STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF HEALTH, BOARD OF ) MEDICINE, )
)
Petitioner, )
)
vs. )
) THOMAS P. TREVISANI, M.D., )
)
Respondent. )
Case No. 03-1952PL
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was held in this case on September 17 through 19, 2003, in Ft. Lauderdale, Florida, before Administrative Law Judge Michael M. Parrish of the Division of Administrative Hearings.
APPEARANCES
For Petitioner: John E. Terrel, Esquire
Elmer C. Ignacio, Esquire Department of Health
4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265
For Respondent: Kenneth Metzger, Esquire
1435 E. Piedmont Drive, Suite 210
Tallahassee, Florida 32312
William P. Dillon, Esquire
Of Counsel to Tilton & Metzger, P.A. McMorrow & Dillon, P.A.
2590 Golden Parkway, Ste 108
Naples, Florida 34105
STATEMENT OF THE ISSUES
The issues in this case are whether Respondent violated Section 458.331(1)(m), and/or (1)(t), Florida Statutes (Supp. 1996), and, if so, what discipline should be imposed.
PRELIMINARY STATEMENT
On or about September 25, 2001, the Department of Health, (“Department”), filed a two-count Administrative Complaint against Respondent. Respondent subsequently disputed facts in the Administrative Complaint and requested a formal hearing.
Then on or about April 28, 2003, the Department filed an Amended Administrative Complaint. The Amended Administrative Complaint was substantially the same charging document as the original Administrative Complaint and contained the same facts, charges, and counts. Respondent again disputed facts in the Amended Administrative Complaint and again requested a formal administrative hearing. The case was referred to the Division of Administrative Hearings ("DOAH"), where it was docketed as DOAH Case No. 03-1952PL.1
On August 12, 2003, Respondent filed a Motion for Summary Final Judgment, which primarily argued that the Department’s prosecution of this case is barred by the six-year statute of limitations in Section 456.073(13), Florida Statutes (2003).
Petitioner filed a Response to the Motion for Summary Judgment.
The Motion for Summary Judgment was denied by an Order dated August 20, 2003.
The final hearing was held as scheduled on September 17 through 19, 2003. At the hearing, the Department presented the testimony of Tess Jahnke; Marlene Ralston; Investigator Lija Scherer; Patient F. V.; Nathan Mayl, M.D.; Marguerite Barnett, M.D.; Charlotte Filip, R.N.; Dr. Timothy Alexander; and Respondent. The Department's Exhibits 1-3, 5, 7-12, 14-16, and
21 were received into evidence.2 Respondent testified on his own behalf and presented the testimony of Dr. Francis Rieger;
Dr. John Tiller; Mr. John Mastrogiovanni; and the deposition testimony of Joy Mylonakis, C.S.T. Respondent’s Exhibits R-1 through R-4 were received into evidence.3
At the Department's request, official recognition was taken of the following statutes and rules: Section 455.241, Florida Statutes (Supp. 1996), and Florida Administrative Code Rules 59R-8.001, 59R-9.003, and 59R-10.002, (1996).4
The transcript of the hearing was filed with the Division on October 20, 2003. The parties were allowed twenty days from the date of the filing of the transcript to file their proposed recommended orders ("PROs"). The due date for filing the PROs was November 10, 2003. Both parties filed timely PROs containing proposed findings of fact and conclusions of law.
The post-hearing submissions of the parties have been carefully considered during the preparation of this recommended Order.5
FINDINGS OF FACT
Based upon the testimony and evidence received at the hearing and the parties' stipulations, the following findings of fact are made:
Findings regarding the parties
The Board of Medicine (Board) is the regulatory board within the Department of Health that is responsible for the regulation of the practice of medicine in Florida.
Respondent is, and was at all times relevant to this proceeding, a licensed physician, Board-certified in plastic surgery. His license number is ME 0030449.
At all times relevant to this proceeding, Respondent practiced at the Florida Center for Cosmetic Surgery (FCCS), which was an office surgery center in Ft. Lauderdale, Florida. Respondent performed cosmetic surgery at FCCS about two to three days a week while still maintaining his own office surgery center in Winter Park, Florida, where Respondent currently practices. From the beginning of the professional relationship between Respondent and FCCS, it was contemplated by all concerned that the relationship would be a part-time, short-term relationship; Respondent was merely providing plastic surgery services and follow-up care on a temporary basis until FCCS
could make a more permanent arrangement with a plastic surgeon who wanted to work full-time for FCCS. Respondent never had any role in the business practices of FCCS, never had any managerial role at FCCS, and never had any ownership interest in FCCS. The agreement between Respondent and the principals at FCCS included an understanding that all patients who sought services at FCCS were patients of the clinic; not patients of the individual surgeon who performed the surgery on a patient. Consistent with that understanding, FCCS also insisted that it was entitled to custody and control of all of the medical charts, and Respondent was not allowed to remove any medical charts from the premises of FCCS. Respondent performed surgery at FCCS for approximately six weeks.
General findings about the relevant surgical procedures
A brow lift is a cosmetic surgery procedure that involves an incision in the patient’s scalp. The incision goes quite deeply into the forehead. After the incision, the scalp is dissected and loosened all the way down to the eyebrows, with the intent of this procedure being to raise up the eyebrows to some degree to give a rejuvenated appearance to the forehead.
The incision in the scalp bleeds easily. In order to minimize the scalp bleeding, an electrocautery device is used for cauterization at the site of the bleeding. An electrocautery device may either be monopolar or bipolar.
A monopolar cauterization device utilizes a “grounding plate” or a “grounding pad” to ground the electric current. The grounding plate or pad is attached to the patient on a fleshy part, typically along the side of a patient’s thigh or on a patient's buttock, away from any bony prominence. "Bovie" is the trade name of a major brand of monopolar cauterization devices. The grounding plate or grounding pad for a monopolar cauterization device is commonly referred to as a "Bovie pad." In contrast, a bipolar cauterization device does not need and does not have a grounding pad.
Liposuction is a medical procedure in which fat is removed from an area of a patient's body by means of a suction device. A cannulus, which is a narrow tube with a sharp tip, is inserted into the desired areas of the body. The cannulus is connected to a vacuum-like device and once the cannulus is inserted into the operative area, it is manually maneuvered by the physician to remove the fat within reach of the cannulus with vacuum suction.
