STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF HEALTH, BOARD ) OF PHYSICAL THERAPY PRACTICE, )
)
Petitioner, )
)
vs. )
) SNEHAL JAWAHARLAI PATEL, P.T., )
)
Respondent. )
Case No. 07-1057PL
)
RECOMMENDED ORDER
Notice was provided and on May 10, 2007, a formal hearing was held in this case. Authority for conducting the hearing is set forth in Sections 120.569 and 120.57(1), Florida Statutes (2006). The hearing commenced at 10:00 a.m. at the Alachua County Civil Courthouse, 201 East University Avenue, Gainesville, Florida. The hearing was held before by Charles C. Adams, Administrative Law Judge.
APPEARANCES
For Petitioner: Lynne A. Quinby-Pennock, Esquire
Department of Health
4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265
For Respondent: Donna M. Keim, Esquire
Brice Kohl Law Firm, P.L. Post Office Box 1860 Alachua, Florida 32616-1860
STATEMENT OF THE ISSUE
Should discipline be imposed against Respondent's physical therapist license for violation of Sections 486.125(1)(j), and (k), Florida Statutes (2002), and Florida Administrative Code Rule 64B17-6.001(2)(g), (3)(f) and (3)(h)?
PRELIMINARY STATEMENT
On October 24, 2006, in Case No. 2005-582899 before the Board of Physical Therapy Practice (the Board), the Department of Health (DOH) brought an Administrative Complaint against Respondent accusing him of a violation of the statute and rule referred to in the Statement of the Issue. The Administrative Complaint was premised upon the following allegations:
* * *
At all times material to this Complaint, Respondent worked at Timber Ridge Nursing and Rehabilitation Center (TR), located in Ocala, Florida.
On or about February 10, 2003, Patient R.G., a then 77 year old female fell sustaining a comminuted fracture of her right patella (knee cap).
On or about February 12, 2003, a licensed medical doctor, specifically an orthopedic surgeon (hereinafter "Doctor") surgically repaired Patient R.G.'s right patella.
On or about February 15, 2003, Patient R.G. was transferred to TR for continued care.
In the transfer orders for Patient R.G., her Doctor referenced continuation of therapy with treatment goals "active assistance, active, partial weight bearing, recovery to full function" and listed to the side were "assist with SLR" and "walker
gait-TDWB right leg." ("SLR" being interpreted as straight leg raises and "TDWB" being interpreted as toe/touch down weight bearing.)
On the TR Care Plan dated February 15, 2003, it was noted that Patient R.G. "knee immobilizer on at all times" as an approach/intervention to be followed by PT, OT (occupational therapy) and nursing.
The TR admitting nurse documented replacing the immobilizer after her examination of Patient R.G.'s incision and dressing.
Respondent preformed [sic] a physical therapy evaluation on Patient R.G. on or about February 17, 2003.
Clarification orders for Patient R.G. were written for "PT 5x weekly x 4 weeks for ther ex, gait, transfers, safety training, neuromuscular re-education and modalities prn." ("Ther ex" being interpreted ad therapeutic exercises and "prn" being interpreted as "as needed.")
A review of the evaluation yielded a correct primary diagnosis and secondary diagnosis for Patient R.G. The precautions/ contraindications for R.G. only included "TDWB right LE."
The short term treatment goals for Patient R.G. included safety in transfers, increasing ROM (range of motion) by 10 degrees, improving balance and strength, while the long term goals focused on ambulation with a walker and attaining ROM of 5-90 degrees.
On or about February 25, 2003,
Patient R.G. presented for follow up with her Doctor whose notes found good alignment at the fracture site, and demonstrated a plan for no bending of the right knee.
Patient R.G. was instructed not to bend her right lower left and to only remove her immobilizer when resting.
TR's documentation of Patient R.G. fails to document the use of the knee immobilizer during physical therapy.
Respondent saw Patient R.G. on or about February 28, 2003 and noted ROM (range of motion) as 0-55 degrees.
Patient R.G.'s AA and PROM continued with each treatment with documentation of Patient R.G.'s complaint of pain. ("AA" being interpreted as active assistance with PROM being interpreted as passive range of motion.)
On or about March 19, 2003, Respondent signed the recertification goals for Patient R.G.; however these goals appear to have been written by someone else.
The knee immobilizer was documented as a precaution/contraindication for
Patient R.G. at the time but the goal for ROM continued.
On or about April 8, 2003, Patient R.G. presented to the Doctor complaining of pain.
R.G.'s Doctor ordered X-rays of her patella and determined the previous aligned patella was displaced. Additional surgery was prescribed for Patient R.G.
Respondent did not contact the Doctor to discuss the Doctor's diagnosis, frequency, precautions or PT plan of care for Patient R.G.
Respondent did not communicate (or collaborate) or did not document communication with the Doctor who referred Patient R.G. when Respondent knew or should have known that R.G.'s knee should not have been moved and/or his plan of care included mobility exercises.
Respondent did not document any justification for the change in Patient R.G.'s plan of treatment.
As a consequence, Respondent is alleged in Count One to have violated Section 486.125(1)(j), Florida Statutes (2002), where:
28. Respondent, by failing to communicate with Patient R.G.'s Doctor about the treatment and/or the actual failure to communicate those concerns with the Doctor practiced beyond the scope permitted by law.
Respondent is alleged in Count Two to have violated Section 486.125(1)(k), Florida Statutes (2002), by violating Florida Administrative Code Rule 64B17-6.001(2)(g), (3)(f) and (3)(h) in that:
Respondent failed to practice PT with that level of care, skill and treatment which is recognized by a reasonably prudent similar physical therapy practitioner when he failed to contact the referring physician to determine the diagnosis and ask or [sic] the clarification of contraindicators, how much was able to be repaired; the precautions to be engaged and/or the protocol of the particular orthopedic surgeon.
Respondent failed to document any collaboration with Patient R.G.'s Doctor regarding his treatment plan, assessment,
change in treatment or in any fashion working in collaboration for the patient's good.
Respondent failed to document any justification for the change in Patient R.G.'s plan of treatment.
Respondent was provided several options in addressing the Administrative Complaint. He chose the third option. That option was to dispute the allegations of fact contained in the Administrative Complaint. Through that option, as evidenced in the form provided him, Respondent asked that he be heard in accordance with Sections 120.569(2)(a) and 120.57(1), Florida Statutes, by an administrative law judge to resolve the dispute. Those paragraphs within the Administrative Complaint that are disputed are reflected in the executed form, elections of rights, signed before a notary public of the State of Florida on December 1, 2006.
