The Issue Whether Respondent violated Subsections 458.331(1)(j), 458.331(1)(t), and 458.331(1)(x), Florida Statutes, and, if so, what discipline should be imposed.
Findings Of Fact The Department is the state agency charged with regulating the practice of medicine pursuant to Section 20.43 and Chapters 456 and 458, Florida Statutes. At all times material to these proceedings Dr. Malave was a licensed physician in the state of Florida, having been issued license number ME 0058695. Patient J.P. first started treating with Dr. Malave in September 1994. She has suffered from various mental illnesses since her childhood. As a child, she was physically and sexually abused by her father and her uncles and began to experience episodes of "lost time" in which she would black out and be unable to recall events which had occurred. These occurrences of "lost time" continued into her adulthood. Patient J.P. has also suffered from severe depression for the majority of her life. In November 1982, she attempted suicide two times and was hospitalized for those attempts, but did not receive any outpatient counseling for the depression following her release from the hospital. In addition to experiencing "lost time" and being depressed, patient J.P. also was bulimic. In 1988, she met R.P. who was a postmaster at the post office where she worked in Imperial Beach, California. She was experiencing "lost time" during her delivery of mail. R.P. referred her to a mental health counselor for her depression and work-related stress. The counselor referred patient J.P. to a psychiatrist, who prescribed anti-depressants and anti-anxiety medications for her. During the same period of time, patient J.P. received treatment for bulimia, including two weeks of inpatient treatment at the Alvaredo Parkway Institute. Patient J.P. married R.P. in 1989 and moved to Florida in 1990. During the first four years that patient J.P. lived in Florida, she was treated by several different physicians for depression and bulimia. In 1992, patient J.P. became the patient of Dr. Phillip Sinaicin, who also treated her for bulimia and depression. He tried different combinations of medications and electroconvulsive therapy, but the treatments were not working. Dr. Sinaicin referred patient J.P. to Dr. Malave, a psychiatrist, for a second opinion. Patient J.P. saw Dr. Malave on September 4, 1994, for a second opinion evaluation. Dr. Malave diagnosed patient J.P. as suffering from Dissociative Identity Disorder (DID), formerly known as multiple personality disorder and as having schizoaffective features. Patient J.P. has multiple distinct personalities or voices, as patient J.P. refers to them. She has a core or birth personality, which appears as J.P. She has other personalities including the following: Bridget, who is sexually preoccupied; Vanessa, who appears with a street- smart vocabulary and manifests when she believes that she needs to take charge of a situation which patient J.P. is not handling very well; Monica, who is a mothering personality to Bridget; Elaine, who is the leader of the group of personalities; Delilah Servano, who is also known as the researcher; and the Brother, who is a street-smart male. J.P., the core personality, is unable to recall and relate when an alter personality is manifesting itself. When another personality takes over, patient J.P. describes the experience as "losing time." The other personalities are sometimes aware of each other and of what happens to each other. The personality Elaine is aware of what all of the other personalities are doing. While being treated by Dr. Malave, patient J.P. disclosed to him that she had been sexually abused by her father and her uncles when she was a child. Dr. Malave explored the sexual abuse by using mental regression exercises which were intended to help patient J.P. remember the abuse. Patient J.P. noticed that she was losing time during her sessions with Dr. Malave, and that it mostly occurred while they were doing the regression exercises. During their treatment sessions, Dr. Malave emphasized to patient J.P. that it was important for her to trust him in order for her to get better. Patient J.P. did come to trust him and believed that as long as she continued to see him that she would be all right. In 1995, patient J.P. began to notice that after some sessions with Dr. Malave when she had lost time that her underwear would be wet and sometimes her jaw would be sore and cramped. On these occasions, Dr. Malave would not escort her out of his office as he normally did after a session. On several occasions when patient J.P. had lost time during a session, she recalled coming back to herself as J.P., the core personality, while she and Dr. Malave were engaged in a sexual act. The first occasion occurred around Christmas in 1995. Patient J.P. lost time and came back to herself during a session and found herself kneeling in front of Dr. Malave performing oral sex on him in his office. She lost time shortly thereafter. Patient J.P. recalled another occasion when she came back to herself during a session and found Dr. Malave sucking on her left breast and kissing her neck and face. Another time during a session, Dr. Malave asked patient J.P., while she was in her core personality state, if she were Bridget. Patient J.P. replied that she was. Dr. Malave went to his office door and locked it and then engaged patient J.P. in sex on his desk. On a fourth occasion, patient J.P. came to herself and found herself lying on the floor in Dr. Malave's office and having sexual intercourse with him. Following that session, patient J.P. experienced vaginal soreness and noticed that her underwear was wet when she left his office. She decided to save the wet underwear and stored it under her bed. Until June 1999, patient J.P. continued to save her wet underwear and place them under her bed after sessions with Dr. Malave when she suspected that sex may have occurred during the session. In June 1999, she placed the underwear in a safe deposit box along with a note explaining her relationship with Dr. Malave. The last time that patient J.P. came back to herself while having sex with Dr. Malave was in August 1999. At that time she found herself having sex with Dr. Malave in his chair in his office. Patient J.P.'s husband noticed that at times something was not right about patient J.P. following her sessions with Dr. Malave. Sometimes when patient J.P. exited Dr. Malave's office, her husband noticed that her hair was disheveled, her blouse was undone, her lipstick was smeared, and her skirt was wrinkled. When he asked patient J.P. what had happened, she told him that she had lost time during the session. Patient J.P.'s husband asked for an explanation from Dr. Malave, who told him that patient J.P. had changed personalities during the session and caused her appearance to become disheveled. Dr. Malave further advised that it was good that she was in session when it happened because patient J.P. would be safe with him. Dr. Malave spoke with patient J.P.'s husband on numerous occasions concerning the diagnosis of DID. During one of their conversations, Dr. Malave told the husband that he had treated another woman with DID and that she had a sexually aggressive personality similar to patient J.P.'s personality Bridget. Dr. Malave advised the husband to keep patient J.P. away from men and to try to keep her at home because she just wanted to have sex. In August 1999, patient J.P. contacted attorney Linda Schwictenberg concerning her suspicions about Dr. Malave having sex with her during their treatment sessions. From August to October 1999, patient J.P. turned over a total of ten pairs of underwear to Ms. Schwictenberg. Patient J.P. kept one pair of underwear in her safety deposit box for security reasons. Ms. Schwictenberg sent the underwear in three separate