsel. You have waited too long if you have not retained legal counsel at this point.