General findings about Patient F. V.
This case arises from surgical procedures performed by Respondent on February 6, 1997, on a patient identified in the record of this case as Patient F. V.
Patient F. V. is a white female, who at the time of the relevant surgery was 43 years old. Patient F. V. wished to
improve her facial features and wished to reduce the fat in her thighs. She went to FCCS to seek cosmetic surgery for those purposes. Patient F. V. had previously undergone cosmetic surgery performed by Dr. Myron Persoff, also at FCCS, on August 23, 1995.
Pre-operative contact between Patient F. V. and FCCS
On January 28, 1997, Patient F. V. contacted FCCS (probably by telephone) and someone at FCSS filled out a consultation form about that contact. The form listed the requested procedures of a facelift/browlift and liposuction. The form also noted a prior facelift by Dr. Persoff, a plastic surgeon also with FCCS. Finally, the form indicated a confirmation note of January 29, 1997, for an appointment date and time of January 30, 1997, at 3:00 p.m.
On January 30, 1997, Patient F. V. went to FCCS for consultation regarding cosmetic surgery. On that date, Patient
F. V. filled out a “Patient Information” form. The form asked Patient F. V. basic questions relating to her medical history and relating to her social history.
Patient F. V.’s next visit to FCCS was on February 3, 1997. February 3, 1997, was the first and only time that Respondent met with Patient F. V. prior to the surgery on February 6, 1997.
On February 3, 1997, a presurgical and anesthesia evaluation form was completed by Certified Registered Nurse Anesthetist (CRNA) Charlotte Filip. This form detailed some history of Patient F. V. and listed the prior surgery to the breast, face, and eyes. The Patient and Nurse Filip signed the form.
During Patient F. V.’s February 3, 1997, visit to FCCS, Respondent conducted an initial physician/patient consultation. During the course of the consultation on February 3, 1997, Respondent conducted a thorough pre-operative consultation with Patient F. V. His activities during that consultation included taking a history and conducting a physical examination. Respondent discussed with Patient F. V. what she wished to have done, and he also discussed with her the risks and benefits of the proposed procedures. During the course of that consultation Respondent made a plan for the surgical procedures to address Patient F. V.'s concerns and desires. Thereafter, Respondent approved Patient F. V. for a brow lift and thigh liposuction. At the conclusion of the consultation on February 3, 1997, Respondent dictated a pre-operative report. The transcription of that dictation is not in F. V.'s medical chart maintained at FCCS. The fate of that dictated pre- operative consultation report is presently unknown.6
At the time of the Patient F. V.'s 1997 surgery, it was the practice of FCCS to prepare, and to maintain in the patient's medical records, a financial check list. For reasons not explained in the record in this case, the financial check list for Patient F. V.'s 1997 surgical procedures is missing from Patient F. V.'s medical chart at FCCS. At that same time, it was also the practice at FCCS for the physician to either provide the patient with pain medications or with a prescription for pain medications prior to surgery, and to document such delivery of medications or prescription for medications in the patient's medical chart. For reasons not explained in the record in this case, such documentation is missing from Patient
F. V.'s medical chart at FCCS.
At the time of Patient F. V.'s 1997 surgery, it was also the practice at FCCS to provide each patient with a pre- surgery instruction sheet listing numerous things the patient should do prior to surgery, as well as things the patient should not do prior to surgery. It was also the practice of FCCS to place a copy of the instruction sheet in the patient's medical chart. For reasons not explained in the record in this case, the copy of the instruction sheet given to Patient F. V. is missing from her medical chart at FCCS.
At the time of the pre-operative consultation on February 3, 1997, FCCS was experiencing delays with the
transcription of dictated reports. Such transcriptions often took as long as one or two weeks. Some of the information generated at the pre-operative conference needed to be promptly communicated to the financial staff at FCCS so that the costs of the procedures to be performed could be determined and so that arrangements for payment could be made with the patient. In some manner not presently remembered, Respondent provided the FCCA financial staff with the information they needed to make the necessary financial arrangements with Patient F. V.7
Patient F. V.’s medical records at FCCS do not contain adequate documentation of Respondent’s pre-operative consultation on February 3, 1997, with Patient F. V. Further, Respondent could not produce any adequate documentation of his February 3, 1997, consultation with Patient F. V.
Day of Patient F. V.’s surgery
Respondent performed surgery on Patient F. V. on February 6, 1997, which consisted of a brow lift and liposuction of her thighs.
Before Respondent began the surgical procedure, CRNA Filip (Nurse Filip) conducted her own physical assessment of Patient F. V. for her purposes as the anesthetist. Nurse Filip also documented the results from the lab tests. Nurse Filip documented her results by hand writing notes on the bottom left portion of the Pre-Operative Checklist.
As evidenced by the anesthesia record in Patient
F. V.’s records, Nurse Filip also performed her duties as the anesthetist for the surgery and documented her pre-operative care of Patient F. V. In the anesthesia record, Nurse Filip documented information including a cursory patient history (allergies, medication being taken, and blood pressure), date, type of surgery, and surgeon. Respondent had no part in documenting any information on the anesthesia records. The anesthesia records for Patient F. V.'s surgery on February 6, 1997, appear to be complete.
The circulator who participates in a surgical procedure has the recordkeeping responsibility of creating an operating room record, which should include a detailed description of the equipment used during the surgical procedure, as well as an itemization of all significant events from the time the patient enters the operating room until the patient goes to the recovery room. During 1997 it was the practice of FCCS to keep the circulator's operating room records in the patient's medical chart. For reasons not explained in the record in this case, the circulator's operating room record is missing from Patient F. V.'s medical chart at FCCS.
The progress note for the day of surgery, February 6, 1997, is a de minimus notation that lists little more than the type of surgery performed, the surgeon's name, the weight of the
patient, the names of the scrub nurse, the circulating nurse, and the CRNA, and the total amount of fat removed. This de minimus progress note is not in Respondent's handwriting.8
In addition to a progress note summarizing the basic details of a surgical procedure, once the surgery is complete the surgeon should also prepare a detailed operative report which describes in detail the manner in which the surgical procedure was performed, including all significant events that occurred during the surgery. Such an operative report should include a description of the type of liposuction and the type of brow lift performed. Such an operative report should also detail the manner in which the surgery was performed and should note any burns, injuries, or other complications arising from the surgery. A sufficiently detailed operative report is especially important in the event of post-operative complications, because details regarding the methods and techniques employed during the surgery can often facilitate an understanding of, and facilitate treatment of, any post- operative complications.