submissions to Lab Corp, a forensic laboratory in North Carolina for DNA analysis. Ms. Schwictenberg, on instructions from Lab Corp, took an oral swab from patient J.P. and sent that specimen to Lab Corp. From the time Ms. Schwictenberg received the panties until she forwarded them to Lab Corp, the panties remained in a drawer in her office to which only she had access. Lab Corp received the submissions and performed a presumptive test to determine whether seminal fluid was present on the first three pair of panties that were submitted. A cutting was taken from one pair of ivory colored panties, the presumptive test revealed the presence of semen. Two black pairs were tested by rubbing filter paper on the panties. The presumptive tests for the two black pairs failed to reveal semen. Lab Corp did a DNA analysis on the remaining seven pairs of panties. DNA is the genetic blueprint of our lives and contains the codes for every physical characteristic and every chemical reaction which takes place in our bodies. With the exception of identical siblings, each person's DNA is unique. Nuclear DNA is inherited in equal portions from our mothers and fathers. DNA is used in forensic cases to determine the identity of a DNA sample. Certain areas of the DNA molecule are different in the general population. These differences are used to develop a profile for a particular sample which is then compared to a profile of a known reference sample in order to determine whether the profiles are similar or different. In cases where sexual misconduct is involved and where there may be two different sources of DNA (the victim and the suspect), a differential extraction is performed. The purpose is to separate the DNA of the sperm source from the DNA of the non-sperm source so that a pure DNA profile for each will be obtained. Lab Corp determined that the DNA profile from the oral swab submitted by patient J.P. could not be excluded as being the source of the non-sperm DNA in all of the panties except one in which a non-sperm fraction was not obtained. The profile developed for the sperm fraction is the same profile developed on the seven pairs of panties on which sperm was detected. In other words, only one sperm donor was detected. Lab Corp did not have a reference specimen from Dr. Malave to make a comparison of the sperm DNA found in the panties. It is possible to transfer the DNA of the sperm fraction from one article of clothing to another. The transference could be done by rubbing the two articles of clothing together or by wetting the article containing the sperm and rubbing it against the other article of clothing. Based on the credible testimony of Meghan Clement, an expert in DNA identification and analysis and in forensic science, the concentrations of DNA in the sperm fraction were too high to have resulted from the sperm having been transferred from another article of clothing to patient J.P.'s panties. On January 6, 2000, Ms. Schwictenberg received the panties from Lab Corp. She gave some of the panties to Investigator John Eckerson of the Volusia County Sheriff's Office. On January 20, 2000, Dr. Malave gave a blood sample to the sheriff's office. Investigator Eckerson sent three pairs of patient J.P.'s panties and Dr. Malave's blood sample to the Florida Department of Law Enforcement (FDLE) laboratory for DNA analysis in January 2000. FDLE personnel made a staincard from Dr. Malave's blood sample. The FDLE testing revealed that there was the possible presence of semen on one of the pairs of panties and no indications of semen present on the other two pairs sent in January 2000. A crime laboratory analyst for FDLE packaged a cutting of the panties containing semen for a later DNA analysis. On February 3, 2000, patient J.P. went to the Rape Crisis Center in Daytona Beach, Florida, where a blood sample was taken from her by a registered nurse. The nurse turned the blood sample over to Deputy Wichman, who also took custody of a pair of panties from patient J.P. Deputy Wichman transported the blood sample and the pair of panties to the sheriff's office, where he placed them in an evidence locker. Patient J.P.'s blood sample was sent to the FDLE laboratory, where a staincard was prepared. On June 20, 2000, Investigator Eckerson took custody of the remaining pairs of panties from Ms. Schwictenberg. Those panties were sent to FDLE for testing. The presence of semen containing spermatozoa was found on four of the pairs of panties submitted in June. A crime laboratory analyst for FDLE prepared cuttings of the four pairs of panties and sent them to another crime laboratory analyst at FDLE for DNA analysis. Timothy Petree, a crime laboratory analyst in the DNA section of the FDLE laboratory, performed a DNA analysis on the blood samples from Dr. Malave and patient J.P. and the five pairs of panties in which semen was found. He first performed a differential extraction of the cuttings which enabled him to separate the sperm cell DNA from any epithelial or skin cell DNA. The next steps include determining how much human DNA was present, setting up the PCR reaction which makes copies of the target DNA segments, and then performing a DNA analysis to determine which DNA fragments were present in the samples. Mr. Petree developed a DNA profile for each of the blood samples and the sperm cells on each of the underwear cuttings. The DNA profile developed from the sperm cells on all five of the underwear cuttings were the same, meaning that there was one sperm donor. The sperm cell DNA profile was compared to the DNA profile developed from Dr. Malave's blood sample. The sperm cell DNA profile matched Dr. Malave's DNA profile at all 14 DNA locations that were compared. The frequency of occurrence of that profile in different populations is as follows: one in 19 quadrillion Caucasians, one in 290 quadrillion African Americans, and one in 13 quadrillion Hispanics. Based on the evidence presented, the sperm found in patient J.P.'s panties came from Dr. Malave. Dr. Malave testified that between January and June 1999, he lost approximately 63 pounds. He further testified that as his underwear would become too large that he would use them to clean up after sexual activity with his wife and discard the underwear in the garbage. It would appear that Respondent's testimony on this subject would be for the inference that somehow the semen that may have been present in his underwear in the garbage was transferred to patient J.P.'s panties, thereby explaining how his semen was found on her underwear. Such an inference is not credible, particularly given the testimony of Meghan Clement that the concentration of sperm present on some of patient J.P.'s panties was too concentrated to have been transferred from another article of clothing. The relationship between a physician and a patient is a sacred trust. The doctor's duties to the patient are to do no harm to the patient and to practice with the greatest diligence to serve the patient's best interest. In this private and confidential relationship, the psychiatrist explores the patient's problems by discussing very intimate thoughts and feelings. Given the level of emotional intimacy in the patient-psychiatrist relationship, the patient sometimes develops sexual feelings toward the psychiatrist, and the psychiatrist sometimes develops sexual feelings toward the patient. These reactions are known as transference and counter-transference, respectively. The psychiatrist has the obligation to recognize the physical and verbal signs of transference in the therapeutic relationship and make sure that the strict sexual boundaries in the relationship are not violated. The personality known as Bridget and Dr. Malave developed sexual feelings toward one another, and it was the responsibility of Dr. Malave to ensure that those feelings did not result in sexual relations between them. Sexual relations between the psychiatrist and the patient are forbidden. Sex within the patient-psychiatrist relationship is very destructive in the therapeutic process and can result in the patient experiencing feelings of guilt, mistrust, and low-self esteem--all of which are counter- therapeutic.