STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE ) ADMINISTRATION )

)

Petitioner, )

)

vs. ) CASE NO. 94-1605

) JANET A. MARLEY, M.D., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, William F. Quattlebaum, held a formal hearing in the above-styled case on August 17, 1994, in Tampa, Florida.

APPEARANCES

For Petitioner: Arthur Skafidas, Esquire

Agency for Health Care Administration 1940 North Monroe Street, Suite 60

Tallahassee, Florida 32399-0792

For Respondent: Bruce D. Lamb, Esquire

Post Office Box 2378 Tampa, Florida 33601

STATEMENT OF THE ISSUE

The issue in this case is whether the allegations of the Administrative Complaint are correct and, if so, what penalty should be imposed.

PRELIMINARY STATEMENT

By Administrative Complaint filed June 1, 1993, the Petitioner alleges that in delivering care to a gynecological patient, the Respondent practiced medicine below an acceptable standard of care, skill and treatment. The Respondent disputed the allegations and requested a hearing. The request was forwarded to DOAH and scheduled for hearing.

At the hearing, Petitioner presented the testimony of two witnesses and had exhibit number 9 admitted into evidence. The Respondent offered the testimony of five witnesses, testified on her own behalf, and had exhibits numbered 1-9 admitted into evidence. Joint exhibits numbered 1-8 were admitted into evidence. The prehearing stipulation filed by the parties was admitted as a Hearing Officer's exhibit.

A hearing transcript was filed. Both parties filed proposed recommended orders, and the Respondent filed a written closing argument, all of which has

been duly considered in the preparation of this Order. The proposed findings of fact are ruled upon in the Appendix which is attached and hereby made a part of this Recommended Order.

FINDINGS OF FACT

1. The Petitioner is the state agency charged by statute with regulating the practice of medicine in the state of Florida.

   
   

2. The Respondent is and at all times material to this case was a licensed physician in the State of Florida, license #ME0026208. The Respondent is Board- certified in obstetrics and gynecology.

   
   

3. On March 7, 1985, Patient #1 was seen for initial examination by the Respondent. The patient, a 25 year old female, was taking birth control pills and experiencing "breakthrough bleeding." The Respondent obtained the patient's history and performed a gynecological examination.

   
   

4. According to the patient's history, an aunt had died from uterine cancer and a grandmother had died from stomach cancer.

   
   

5. During the March 7 gynecological exam, the Respondent diagnosed an "erosion" of the patient's cervix. Upon discovering the condition, the Respondent performed a Pap smear and prescribed Ortho Novum 1/50 for the patient.

   
   

6. A cervical "erosion" is a condition where the tissue lining the endocervical canal (columnar epithelium) extends beyond the interior of the cervix and displaces the outer surface of the cervix (squamous epithelium.) Although this condition is more correctly referred to as an "eversion" or "ectropion" rather than an "erosion," the Respondent's usage of "erosion" was apparently common among practitioners and was consistent throughout her treatment of the patient.

   
   

7. A Pap smear is a test which requires removal of cells from a cervix by scraping the cervix with an instrument. The cell sample is sent to a lab and microscopically examined. The lab reports the findings of the microscopic observation to the physician.

   
   

8. A Pap smear is a screening test and should be utilized only to determine whether further investigation is warranted. The purpose of the Pap smear test is to determine whether abnormal, perhaps pre-cancerous, cellular activity is occurring.

   
   

9. A Pap smear is inadequate to provide diagnosis of a specific condition, especially the existence or nonexistence of cervical cancer. A Pap smear reflects only the condition of cells available on the surface of the cervix. In order to determine the condition of the cervix below the surface tissue, additional testing is required.

   
   

10. Subsequent to the time period at issue in this case, the Pap smear scale has been replaced by a more precise reporting system known as the Bethesda system.

    
    

11. At all times material to this case, Pap smears were classified on a scale of one to five. A Class I Pap smear is a "normal" test result with no atypical cell activity. A Class II Pap smear indicates that some level of

    abnormal activity is occurring, ranging from insignificant abnormalities to conditions requiring additional attention. A Class III Pap smear reports the presence of potentially pre-cancerous cell activity. Classes IV and V report the presence of malignant cells. There is some overlap in the Pap classifications.