On March 6, 2007, DOH forwarded the case to the Division of Administrative Hearings (DOAH) to assign an administrative law judge to conduct a hearing in accordance with Respondent's request for formal hearing. The assignment was made by Robert
S. Cohen, Director and Chief Judge of DOAH in reference to DOAH Case No. 07-1057PL. The assignment was to the present administrative law judge.
A hearing date was established based upon written responses by the parties concerning their availability for hearing.
Consistent with the Order of Pre-hearing Instruction, the parties filed a joint pre-hearing stipulation. Within the stipulation, the parties have set out facts upon which they agree. The factual stipulations are reflected in the Findings of Fact to the this Recommended Order.
Petitioner presented Segismundo Pares, M.D.; Patient R.G.; and Dana Lameier, P.T. as its witnesses. Petitioner's Exhibits B and D were admitted. Respondent testified in his own behalf and presented John Hisamoto, P.T.; Marty Huegel, P.T.; Mike Mandarino and Rebecca McLuskey as his witnesses. Respondent's Exhibits A through C were admitted. Joint Exhibits A through C were admitted.
On June 11, 2007, a two-volume hearing transcript was filed. Petitioner and Respondent filed proposed recommended orders, which have been considered in preparing the Recommended Order.
FINDINGS OF FACT
Stipulated Facts
Petitioner is the state agency charged with the regulation of Physical Therapy Practice pursuant to Chapters 20, 456, and 486, Florida Statutes.
Respondent, Snehal Jawaharlai Patel, is a licensed Physical Therapist in the State of Florida, having been issued license number PT 20254.
Respondent's mailing address of record is 2601 NW 44th Place, Gainesville, Florida 32605.
Respondent was an employee working for Rehab Therapy Works and providing physical therapy services at Timber Ridge in February 2003.
Respondent provided services to Patient R.G. while she was a resident at Timber Ridge.
Dr. Pares was R.G.'s primary physician as reflected on the Timber Ridge Intake Sheet dated February 15, 2003.
The February 17, 2003, Plan of Treatment Mr. Patel prepared was approved and signed by Dr. Pares on February 17, 2003.
Dr. Cannon's April 14, 2003, correspondence to Timber Ridge indicates that Ms. G's patella was reduced and well- aligned on her February 25, 2003, office visit.
The February 25, 2003, office note of Dr. Cannon indicating no bending of the knee was misfiled by Timber Ridge and was not transcribed by Timber Ridge.
Patient R.G.: Her Care
On February 10, 2003, Patient R.G. was 76-years old when admitted to Munroe Regional Medical Center (MRMC) in Ocala,
Florida. The patient was brought to the emergency room at that facility having slipped in a puddle at Langley Medical Center causing her to fall on her right knee. X-ray findings at MRMC revealed a right patella fracture. Patient R.G. was treated by Odest Frank Cannon, Jr., M.D., an orthopedic surgeon.
On February 12, 2003, Dr. Cannon addressed the patient's condition by performing a right patella open reduction internal fixation (ORIF).
On February 15, 2003, Patient R.G. was transferred from MRMC to Timber Ridge Nursing and Rehabilitation Center (Timber Ridge) in Ocala, Florida, for rehabilitation. The nature of the rehabilitation to be provided at Timber Ridge was in relation to speech therapy, physical therapy, occupational therapy and management of medical care. Principally, the patient was placed at Timber Ridge to receive physical therapy following the knee surgery.
When Patient R.G. was referred to Timber Ridge by Dr. Cannon, it was pursuant to the Physicians' Referral Form 3008 (Form 3008), establishing what Dr. Cannon had in mind by
way of physician's orders, guidance in caring for the patient at Timber Ridge. The physician's referral was faxed to Timber Ridge on February 15, 2003, and bore Dr. Cannon's signature. In the pre-established format, Form 3008 refers to physical therapy
where it reflects Dr. Cannon's comments and execution as follows:
PHYSICAL THERAPY: [ ] New Referral [x] Continuation of Therapy - Assist SLR
Walker gait - TDWB R leg
TREATMENT GOALS: (Please Check) Frequency of Treatment _ Sensation Impaired [ ] Yes [ ] No
Restrict Activity [ ] Yes [ ] No [ ] Stretching [ ] Coordinating Activities [ ] Progress Bed to Wheelchair
[ ] Passive ROM [ ] Non-weight Bearing [x] Recovery to Full Function
[x] Active Assistance [x] Partial Weight Bearing [ ] Wheelchair Independent
[x] Active [ ] Full Weight Bearing [ ] Complete Ambulation
[ ] Progressive Resistive Precautions:
[ ] Cardiac
Other
Segismundo Pares, M.D., is a family-physician who was employed at Timber Ridge when Patient R.G. was treated.
Dr. Pares as a family-physician is licensed in Florida. He is board-certified in family practice, geriatric medicine and hospice and palliative care. In his time at Timber Ridge, he was assigned to manage the medical problems that patients at Timber Ridge may have experienced, such as cardiac disease, lung disease, kidney disease, etc. The orthopaedic condition for patients undergoing rehabilitation at Timber Ridge was the responsibility of a physiatrist, a rehabilitation doctor at Timber Ridge, in conjunction with specialists in physical therapy, occupational therapy and speech therapy. The physiatrist was also involved in other matters of rehabilitation. The physiatrist at Timber Ridge was a
Dr. Scott.
Dr. Pares relied on Dr. Scott as a physiatrist to attend weekly team meetings, during which Patient R.G.'s physical therapy needs would be discussed. His expectation was that Dr. Scott would address any problems in providing physical therapy to the patient.
For the most part, Dr. Pares primarily managed medical care for patients. But he had overall oversight over patient care.
In his oversight role, Dr. Pares' plan of treatment for physical therapy in relation to Patient R.G. involved certifying the appropriateness of that therapy, relying upon Respondent who had produced the plan of treatment in that discipline.
At present Dr. Pares has no recollection of Patient
R.G. while she was at Timber Ridge.
Another form of orders established in providing patient care at the facility, was telephone orders or facsimile orders from outside health care practitioners. Dr. Pares as the attending physician at Timber Ridge was responsible for signing off on those orders after review. This process did not involve conversations between Dr. Pares and the health care provider who initiated the telephone order or facsimile order. In addition, Dr. Pares would give his own telephone orders concerning patient care.