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered finding that Ronald Malave, M.D., violated Subsections 458.331(1)(j), (t), and (x), Florida Statutes, revoking his license to practice medicine, and assessing the costs of the investigation and prosecution of the case against him. DONE AND ENTERED this 21st day of August, 2002, in Tallahassee, Leon County, Florida. ___________________________________ SUSAN B. KIRKLAND 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 21st day of August, 2002. COPIES FURNISHED: Robert C. Byerts, Esquire Department of Health 4052 Bald Cypress Way, BIN C65 Tallahassee, Florida 32399-3265 William M. Furlow, Esquire Katz, Kutter, Haigler, Alderman, Bryant & Yon 106 East College Avenue, Suite 1200 Post Office Box 1877 Tallahassee, Florida 32302-1877 David P. Hill, Esquire 128 East Livingston Street Orlando, Florida 32801 Kim M. Kluck, Esquire Department of Health 4052 Bald Cypress Way, Bin C65 Tallahassee, Florida 32399-3265 Chandler R. Muller, Esquire 1150 Louisiana Avenue, Suite 2 Post Office Box 2128 Winter Park, Florida 32790-2128 Tanya Williams, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue Whether Respondent violated Sections 491.009(2)(k), and 491.009(2)(s), Florida Statutes, and, if so, what penalty should be imposed.
Findings Of Fact At all times material, Respondent held a license as a Mental Health Counselor in the State of Florida. Petitioner, through the Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, is the state agency that licenses and has regulatory jurisdiction of Clinical Social Workers. Respondent was employed as a counselor by the ACT Corporation (ACT) at the time of the incident that is the basis for this case. ACT operates a residential psychiatric treatment facility at which Respondent was employed. T.J. was a patient in the ACT facility from December 26, 1996 until mid-February, 1997. While at ACT, T.J. was diagnosed with bipolar disorder. T.J. had both group sessions and private sessions with Respondent while she was an in-patient at ACT. The private sessions took place in Respondent's office. Respondent and T.J. talked on the telephone, and he brought her small items, like lip-gloss and gum, that she was not allowed to have. T.J. alleges that the sessions became sexual on or about the second private therapy session. She alleges sexual contact during the in-patient sessions involved kissing and touching, that was consensual. T.J. states that she trusted Respondent and was in love with him. T.J. alleges this sexual relationship with Respondent continued after T.J. left ACT in February. There was never a therapeutic relationship between Respondent and T.J. after T.J. left the hospital. There was never any discussion of a fee arrangement, and no fees were ever paid for counseling sessions. Two days after T.J. left ACT, Respondent picked her up from her home and took her to Sapporo's for dinner and drinks. Following dinner, they went to a bar called the Barracks. T.J. alleges that when Respondent brought T.J. home that night they engaged in oral sex and intercourse. A few days later, T.J. and Respondent met for dinner at the Olive Garden. At the Olive Garden they had dinner and drinks. T.J. alleges that following dinner, Respondent walked T.J. to the van she was driving, they kissed and then had sexual intercourse in the van. On Valentine's Day Respondent came to T.J.'s house for dinner. T.J. lived with her parents. He brought her flowers and a bottle of wine for her parents. A card accompanied the flowers that said: "Sorry! No candy. Hope this will do instead." The envelope said "Traci." Following dinner, they went out to the Flagler Tavern. T.J. alleges that when they returned to T.J.'s house Respondent stayed until early morning and they had oral sex and intercourse. Respondent denies any sexual intimacy with T.J., and asserts that their relationship was one of patient-therapist even after she left ACT. T.J.’s testimony was presented by deposition. There was no opportunity to observe her. She was diagnosed contemporaneously with the events to which she testified with a condition that makes her credibility difficult to assess. Respondent testified at hearing denying the sexual relationship with T.J. I do not find the deposition testimony of T.J. credible regarding the allegations of sexual relations with Respondent. I find that there was a relationship between Respondent and T.J. because Respondent verifies the social contacts T.J. reported. Respondent did not perform any counseling with T.J. on the various occasions when they went to the bars and restaurants. This relationship was inconsistent with existing standards of professional conduct, as testified to by experts at hearing and exemplified in the code of ethics which ACT had. T.J. continued therapy as an outpatient with another ACT therapist for a short time after she was released from the hospital. During one of these sessions, T.J. told the outpatient therapist about her social/personal relationship with Respondent. Shortly thereafter, ACT fired Respondent for violation of ACT's code of ethics. This code prohibited personal relationships between patients and employees of the facility. Respondent had his Florida Teaching Certificate permanently revoked when he worked as a counselor at Deland Senior High School. He was charged with sexual misconduct with a student, and did not contest the charges formally. Psychotherapy is dependent upon a personal relationship between the patient and the therapist. Patients often develop emotional relationships or attachments to counselors or therapists because of the creation of an environment of trust. It is important that therapist recognize that this relationship is an outgrowth of treatment, and not to take advantage of the patient. Respondent had a relationship with T.J. that is contrary to the professional standards of practice, notwithstanding the allegations of sexual misconduct. His professional relationship should have been confined to the clinical setting, and the social activities in which he engaged with T.J. were inappropriate.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, enter a final order adopting this order and revoking Respondent’s license and assessing a fine of $1,000 against him pursuant to Rule 64B4- 10.002 formerly 59P-5.001, Florida Administrative Code, the Board's penalty guidelines. DONE AND ENTERED this 17th day of May, 2001, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN 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 17th day of May, 2001. COPIES FURNISHED: Ismael Lopez 13691 Gavina Avenue, No. 447 Sylmar, California 91342 Mary Denise O'Brien, Esquire Department of Health 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Susan Foster, Executive Director Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling Department of Health 4052 Bald Cypress Way, Bin C08 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue The issues in this case, as set forth in the Prehearing Stipulation, are as follows: Whether Respondent was terminated from the State Medicaid Program; [Case No. 14-2488, Count I] Whether Respondent failed to update his practitioner profile within fifteen days of the filing of the order terminating him from the State Medicaid Program; [Case No. 14-2488, Count II] Whether Respondent exercised influence within the patient-physician relationship with T.J.[1/] for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with T.J.; [Case No. 14-1342, Counts I & II] Whether Respondent exercised influence within the patient-physician relationship with M.B. for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with M.B.; [Case No. 14-1343, Counts I & II] Whether Respondent exercised influence within the patient-physician relationship with C.J. for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with C.J.; [Case No. 14-1343, Counts I & II] Whether Respondent exercised influence within the patient-physician relationship with D.K. for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with D.K.; [Case No. 14-1343, Counts I & II] Whether Respondent exercised influence within the patient-physician relationship with A.H. for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with A.H.; [Case No. 14-1343, Counts I & II] and Whether Respondent exercised influence within the patient-physician relationship with S.D. for the purposes of engaging in sexual activity and/or whether Respondent engaged in sexual conduct with S.D. [Case No. 14-1343, Counts I & II]