    
    

12. Because of the imprecision of the Pap smear grading scale, it was important that physicians communicate with testing laboratories to determine how the lab reports were to be interpreted.

    
    

13. At all times material to this case, the Respondent utilized the cytology services of Accutech Laboratory for review and reporting of Pap smears. A cytologist is primarily focused on examination of the cell sample and categorization of atypical cells and differentiation between dysplastic and inflammatory cells.

    
    

14. Dysplasia is the appearance of abnormal cells which may or may not represent pre-cancerous cellular activity, depending on the severity of the cellular abnormalities.

    
    

15. According to the Accutech cytologist, where atypical cells were present but no dysplastic cells were identifiable, the test was reported as Class II, with a recommendation that a follow-up test be performed in one month.

    
    

16. Although a Class II test report is regarded as a benign result, it does not mean that there is no dysplasia. It means only that the inflammatory changes are severe, that it is impossible to determine whether or not dysplasia is present, and that the patient should be re-tested in one month.

    
    

17. If dysplastic cells are identifiable, the test is reported as Class III or higher.

    
    

18. It is the physician's responsibility to determine the cause of the abnormal activity and the proper course of treatment.

    
    

19. The Respondent's husband, who was also her partner in their medical practice, had discussed the classification system with Accutech representatives. Accutech utilized a series of internal gradations within the Pap smear classifications. Both the Respondent and her husband were aware of the reporting system used by the lab.

    
    

20. According to the lab report for the March 7, 1985 Pap smear, the test results were reported as "Class I Negative, no atypical cells present" with marked inflammation. At the time of this initial consultation, the patient had experienced breakthrough bleeding.

    
    

21. According to the patient's medical records, another Pap smear was performed on September 6, 1985, and was reported as "Class IB Mildly atypical cells present, secondary to inflammation." The Respondent noted that the cervical erosion had healed and diagnosed the patient with a yeast infection.

    
    

22. Yeast infections can result in the presence of inflamed cells which will be reported in the Pap smear report. In this case, the diagnosis of a yeast infection was made visually. The Respondent did not perform a wet smear or culture to confirm the diagnosis at any time during the course of treatment of this patient.

23. On April 4, 1986, the Respondent examined Patient #1 and performed a Pap smear. During the examination, the Respondent again noted evidence of a yeast infection and a small cervical erosion.

    
    

24. On April 22, 1986, the Respondent received the cytology report of the April 4 Pap smear. The lab reported the smear as "Class II Atypical cells present, cannot rule out dysplasia, suggest repeat in one month." The report also noted the presence of marked cervicitis.

    
    

25. Cervicitis is an inflammation of the cervix. Because the columnar epithelium is more susceptible to infection than the squamous epithelium, patients with "erosion" more often suffer from cervicitis than would otherwise be the case.

    
    

26. The Respondent did not document the presence of marked cervicitis in her examination notes.

    
    

27. The results of the April 4 test were reported to the Patient, who was provided with a prescription for an antibacterial ointment and an appointment for a follow-up test.

    
    

28. On May 20, 1986, the Respondent again examined Patient #1 and performed the follow-up Pap smear. During the examination, the Respondent noted that the appearance of the cervix was improved, but still not completely healed. The Respondent also noted a small white area on the cervix which was presumed to be evidence of a yeast infection.

    
    

29. According to the report of the May 20 Pap smear, which was received on June 6, 1986, the test was again reported as "Class II Atypical cells present, cannot rule out dysplasia, suggest repeat in one month." The report also notes the presence of marked inflammation. The patient was notified of the result and advised that the Respondent recommended cryocautery treatment.

    
    

30. Cryocautery is a procedure where a supercooled probe tip is placed against the abnormal surface of the cervix, destroying the surface area touched by the probe. Successful cryocautery results in the destroyed tissue being replaced by healthy squamous epithelium tissue.

    
    

31. On July 8, 1986, the cryocautery procedure was performed on the patient. According to the records of the Respondent, the procedure was performed only to address the patient's "persistent" Class II Pap smear. The records fail to document any other reason for the procedure.

