STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, Petitioner, v. CASE NO. 2007-20245 CHARLES MICHAEL GERARDI, Ph.D., Respondent. DMINISTRA’ MPLAINT COMES NOW, Petitioner, Department of Health, by and through its undersigned counsel, and files this Administrative Complaint before the Board of Psychology against the Respondent, Charles Michael Gerardi, Ph.D., and in support thereof alleges: 1. Petitioner is the state department charged with regulating the practice of psychology pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 490, Florida Statutes. 2. At all times material to this Complaint, Respondent was a licensed psychologist within the state of Florida having been issued license number PY 5833. 3. Respondent's address of record is 214 Scotland Street, Dunedin, Florida 34698. 4. From on or about March of 2003 until on or about May of 2005, Respondent worked as an independent contractor for Mark Kantzler, D.O., a licensed osteopathic physician and owner and operator of West Coast Personal Injury Family Medicine located in Madeira, Florida. C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 1 Filed January 24, 2012 8:00 AM Division of Administrative Hearings Lali. 5. Respondent was employed by Dr. Kantzler as a clinical psychologist specializing in psychopharmacology. 6. Beginning in July of 2003, and continuing until August of 2004, Respondent saw Patient JN, an existing patient of Dr. Kantzler, regularly at the West Coast Personal Injury Famtly Medicine Center. On some occasions, Respondent met with the patient with either Dr. Kantzler or with Dr. Kantzler’s physician assistant present. 7. During the time that Patient JN was seen by Respondent at Dr. Kantzler’s office, Respondent routinely completed the subjective, objective, assessment and plan portions of the patient's medical record. Respondent documented physical conditions reported by the patient, as well as, objective physical and medical conditions. Respondent listed medications prescribed to Patient JN and regularly documented that the patient “understood his medication.” The patient was routinely diagnosed with anxiety disorder and depression. 8. On or about July 7, 2003, Patient JN presented to Dr. Kantzler's office and met with Respondent for the first time. Respondent documented that the patient reported diarrhea. Respondent noted “lungs-congested, heart regular, stomach acid reflux, bowels regular.” In addition, Respondent noted the patient was “oriented X 4” and “affect t”, “mood *”, “friendly”, “cooperative” and “mental status — stable”. 9. On or about October 14, 2003, Patient JN presented to Dr. Kantzler's office for follow-up and once again Respondent completed the subjective, objective and assessment portions of JN‘s medical record. Respondent noted that Respondent's heart C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 2 was regular and his mental status was good and noted that Patient JN “needs injection therapy by Dr. Kantzler and massage therapy.” 10. On or about October 22, 2003, Patient JN presented to Dr. Kantzier's office for a follow-up visit and was seen by Respondent. Respondent noted Patient JN‘s “heart regular” and “stomach soft.” Respondent noted that Patient JN needed Albuteral. Respondent noted that Patient JN‘s lower back pain was up, as well as his thoracic pain and lumbar pain. Patient JN was “oriented X 4, affect t mood f, friendly/cooperative.” 11. On or about November 5, 2003, Patient JN presented to Dr. Kantzler’s office for a follow-up visit and Respondent completed the subjective, objective and assessment portion of the patient’s medical record. Under the subjective portion of the record, Respondent indicated the patient reported an increase in his lower back pain, and continued cervical, thoracic and lumbar pain. The patient also reported a loss of appetite and nausea. Under the objective portion of the record, Respondent listed “lungs — requires Albuteral,” “heart — regular strong,” stomach - acid reflux takes Nexium,” and “bowels — regular.” Respondent noted the patient's “affect tT mood ft, friendly ~ cooperative” and “mental status - stable.” However, Respondent also noted that the patient is “very upset/concerned by his chronic pain.” 12. On or about November 12, 2003, Patient JN presented to Dr. Kantzler’s office for follow-up and was seen by Respondent. Respondent noted that Patient JN was under severe stress and was having visual dreams and hallucinations about devils. The records contain no documentation of any discussion Respondent had with the C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Fites\OLK4\AC 7-31-09 final.doc 3 patient about his hallucinations and does not contain a plan or treatment regarding the patient’s change in his mental health status. 