Findings Of Fact Petitioner, Department of Health, Board of Medicine (the “Department”) is the State agency responsible for licensing and monitoring physicians in the State of Florida. The Department regulates the practice of medicine in accordance with section 20.43 and chapters 456 and 458, Florida Statutes. Unless specifically stated otherwise herein, all references to Florida Statutes will be to the 2014 codification. Respondent is a licensed Florida physician, certified in the area of pain management, holding license number ME 97134. At all times relevant hereto, Respondent was practicing medicine at one of two locations: the Back Authority for Contemporary Knowledge, (a pain management clinic known as the “Back Center” located in Melbourne, Florida); and Advantacare (in its Altamonte Springs and Daytona Beach offices). Respondent was employed at the Back Center from January 2008 through September 2011, and at Advantacare from March 2012 through April 2013. Respondent provided pain management services for numerous patients during his tenure at each of the clinics. While at the Back Center, he saw 50 to 60 patients per day in an 8-hour workday, doing about 15 medication injections per day. At Advantacare he was seeing about 30 patients per day. By all accounts, Respondent is a skilled and proficient pain management physician. At Advantacare, Respondent would see patients for regular office visits at the Altamonte Springs office on Monday, Tuesday, Thursday, and Friday; Wednesday would be set aside for administering injections under a fluoroscope, described as sort of a C-shaped X-ray machine, performed at the Daytona Beach office. None of the sexual behavior alleged in the Administrative Complaints occurred during injections performed under fluoroscope. A general policy existed at the Back Center that required physicians to have another facility employee (medical technician, nurse, other) present in an examination room when a physician was providing care to a patient not of the same gender as the doctor. This “chaperone” policy is standard in the health care industry. There is no credible evidence that Respondent was ever shown the Back Center’s policy in writing, although it is probable the policy was accessible on the website of the entity (Osler Corporation) that owned the Back Center for a period of time. As a practicing physician, Respondent was also presumed to be aware of and to follow the chaperone policy and he admitted knowing about the policy in general. Respondent was, however, verbally apprised of the policy by his supervisor, Dr. Hynes, by the clinic operations manager, Mr. Pachkoski, and by the chief administrative officer, Cathy Bird. Respondent acknowledged that it was best to have another person in the examination room if he was providing treatment to a female patient. If no chaperone was available, it was his stated practice to keep the door open. Respondent did not feel like assistants were always available to chaperone, but neither his supervisor (Dr. Hynes) nor a co-physician (Dr. Zaidi) remembers Respondent complaining that staff was not available at the Back Center. The testimony of all six complainants in this case contradicts Respondent’s contention; each of them said they were treated by Respondent (alone) in a room with the door closed. When asked directly whether he ever treated female patients at the Back Center in a room with the door closed, Respondent admitted that it happened on occasion. The best and most persuasive evidence in this case is that a chaperone policy did exist and that Respondent did not follow the policy. Between September 2008 and January 2013, Respondent treated six female patients who are the subjects of the Department’s Administrative Complaint. Each of the patients is identified only by their initials in an attempt to maintain their confidentiality and privacy. The six patients will be addressed in chronological order based on the dates of their alleged mistreatment by Respondent. Patient S.D. Patient S.D. was a patient of Respondent between September and December 2008. S.D.’s status as a patient was stipulated to by the parties.2/ While she was Respondent’s patient, S.D. was also an employee of the Back Center. During the period of time Respondent was treating S.D., they engaged in a series of emails which could be construed as very sexual in nature. For example, on September 23, 2008, Respondent and S.D. had the following email exchange: S.D. – “You buying Dinner….Or am I your [f***ing] dinner????”Respondent – “What do you think? I want u as breakfast, lunch and dinner. My precious love.” S.D. – Ok so what am I going to eat LOL??? Let me guess a protein shake”Respondent – “If I shake it hard enough yes.” Then, on September 25, the two had this email exchange:Respondent – “NO I WANT U TO FEED ME!!! AND NO YOU R NOT GOING THERE!!! ABSOLUTELY NOT!!! I’M UR MAN AND I SAY NO.”S.D. – “Then act like it and stop flirting with the [f***ing] skank!”Respondent – “WHY? GETTING JEALOUS SWEETHEART?”S.D. - “No I guess I have no reason to be.” Respondent – “EXACTLY, YOU HAD ME AT LUNCH AND LEFT TO GO TO WORK. SO YOU CAN’T SAY ANYTHING, PRECIOUS.” Respondent denies that the exchange of emails with S.D. suggests anything of a sexual nature. He said, e.g., that in his Iranian culture, talking about eating someone was tantamount to saying you cared deeply for them. Respondent’s denial of the sexual nature of the emails is not persuasive. S.D. did not testify at final hearing nor was her testimony preserved by way of a deposition transcript. The Department offered into evidence an exhibit comprised of various emails between S.D. and Respondent, two of which were discussed above. At least one co-worker, Lizamar Korfhage (a physician’s assistant at the Back Center), heard S.D. yell loudly in the office--as S.D. was being terminated from employment--that she (S.D.) and Respondent were having sexual relations. Cathy Bird, former chief administrative officer at the Back Center, had discussed the alleged affair with S.D. during several conversations before S.D.'s employment with the Back Center ended. Bird also talked with Respondent about the situation after S.D. was fired from the Back Center. Respondent was concerned that S.D. would tell Respondent’s wife about the affair and sought Bird’s guidance in the matter. Based upon the entirety of the clear and convincing evidence presented, Respondent was involved in a sexual relationship with S.D. at some point in time when S.D. was also a patient of the Back Center. Patient T.J. Patient T.J. was a 37-year-old patient when she saw Respondent at the Back Center on October 29, 2010. T.J. had seen Respondent professionally some 16 or so times previously. No inappropriate conduct had occurred on any of those visits. On the October 29 visit, T.J. was escorted into an examination room by a nurse as usual. Respondent came in