One of the telephone orders signed off by Dr. Pares was dated February 17, 2003. It refers to: "PT clarification order: PT 5X weekly X 4 weeks for therapy, gait transfer, safety training, neuromuscular . . . " and other matters that Dr. Pares could not interpret at the hearing. The complete clarification order written down by the Respondent stated: "PT Clarification Order: PT 5 x weekly x 4 weeks for therex, gait transfer, safety training, neuromuscular reeducation & modalities PRN." Respondent signed the notations. Dr. Pares signed this outside telephone order on February 20, 2003, as the reviewing authority. Dr. Pares has no recollection of conversations with other persons concerning that telephone order.
Respondent wrote the details of the February 17, 2003, telephone order on the form maintained at Timber Ridge in relation to Patient R.G. Dr. Pares relied upon Respondent when signing the telephone order under Respondent's recorded information, without knowledge of where the instructions originated that established the substance of the telephone order received on that date. Respondent's role in that act will be explained.
Respondent's Treatment of Patient R.G.
After he was licensed as a physical therapist in Florida in 2002, Respondent began his practice. In February
2003 when he provided treatment to Patient R.G., he was a staff physical therapist at Timber Ridge. His duties at that facility were to direct clinical care provided by his assistant, after evaluation and assessment of patients needs, as well as provide treatment and physical therapy to the patients.
On February 15, 2003, when Patient R.G. came to Timber Ridge, Respondent's interpretation of the orders from Dr. Cannon on Form 3008 in the physical therapy section, was "Assist with straight leg raise (which is a separate clause), walker gait, touch down weight-bearing right leg, active assistive range of motion, active range of motion, also partial weight-bearing and recovery to full function." These orders were in view of
Dr. Cannon's primary diagnosis set forth in the Form 3008 pertaining to a patella fracture, with ORIF on the patient's right knee.
Respondent observed that the Form 3008 did not list any precautions in addressing the patient's physical therapy needs.
Based upon the information set forth in the Form 3008 Respondent proceeded with the belief that Dr. Cannon expected that the physical therapy for Patient R.G. immediately begin with the performance of active range of motion. This was in keeping with Respondent's experience with this type of patient. At the time of hearing, the Respondent had dealt with
approximately a dozen cases in provision of physical therapy to patients with this condition.
Nothing in the Form 3008 from Dr. Cannon, pertaining to physical therapy, created an impression in Respondent's mind that he should have not performed range of motion exercises on Patient R.G.
There was a question in Respondent's mind concerning the weight-bearing status of Patient R.G., a separate consideration from the question of active range of motion. Respondent addressed the weight-bearing status question by seeking clarification from Dr. Cannon.
When Respondent called Dr. Cannon to clarify the weight bearing status, he took the opportunity to make certain of other aspects of the orders previously given by Dr. Cannon, should there be an error of perception concerning other items set forth in Form 3008 pertaining to the patient physical therapy.
On February 17, 2003, Respondent wrote the note in the patient's chart concerning Dr. Cannon's physician's telephone order. The note refers to the "PT clarification order" and the expectation that the patient have "therex." Respondent intended by his entry in the patient chart, that he understood
Dr. Cannon's orders to include range of motion. The note on the clarification order does not specifically refer to the term
"range of motion." It does not specifically refer to "weight bearing," the issue which prompted the call for a clarification order.
Respondent concedes that the term "therex" has a number of possible definitions when addressing types of therapeutic exercise.
After receiving the clarification order from Dr. Cannon, Respondent prepared a plan of treatment for
Patient R.G. It called for active range of motion exercises to be performed by the patient, increasing the range over time.
Leslie Sutack, a physical therapy assistant supervised by Respondent provided the physical therapy to Patient R.G.
Ms. Sutack's efforts were overseen by Respondent on a daily basis. Respondent was in the same room while Ms. Sutack provided physical therapy to Patient R.G.
Dr. Pares signed the plan of treatment for Patient R.G. in relation to physical therapy.
Dr. Scott was aware that Patient R.G. was receiving physical therapy that included range of motion.
On April 9, 2003, Respondent became aware that Patient R.G. had seen Dr. Cannon earlier and that Dr. Cannon's order was for no range of motion on the part of the patient. Respondent was unaware of this choice by Dr. Cannon prior to that date in April 2003 because of an institutional error at
Timber Ridge, in which Dr. Cannon's order against range of motion had been misplaced. Ordinarily, Dr. Cannon's order would have been provided to the physical therapy department at Timber Ridge where Respondent was employed.
The order from Dr. Cannon was dated February 25, 2003, prohibiting range of motion therapy. Without awareness, Respondent preceded with range of motion treatment from February 15, 2003 until the April 2003 date based upon his understanding of Dr. Cannon's February 15, 2003, orders in the Form 3008 for Patient R.G.
Mike Mandarino was the director of rehabilitation at Timber Ridge while Patient R.G. was undergoing treatment. He has experience with orders from physicians at MRMC for patient care after transferring to Timber Ridge. The orders would be provided on the Form 3008.
Absent an addendum to the Form 3008 by the referring physician, Timber Ridge personnel would use the Form 3008 as controlling when determining the doctor's choices for treatment.
Mr. Mandarino explains that Dr. Pares' role at Timber Ridge at the time was that as the person responsible for the overall patient care. Dr. Scott oversaw rehabilitation received by a patient.
In his testimony, Mr. Mandarino confirmed that Dr. Cannon's February 25, 2003, order prohibiting range of motion for Patient R.G. had been misfiled at Timber Ridge. Expert Opinion
Dana Lameier is licensed in Florida as a physical therapist. She has been licensed for 14 years. She earned a Bachelor's degree in physical therapy from the University of South Alabama. She also holds a master's degree in health care administration from Webster University. She actively practices physical therapy.
On occasion she has served as a teacher in physical therapy. She had been an adjunct instructor for Pope Community College.
Ms. Lameier's present position is as Director of Rehabilitation at Osceola Regional Medical Center. She is responsible for supervising the therapy services provided in the hospital and through the outpatient services in that facility. Those therapy services include physical therapy. Ms. Lameier supervises three physical therapy assistants. She treats patients in the hospital setting and as outpatients.