    
    

32. The Respondent failed to make a definitive diagnosis of Patient #1's condition prior to performing the cryocautery. A "persistent" Class II Pap smear is not a diagnosis. It is inappropriate to perform cryocautery without first obtaining a definitive tissue diagnosis by biopsy or other test.

    
    

33. Although one of the treatments for cervicitis at that time was cryocautery, the Respondent failed to note a diagnosis of cervicitis based on the May examination or Pap smear. Further, although cryocautery is also used to treat cervical erosion, at the time the May exam was performed, the Respondent noted that the appearance of the patient's cervix was improved since the April exam.

34. The standard of care is to rule out dysplasia prior to further treatment. Based on the medical information at hand, it was not possible to have ruled out dysplasia prior to the cryocautery.

    
    

35. Following the second Class II Pap smear, the Respondent should have performed a biopsy or colposcopy of the patient to determine whether dysplastic cells were present and to obtain a certain diagnosis of the patient's condition.

    
    

36. A biopsy is a procedure requiring removal and examination of tissue samples. Colposcopy is a method of examining a cervix under magnification after an acidic solution applied to the area results in enhanced ability to detect cell abnormalities.

    
    

37. The Respondent did not have a colposcope in her office at this time. The Respondent should have referred Patient #1 to another physician for the procedure or should have performed the procedure in a hospital facility where the equipment was available. In the alternative, the Respondent should have performed a tissue biopsy.

    
    

38. It was below the acceptable standard of care for the Respondent to perform cryocautery on Patient #1 without first determining the cause of the "persistent" Class II Pap smear test reports.

    
    

39. It was below the standard of care for the Respondent to perform cryocautery without making a definitive diagnosis of Patient #1's condition.

    
    

40. It was below the acceptable standard of care for the Respondent to proceed without performing a biopsy or colposcopy to determine whether dysplastic cells were present.

    
    

41. Providing treatment without first making a definitive diagnosis increases the difficulty of making a diagnosis at a later date.

    
    

42. On August 19, 1986, the Respondent examined Patient #1 and performed a Pap smear. By examination (the first since the cryocautery procedure was performed) the Respondent noted that the patient's cervix, which had been healing prior to the cryocautery procedure, appeared to have finished healing.

    
    

43. According to the report of the August 19 Pap smear, the test report a "Class IB Mildly atypical cells present, secondary to inflammation." The report also notes the presence of moderate cervicitis.

    
    

44. On October 17, 1986, the Respondent examined Patient #1 and performed a Pap smear. According to the report of the October 17 Pap smear, the report identifies the smear as "Class IB Mildly atypical cells present, secondary to inflammation." The report also notes the presence of marked inflammation and trichomonas.

    
    

45. Tricomonas are parasitic one cell organisms which may or may not cause symptoms including itching, discharge and odor, and may not be detectable except through testing.

    
    

46. On May 21, 1987, the Respondent examined Patient #1 and performed a Pap smear. The Respondent documented a small erosion on the cervix. According to the report of the May 21 Pap smear, the report identifies the smear as "Class I Negative, no atypical cells present." The report also notes the presence of moderate inflammation.

47. On December 4, 1987, the Respondent examined Patient #1 and performed a Pap smear. During the pelvic examination, the Respondent noted that the patient's cervix bled easily. The Respondent diagnosed the patient with cervicitis. The Respondent directed the patient to return in one month for follow-up.

    
    

48. According to the report of the December 4 Pap smear, the smear was "Class I Negative, no atypical cells present." The report also notes the presence of an undisclosed level of inflammation.

    
    

49. The patient did not return for the one month follow-up.

    
    

50. According to the Respondent's records, medical services to Patient #1 were discontinued on May 9, 1988.

    
    

51. On May 10, 1988, the patient was examined by Richard Long, M.D. The patient was complaining of heavy cervical pain and bleeding.

    
    

52. The initial symptoms of cervical cancer may include abnormal discharge, abnormal or irregular bleeding, and post-coital bleeding. Based on symptoms and her health history including the familial experience with carcenoma, Dr. Long determined that biopsy was required.

    
    

53. On May 26, 1988, the patient underwent a dilation and currettage, including a conization biopsy procedure. The result of the biopsy indicated that the patient had cervical carcinoma.