13. On or about December 9, 2003, Patient JN presented to Dr. Kantzler’s office for follow-up and was seen by Respondent. Respondent completed the subjective, objective and assessment portion of the patient’s record. The record contains no documentation regarding Patient JN’s mental condition relative to his condition on November 12, 2003. Respondent notes that he and Patient JN discussed “his total disability and adjusting to adult life.” 14. On or about December 16, 2003, Patient JN presented to Dr. Kantzler’s office for follow-up and was seen by Respondent. Respondent recorded the subjective, abjective and assessment portions of the medical records. Respondent noted that he discussed medication with the patient and his medical condition. 15. Onor about January 13, 2004, Patient JN presented to Dr. Kantzler’s office and for follow-up with Respondent. Respondent noted the subjective, objective and assessment portions of the medical records. On this date, Respondent notes “depression”, “anorexia” and “COPD.” The record contains no indication as to upon what Respondent based these diagnoses. 16. On or about January 27, 2004, Patient JN presented to Dr. Kanztler’s office for follow-up and was seen by Respondent. Respondent completed the subjective, objective and assessment portion of the patient's medical record. Under the subjective portion of the record, Respondent indicated the patient reported lower back pain and cervical pain. Under the objective portion of the record, Respondent listed C:\Documents and Settings\LopezLX2\Locat Settings\Temporary Internet Files\OLK4\ACT 7-31-09 final.doc 4 “lungs -— asthma R/O COPD”” “heart — regular” “stomach — GERD acid reflux” and “bowels — regular.” Respondent noted the patient's “affect t mood t, friendly - cooperative” and “mental status - stable.” Respondent assesses the patient with anxiety and depression but there is no documentation regarding the management of anxiety or depression. 17. On or about February 9, 2004, Respondent saw Patient JN as an emergency appointment for increased anxiety and panic disorder. Respondent noted that Patient JN presented frightened and upset but there is no further legible documentation regarding Respondent's treatment plan for Patient JN. 18. On or about March 3, March 22, and April 19, 2004, Patient JN presented to Respondent for follow-up. Respondent completed the subjective, objective and assessment portion of the patient's medical record. Respondent listed under plan “psych counseling.” Respondent also noted that the patient “understands all meds.” 19. On or about May 3, 2004, Patient JN presented to Dr. Kantzler’s office for follow-up and was seen by Respondent. Respondent noted that the patient presented with lower back pain and sciatica. Respondent documented that the patient's lungs were clear and his heart was regular. Respondent noted that Patient JN understood his medication and is “capable of handling opiate/oxycodone.” In addition to pain medication, Respondent listed psychological counseling and Xanax as part of the treatment plan for this patient. 20. On or about June 10, 2004, Patient JN presented to Dr. Kantzler’s office for follow-up and was seen by Respondent. Respondent completed the subjective, C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 finai.doc 5 objective, and assessment portion of the patient's medical record. Respondent also recorded the treatment plan as being several pain medications, as well as Effexor. There is no documentation in the patient’s record explaining why Effexor was added to Patient JN’s prescriptions. 21. — Effexor is a legend drug used to treat depression. 22. On or about June 24, 2004, Patient JN presented to Dr. Kantzler's office for follow-up. In addition, to the above described information noted by Respondent on the patient's medical record, Respondent listed Patient JN with an Axis I diagnosis of “GAD/dysthymia” and included prescriptions for Xanax and Valium. The record does not document Respondent's basis for the diagnosis or the medications prescribed. 23. Onor about July 22, August 5, and August 18, 2004, Patient JN presented to Dr. Kantzler’s office for follow up. Respondent completed the subjective, objective, assessment, and treatment plan on the patient’s medical record. In addition, Respondent noted beside “psychology - understands all medication” but only noted “counseling” on the July 22 visit. 