Ms. Lameier has familiarity with the expectations for documentation of services provided by a physical therapist. She gained that understanding through her formal education, continuing education, reading of books, on the job training, and
through the Joint Commission on Accreditation of Health Care Organizations (JACHO).
Ms. Lameier is familiar with the standards of practice for physical therapists in Florida. She is familiar with the standard of care for physical therapists in addressing orthopaedic cases. Ms. Lameier is familiar with the circumstances of patients who are dealing with recovery from knee surgery, this through her schooling and her work experience, involving somewhere between 20 and 50 cases.
Ms. Lameier is uncertain concerning the number of knee rehabilitation patients that she has assisted who have undergone ORIF. Although Ms. Lameier is not certain of the number of patients she has treated following ORIF of the petalla, she agrees that it would be less than 20 patients.
The nature of her work done in physical therapy has involved extensive association with orthopedic surgeons.
Concerning Patient R.G., Ms. Lameier understood that the patient had a severely comminuted fracture. In addressing rehabilitation for that type of surgery, Ms. Lameier believes that full recovery of the function is expected in six months. Bone healing would take place within six to eight weeks.
In addressing a person who had undergone ORIF, before providing physical therapy, Ms. Lameier would wish to know the medical history, such as problems with diabetes, osteoporosis,
opteopenia, medications taken by the patient and other matters that might influence the rehabilitation. Age is a factor that enters into the discussion because elder patients heal more slowly and tend to have more medical issues.
According to Ms. Lameier, when addressing physical therapy for a patient, the therapist, like other health care professionals, needs to be concerned that no harm befall the patient. If there is a question concerning the approach to care, Ms. Lameier would take a more conservative approach until certain of the underlying status of the patient.
Ms. Lameier was accepted as an expert in the standard of care expected of physical therapists practicing in Florida.
Ms. Lameier is familiar with the requirements of a plan of a treatment for a patient undergoing physical therapy. Following an evaluation of the patient's condition, consistent with the requirements of law, the physical therapist prepares a plan that lists the short-term and long-term goals for the patient. The plan includes the interventions that are involved with the care, the modalities to be used and a discharge plan. The physical therapist is responsible for creating the plan of care based upon his or her judgment.
In performing the evaluation leading to the plan of care, a review of documents pertaining to the patient is made. Tests are performed to ascertain the patient's strength,
balance, potentiality for range of motion, all directed toward gaining an impression of the patient's ability to perform physical activities.
The plan of care may be changed to address the patient's status at a given time.
The plan of care may be referred to as a plan of treatment, as it was in Patient R.G.'s case.
According to Ms. Lameier, in relation to telephone orders, the physical therapist is expected to discuss the order with the physician, physician assistant, or nurse practitioner who gave the order and read back the order once the physical therapist has written it down. The written information concerning the order recorded by the physical therapist would reflect the name of the practitioner who gave the order and the physical therapist, with the physical therapist's signature affixed.
In reviewing the plan of treatment created by Respondent to address Patient R.G.'s condition, Ms. Lameier commented on information available to the Respondent before he created the plan of treatment. To arrive at her opinions concerning the care Respondent provided Patient R.G.,
Ms. Lameier reviewed documents from Timber Ridge, MRMC, documentation from Dr. Cannon's office, and certain affidavits.
Part of that information came from the Form 3008 created by Dr. Cannon.
Ms. Lameier expressed the opinion that Respondent did not meet the standard of care expected of him in preparing the plan of care for Patient R.G. She arrived at this opinion based upon her knowledge of the Form 3008 for the patient, her training as a physical therapist, and basic protocols, for what she describes as the orthopedic process. In her opinion, when you have a patella fracture, such as the case at issue, which she again describes as a severely communited patella fracture, the standard of care is to leave the knee in extension until it is radiographically demonstrated that bone healing is taking place. As a physical therapist, Ms. Lameier believes that the bone healing in a healthy individual generally requires 6 to 8 weeks. In an elderly person with diabetes, and osteoporosis it may take longer, as with Patient R.G. Ms. Lameier mentions the protocol for immobilization of the knee as 3 to 6 weeks in that case.
Ms. Lameier's opinion concerning Respondent's care provided Patient R.G. is in recognition of the need for Respondent to practice with the level of care, skill and treatment recognized by a reasonably prudent similar physical therapist, as being acceptable under similar conditions and circumstances. Ms. Lameier does not believe that the Respondent
met the standard of care in that he was not knowledgeable of the basic protocols for bone healing and of the orthopedics involved with Patient R.G.; that he performed a range of motion early and without specific recommendation from the orthopedic surgeon, and that his choices could have caused harm or failure of the device that was created to hold the patella together.
Respondent had identified range of motion as a goal for Patient R.G. to be carried out by the physical therapist assistant. Ms. Lameier thinks this was inappropriate given the severity of the knee injury experienced by the patient and that the physical therapy was undertaken prematurely.
In describing the duties of the doctor and the physical therapist, the referring physician makes the diagnosis for the patient and the physical therapist determines the appropriate rehabilitation to be provided in view of the diagnosis, according to Ms. Lameier. In this example, the physician's diagnosis was fractured patella and the physical therapy treatment that Respondent was to provide was a response to the patient's difficulty walking.
Ms. Lameier expressed the opinion that Respondent failed to properly interpret the physician's referral in Patient R.G. Had there been some question or uncertainty on Respondent's part, he should have contacted the physician, the
physician assistant, or the nurse practitioner associated with the physician.
Ms. Lameier believes that Respondent should have made the physical therapy assistant under his supervision aware of special problems or cautioned that person of special problems or contraindications for Patient R.G., that might limit her range of motion because of the surgery that the patient had undergone.
In Ms. Lameier's opinion, having failed to properly interpret the physician's referral in Form 3008, Respondent did not follow up for specific clarification of that referral. He then created a plan of care to utilize what Ms. Lameier refers to as "pretty aggressive range of motion for something that has a protocol of general immobility initially."
In addition, Ms. Lameier expressed the opinion that Respondent did not document clearly the precautions, special problems, or contraindications that were involved in the diagnosis. There is a requirement for documentation of contraindications in Ms. Lameier's opinion.
Ms. Lameier's reading of Dr. Cannon's instructions in the Form 3008 for physical therapy, is that Dr. Cannon calls for continuation of therapy; assists with SLR, referring to straight leg raises; walker gait; and TWB, referring to touchdown weight- bearing on the right leg.