54 Beginning in June 1988, the patient was treated by Mitchell Hoffman, M.D., an oncologist, for invasive non-keratinizing Stage III squamous cell cervical cancer. The treatment continued through April 1993, when it was discontinued.

1. Upon initial consultation with the Respondent, the patient presented with "breakthrough" bleeding. At the time of the last examination by the Respondent, it was noted that the cervix bled easily. Both types of bleeding could be considered abnormal.

   
   

2. There is no evidence that the Respondent attempted to confirm that the breakthrough bleeding was related to use of birth control pills. There is no evidence that the Respondent attempted to determine the cause of the bleeding occurring at the time of the final consultation.

   
   

3. The appearance of the cervix in cervical cancer patients may include a hard "indurated" surface and bleeding on contact.

   
   

4. It is possible that a patient may bleed when a physician scrapes the cervix vigorously during the taking of a smear. There is anecdotal information that patients complained about the Respondent's scraping method.

   
   

5. When the Patient #1's cervix bled easily at the time of the last consultation, the Respondent advised that the patient return in one month. The patient did not return.

   
   

6. The progression of cervical cancer is classified by stages, ranging from Stage I, the earliest occurrence, to Stage IV, the most advanced level.

7. Stage III cancer involves tissues around the affected organ. In this case, the patient's left ureter was blocked by the cancer, and was classified at the time of discovery as Stage III.

   
   

8. Dr. Hoffman treated the patient through radiation and chemotherapy. The cancer continued to spread.

   
   

9. The patient was compliant with the requirements of her treatment.

   
   

10. The patient's illness progressed as would be expected for this type of cancer.

    
    

11. Patient #1 expired on June 7, 1993.

    
    

12. The patient's cancer originated in her cervix.

    
    

13. Although is it not possible to determine when the patient's cervical cancer originated, the greater weight of the evidence establishes that the patient's cancer existed during the period of time she was receiving treatment from the Respondent.

    
    

14. The patient's potential for survival would have been increased had her cancer been detected at an earlier stage.

    
    

15. In performing cryocautery without confirming the diagnosis of the patient's condition, the Respondent failed to practice medicine with an acceptable level of care, skill, and treatment which a reasonably prudent similar physician recognizes as acceptable under similar conditions and circumstances.

    
    

16. The Respondent asserts that the cervical cancer from which the patient expired was a strain of cervical cancer associated with the Human Papilloma Virus (HPV) which progresses extremely quickly and that the cancer did not exist during the time of treatment provided by the Respondent. There is no credible evidence that cervical cancer related to HPV progresses at the rate which would support the Respondent's assertion under the circumstances of this case. The assertion is rejected.

    
    

    CONCLUSIONS OF LAW

    
    

17. The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding. Section 120.57(1), Florida Statutes.

    
    

18. Petitioner has responsibility for disciplinary action taken against licensed physicians. The burden of proof is on the Petitioner to establish the truthfulness of the allegations of the Amended Administrative Complaint by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987). As to the allegations of the administrative complaint as noted in the findings of fact set forth above, the burden has been met.

    
    

19. In relevant part, Section 458.331(1), Florida Statutes (1991), provides as follows:

    
    

    The following acts shall constitute grounds for which the disciplinary actions in subsection (2) may be taken:

    (t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonable prudent similar physician as being acceptable under similar conditions and circumstances....

    
    

20. The evidence establishes that by performing cryocautery without first confirming the diagnosis of the patient's condition, the Respondent failed to practice medicine with that level of care, skill, and treatment which is recognized by a reasonable prudent similar physician as being acceptable under similar conditions and circumstances and therefore has violated Section 458.331(1)(t), Florida Statutes.

    
    

21. Penalties for violation of disciplinary statutes are established by guidelines set forth at Rule 59R-8.001, Florida Administrative Code. The penalty for violation of Section 458.331(1)(t) ranges from two years probation to revocation or denial and an administrative fine from $250 to $5,000. The recommended penalty is as stated below.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED:

That the Agency for Health Care Administration enter a Final Order determining that Janet A. Marley, M.D. has violated Section 458.331(1)(t), Florida Statutes, reprimanding the Respondent, placing the Respondent on probation for a period of three years and imposing an administrative fine of

$3,000.