and, after examining her, suggested that trigger point injections might help alleviate her pain, which she described as being a “2” on a scale of 1 to 10.3/ She agreed to the plan of treatment. Respondent had T.J. sit on an armless stool and lean her arms and head onto a desk. Respondent stood on her left side and began administering injections into her neck. As he leaned against her body, T.J. felt what she described as Respondent’s erect penis rubbing on her upper arm or shoulder. She felt like Respondent was intentionally rubbing her in what she later concluded to be a sexual manner. When he finished the injections, Respondent did not act any differently than usual. T.J. felt like something “weird” had just happened, but decided not to report it because she was not completely sure about her perceptions. Respondent, in contradiction to T.J.’s testimony, said he generally stayed four to five inches away from his patient when administering the injections, but would sometimes come into contact with them. T.J. returned for a follow up visit on November 24, 2010, receiving another injection by Respondent. She reported no misconduct by Respondent on that date. On December 23, 2010, T.J. returned to the Back Center for additional treatment. This time, her pain was radiating all the way down to her buttocks area and was described as a “3” out of 10. She was again escorted to an examination room to wait for Respondent. Respondent came in and closed the door, as was his usual practice during T.J.’s visits. After examining her, Respondent suggested injections for sacroiliac joint pain. T.J. was told to lie on the examination table on her left side. Respondent had T.J. lower her jeans to just below her knees. She had her left leg out straight and her right leg bent at the knee and across her left leg. Respondent then began to press his fingers on different parts of her inner thigh searching for the source of her pain. The pain was centered between her knee and buttocks area, and Respondent made an injection in that area. Respondent then had T.J. roll over to her right side as he pulled the table slightly away from the wall and placed himself between the wall and the table. Respondent began pushing on her inner thigh again, starting at her knee and moving upward toward her buttocks. As he did that, his tone of voice changed and he began panting. He continued to touch and probe her thighs as his hands went higher until he ultimately touched her vagina. T.J. immediately said, “That’s it” and quickly got off the examination table and pulled up her jeans. Respondent appeared sweaty and red-faced, looking to T.J. like a person who had just engaged in sex. T.J. then began to consider whether Respondent’s behavior during the October 29, 2010, visit had indeed been sexual in nature as well. She concluded that it was, and decided not to see Respondent for treatment in the future. She did not, however, report either of the incidents to the Back Center immediately. She ultimately did so, telling physician's assistant Korfhage about the incident some 10 months later. After seeing a report on television in 2013 that Respondent had been accused by another patient of sexual misconduct, she decided to make a report to the police about her own experiences with Respondent. When the police did not prosecute, she contacted an attorney in order to file a civil action against Respondent. T.J. appeared to be honest and forthright during her appearance at final hearing. Her testimony about her version of the events was credible, clear, and convincing. In his testimony at final hearing, Respondent did not specifically refute T.J.’s testimony so much as he explained how his normal process would not allow for the kind of touching T.J. alleged to have occurred. Respondent did not specifically or directly deny touching patient T.J.’s vagina, saying only that there would be no reason to do so. Patient D.K. (also known as D.W.) D.K. was a regular patient of Respondent and the Back Center. She had an appointment on January 13, 2011, to see Respondent for pain she was experiencing in her lower back and sides. On previous visits to the Back Center, Respondent had done localized injections to help D.K. deal with the pain. On those visits, she had simply rolled her pants down below her waist and leaned against the examination table in order for Respondent to do the injections. On the January 13 visit, she was told to lie on the table and pull her jeans down to her knees while Respondent went to prepare the medications. Respondent returned, closing the door as he came into the room. Respondent began injecting medications into her back and both sides. He then moved lower and administered injections into her thighs although she had not complained about any pain in that area. Respondent then moved her jeans down to her ankles and began administering injections into her calves. While he was injecting her, she felt him rubbing his erect penis against her thighs and heard his breathing get heavier. She could also feel Respondent lean closer to her and felt his breath on her thighs as he injected her calves. After the injections were complete, D.K. said Respondent was sweating, flushed, and “looked like my husband after we’ve had intercourse.” D.K. left the office and returned to her car. She immediately began to mentally process what had occurred to her, but did not immediately tell anyone at the Back Center. She was shocked and upset by the event but waited a few days before telling her husband what had happened. She then reported the events to someone at the Back Center. The Back Center asked her to come in so she could discuss the situation with Dr. Hynes, medical director of the Back Center. Later, D.K. made a complaint to local law enforcement about the incident. D.K. has also contacted an attorney to look into filing a civil lawsuit against Respondent. In response to the complaint by D.K., Dr. Hynes mandated that Respondent have a medical assistant with him during any contact with female patients. Despite the prohibition, Respondent continued to see female patients in an examination room without others present. He was confronted several times by the site operations manager about this violation, but Respondent did not change his behavior. D.K. was a credible witness. She provided a clear and unequivocal description of what transpired during her visit to the Back Center on January 13, 2011. Patient C.J. Patient C.J. presented to the Back Center experiencing pain as a result of shrapnel wounds received while she was serving in the U.S. Army in Afghanistan. C.J. did not testify at final hearing so her physical demeanor could not be assessed. Her deposition transcript was admitted into evidence over objection. In May 2011, C.J. was referred to the Back Center by her treating physician at Patrick Air Force Base. She took the referral, called the Back Center, and was assigned to Respondent for pain management services. C.J. went to the Back Center on May 4, 2011. She was experiencing significant pain and was physically uncomfortable. C.J. was processed in by a receptionist and then led to an examination room by a female employee. The employee took C.J.’s blood pressure, gathered some personal information, and left the room. On that date, C.J. was wearing jeans, a blouse, and open- toed shoes. She had on “full underwear” that day. Respondent came into the room and examined C.J. as she sat on the examining table. He advised C.J. that an injection might benefit her. As C.J. remembered it, the injection was to be in the side of her neck, and then in her back or hip. Respondent left the room to obtain the medications as C.J. waited. Upon his return to the room, Respondent injected Depo- Medrol 40 mg, Toradol 30 mg, Lidocaine 2% 0.5 mL, and Marcaine 0.5 mL into the left side of her neck. After the initial