More specifically, the straight leg raise would mean lifting the leg straight up with no bend at the knee, with the pivot point being at the hip. The reference to assist with straight leg raise is describing circumstances after a patella fracture or an injury to the patella. There is a weakness in the quadricep muscle that would prohibit being able to lift the leg independently, so assistance is required.
On the subject of any orders that Dr. Cannon gave concerning active range of motion for Patient R.G., Ms. Lameier expressed the belief that the physician included in his treatment goals for active assist movement and active movement, referring to the assist with the straight leg raise. The check off of the word "active" meant active range of motion that the therapist does not participate in. While the Form 3008 could be interpreted as an order to begin an immediate active range of motion for Patient R.G., Ms. Lameier does not believe that it would be a range of motion to the knee. The straight leg raise is a hip exercise. The reference within the Form 3008 to "active assistance" pertained to assistance with the straight leg raise, in her view. Recognizing precautions and contraindications related to the underlying diagnosis for Patient R.G., Ms. Lameier does not believe that Dr. Cannon would ask a physical therapist to perform active range of motion to the knee. This in connection with the reference to assisting
with the straight leg raise, meaning that the doctor would like active assistance during those exercises progressing to active range of motion. Ms. Lameier acknowledges that a physical therapist might form a different interpretation of Dr. Cannon's orders but any question about active range of motion to the knee to commence immediately, would raise a "red flag" that would cause her to contact the physician to clarify the order, if that were the interpretation arrived at.
However, if a physician wanted to inform a physical therapist of precautions for the patient, such as not bending the knee or keeping the knee immobile at all times, Ms. Lameier would "hope" that it would be stated in the Form 3008. That would be her expectation. No precautions were indicated by Dr. Cannon in the Form 3008 in the case involving Patient R.G.
Ms. Lameier's reading of the reference to walker gait, is that when the patient walks she uses a walker and that she only puts her toe down for weight bearing, to be used as a balance on the right leg side. The reference to walker gait does not mean bending the leg, according to Ms. Lameier's interpretation of Dr. Cannon's orders. TWB does not mean bend the leg. Walker gait - TWB does not mean bend the leg.
The box that is checked for "active assistance" to be provided Patient R.G., in Ms. Lameier's interpretation, means that the therapist would provide some of the work, in that the
patient is unable to do it independently. This reference does not refer to range of motion, nor to the expectation that Patient R.G.'s knee be bent, as Ms. Lameier perceives it.
In the box marked "active" in relation to physical therapy to be provided Patient R.G., it is interpreted by Ms. Lameier to mean that the physician wanted the patient to
progress toward active movement. As Ms. Lameier comments, "So the straight leg raise needs active assistance to begin; but we would hope that as she recovers and gains more function and strength, that she would be able to perform those actively, meaning the therapist would not need to assist with the movement."
According to Ms. Lameier in her understanding of the box marked "partial weight bearing," this would mean " . . . approximately 50 percent of the weight . . . " Ms. Lameier remarks, "and again, the treatment goal when she started out as touch down weight-bearing, meaning just her toe down for balance and the goal being that she would progress to partial weight- bearing."
Finally, there is a reference in the physical therapy section in Form 3008 for Patient R.G. checked in the box as "recovery to full function." This is understood by Ms. Lameier to be a long-term goal for the patient to return to full function, live independently, as she had prior to the injury.
In commenting on the February 17, 2003, clarification order, Ms. Lameier's interpretation is that it called for five times weekly times four weeks for therex, gait transfer, safety training, neuromuscular-education and modalities PRN, as signed by Respondent. It was also signed by Dr. Pares. Ms. Lameier refers to this as a "standard clarification order" that is required for every patient in the skilled nursing facility. In the sequence, the physical therapist must make certain that there is an initial order for physical therapy, evaluation and treatment, followed by the performance of an evaluation, creation of a plan of care and then a clarification order, which includes all the interventions in the plan that the therapist would use. In her reading, Ms. Lameier does not believe that the February 17, 2003, clarification order makes mention of weight-bearing status pertaining to Patient R.G., nor does it contain any direction on performing bending of the knee exercises.
Ms. Lameier's emphasis on the February 17, 2003, telephone order was that it did not specify or confirm active range of motion for Patient R.G. It did not include an indication or directive to bend the knee to perform knee exercises involving bending of the knee; and it did not comment on weight-bearing.
Her interpretation of "therex" is that it is a broad term intended to refer to therapeutic exercises, everything from aerobic exercises, stretching, strength exercises, range of motion, etc. The reference to the term in this case is not apparent as to the exercise(s) expected to be performed by Patient R.G., according to Ms. Lameier.
Ms. Lameier expressed the opinion that Respondent failed to ask for clarification or contraindicators for Patient R.G., in that she finds no indication in the patient chart that supports that Respondent made contact with the physician, or others on the physician's staff to make those determinations.
Assuming that Respondent called the orthopedic physician to receive clarification with regard to weight bearing and range of motion, Ms. Lameier did not find documentation in the Timber Ridge records to reflect receipt of a clarification order on those subjects. In her opinion, to be an acceptable clarification order it needs to be written verbatim.
In expressing her opinion concerning the comminuted fracture, Ms. Lameier acknowledged that information provided to Timber Ridge only referred to a right patella fracture with ORIF. Concerning her comments on the comminuted fracture, the reference is out of the operative record or report from
Dr. Cannon which refers to "the inferior pole was comminuted
. . . ." That report was rendered on February 10, 2003. No indication of precautions concerning the fracture were provided prior to February 25, 2003, the physician's note of February 25, 2003, information not made known to Respondent until April 2003. The misfiled note from Patient R.G.'s chart maintained by
Dr. Cannon, dated February 25, 2003, refers to "no bending of RLE." The RLE was understood to mean right lower extremity.
John Hisamoto is a physical therapist. He was licensed in Florida in 1981. He has practiced physical therapy in Florida since that time.
At present Mr. Hisamoto practices at Proactive Physical Therapy. He has been in that position for 14 years. Mr. Hisamoto has experience treating patients who have suffered knee injuries. He has treated in excess of 5,000 who were seen following knee surgery.
Mr. Hisamoto is an instructor at the University of South Florida, where he teaches therapeutic rehabilitation and modalities.
Mr. Hisamoto acts as a consultant to a number of professional sports teams: the New York Yankees (baseball), the Tampa Yankees (baseball) and the Tampa Bay Lightning (hockey).