24. Respondent did not engage in counseling or therapy with Patient JN. Respondent did not conduct or document a clear statement of what his role in Dr. Kantzler's office was. Respondent did not conduct or document a thorough assessment of Patient JN’s psycholoical symptoms. Although Respondent noted repeatedly that the patient understood the medication he was taking, Respondent did not conduct any assessment of addictive personality and failed to respond to positive drug screens indicating controlled substances other than those prescribed. C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 6 25. Respondent's records for Patient JN do not adequately document any discussion with Patient JN regarding the role of Respondent in Dr. Kantzler’s office or in regard to the patient's treatment. Respondent's records do not adequately document counseling by Respondent of Patient JN or any documentation regarding Patient JN‘s diagnosis, treatment plan, or the effectiveness of the prescribing medication on Patient JN's symptoms of anxiety, depression and/or dysthymia. The records do not contain informed consent documentation. Respondent's records do not document a consent to treatment or a waiver of confidentiality in regard to the presence of Dr. Kantzler or his physician assistant when Respondent met with Patient JN. COUNT ONE 26. Petitioner realleges and incorporates herein Paragraphs one (1) through twenty-five (25) as if fully set forth herein. 27. Section 490.009(1)(r), Florida Statutes (2003)(2004), Florida Statutes, provides that failing to meet the minimum standards of performance in professional activities when measured against generally prevailing peer performance, including the undertaking of activities for which the licensee is not qualified by training or experience, constitutes an act for which disciplinary action may be taken. 28. Respondent has failed to meet the minimum standards of performance in professional activities when measured against generally prevailing peer performance in one or more of the following ways: a. By failing to conduct an initial assessment of Patient JN‘s psychological condition; and/or C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 7 b. By failing to document adequate symptoms in support of his diagnosis of Patient JN; and/or on By failing to conduct adequate psychological testing to confirm a diagnosis of Patient JN; and/or d. By failing to create a treatment plan to address Patient JN’s psychological condition; and/or e. By failing to clarify his role for in Dr. Kanztler’s office; and/or f. By failing to actually provide counseling and treatment to Patient IN. Gg. By failing to intervene appropriately when patient appeared to be decompensating as evidenced by reports of hallucinations. 29. Based on the foregoing, Respondent violated Section 490.009(1)(r), Florida Statutes (2003)(2004), by failing to meet minimum standards of performance in professional activities when measured against generally prevailing peer performance, including the undertaking of activities for which the licensee is not qualified by training or experience. COUNT TWO 30. Petitioner realleges and incorporates herein Paragraphs one (1) through twenty-five (25) as if fully set forth herein. C:\Documents and Settings\Lopezl X2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 31. Section 490.009(1)(w), Florida Statutes (2003)(2004), provides that violating any provision of this chapter of chapter 456, or any rules adopted pursuant thereto, constitutes an act for which disciplinary action may be taken by the Board. 32. Rule 64B19-19.003(1), Florida Administrative Code, provides that licensed psychologists shall maintain psychological records for each service user and shall record information concerning consultations and/or services rendered by the psychologist to the service user with a reasonable time following that consultation or the rendition of service. 33. Rule 64B19-19.0025(1) and (2), Florida Administrative Code, provides that licensed psychologist shall maintain records that chronicle and document: (1) psychologists’ services and the records must include the following: basic identification data such as name, address, telephone number, age and sex; presenting symptoms or requests for services; dates of service and types of services provided. Additionally, as applicable, these records must include: test data (previous and current); history including relevant medical data and medication, especially current; what transpired during the service sessions; significant actions by the psychologist, service user, and service payer; psychologist’s indications suggesting possible sensitive matters like threats; progress notes; copies of correspondence related to assessment or services provided; and notes concerning relevant psychologist’s conversation with persons significant to the service user. (2) Written informed consent must be obtained concerning all aspects of C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 9 services including assessment and therapy. 