There is no clear and convincing evidence as to whether Respondent did or did not prepare a detailed operative report of the type described in the immediately preceding paragraph. What is clear is that such an operative report is missing from Patient F. V.'s medical chart at FCCS.9
Respondent's recollection of the details of the subject surgery on February 6, 1997, is not very good. Although he seems to have a clear recollection of some details, he does not appear to recall some other equally important details. He does, however, remember that after the surgery he wrapped Patient F. V.'s forehead with Ace wrap and placed a strip of tape along the forehead to immobilize the Ace wrap. He also applied Ace wrap to the patient's thighs at the conclusion of the surgery. The Ace wraps on the thighs were also secured with strips of tape. At the conclusion of the surgical procedures on February 6, 1997, there were no visible blisters at the locations where blisters were visible on February 7, 1997.
During the surgical procedures performed on February 6, 1997, on Patient F. V., Respondent did not use a monopolar catherization device. Therefore, no grounding pads were used during that surgery.
Findings regarding post-operative care
FCCS’s post-operative policy in effect in February of 1997 required the patient to return for post-operative follow up as follows: one day, one week, two weeks, and one month. Patient F. V. returned the next day, February 7, 1997, and was seen by Respondent.
On February 7, 1997, the patient’s head dressing was removed, the bandages on the patient's thighs were removed, and
the patient was advised to follow up in 5 days to have sutures removed. Respondent’s notes for this visit included a notation that the patient was "doing great," and that the patient should return for staple removal. Respondent's notes also mention a "forehead blister" which is noted to be "clean," and a "tape blister" on the left thigh. On February 7, 1997, Patient F. V. had a blister on her left thigh. This thigh blister was located on the front of the thigh, a few inches above the kneecap. On February 7, 1997, the patient also had a smaller blister on her forehead above her left eye.10
Respondent’s post-operative progress note of the February 7, 1997, visit does not document a treatment plan for the injuries on the forehead or the thigh. However, in this regard it must be noted that there is no evidence that either blister required treatment on February 7, 1997, or that either blister appeared to require any future treatment other than follow-up observation.11
Patient F. V. returned to FCCS on February 13, 1997, and was seen again by Respondent. The written progress note for that day recorded her weight, but no other subjective or objective complaints were noted. The progress note mentions a "possible tape blister" on the patient's upper left thigh. On this occasion the top of the thigh blister had come off and an unprotected layer of skin was at that site. The thigh blister
needed treatment to prevent infection. The progress note also mentions that Bacitracin, an antibiotic, was applied to the thigh blister and that the blister site was covered by a 4” x 4” piece of gauze held in place by a small piece of paper tape.
There are no notes concerning the lesion on the forehead. In this regard it must again be noted that there is no evidence that the forehead blister required any treatment at the time of this visit.12 Patient F. V. was advised to come back in one week to have the staples removed.
The next entry in the progress notes states that Patient F. V. returned three days later, on February 16, 1997. Although the matter is not entirely free from doubt, the visit recorded as having occurred on February 16, 1997, probably actually took place on February 17 or 18, 1997.13 The progress note for that visit first notes that the patient was happy. It also notes that the stitches and the staples were removed. The progress note concludes with the following: "Script given for Silvadene 1% due to burn on leg and forehead." It is not clear from the progress notes who saw the patient at this visit, but it was probably one of the physicians (other than Respondent) who worked at FCCS, inasmuch as a prescription was written during this visit.
Both Bacitracin and Silvadene were appropriate antibiotics for the patient's thigh and forehead lesions.
Silvadene has a more penetrating quality to it and can penetrate scabs better.
On February 24, 1997, Patient F. V. called the FCCS regarding the lesion on her leg. A dermatologist friend of hers had advised her to discontinue the Silvadene cream and to contact her physician about the lesion. Patient F. V. wanted Respondent to see her. She was advised to come in the next day to see one of the other physicians employed at FCCS.
The next day (February 25) Patient F. V. returned to FCCS for further follow up treatment. She was seen by
Dr. Alexander, one of several physicians employed by FCCS, who advised her to leave the lesion dry and see how it heals. The lesion on the thigh was described as "dry and scabbed." The patient was very unhappy during this visit.
On February 26, 1997, Patient F. V. returned to FCCS and was seen by Respondent. Respondent noted that she was doing very well “except for left leg burn.” Respondent also noted as a possible cause of the lesion on the patient's left leg: “probable ground plate sensitivity.” There are no subjective complaints recorded. The record also does not contain any type of plan concerning the left leg burn. In this regard it should be noted that on the previous day Dr. Alexander had advised the patient to leave the burn dry and see how it heals. In all probability, during the following 24-hour period there was no
change to the lesion on Patient F. V.'s thigh that required any additional treatment plan other than the "wait and see" plan noted by Dr. Alexander the day before.
Photographs were taken on the visit of February 26, 1997. There are several post-operative photographs of the left leg lesion.
On March 20, 1997, Patient F. V. returned to FCCS and was seen by Respondent. Respondent noted that she was doing better and that her leg lesion was improving. There are no clearly documented objective or subjective complaints. There is no plan documented other than return ASAP.
Respondent’s medical record of March 20, 1997, does not document a plan for the course and scope of treatment for Patient F. V. Although Respondent documents a concern with the forehead, he did not document what concerns he had or how he planned to treat the concerns.14
After the visit of March 20, 1997, Patient F. V. did not return to the FCCS for over a year. On June 4, 1998, Patient F. V. was seen by two physicians at FCCS. Both physicians examined Patient F. V. and then prepared progress notes reporting what they had observed and proposing a plan to address what they had observed.
Respondent discontinued his professional relationship with FCCS on or about April 1, 1997. Prior to leaving FCCS,
Respondent reviewed all of his charts and had the opportunity to make sure all the histories and physicals were complete. To the best of Respondent's recollection, when he left FCCS there were no charting problems in any of the medical charts of any of the patients who had been treated by Respondent at FCCS.