More specifically Mr. Hisamoto is familiar with the protocol when treating a fractured patella with ORIF, such as experienced by Patient R.G.
Mr. Hisamoto was accepted as an expert in physical therapy to offer opinion testimony.
In connection with the physical therapy to be provided a patient with that condition, the patient has undergone a reduction in the fracture to improve the congruency in the joints and to hasten bone healing. There is the effort to improve the capacity to perform early range of motion to lessen stiffness and problems associated with the knee. The physical therapy that the patient who has undergone ORIF would be exposed to, could include use of a knee immobilizer to perform some touchdown weight-bearing activities. Here the Timber Ridge treatment plan called for the use of a knee immobilizer on the right knee. The patient is taught to do transfers, how to begin touchdown positions. One of the other considerations in the therapy is the range of motion exercises that the patient is taught to perform.
In Mr. Hisamoto's experience, after ORIF, two or three days beyond the operation is allowed for wound healing. Then the range of motion exercises begin. This is a choice made by the physician. From Mr. Hisamoto's experience, the patient will have been put through a full range of motion by the physician at the time of surgery. The full range of motion is through an arc of 0 to 90 degrees. Given the degree of swelling following an
injury, the full range of motion within that arc is not immediately available when performing physical therapy.
In the case such as Patient R.G.'s early range of motion would be 0 to 30 degrees or 0 to 45 degrees.
Mr. Hisamoto's opinion is that Respondent's plan of treatment calling for range of motion increased by 10 degrees in the first two weeks was a very conservative choice, not an inappropriate response to Patient R.G.'s case.
Mr. Hisamoto offered no criticism of Respondent's choice to call for clarification of the initial orders on the Form 3008. He finds the initial orders in the Form 3008 provided by Dr. Cannon evident in the diagnosis and the expectation by the physician that what was to occur was the use of active-assist range of motion, the accepted standard of care for ORIF of the patella.
In Mr. Hisamoto's opinion, he would have expected any precautions to be set forth in the Form 3008 if Dr. Cannon had that intention. They were not detailed.
From Dr. Cannon's notes concerning the operation on Patient R.G.'s knee, Dr. Cannon had confirmed the range of motion in the patient's knee while in the operating room.
Dr. Cannon noted that the fracture was very stable. Under those circumstances, Mr. Hisamoto believes that it would be appropriate for the patient to be exposed to early range of
motion exercises by the physical therapist. In that connection, Mr. Hisamoto described the pursuit of active range of motion exercises as depending on the physician who performed the surgery and any complications that may have been experienced in relation to the wound, the incisional site. Active range of motion would occur in the first week, taking into account the need to pay attention to the incisional site. That is what transpired in Respondent's care provided Patient R.G. as to timing.
Mr. Hisamoto expressed the opinion that Respondent met the standard of care in providing services to Patient R.G. consistent with what would be expected of a physical therapist in Florida. This included necessary communication by Respondent with physicians involved with Patient R.G.'s treatment.
Finally, concerning the clarification order notations made by Respondent on February 17, 2003, Mr. Hisamoto expressed the opinion that there are multiple definitions that may be ascribed to the term "therex".
Marty Huegel is a licensed physical therapist in Florida. He received his license in 1979. Since that time he has consistently practiced physical therapy.
Currently Mr. Huegel is the Director of Physical Therapy for Quest Physical Therapy in Gainesville, Florida. He
also serves as the Director of Rehabilitation for the University of Florida Athletic Association.
Mr. Huegel has experience treating patients with knee problems. He has treated approximately 6,000 knee patients following their surgery. Mr. Huegel is familiar with the protocol for treating a fracture of the patella with ORIF, such as the case of Patient R.G. Mr. Huegel has had what he describes as "quite a few" cases involving patients in the age group represented by Patient R.G.
Mr. Huegel was received as an expert in the field of physical therapy to offer opinion testimony.
Mr. Huegel expressed his opinion concerning the appropriate protocol or standard of care for patients such as Patient R.G. when addressing an ORIF after patella fracture by provision of physical therapy. The primary concern is that stabilization of the fracture be achieved. The surgeon will provide assurance to the physical therapist through the operative note that the patient has been taken through the range of motion following the surgery. This is in anticipation of the need to move the knee to avoid stiffness. Ordinarily the only thing that would prohibit the movement of the knee would be wound issues. Those wound issues would be more prevalent in older patients. If the wound is closed and appears to be healing, then the physical therapist is interested in immediate
motion for the patient in the knee. With some patients the movement of the knee can occur the day after surgery. In older patients it may be a few days before that would be an appropriate choice, principally in relation to wound management. In the elderly patients Mr. Huegel has a concern that the range of motion exercises begin early because those patients, if they experience stiffness, can become disabled.
Mr. Huegel agrees with Respondent's choice to begin range of motion physical therapy for Patient R.G. on
February 17, 2003.
Mr. Huegel refers to the immobilizer that was prescribed for Patient R.G. He explains that when physical therapy is being provided to the patient, the immobilizer would be removed in the setting where physical therapy was being provided. Otherwise the patient would utilize the immobilizer.
Mr. Huegel does not believe that it would be the appropriate standard of care to wait for radiographic evidence of healing before range of motion exercises are undertaken. That would be important if the surgeon were concerned that there was not the expected fixation in the fracture. Mr. Huegel would expect the physician to mention the problem with fixation if it were there and indicate that the knee not be moved for a period of time or limit the range of motion and its arc. In
Patient R.G.'s case, the operative report was to the effect that
the fracture was stable as Mr. Huegel understood the circumstances. That information would have been relied upon by Mr. Huegel in his plan of care, consistent with his belief that the patient was a proper candidate for early range of motion exercise.
In reviewing the Form 3008 in the section pertaining to physical therapy, Mr. Huegel expressed his understanding of Dr. Cannon's orders. His interpretation was that the doctor expected assistance with straight leg raises. Dr. Cannon wants the patient to use a walker for gait. The form in it depiction of the goals refers to the "active" box being checked and what Mr. Huegel refers to as "assisted active" concerning range of motion. The placement of those terms on the form under the term for "passive range of motion (ROM)," leads him to conclude that the doctor was absolute in his expectation that the knee be moved right away. Nothing in the doctor's orders found on Form 3008 led Mr. Huegel to believe that the physician did not intend that immediate active range of motion begin for Patient R.G.
Mr. Huegel considers the matter set forth in the Form 3008 pertaining to physical therapy, to constitute the original order for physical therapy prepared by Dr. Cannon.