34. | Respondent failed to maintain adequate psychological records for Patient JN and failed to record information concerning consultations and/or services rendered by the psychologist by failing to document the basis for Respondent’s diagnosis, by failing to adequately document psychological symptoms, by failing to document what counseling transpired during the sessions with Patient JN, by failing to document an appropriate treatment plan or recommendation, by failing to document his role in the treatment of Patient JN and by failing to keep psychological records separate from medical records. Finally, Respondent failed to obtain or document written informed consent from JN concerning all aspects of services including assessment and therapy. 35. Based on the foregoing, Respondent has violated Section 490.009(1)(w), Florida Statutes (2003)(2004), by violating any provision of this chapter of chapter 456, or any rules adopted pursuant thereto by violating Rule 64B19-19.003(1), Florida Administrative Code. COUNT THREE 36. — Petitioner realieges and incorporates herein Paragraphs one (1) through twenty-five (25) as if fully set forth herein. 37. Section 456.072(1)(0), Florida Statutes (2003)(2004), provides that practicing or offering to practice beyond the scope permitted by law or accepting and performing professional responsibilities the licensee knows, or has reason to know, the licensee is not competent to perform constitutes an act for which disciplinary action may be taken by the Board. C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 10 38. Section 490.003(4), Florida Statutes, defines the practice of psychology as: the observations, description, evaluation, interpretation, and modification of human behavior, by the use of scientific and applied psychological principles, methods, and procedures, for the purpose of describing, preventing, alleviating, or eliminating symptomatic, maladaptive, or undesired behavior and of enhancing interpersonal behavioral health and mental or psychological health. The ethical practice of psychology includes, but is not limited to, psychological testing and the evaluation or assessment of personal characteristics such as intelligence, personality, abilities, interests, aptitudes, and neuropsychological functioning, including evaluation of mental competency to manage one's affairs and to participate in legal proceedings; counseling, psychoanalysis, all forms of psychotherapy, sex therapy, hypnosis, biofeedback, and behavioral analysis and therapy; psychoeducational evaluation, therapy, remediation, and consultation; and use of psychological methods to diagnose and treat mental, nervous, psychological, marital, or emotional disorders, illness, or disability, alcoholism and substance abuse, and disorders of habit or conduct, as well as the psychological aspects of physical illness, accident, injury, or disability, including neuropsychological evaluation, diagnosis, prognosis, etiology, and treatment. 39. Respondent practiced or offered to practice beyond the scope permitted by his license to practice psychology and he accepted and performed professional responsibilities he knew, or had reason to know, that he was not competent to perform by repeatediy performing and documenting the subjective, objective, assessment and plan of treatment for Patient JN. 40. Based on the foregoing, Respondent violated Section 456.072(1)(o), Florida Statutes (2003)(2004), provides that practicing or offering to practice beyond the scope permitted by law or accepting and performing professional responsibilities the licensee knows, or has reason to know, the licensee is not competent to perform. C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 11 WHEREFORE, the Petitioner respectfully requests that the Board of Psychology enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective action and/or any other relief that the Board deems appropriate. SIGNED this 21+. day of Avgusk , 2009. Ana M. Viamonte Ros, M.D., M.P.H. State Surgeon General FILED 2p AN, Re ve dy DEPARTMENT OF HEALTH TY CLERK Caro! L. Gregg CLERK Ongetr Bactow Assistant General Counsel DATE G-1-0F Florida Bar # 181515 Department of Health Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 (850) 245-4640 PCP Date: 3] 25109 (850) 245-4681 FAX ate: = PCP Members! >. “meRivas, Webster C:\Documents and Settings\LopezLX2\Local Settings\Temporary Internet Files\OLK4\AC 7-31-09 final.doc 12 NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed. C:\Documents and Settings\LopezLX2\Locai Settings\Temporary Intemet Files\OLK4\AC 7-31-09 final.doc 13

Docket for Case No: 12-000360PL