injection, Respondent left the room while the medication took effect. C.J. began to feel very relaxed and sleepy. Respondent recollects that C.J. complained of feeling light-headed, but does not believe any medication he injected would have caused that to happen. Respondent later returned to the room and prepared to give C.J. another injection into her hip area. She sat up on the table as Respondent pulled one end of the table slightly away from the wall.4/ After moving the table, Respondent had C.J. lie down on her side, lift her blouse, and unbuckle her jeans. She then slid her jeans and underwear down past her hips as directed. At that point, Respondent began injecting a solution into C.J.’s hip. As the injection was proceeding, she felt Respondent slide his hand over her hip and “in my groin area.” While doing that, Respondent’s crotch was pressed against C.J.’s buttocks. C.J. felt what she believed to be Respondent’s erect penis pushing against her buttocks as he administered the injection. After the injection was completed, Respondent came around from behind the table and told C.J. she would need to come see him again in a few weeks. C.J. got up from the table and began to realize that “something was not right” about the treatment she had just received. When C.J. went to the front desk to check out, she asked a nurse to identify the medications which had been injected but was unable to get that information. C.J. then left the Back Center and immediately called her nurse case manager at Patrick Air Force Base to report what had occurred. Her nurse advised C.J. to call 911 to report the incident; C.J. did so as she walked out to her car in the parking lot. A policeman arrived some 20 minutes later and took her statement. The officer then went inside to talk to Respondent. He said Respondent appeared to be surprised and shocked by C.J.’s allegation. The police decided not to file any charges against Respondent based on C.J.’s complaint. The reporting police officer (Middendorf) seemed to question C.J.’s veracity or truthfulness on the day of the incident. He said C.J. was upset and seemed lethargic, except when she was talking on the telephone to “one of her superiors.” According to Middendorf, C.J. acted consistent with someone who may be under the influence of drugs. He did acknowledge that C.J. had just come out of a pain management clinic. Middendorf also felt C.J. was either confused or not telling the truth concerning where Respondent had allegedly touched her. C.J., who was obviously distraught at the time, indicated both her pubic area and her outer thigh when she told Middendorf that Respondent had touched her “groin.” Middendorf challenged her about that and C.J. became defensive and argumentative. He did not provide any credible testimony as to why he believed she might be lying to him. His statement that C.J.’s voice changed when she was talking to her office on the phone is not conclusive evidence that she was not telling him the truth. C.J. never returned to the Back Center. She obtained pain management treatment elsewhere. Inasmuch as C.J.’s demeanor could not be judged because she did not appear in person, her testimony must be considered using other factors. In this case, the testimony was very similar to the facts described by other patients of Respondent concerning their treatment by him. The events as described by C.J. were believable and convincing, especially when compared to the allegations by other alleged victims. Neither C.J. nor any of the other alleged victims/complainants has talked to other alleged victims about their experiences, so there does not appear to be any collusion between the victims. Patient M.B. Patient M.B. was already a regular patient at the Back Center when she first saw Respondent on July 7, 2011. Respondent’s notes in M.B.’s chart indicate the patient was presenting for “initial evaluation” that day, but that was not correct; she had already been seen several times by other physicians at the Back Center. M.B. had chronic lumbalgia (low back pain) and lower extremity dysesthesia (a burning sensation) which was increasing progressively. Respondent examined M.B., discussed his findings, and scheduled a follow-up appointment for August 2, 2011, at which time he gave her an injection of 1% Xylocaine with approximately 30 ml of Lidocaine 1% on both of her side hips. He also injected a block with a solution containing 2 ml of Marcaine 0.5%, 2 ml of Lidocaine 2%, and 2 ml of Depo- Medrol 80 mg into M.B.’s joints. M.B. reported no suspicious or untoward behavior by Respondent during the July 7 and August 2 appointments. On August 29, 2011, M.B. returned to see Respondent. She presented with pain in her hips and left side. Nurse Bobbi McDonald escorted M.B. to the examination room and took her vital signs before leaving. Respondent came into the room, alone, and closed the door. At that visit, M.B. was wearing khaki mid-thigh cargo shorts, a blouse that tied around her neck, and bikini underwear. Respondent asked about her pain, touched points on her body to identify the exact pain locations, and adjusted her back manually. He then suggested injection of a steroid as a stop-gap measure prior to scheduling her for a fluoroscope injection later. M.B. agreed to the plan. Respondent left the examination room to get the medication. When he returned, he was alone and again he closed the door. Respondent told M.B. to pull her shorts down below her waist and to cover herself with a paper gown. She pulled her shorts and underwear down about halfway across her buttocks, which was lower than she would normally pull them for fluoroscope injections. Respondent began to clean the area for the injection and asked M.B. to pull her garments down further, below her buttocks. Respondent then pulled the table out from the wall and he went between the table and the wall. He injected M.B.’s hip about five times with a solution containing Depo Medrol 80, Toradol 60, Lidocaine, and Marcaine 1 ml. As he injected her, M.B. could feel Respondent’s groin touching her hip. She could feel what she believed to be Respondent’s erect penis rubbing against her in a back and forth motion. By this time, her paper gown had fallen off, exposing her buttocks and vaginal area. After the last injection, M.B. felt Respondent’s fingers touching her vagina. As she pushed upward to get off the table, M.B. felt Respondent touch her vagina again. She got off the table, pulled up her pants, and sat down as the doctor began talking to her. M.B. did not say anything to Respondent. She immediately believed that she had been sexually assaulted, but was too confused and shocked to say anything to anyone. M.B. did not initially report Respondent’s behavior to the Back Center. She later reported her allegations to the Melbourne Police Department and also filed a civil lawsuit against Respondent and the Back Center. (M.B. would continue to return to the Back Center, but did not see Respondent again for any of her treatments.) M.B.’s testimony was not as immediately believable as that of some of the other witnesses. Based on her personality, fear of the process, or some other factor, she seemed to be fairly emotionless in describing the incident. However, inasmuch as her testimony was corroborated by what other patients had experienced, her clearly enunciated statements are convincing. Further, M.B. exhibited extreme visual cues as to her intense dislike for Respondent at the final hearing. The testimony of M.B. alone would not be clear and convincing evidence of any wrongdoing by Respondent. However, her testimony is corroboration of and support for the testimony of other victims. Respondent's employment at the Back Center was terminated shortly after M.B.'s appointment with him. There is no evidence as to Respondent's employment from September 2011 until he went to Advantacare