DONE and RECOMMENDED this 26th day of October, 1994, in Tallahassee, Florida.

WILLIAM F. QUATTLEBAUM

Hearing Officer

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 26th day of October, 1994.

APPENDIX TO RECOMMENDED ORDER, CASE NO. 94-1605

To comply with the requirements of Section 120.59(2), Florida Statutes, the following constitute rulings on proposed findings of facts submitted by the parties.

Petitioner

The Petitioner's proposed findings of fact are accepted as modified and incorporated in the Recommended Order except as follows:

12. Rejected, cumulative.

22, 28-29. Rejected, unnecessary.

33-35. Rejected, subordinate, cumulative.

39. Rejected, evidence does not establish a July 1986 office visit. 40-41. Rejected, subordinate.

44-45. Rejected, subordinate, cumulative.

57. Rejected as to training obtained after the cryocautery performed in this case, irrelevant.

60. Rejected, subordinate.

61-62. Rejected. The theory that "good" cells grow over the "bad" cells is rejected as not supported by the greater weight of credible and persuasive evidence.

70-71. Rejected, cumulative.

90. Rejected, unnecessary.

92-93. Rejected, unnecessary.

Respondent

The Respondent's proposed findings of fact are accepted as modified and incorporated in the Recommended Order except as follows:

13. Rejected. The greater weight of credible and persuasive evidence establishes that it was below the standard of care for the Respondent to perform cryocautery without making a definitive diagnosis of Patient #1's condition by either biopsy or colposcopy.

1. Rejected, unnecessary.

2. Rejected. There was a small white area on the cervix which the Respondent presumed to be a yeast infection. No confirmatory testing was performed.

3. Rejected, contrary to the greater weight of credible and persuasive evidence. The repeat Pap smear (performed on May 20, 1986) was not performed within six weeks of the April 4. 1986 test.

19. Rejected, irrelevant. There is no evidence that during the time care was provided to Patient #1 any lab other than Accutech was utilized by the Respondent.

22. Rejected, irrelevant.

24. Rejected, not supported by the greater weight of the evidence. A Class II report indicates only that atypical cells are present, that other factors make it impossible to determine whether dysplastic cells are present, and that the test should be redone. It does not establish that there are no dysplastic cells present in the sample.

27, 32. Rejected, subordinate.

33. Rejected, irrelevant.

1. Rejected, not supported by the greater weight of the evidence. It should be noted that the Respondent apparently chose not to rely on the representations of the laboratory after the second Class II report. Although the report suggested re-testing, the Respondent performed cryocautery without confirming a diagnosis.

2. Rejected. The greater weight of the evidence establishes only that the procedure was performed to address the persistent Class II Pap smear.

41. Rejected, not supported by the greater weight of credible and persuasive evidence. Given the two Class II Pap smear reports , and the fact that dysplasia could not be ruled out, it was not reasonable to perform cryocautery without further investigation of the underlying situation.

44. Rejected, cumulative.

49. Rejected. Not supported by the greater weight of credible and persuasive evidence.

51. Rejected. Not supported by the greater weight of credible and persuasive evidence.

53. Rejected, unnecessary.

56. Rejected, irrelevant.

COPIES FURNISHED:

Douglas M. Cook, Director

Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida 32308

Harold D. Lewis, Esquire

Agency for Health Care Administration The Atrium, Suite 301

325 John Knox Road

Tallahassee, Florida 32303-4131

Arthur Skafidas, Esquire

Agency for Health Care Administration 1940 North Monroe Street, Suite 60

Tallahassee, Florida 32399-0792

Bruce D. Lamb, Esquire

1. Box 2378

   Tampa, Florida 33601

   
   

   NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

   
   

   All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least ten days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the Final Order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.

   =================================================================

   AGENCY FINAL ORDER

   =================================================================

   
   

   STATE OF FLORIDA

   AGENCY FOR HEALTH CARE ADMINISTRATION BOARD OF MEDICINE

   
   

   AGENCY FOR HEALTH CARE ADMINISTRATION, BOARD OF MEDICINE,

   
   

   Petitioner,

   
   

   v. CASE NO: 91-07943

   JANET A. MARLEY, M.D., DOAH CASE NO: 94-1605 LICENSE NO: ME 0026208

   Respondent.