Mr. Huegel would not have sought clarification from Dr. Cannon of the information set forth in the physical therapy
section to Form 3008. He believes the explanation in the Form 3008 is straight forward enough.
Mr. Huegel believes that he could have prepared a plan of treatment based upon the information set forth in the physical therapy section to the Form 3008 related to
Patient R.G.
Mr. Huegel reviewed the plan of treatment prepared by Respondent for Patient R.G. He believes that that plan was appropriate, with the exception that he deemed it to be conservative in its reference to as goal of 10 degrees of range of motion. Mr. Huegel would have extended the range of motion and the arc 30 to 40 degrees. Otherwise Mr. Huegel offered no criticism of Respondent's plan of treatment. This reference is to the expectation of physical therapy within the first two weeks as to the arc or range of motion. Mr. Huegel does not believe that the treatment provided by Respondent for
Patient R.G. was too aggressive.
Mr. Huegel does not believe that there were any precautions that Respondent should have taken in treating Patient R.G. that were not taken.
Respondent properly documented the treatment of Patient R.G. in Mr. Huegel's opinion.
In Mr. Huegel's opinion, Respondent practiced physical therapy with the level of care, skill and treatment recognized by a reasonably similar physical therapist as acceptable under similar conditions and circumstances.
Mr. Huegel expressed the opinion that Respondent communicated appropriately with physicians regarding the patient's treatment. Mr. Huegel expressed the opinion that Respondent properly interpreted the orders received from Dr. Cannon and followed those orders.
Having considered the opinions of the experts in view of the allegations of the Administrative Complaint and facts found, the opinions expressed by Mr. Hisamoto and Mr. Huegel that Respondent practiced with the level of care, skill and treatment recognized by a reasonably prudent similar physical therapy practitioner as being acceptable under similar conditions and circumstances is more persuasive. Their opinion that Respondent interpreted and acted in accordance in the orders from Dr. Cannon, known to Respondent, is accepted. Their opinion that Respondent participated appropriately, as part of the collaborative effort to treat Patient R.G. is accepted. Based upon their opinion, nothing in the Respondent's conduct in relation to the treatment provided Patient R.G. is considered beyond the opportunity provided under his license or outside his competence to perform.
Prior Disciplinary History
There was no indication of prior discipline imposed against Respondent's physical therapist license.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding in accordance with Sections 120.569, 120.57(1) and 456.073(5), Florida Statutes (2006).
Respondent is a licensed physical therapist in Florida. He was issued the license by the Department. The license number is PT 20254.
Through the Administrative Complaint, Respondent has been accused of violations set forth in two separate counts.
Count One accuses Respondent of violating Section 486.125(1)(j), Florida Statutes (2002):
. . . by failing to communicate with Patient R.G.'s doctor about the treatment and/or the actual failure to communicate those concerns with the doctor, practicing beyond the scope permitted by law.
Section 486.125(1)(j), Florida Statutes (2002), states in pertinent part:
The following acts constitute grounds for . . . disciplinary action, as specified in s. 456.072(2):
* * *
Practicing or offering to practice beyond the scope permitted by law or accepting and performing professional responsibilities which the licensee knows or has reason to know that she or he is not competent to perform, including, but no limited to, specific spinal manipulation.
Count Two accuses Respondent of violating Section 486.125(1)(k), Florida Statutes, when he violated:
Florida Administrative Code Rule 64B17- 6.001(2)(g), by failing to practice physical therapy with that level of care skill, and treatment which is recognized by a reasonably prudent similar physical therapy practitioner as being acceptable under similar conditions and circumstances; or
Florida Administrative Code Rule 64B17- 6.001(3)(f), by failing to collaborate with members of the health care team when appropriate; or/and
Florida Administrative Code Rule 64B17- 6.001(3)(h), by failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, initial physical therapy assessment, plan of treatment, treatment notes, progress notes, examination results, test results, and discharge summary.
In particular Respondent is accused of violating those provisions in that:
Respondent failed to practice PT with that level of care, skill and treatment which is recognized by a reasonably prudent similar physical therapy practitioner when he failed to contact the referring physician to determine the diagnosis and ask or [sic] the clarification of contraindicators, how much was able to be repaired; the precautions to be engaged and/or the
protocol of the particular orthopedic surgeon.
Respondent failed to document any collaboration with Patient R.G.'s Doctor regarding his treatment plan, assessment, change in treatment or in any fashion working in collaboration for the patient's good.
Respondent failed to document any justification for the change in Patient R.G.'s plan of treatment.
Section 486.125(1)(k), Florida Statutes (2002), upon which the violations are based states in pertinent part:
The following acts constitute grounds for . . . disciplinary action, as specified in s. 456.072(2):
* * *
Violating any provision of this chapter or chapter 456, or any rules adopted pursuant thereto.
Passages within the rules that are involved with the Administrative Complaint state:
32. Rule 64B17-6.001(2)(g), Florida Administrative Code (F.A.C.) states in pertinent part: physical therapist . . . must practice physical therapy with that level of care skill, and treatment which is recognized by a reasonably prudent similar physical therapy practitioner as being acceptable under similar conditions and circumstances.
33. Rule 64B17-6.001(3)(f), F.A.C. states
that the physical therapist's professional responsibilities include, but are not limited to (in pertinent part):
1. Interpretation of the practitioner's referral;
3. Identification of and documentation of precautions, special problems, contra- indicators; and/or being acceptable under similar conditions and circumstances
6. Delegation of appropriate tasks.
34. 64B17-6.001(3)(h), F.A.C. states
physical therapist shall keep written medical records justifying the course of treatment of the patient, including, but not limited to, initial physical therapy assessment, plan of treatment, treatment notes, progress notes, examination results, test results, and discharge summary.
This is a disciplinary case, and for that reason Petitioner bears the burden of proof. That proof must be sufficient to sustain the allegations in the Administrative Complaint by clear and convincing evidence. See Department of Banking and Finance, Division of Securities and Investor
Protection v. Osborne Stern and Co., 670 So. 2d 932 (Fla. 1996); and Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987). The term clear and convincing evidence is explained in the case In re: Davey, 645 So. 2d 398 (Fla. 1994), quoting, with approval from Slomowitz v. Walker, 429 So. 2d 797 (Fla. 4th DCA 1983).