Patient F. V. returned to FCCS on June 4, 1998, and was seen by Dr. Alexander. Dr. Alexander was another plastic surgeon who worked at FCCS. Following his examination of Patient F. V. on June 4, 1998, Dr. Alexander prepared a progress report reading as follows: "6/4/98. Depressed area above the left eye on the forehead, dime size. Second degree burn, one- inch long depigmented burn scar left medial thigh. Also two- inch wide scar, medial forehead lift scar. Plan, revise all scars."
On June 4, 1998, patient F. V. was seen by another physician identified in progress notes as "Dr. H."15 Following his examination of Patient F. V. on June 4, 1998, the second physician ("Dr. H") prepared a progress note reading as follows:
Dr. H, 6/4/98 1.7 x .8 centimeter hypopigmented scar with surrounding hypopigmentation 2mm. flat non-tender
.8 x .6 centimenter thin skin left upper forehead appears like lower dermis mobile to touch but doesn't animate on her own. Can't really see scar - just notice conture deformity. Rec - Excise leg scar vertically. ? Alloderm under depressed scar left forehead. Discuss with patient.
G.L.A.D.
Patient F. V. has elected not to have scar revision surgery.
When Respondent discontinued his professional relationship with FCCS, he left all of the medical records concerning his care and treatment of Patient F. V. in the possession and custody of FCCS. Respondent did not take any copies of any medical records concerning Patient F. V. when he discontinued his relationship with FCCS. It was not until the latter part of 1999 that Respondent first obtained possession of a copy of the FCCS medical records concerning Patient F. V. He obtained those copies by means of a discovery request.
As of the time of the final hearing in this case, several documents were missing from the medical records concerning Patient F. V. maintained by FCCS. The missing documents included the following: a detailed pre-operative report; a detailed operative report prepared by Respondent or prepared by someone acting pursuant to Respondent's direction and control; a financial check list; written documentation of medications provided to or prescribed for the patient; and a sheet of pre-surgery instructions regarding what the patient should and should not do. At several times during the period from 1998 through 2002, the medical records at FCCS concerning Patient F. V. were searched in an effort to locate a detailed
pre-operative report and/or a detailed operative report. Such documents could not be found in the FCCS records on those occasions.
Without an operative note (or some other form of detailed information regarding the manner in which the surgical procedures at issue were performed) it is virtually impossible to reach a reliable determination as to what caused the injuries on the patient's left thigh and forehead. On the basis of the record in this case, the causes of the forehead and thigh lesions observed on Patient F. V. on February 7, 1997, are unknown. Because the causes are unknown, it is also unknown whether such lesions were caused by act or omission by Respondent. And, because no specific act or omission by Respondent has been identified as the cause of either lesion, it is impossible to determine whether any such unidentified act or omission, if any, might or might not have constituted a departure from the applicable standards of care.
There is no clear and convincing evidence that Respondent "fail[ed] to properly administer liposuction, causing full-thickness burns to Patient F. V.'s left thigh area."
There is no clear and convincing evidence that Respondent "fail[ed] to properly perform the brow lift, causing full-thickness burns to Patient F. V.'s forehead."
There is no clear and convincing evidence that Respondent "improperly plac[ed] or fail[ed] to appropriately supervise the placement of the grounding pads of the Bovie unit."
There is no clear and convincing evidence that Respondent did "not adequately maintain[ ] his surgical equipment relating to liposuction and brow lift procedures."
There is no clear and convincing evidence of Respondent's "failing to properly document Patient F. V.'s preoperative consultation."
There is no clear and convincing evidence of Respondent's "failing to properly document a post-operative report of the procedures."
There is no clear and convincing evidence of Respondent's "failing to complete or create an appropriate operative report for the procedures."
CONCLUSIONS OF LAW
Jurisdiction and burden of proof
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding pursuant to Sections 120.569, 120.57(1), and 456.073(5), Florida Statutes (2003).
Where the revocation or suspension of the physician's license is sought, proof greater than a mere preponderance of
the evidence must be submitted before the Board of Medicine (Board) may take punitive action against a licensed physician. Clear and convincing evidence of the physician's guilt is required. Section 458.331(3), Florida Statutes. See also Department of Banking and Finance, Division of Securities and Investor Protection v. Osborne Stern and Company, 670 So. 2d 932, 935 (Fla. 1996); Ferris v. Turlington, 510 So. 2d 292 (Fla.
1987); McKinney v. Castor, 667 So. 2d 387, 388 (Fla. 1st DCA
1995); Tenbroeck v. Castor, 640 So. 2d 164, 167 (Fla. 1st DCA 1994); Nair v. Department of Business and Professional
Regulation, 654 So. 2d 205, 207 (Fla. 1st DCA 1995); Pic N' Save v. Department of Business Regulation, 601 So. 2d 245 (Fla. 1st DCA 1992); Munch v. Department of Professional Regulation, 592 So. 2d 1136 (Fla. 1st DCA 1992); Newberry v. Florida Department
of Law Enforcement, 585 So. 2d 500 (Fla. 3d DCA 1991); Pascale v. Department of Insurance, 525 So. 2d 922 (Fla. 3d DCA 1988); Section 458.331(3), Florida Statutes; Section 120.57(1)(h), Florida Statutes ("Findings of fact shall be based on a preponderance of the evidence, except in penal or licensure disciplinary proceedings or except as otherwise provided by statute.").
"'[C]lear and convincing evidence requires that the evidence must be found to be credible; the facts to which the witnesses testify must be distinctly remembered; the testimony
must be precise and explicit and the witnesses must be lacking in confusion as to the facts in issue. The evidence must be of such weight that it produces in the mind of the trier of fact a firm belief or conviction, without hesitancy, as to the truth of the allegations sought to be established.'" In re Davey, 645 So. 2d 398, 404 (Fla. 1994), quoting, with approval, from Slomowitz v. Walker, 429 So. 2d 797, 800 (Fla. 4th DCA 1983).
When the Board seeks to take punitive action against a physician, such action may be based only upon those offenses specifically alleged in the administrative complaint. See
Cottrill v. Department of Insurance, 685 So. 2d 1371, 1372 (Fla. 1st DCA 1996); Chrysler v. Department of Professional Regulation, 627 So. 2d 31 (Fla. 1st DCA 1993); Klein v.