in March 2012. Patient A.H. Patient A.H. presented to Advantacare (Daytona Beach office) on January 9, 2013, in an effort to address pain she was suffering as a result of an automobile accident that occurred in October 2012. She wanted to reduce her pain while also reducing the amount of medications she was taking. A.H. had a job which required driving, so she needed to be as drug-free as possible. A.H. was escorted to the examination room. She remembers that Respondent came in, closed the door, and propped it shut. Respondent remembers the door to that room being open, that it would open by itself unless something was placed against it. The medical technician assigned to Respondent said the door did not have any problems, but it would always be half open. There is no corroborated evidence as to whether the door to the room was open, closed, or ajar when A.H. was being examined. Respondent examined A.H. and began to show her some exercises and stretches that he thought might alleviate some of her pain. As she was sitting in a chair being shown how to stretch, A.H. felt Respondent’s erect penis pushing against her back. She quickly told Respondent “I’ve got it” in order to stop his actions. She got up quickly and moved to another chair in the office. A.H. clearly described what she had felt and had no confusion or doubt about what happened. Her testimony about the incident was credible. Respondent then told A.H. to lie on the table on her side with her arms stretched out in front of her. Despite what had just happened, A.H. complied with his directions.5/ When she got into position, Respondent had A.H. move her body over to the very edge of the table and began to manipulate her back. As his hands continued down her back, she felt his hands go down inside her panties. As this happened, she could feel Respondent “humping” her, grinding his groin area against her backside. Respondent then told A.H. to change positions on the table, moving her feet to the opposite end. Amazingly, she again complied with his instructions. Respondent began touching her upper thigh near her vagina and “did the same thing he had done before.” At that, A.H. quickly moved off the table and onto a chair, where she sat rigid and refused to move. Respondent seemed calm and relaxed, showing no sign of having acted inappropriately. A.H. did not tell anyone at Advantacare about the incident on that day because she could not fully grasp what had happened. As she began to understand the situation better, she was worried about reporting the incident because it would be her word against the doctor’s. A.H. did tell another doctor (Dr. Jacobson) about the incident when she saw him the next day for a regularly scheduled appointment. Dr. Jacobson had been an employee with Advantacare and presumably relayed A.H.’s allegations to the center. A.H. also reported the incident to the Board of Health and to law enforcement. She later contacted an attorney about filing a civil lawsuit against Respondent. A.H. did not return to Advantacare for treatment after this event because of the traumatic impact of the incident. Respondent has no independent recollection of A.H. as a patient, but said he did not touch her inappropriately. A.H.’s testimony was believable. She was a credible witness and articulated her testimony clearly. It is strange that A.H. would continue to obey Respondent even after he had touched her inappropriately, but she was obviously a compliant person, especially as it relates to physicians. Respondent’s defenses to allegations by patients Respondent claims he never saw a written chaperone policy at the Back Center but that he knew that it existed. According to him, there was insufficient staff available to make it possible to comply with the policy. Respondent’s testimony in this regard is rejected as being contrary to better, more persuasive evidence. Respondent said he was on several medications for “five or six years” prior to the final hearing, including Zoloft for mild depression, Lisinopril for hypertension, and Toprol for hypertension. One of the possible side effects of those medications is impotence or erectile dysfunction. However, during the time he was taking these drugs, Respondent fathered his two children. There is no competent evidence that Respondent suffered from impotence or erectile dysfunction during the time of any of the allegations about sexual misconduct. Respondent usually wore a lab coat when treating patients. The coat is long and had large pockets in the front, at about groin level. Respondent would keep empty syringes in his coat pocket. He suggests that female patients who said they felt his erect penis were actually feeling the syringes. His suggestion is not very plausible or persuasive. Respondent demonstrated at final hearing the normal physical stance he took when doing an injection of a patient in an examination room setting. He suggested that his body would be turned at a 45-degree angle from the patient rather than facing them directly, thus eliminating the possibility of full frontal contact with the patient. He also said that he generally stood four or five inches away from the patient, but might come into contact with the patient occasionally. Neither the statements nor his demonstration were persuasive. Respondent’s contention is that each and every one of the patients who alleged sexual misconduct was lying. He suggests that patient D.K. was overweight and thus would not have sexually aroused him. Also, he maintains that her description of the injections being performed while Respondent was rubbing against her would have necessarily resulted in horrible pain at best or a broken needle at worst. He claims that since patient M.B. was married to a policeman, she would have necessarily taken photographs of her numerous injections to preserve a record and she would have complained immediately. Her failure to do so, he suggests, impugns her testimony. Respondent contends that patient T.J.’s tardiness in reporting her allegations suggests the allegations were false. Respondent refutes A.H.’s allegations on the basis that there was a disagreement as to the physical layout of the medical office. Respondent contends there is no evidence that patient S.D. (his alleged lover) was his patient, even though there is a stipulation to that effect. Despite these speculative defenses, the evidence presented by the alleged victims is credible and accepted as fact. Failure to update practitioner profile A letter dated March 27, 2013, advising Respondent of his termination from participation in the Medicaid Program, was mailed to Respondent at two separate addresses: 2222 South Harbor City Boulevard, Suite 610, Melbourne, Florida 32901, i.e., the address of the Back Center, and 930 South Harbor City Boulevard, Melbourne, Florida 32901, the address for Osler (the company with whom the Back Center merged at some point in time). The letter to 2222 South Harbor City Boulevard was received on April 1, 2013, and an acknowledgement was signed by Chandra Carrender, a Back Center employee. Respondent’s employment with the Back Center had been terminated some 16 months previously, i.e., in August 2011. The letter mailed to 930 Harbor City Boulevard was returned as undeliverable. The termination letter provided Respondent notice of his right to contest the decision. He was given 21 days from receipt of the letter to file a Petition if he wanted to challenge the termination. Respondent did not file a challenge, so on or about June 21, 2013, a Termination Final Order was filed by the Agency for Health Care Administration (AHCA), setting forth Respondent’s termination from participation in the Florida Medicaid Program. The termination was issued pursuant to section 409.913, Florida Statutes. By law, Respondent was required to update his Florida practitioner profile within 