Given the penal nature of this case, Section 486.125(1)(j) and (k), Florida Statutes (2002), has been strictly constructed. Any ambiguity favors the Respondent. See
State v. Pattishall, 99 Fla. 296 and 126 So. 147 (Fla. 1930),
and Lester v. Department of Professional and Occupational Regulation, State Board of Medical Examiners, 348 So. 2d 923 (Fla. 1st DCA 1977).
As referred to previously, the disciplinary response that may be imposed should Respondent be found in violation of Section 486.125(1)(j) and (k), Florida Statutes (2002), is set forth in Section 456.072(2), Florida Statutes (2002), which states:
(2) When the board . . . finds any person guilty . . . of any grounds set forth in the applicable practice act, . . . it may enter an order imposing one or more of the following penalties:
* * *
Suspension or permanent revocation of a license.
Restriction of practice or license, including, but not limited to, restricting the licensee from practicing in certain settings, restricting the licensee to work only under designated conditions or in certain settings, restricting the licensee from performing or providing designated clinical and administrative services, restricting the licensee from practicing more than a designated number of hours, or any other restriction found to be necessary for the protection of the public health, safety, and welfare.
Imposition of an administrative fine not to exceed $10,000 for each count or separate offense. If the violation is for fraud or making a false or fraudulent representation, the board, or the department
if there is no board, must impose a fine of
$10,000 per count or offense.
Issuance of a reprimand or letter of concern.
Placement of the licensee on probation for a period of time and subject to such conditions as the board, or the department when there is no board, may specify. Those conditions may include, but are not limited to, requiring the licensee to undergo treatment, attend continuing education courses, submit to be reexamined, work under the supervision of another licensee, or satisfy any terms which are reasonably tailored to the violations found.
Corrective action.
Imposition of an administrative fine in accordance with s. 381.0261 for violations regarding patient rights.
Refund of fees billed and collected from the patient or a third party on behalf of the patient.
Requirement that the practitioner undergo remedial education.
In determining what action is appropriate, the board, . . . must first consider what sanctions are necessary to protect the public or to compensate the patient. Only after those sanctions have been imposed may the disciplining authority consider and include in the order requirements designed to rehabilitate the practitioner. All costs associated with compliance with orders issued under this subsection are the obligation of the practitioner.
Pertaining to Count One, Respondent did communicate with Dr. Cannon concerning care provided Patient R.G., in
particular related to Dr. Cannon's intensions for physical therapy in association with the patient's weight-bearing status. In addition, Respondent communicated with Dr. Cannon on other topics related to physical therapy for Patient R.G. All this was unnecessary. Dr. Cannon had provided Respondent sufficient information about Patient R.G. in the section on physical therapy in Form 3008, as supplemented in the telephone order clarifying the initial order. His knowledge of the case allowed Respondent to proceed with care and treatment within the scope of his license, within Respondent's competence. With the knowledge of the initial orders provided in the Form 3008 and the clarification order by telephone, Respondent provided care and treatment to Patient R.G. according to the plan of treatment prepared by Respondent, as envisioned by Dr. Cannon. Further orders noted in Patient R.G.'s chart, created by Dr. Cannon on February 25, 2003, were not made known to Respondent until April 2003. This was in relation to Dr. Cannon's plan calling for "no bending on RLE" and "may undo immobilizer when resting." Respondent was not responsible and is not held accountable for failures within Timber Ridge to properly place that chart information from Dr. Cannon and distribute it, to include Respondent. Otherwise it was acceptable for Respondent to provide physical therapy to Patient R.G. through the physical
therapy assistant that included range of motion exercises and the bending of the patient's right knee.
Petitioner has failed to prove a violation of Section 486.125(1)(j), Florida Statutes (2002), as alleged in Count One.
Concerning Count Two, Petitioner has failed to prove that Respondent practiced physical therapy with less than the level of care, skill, and treatment which is recognized by a reasonably prudent similar physical therapist practitioner, as being acceptable under similar conditions and circumstances when providing care and treatment to Patient R.G. Respondent acted appropriately in carrying out Dr. Cannon's orders, known to the Respondent. He established a treatment plan and properly pursued the treatment plan for Patient R.G. Respondent properly understood Dr. Cannon's diagnosis, a fracture in the right patella, the ORIF that corrected it, and then proceeded with the treatment and care absent any contraindicators in the Form 3008 related to physical therapy, meeting the expectations concerning the physical therapy set out in Form 3008. Precautions that were established on February 25, 2003, notwithstanding, Respondent followed the protocol of Dr. Cannon to the extent the physician made it known. There was no violation of Florida Administrative Code 64B-16.6001(2)(g) pertaining to standard of care.
Florida Administrative Code Rule 64B17-6.001(3)(f) was not violated in Respondent's collaborative efforts with other health care providers. In particular, in Respondent's interpretation of Dr. Cannon's referral, to Respondent's knowledge, no precautions, special problems, or contraindications were provided by Dr. Cannon that made it necessary to communicate with the physician and to provide further documentation of the doctor's choices on those subjects. Respondent properly documented his care in the treatment plan. Respondent delegated appropriate tasks to his physical therapy assistant in caring for Patient R.G.
Respondent did not violate Florida Administrative Code Rule 64B17-6.001(3)(b). This rule obligates Respondent to keep medical records related to his treatment, not to provide verbatim transcriptions of Dr. Cannon's clarification order. Respondent kept adequate records of his treatment.
Overall, no violation of Section 486.125(1)(k), Florida Statutes (2002), has occurred.
Based upon the findings of facts found and the conclusions of law reached, it is
RECOMMENDED:
That a final order be entered dismissing Counts One and Two to the Administrative Complaint.
DONE AND ENTERED this 2nd day of August, 2007, in Tallahassee, Leon County, Florida.
S
CHARLES C. ADAMS
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 2nd day of August, 2007.
COPIES FURNISHED:
Lynne A. Quinby-Pennock, Esquire Department of Health
4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265
Donna M. Keim, Esquire Bice Kohl Law Firm, P.L. Post Office Box 1860 Alachua, Florida 32616
Susie K. Love, Executive Director Board of Physical Therapy Practice Department of Health
4052 Bald Cypress Way, Bin C05 Tallahassee, Florida 32399-1701
Josefina M. Tamayo, 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 |
|---|---|---|
| Sep. 24, 2007 | Agency Final Order | |
| Aug. 02, 2007 | Recommended Order | Respondent did not practice outside his professional competence. |