Department of Business and Professional Regulation, 625 So. 2d 1237, 1238-39 (Fla. 2d DCA 1993); Arpayoglou v. Department of Professional Regulation, 603 So. 2d 8 (Fla. 1st DCA 1992); Willner v. Department of Professional Regulation, Board of Medicine, 563 So. 2d 805, 806 (Fla. 1st DCA 1992); Celaya v.
Department of Professional Regulation, Board of Medicine, 560 So. 2d 383, 384 (Fla. 3d DCA 1990); Kinney v. Department of State, 501 So. 2d 129, 133 (Fla. 5th DCA 1987); Sternberg v.
Department of Professional Regulation, 465 So. 2d 1324, 1325 (Fla. 1st DCA 1985); Hunter v. Department of Professional Regulation, 458 So. 2d 842, 844 (Fla. 2d DCA 1984).
Furthermore, in determining whether Section 458.331(1), Florida Statutes, has been violated in the manner charged in the administrative complaint, one "must bear in mind that it is, in effect, a penal statute. . . . This being true the statute must be strictly construed and no conduct is to be regarded as included within it that is not reasonably proscribed by it. Furthermore, if there are any ambiguities included such must be construed in favor of the . . . licensee." Lester v. Department of Professional and Occupational Regulations, 348 So. 2d 923, 925 (Fla. 1st DCA 1977).
New legislation
By operation of new legislation enacted during the 2003 session of the Florida Legislature, effective September 15, 2003, "[t]he determination of whether or not a licensee has violated the laws and rules regulating the profession, including a determination of the reasonable standard of care, is a conclusion of law to be determined by the board . . . and is not a finding of fact to be determined by an administrative law judge." See Chapter 2003-416, Laws of Florida, at Section 20 (amending Section 456.073(5), Florida Statutes (2002)). Because this proceeding is one of the very first cases to be tried following the effective date of the above-quoted amendments, there does not yet appear to be any decisional guidance from the Department of Health, from any of the boards, or from any
appellate court, as to what extent, if any, the above-quoted amendment requires any changes in the manner in which hearings before the Division of Administrative Hearings should be conducted, or requires any changes in the content of the recommended orders prepared by the DOAH administrative law judges. Nor have the parties to this case offered much in the way of guidance. By their conduct at hearing both parties seemed to be of the view that the above-quoted statutory amendments did not change the nature of the evidence to be offered in cases of this nature, because both parties requested, and were granted, the opportunity to offer expert witness testimony on the subject matter of whether Respondent "has violated the laws and rules regulating the profession," as well as on the subject matter of what constitutes the "reasonable standard of care."
The proposed recommended orders submitted by the parties do not suggest that the above-quoted statutory language requires any changes to the type of content that has customarily been included in recommended orders in cases of this nature. Respondent's proposed recommended order does not even mention the statutory amendments. Petitioner's proposed recommended order offers only the following regarding those amendments:
This Legislative act appears to be a response to the recent case of Gross v. Dept. of Health, 819 So. 2d 997, 1003 (Fla.
5th DCA 2002) ("whether a doctor deviated from the applicable standard of care is an issue of fact to be determined by the administrative law judge"). Case law has dealt with hearing officers (now ALJs) or agencies erroneously labeling what is essentially a factual determination a “conclusion of law.” See, Kinney v. Dept. of State, 501 So. 2d 129, 132 (Fla. 5th DCA 1987) ("labeling what is essentially a factual determination a 'conclusion of law,’ whether by the hearing officer or the agency does not make it so"). Another case has stated that simply because a conclusion of law is masked or presented as a finding of fact by the ALJ does not insulate it from its proper status as a conclusion of law subject to review by the Board or reviewing agency. Goss v. District School Board of St. John’s County, 601 So. 2d 1232 (Fla. 5th DCA 1992). There is no case law clarifying the review power of the courts when the Legislature essentially renames a finding of fact as a conclusion of law. However, since the Legislature creates the laws and the courts interpret them, deference must be given to the plain language of Chapter
2003-416, Laws of Florida, at Section 20 (amending Section 456.073(5), Florida Statutes (2002) even though it conflicts with the prior interpretation of the statute by one of the District Courts of Appeal.
There is some question on whether this substantive change is applicable to the case at bar and it is found that it is not applicable.
The undersigned is unable to agree that the subject amendments to Section 456.073(5), Florida Statutes (2002), are not applicable. Instead, because the amendments appear to address matters of procedure rather than matters of substance, the amendments appear to be applicable to cases pending as of
the effective date of the law that created the amendments. See Basel v. McFarland & Sons, Inc., 815 So. 2d 687 (Fla. 5th DCA 2002), in which the court noted at page 692: "In the absence of clear legislative intent, a law affecting substantive rights is presumed to apply prospectively only while procedural or remedial statutes are presumed to operate retrospectively. See
Young v. Altenhaus, 472 So. 2d 1152 (Fla. 1985)." See also Life Care Centers of America, Inc. v. Sawgrass Care Center, Inc., 683 So. 2d 609 (Fla. 1st DCA 1996).
The language of the subject amendments to Section 456.073(5), Florida Statutes (2002), is sufficiently broad for it to be interpreted and applied in more than one way. And some of the possible interpretations and applications might at some future date provide a basis for modification of the manner in which administrative hearings in such cases are conducted. But such possible interpretations and applications are merely possibilities; they are not certainties. Therefore, unless and until there is some authoritative interpretation or implementation of the subject amendments directing otherwise, the most prudent course appears to be for the DOAH administrative law judges to continue to receive evidence and to continue to make "determinations" (by findings of fact or by conclusions of law) as to what constitutes the "reasonable standard of care" and as to whether a licensee "has violated the
laws and rules regulating the profession;" especially in cases like this one in which both parties requested such a course of action by the administrative law judge.16
The specific statutes and charges
At the time of the events that form the basis for the charges in this case, Sections 458.331(1)(m) and 458.331(1)(t), Florida Statutes (Supp. 1996), authorized the Board to revoke, suspend, or otherwise discipline the license of a physician for the following reasons:
(m) Failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations;
* * *
(t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. The board shall give great weight to the provisions of
s. 766.102 when enforcing this paragraph. As used in this paragraph, "repeated malpractice" includes, but is not limited to, three or more claims for medical malpractice within the previous 5-year period resulting in indemnities being paid in excess of $10,000 each to the claimant in a judgment or settlement and which incidents involved negligent conduct by the physician. As used in this paragraph, "gross malpractice" or "the failure to practice medicine with that level of care, skill, and
treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances," shall not be construed so as to require more than one instance, event, or act. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph.