   /

   
   

   FINAL ORDER

   
   

   THIS MATTER was heard by the Board of Medicine (hereinafter Board) pursuant to Section 120.57(1)(b)10., Florida Statutes, on. December 2, 1994, in Orlando, Florida, for consideration of the Hearing Officer's Recommended Order (Attached as App. A) in the case of Agency for Health Care Administration, Board of Medicine v. Janet A. Marley, M.D. At the hearing before the Board, Petitioner was represented by Arthur Skafidas, Senior Attorney. Respondent was present and represented by Bruce D. Lamb, Esquire. Upon consideration of the Hearing Officer's Recommended Order after review of the complete record and having been otherwise fully advised in its premises, the Board makes the following findings and conclusions:

   
   

   RULINGS ON EXCEPTIONS TO FINDINGS OF FACT

   
   

   1. Respondent's Exception to the first and third sentences contained in paragraph 55 of the Recommended Order is accepted.

      
      

   2. Respondent's Exception to paragraph 56 of the Recommended Order is accepted.

      
      

   3. Respondent's Exception to paragraph 67 of the Recommended Order is accepted.

      
      

   4. The Hearing Officer's Recommended Findings of Fact, as amended, are approved and adopted and incorporated herein.

      
      

   5. There is competent, substantial evidence to support the Board's finding herein.

FINDINGS OF FACT

1. The Hearing Officer's Recommended Findings of Fact are approved and adopted and are incorporated herein by reference as the Findings of Fact of the Board in this cause.

   
   

2. There is competent, substantial evidence to support the Board's findings herein.

CONCLUSIONS OF LAW

1. The Board has jurisdiction over the parties and subject matter of this case pursuant to Section 120.57 and Chapter 458, Florida Statutes.

   
   

2. The Board rejects the Conclusions of Law contained in paragraph 74 and

   75 of the Recommended Order.

   
   

3. The Board finds that there is no competent substantial evidence to support the Conclusion of Law that Respondent violated Section 458.331(1)(t), Florida Statutes, as alleged in the Administrative Complaint.

   
   

4. The Conclusions of Law of the Recommended Order, as amended, are approved and incorporated herein.

   
   

5. There is competent substantial evidence to support the Conclusions of Law of the Board.

DISPOSITION

In light of the foregoing Findings of Fact and Conclusions of Law the Board hereby determines that pursuant to Rule 61F6-20, Florida Administrative Code, the penalty recommended by the Hearing Officer is appropriate as set forth in the Recommended Order.

WHEREFORE, it is found, ordered and adjudged that the Respondent has not violate Section 458.331(1)(t), Florida Statutes and pursuant to Rule 61F6-20, all charges filed against Respondent in this case shall be DISMISSED.

This Final Order becomes effective upon its filing with the Clerk of the Agency for Health Care Administration.

NOTICE

The parties are hereby notified pursuant to Section 120.59(4), Florida Statutes, that an appeal of this Final Order may be taken pursuant to Section 120.68, Florida Statutes, by filing one copy of a Notice of Appeal with the Clerk of the Agency for Health Care Administration and one copy of a Notice of Appeal with the required filing fee with the District Court of Appeal within thirty (30) days of the date this Final Order is filed.

DONE and ORDERED this 23 DAY OF December, 1994.

BOARD OF MEDICINE

GARY E WINCHESTER, M.D. VICE-CHAIRMAN

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order and its attachments have been forwarded by U.S. Mail to Janet A. Marley, M.D., 3905 Eden Roc Circle East, Tampa, Florida 33634-7417, Daniel Manry, Hearing Officer, The DeSoto Building, 1230 Apalachee Parkway, Tallahassee, Florida 32399-1550, Bruce D. Lamb, Esquire, P.O. Box 2378, Tampa, Florida 33601-2378, and by hand delivery to Larry G. McPherson, Jr., Chief Medical Attorney, Agency for Health Care Administration, 1940 North Monroe Street, Tallahassee, Florida 32399-0792 on this 27th day of December, 1994.

Marm Harris, Ed.D. Executive Director

Docket for Case No: 94-001605

Orders for Case No: 94-001605