Count One of the Amended Administrative Complaint charges Respondent with having violated Section 458.331(1)(t), Florida Statutes (Supp. 1996). In this regard, paragraph 12 of the Amended Administrative Complaint charges the following:
12. Respondent failed to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances in the treatment of Patient F. V., based upon one or more of the following:
failing to properly administer liposuction, causing full-thickness burns to Patient F. V.'s left thigh area;
failing to properly perform the brow lift, causing full-thickness burns to Patient F. V.'s forehead;
improperly placing or failing to appropriately supervise the placement of the grounding pads of the Bovie Unit or not adequately maintaining his surgical equipment relating to liposuction and brow lift procedures.
Directing attention first to the allegations in subparagraph (a) of paragraph 12, there is no clear and
convincing evidence in the record of this case that Respondent "fail[ed] to properly administer liposuction, causing full- thickness burns to Patient F. V.'s left thigh area." Although the expert witness testimony in this case contains several different opinions as to what might have been the cause of the injury to the patient's left thigh, none of the experts could identify any specific act, or failure to act, by Respondent that, in fact, was clearly the cause of the injury.17 Specifically, there is no clear and convincing evidence that during the liposuction procedure on Patient F. V. there was anything improper about the manner in which Respondent performed the liposuction procedure. Therefore, so much of Count One as relies on the allegations in subparagraph (a) of paragraph 12 should be dismissed for lack of sufficient proof.
Directing attention next to the allegations in subparagraph (b) of paragraph 12, there is no clear and convincing evidence in the record of this case that Respondent "fail[ed] to properly perform the brow lift, causing full- thickness burns to Patient F. V.'s forehead." Similar to the circumstances discussed above regarding subparagraph (a), none of the experts could identify any specific act, or failure to act, by Respondent that, in fact, was clearly the cause of the injury to the patient's forehead.18 Specifically, there is no clear and convincing evidence that during the brow lift
procedure on Patient F. V. there was anything improper about the manner in which Respondent performed the brow lift procedure.
Therefore, so much of Count One as relies on the allegations in subparagraph (b) of paragraph 12 should be dismissed for lack of sufficient proof.
Directing attention now to the last subparagraph of paragraph 12, subparagraph (c), there is no clear and convincing evidence in the record of this case that Respondent is guilty of "improperly placing or failing to appropriately supervise the placement of the grounding pads of the Bovie Unit or not adequately maintaining his surgical equipment relating to liposuction and brow lift procedures." With regard to the first half of subparagraph (c), the half regarding the "Bovie Unit," it is important to note that a so-called "Bovie Unit" is an electrocautery device that comes in two basic models, monopolar or bipolar. Monopolar devices require, and are equipped with, grounding pads. Bipolar devices do not need, and do not have, grounding pads. There is no clear and convincing evidence that Respondent used a monopolar device during the surgery he performed on Patient F. V. To the contrary, the greater weight of the evidence is to the effect that Respondent used a bipolar electrocautery device, which device did not have a grounding pad that could be improperly or incorrectly placed.19 And with regard to the second half of subparagraph (c), there is no
evidence at all regarding the maintenance of Respondent's surgical equipment; specifically, no evidence that any maintenance of any such equipment was in any way inadequate. Therefore, so much of Count One as relies on the allegations in subparagraph (c) of paragraph 12 should be dismissed for lack of sufficient proof.
Count Two of the Amended Administrative Complaint charges Respondent with having violated Section 458.331(1)(m), Florida Statutes (Supp. 1996). In this regard, paragraph 16 of the Amended Administrative Complaint charges the following:
16. Respondent failed to keep written medical records that justify the course of treatment of Patient F. V. in one or more of the following ways:
By failing to properly document Patient F. V.'s pre-operative consultation;
By failing to properly document a post-operative report of the procedures;
By failing to complete or create an appropriate operative report for the procedures.
Directing attention first to the allegations in subparagraph (a) of paragraph 16, there is a certain amount of ambiguity in the allegations that Respondent failed to keep written medical records that justify the course of treatment of Patient F. V. "[b]y failing to properly document Patient F. V.'s pre-operative consultation." The failures alleged in paragraph
16 and its subparagraphs could come about in either of two ways:
(1) Petitioner could be alleging that Respondent at one time prepared sufficient medical records during the course of treating the patient, but later failed to "keep" those records because he did not "retain" the records and could not produce them upon request, or (2) Petitioner could be alleging that Respondent failed to ever prepare sufficient medical records and, therefore, never had any sufficient records to keep. Following careful consideration of the language of the three subparagraphs of paragraph 16, it appears that the most logical interpretation of those subparagraphs is to interpret them as allegations that Respondent failed to ever prepare sufficient medical records of the types described in each of the three subparagraphs of paragraph 16.20
Subparagraph (a) of paragraph 16, alleges that Respondent failed to properly document Patient F. V.'s pre- operative consultation. That allegation has not been established by clear and convincing evidence. To the contrary, the greater weight of the evidence is to the effect that promptly following Respondent's pre-operative consultation with Patient F. V., he dictated an adequate pre-operative consultation note. That note is presently missing from the patient's chart, but there is no evidence in the record of this case upon which to attribute the absence of the missing document
to any act or omission of Respondent. Therefore, so much of Count Two as relies on the allegations in subparagraph (a) of paragraph 16 should be dismissed for lack of sufficient proof.
Turning next to the allegations in subparagraph (b) of paragraph 16, there is no clear and convincing evidence in the record of this case that Respondent failed to keep written medical records that justify the course of treatment of Patient
F. V. "[b]y failing to properly document a post-operative report of the procedures." To the contrary, the greater weight of the evidence is to the effect that shortly after the surgery on
June 6, 1997, Respondent dictated a detailed operative report. That note is presently missing from the patient's chart, but there is no evidence in the record of this case upon which to attribute the absence of the missing document to any act or omission of Respondent. Therefore, so much of Count Two as relies upon the allegations in subparagraph (b) of paragraph 16 should be dismissed for lack of sufficient proof.
And, finally, attention is directed to the allegations in subparagraph (c) of paragraph 16, which allege that Respondent failed to keep written medical records that justify the course of treatment of Patient F. V. "[b]y failing to complete or create an appropriate operative report for the procedures." The allegations in subparagraph (c) of paragraph
16 appear to use different words to allege what appears to be
the same violation that is alleged in subparagraph (b) of paragraph 16. Inasmuch as the violation alleged in subparagraph
(c) appears to be indistinguishable from the violation alleged in subparagraph (b), the two alleged violations should be disposed of in the same manner for the same reasons. Therefore, so much of Count Two as relies upon the allegations in subparagraph (c) of paragraph 16 should be dismissed for lack of sufficient proof.21
Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine issue a final order in this case dismissing all parts of both counts of the Amended Administrative Complaint because none of the violations alleged in the Amended Administrative Complaint have been proved by clear and convincing evidence.
DONE AND ENTERED this 31st day of December, 2003, in Tallahassee, Leon County, Florida.
S
MICHAEL M. PARRISH
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675 SUNCOM 278-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 31st day of December, 2003.
ENDNOTES
1/ At the beginning of the final hearing the Petitioner moved, without objection, to further amend the Amended Administrative Complaint. The effect of the amendment allowed at the final hearing is to add the following words at the end of the fourth page of the Amended Administrative Complaint: "probation and/or any relief that the Board deems appropriate."
2/ The following is a more detailed description of the exhibits offered by Petitioner that were received in evidence: Exhibit 1, Respondent’s Answers to Admissions and Petitioner’s Request for Admissions; Exhibit 2, Respondent’s Licensure Certification; Exhibit 3, Patient F. V.’s medical records from Florida Center for Cosmetic Surgery, Inc. (FCCS), including pictures; Exhibit 3a, Patient F. .’s medical records from FCCS, including pictures from the records’ custodian; Exhibit 5, Dr. Mayl’s Curriculum Vitae; Exhibit 7, Dr. Barnett’s Curriculum Vitae; Exhibit 8, Respondent’s letter dated 3/4/1999 to Investigator; Exhibit 9, Investigative Report dated 8/16/1999 and 4/8/1999; Exhibit 10, Supplemental Investigative Report dated 2/7/2001; Exhibit 11, Letter dated 2/2/2001 from Steven Miller, Plaintiff’s attorney, to the Agency for Health Care Administration (AHCA); Exhibit 12, Letter from Sherman Clay, President at FCCS, to Ms. Scherer, AHCA; Exhibit 14, FCCS’s Department of State Annual Reports dated 4/22/1996 and 1/28/1997; Exhibit 15, Articles of Incorporation of FCCS; Exhibit 16, Articles of Incorporation of Thomas P. Trevisani, M.D., P.A.; and Exhibit 21, Rebuttal exhibit – pictures of Patient F. V. obtained from Respondent in his office during his deposition.
3/ The following is a more detailed description of the exhibits offered by Respondent that were received in evidence: Exhibit 1, CV of Dr. Trevisani; Exhibit 2, Transcript of deposition of Joy Mylonakis; Exhibit 3, CV of Dr. Tiller; and Exhibit 4, CV of Dr. Rieger.
4/ In addition to the 1996 statutory and rule provisions of which official recognition was specifically requested and granted, there are several other statutory provisions that have a bearing on the disposition of the issues in this case. In
disposing of the issues in this case, the administrative law judge has applied the statutory provisions in effect at the time of the events that form the basis for this case, except to the extent to which such reliance may be precluded by recent legislative enactments.
5/ Neither of the PROs contains more than cursory mention of the amendments to Section 456.073(5) and to Section 458.331(1)(t), Florida Statutes, wrought by Sections 20 and 25 of Chapter 2003-416, Laws of Florida.
6/ There are numerous possible explanations for the absence of the preoperative note dictated by Dr. Trevisani on February 3, 1997. The possibilities include: the dictation was lost or misplaced and was never transcribed; the dictation was transcribed, but the transcript was misfiled; the transcript was properly filed, but later removed from the chart by persons unknown for reasons unknown. There is nothing in the evidence in this case that clearly and convincingly establishes which of these possibilities is what really happened.
7/ At the final hearing (which was some six years after the events at issue), no one seemed to recall how the information needed by the financial staff was communicated to the financial staff. Perhaps the information on the Pre-Operative Check List sufficiently addressed the information needs of the financial staff. Respondent speculated as to a couple of other ways in which information might have been communicated to the financial staff, but Respondent did not appear to have any specific recollection of how the information relating to Patient F. V. was furnished to the financial staff in February of 1997.
8/ The evidence in this case does not identify the author of the February 6, 1997, progress note. The evidence in this case does not indicate whether Respondent had any role in preparing that de minimus progress note.
9/ Although the matter is not entirely free from doubt, there is evidence in the record to the effect that it is more likely than not that Respondent did prepare an adequate operative report, but that the report, for reasons unknown, either was never placed in the correct chart or was removed from the chart by an unknown person for an unknown reason.
10/ The patient's post-operative recovery from the two surgical procedures was uneventful with the exception of the two blisters first noted on February 7, 1997.
11/ On February 7, 1997, Patient F. V. was advised to return for a follow-up visit in five days. The patient returned on February 13, 1997.
12/ The forehead lesion was a de minimus lesion, even in the opinion of the patient. After describing the lesion on her thigh, Patient F. V. went on to explain as follows: "There was a little one on my forehead, too, but that was so small it didn't bother me." Transcript, page 85. See also the notes prepared by "Dr. H" when he examined Patient F. V. in July of 1998. In view of the de minimus nature of the forehead lesion, it is most unlikely that it ever needed any treatment or attention other than observation when the patient was being seen about other matters.
13/ February 16, 1997, was a Sunday. Although there is no evidence in the record as to the days of the week on which the FCCS clinic was open for business, it is unlikely that FCCS was seeing patients on a Sunday and also unlikely that FCCS had a physician at the clinic on Sunday to write a prescription.
14/ It is also unclear whether the "forehead" concerns relate to the small forehead blister over the left eye, or whether they relate to another medial forehead lesion or scar which is mentioned in some later progress notes by other physicians. And it is further unclear whether the "forehead" concerns noted in the March 20, 1997, progress note are concerns by the Respondent or are concerns expressed by the patient.
15/ The physician described in the progress notes as "Dr. H" was not clearly identified at the final hearing. One witness (Dr. Alexander) identified "Dr. H' as "Dr. Heisinger." In Petitioner's PRO "Dr. H" is referred to as "Dr. Hunsacker." The matter is not further clarified in the record of this case.
16/ Some of my "determinations" as to whether Respondent "has violated the laws and rules regulating the profession" are located in the Findings of Fact portion of this Recommended Order, and other such "determinations" are located in the Conclusions of Law. The ALJ has tried to place such determinations where he believes they belong, taking into consideration both a long history of appellate court guidance on such matters and the new legislative pronouncement which does not appear to have yet been the subject of board, department, or judicial interpretation. In any event, the placement of such determinations in one part of the Recommended Order or the other
does not appear to be of any great moment, because it is reasonable to expect that the appellate courts will continue to be of the view, regardless of where placed and regardless of how characterized, a fact will continue be a fact and a conclusion of law will continue to be a conclusion of law.
17/ Both of the expert witnesses who testified on behalf of Petitioner candidly admitted that they did not really know what had happened to cause the two lesions. Dr. Barnett thought the thigh lesion was "most likely" caused by rough handling of the liposuction instruments, but conceded there were other possible causes, some of which might not be a deviation from the applicable standard of care. Dr. Mayl candidly stated that he did not have sufficient information upon which to form an opinion as to what caused the subject lesions. He also stated he did not have enough information to state whether Respondent deviated from the standard of care in any of the ways alleged in the Amended Administrative Complaint. Dr. Mayl also opined that even if Dr. Barnett's causation theory were to be correct, Respondent's handling of the liposuction instruments still might not be a departure from applicable standards of care. In
Dr. Mayl's words, such complications are not "entirely preventable." And towards the end of his testimony, Dr. Mayl agrees that ". . . there's an enormous amount of possibilities of what may have caused this injury, some [of] which are not a breach of the standard of care." And it should also be noted that, while it is clear that Patient F. V. had a lesion on her left thigh the day after her surgery, there is no clear and convincing evidence that such lesion was a "full-thickness burn." And as a final note on this issue, Petitioner concedes in its proposed recommended order that there is no clear and convincing evidence that the lesion on the patient's left thigh resulted from any departure by Respondent from the applicable standard of care.
18/ Dr. Barnett hardly mentions the lesion on the patient's forehead and certainly gives no clear and convincing opinion as to what caused that lesion. Similarly, Dr. Barnett does not offer any clear and convincing opinion as to whether whatever caused the forehead lesion was or was not a departure from the applicable standard of care. Dr. Mayl simply does not have enough information about how the brow lift surgery was done to form an opinion as to whether Respondent's performance of that surgery was or was not a departure from applicable standards of care. And it should also be noted that, while it is clear that Patient F. V. had a lesion on her forehead over her left eye the day after her surgery, there is no clear and convincing evidence
that such lesion was a "full-thickness burn." Quite to the contrary, the evidence in the record is to the effect that the lesion over the patient's left eye was a small blister involving only the top layer of skin, a minor injury that, at most, needed only de minimus attention (primarily periodic observation) and that was not expected to, and, in fact did not, result in any significant consequences. See notes by "Dr. H," who noted following an examination of Patient F. V.'s forehead a year after the surgery, "[F]lat non-tender .8 x .6 centimeter thin skin left upper forehead appears like lower dermis mobile to touch but doesn't animate on her own. Can't really see scar - just notice conture deformity." (Emphasis added.)
19/ There is no clear and convincing evidence that any of the operating rooms at FCCS were equipped with monopolar electrocautery devices. And even if such monopolar devices were available, Respondent's clear and uncontradicted testimony was that he always used bipolar devices when performing surgical procedures of the type he performed on Patient F. V.
20/ In this regard it is also important to remember that in penal proceedings any ambiguities must be construed in favor of the licensee. See Lester v. Department of Professional and Occupations Regulations, 348 So. 2d 923 (Fla. 1st DCA 1977).
21/ In reaching the determinations that the evidence is insufficient to establish the record-keeping violations alleged in Count Two, the ALJ has not overlooked the testimony of
Dr. Barnett and Dr. Mayl on that subject. Dr. Barnett and Dr. Maly both expressed criticism of several aspects of Respondent's medical records regarding Patient F. V., but much of that criticism related matters that were not charged as violations in the Amended Administrative Complaint. Further,
much of what Dr. Barnett and Dr. Mayl identified as deficiencies in Respondent's record preparation was based on factual assumptions different from what is reflected in the evidence in this case. Specifically, both Dr. Barnett and Dr. Mayl opined that Respondent's medical records were deficient because they did not contain an adequate pre-operative consultation report or an adequate operative report, and they appear to have assumed for purposes of formulating their opinions that such documents were never prepared. Yet the greater weight of the evidence is to the effect that Respondent did prepare an adequate pre- operative consultation report and did prepare an adequate operative report, both of which are missing from the FCSS medical chart that was never in the custody or control of Respondent. The foregoing comments regarding the testimony of
Dr. Barnett and Dr. Mayl apply equally to the testimony of Dr. Tiller and Dr. Rieger, to the extent the latter two expressed any criticism of Respondent's medical records concerning Patient F. V.
COPIES FURNISHED:
John E. Terrel, Esquire Elmer C. Ignacio, Esquire Department of Health
4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265
Kenneth Metzger, Esquire
1435 E. Piedmont Drive, Suite 210
Tallahassee, Florida 32312
William P. Dillon, Esquire
Of Counsel to Tilton & Metzger, P.A. McMorrow & Dillon, P.A.
2590 Golden Parkway, Ste 108
Naples, Florida 34105
Larry McPherson, Executive Director Board of Medicine
Department of Health 4052 Bald Cypress Way
Tallahassee, Florida 32399-1701
R. S. Power, Agency Clerk Department of Health
4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
William W. Large, General Counsel Department of Health
4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within
15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 14, 2006 | Other | |
| Aug. 05, 2005 | Mandate | |
| Jul. 20, 2005 | Opinion | |
| May 04, 2004 | Agency Final Order | |
| Dec. 31, 2003 | Recommended Order | All counts in the Administrative Complaint should be dismissed due to the absence of clear and convincing evidence to prove the alleged violations. |