15 days of receipt of the Termination Final Order. The Termination Final Order was mailed to Respondent, return receipt requested, at two different addresses: The 930 South Harbor City Boulevard address and the 2222 South Harbor City Boulevard address. Respondent denies having received the letter or TFO until just prior to the formal administrative hearing in this matter. Licensed physicians in the State of Florida are required to maintain a current address of record with the Agency for Health Care Administration (AHCA) and the Department of Health. Neither Respondent nor the Department provided evidence as to what Respondent’s official address of record was at the time the TFO and the letter were sent to Respondent at the two Harbor City Boulevard addresses. According to the deposition testimony of Michael West of the AHCA Medicaid Program Integrity office, the notices were sent to Respondent’s “address of record” per section 409.913(6), Florida Statutes. West’s testimony, however, did not specify what address that was. It might be logically presumed that one or both of the Harbor City Boulevard addresses were the “address of record,” because that is where the notices were mailed. However, there is no clear and convincing evidence as to Respondent’s official address of record at the time the Termination Final Order was mailed. The statutory section referred to by West states: Any notice required to be given to a provider under this section is presumed to be sufficient notice if sent to the address last shown on the provider enrollment file. It is the responsibility of the provider to furnish and keep the agency informed of the provider’s current address. United States Postal Service proof of mailing or certified or registered mailing of such notice to the provider at the address shown on the provider enrollment file constitutes sufficient proof of notice. Any notice required to be given to the agency by this section must be sent to the agency at an address designated by rule. Respondent did not update his Florida practitioner profile because he claims never to have received a copy of the TFO or the letter. Neither Respondent nor the Department provided direct evidence of Respondent’s “address last shown on the provider enrollment file” as of March 27, 2013.6/ Other factual considerations Respondent was terminated from employment at the Back Center in September 2011. The termination occurred as follows: T.J. reported the alleged October 29, 2010 incident in April 2011. Dr. Hynes was already aware of another incident (from D.K. in January 2011). Dr. Hynes met with Respondent to discuss his alleged behavior. Respondent denied the allegations, saying that people just seem to like him and take advantage of him. He said the patients were lying about the incidents. Dr. Hynes mandated at that time that Respondent have a chaperone in the examining room with every female patient. Rather than being allowed to exercise “medical judgment” like other doctors in the clinic, Respondent was ordered to always use a chaperone with all female patients. After patient C.J.’s allegations came to light in May 2011, Dr. Hynes told Respondent that three times was enough; something had to be done. The Back Center commenced preparation of a termination letter. The letter was to tell Respondent that, pursuant to his Employment Agreement, the Back Center was providing him the 180-day notice of termination of employment “without cause.” The purpose of that letter was to allow Respondent time to find a job and not have a blemish on his record. One of the bases for the termination letter was that Respondent had been referred to the Physicians Recovery Network (PRN) for counseling to address his behavior. Dr. Hynes presumed Respondent was obtaining that counseling. However, when C.J. reported the incident on May 4, 2011, Dr. Hynes found out that Respondent had not been going to PRN as he had previously indicated. At about the time the 180-day letter was being drafted, another incident (by patient M.B.) was reported to the Back Center. Upon hearing of that allegation, Dr. Hynes verbally fired Respondent, effective immediately, with cause. The 180-day letter was not actually delivered to Respondent until after the verbal termination, so the letter was moot when it arrived. Respondent did not tell his next employer, Advantacare, that he had been terminated from employment by the Back Center. He also did not advise Advantacare about the sexual allegations made by patients at the Back Center. In summary, Respondent engaged in activities of a sexual nature with patients at the Back Center in December 2010, January 2011, May 2011, and August 2011 (in addition to his relations with S.D. in 2008–2010). He engaged in sexually related touching of a patient at Advantacare in January 2013. His employment with the Back Center was terminated in September 2011; his employment with Advantacare was terminated in April 2013. Former patients of Respondent expressed dismay that he was being charged with the violations set forth in the Administrative Complaint. They found Respondent to be a caring and professional doctor. It is clear Respondent did not treat all his patients the same way he treated the victims identified herein. Some of his co-workers said they did not see Respondent engage in any of the alleged actions. They did not receive any complaints from other patients. Respondent obviously has a stellar reputation with some of his patients and co-workers. That status, however, does not excuse his behavior with the victims in the present cases. It is also alleged that Bobbi McDonald was a rumor-mongerer and a liar. She appeared credible at final hearing and there is no competent, substantial evidence to support the dispersions cast by others. It should be noted that several witnesses identified by Respondent were displeased with the manner in which they were questioned by Department personnel prior to the final hearing. The witnesses expressed extreme discomfort when Department employees (attorneys) suggested that Respondent was “an addict” or a sociopath. While a state agency is bound to pursue all claims against individuals which it is responsible for licensing and monitoring, it is improper to harangue or disparage such persons in order to sway potential witnesses’ testimony. Upon full review of the evidence in this case, the potential witnesses who complained about the Department’s aggressive nature did not provide substantive testimony on the issues of this case. Thus, any harm which may have resulted from the Department’s statements would not affect the final decision herein.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Department of Health revoking Respondent, Albert Esmailzadeh, M.D.’s license to practice medicine in the State of Florida. It is further RECOMMENDED that the final order assess the cost of investigating and prosecuting this case, and that payment of such costs be assessed against Respondent, Albert Esmailzadeh, M.D. DONE AND ENTERED this 19th day of November, 2014, in Tallahassee, Leon County, Florida. S R. BRUCE MCKIBBEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 19th day of November, 2014.
The Issue This is a license discipline case in which the Petitioner seeks to take disciplinary action against the Respondent, a physician specializing in psychiatry, on the basis of allegations that he violated subsections (j), (t), and (x) of Section 458.331(1), Florida Statutes, by engaging in a sexual relationship with one of his psychiatric patients.
Findings Of Fact The Respondent is, and has been at all times material hereto, a licensed physician in the State of Florida, having been issued License Number ME 0041587. The Respondent was employed by the Nova University Community Mental Health Clinic ("Nova Clinic") in Coral Springs, Florida, from about October of 1987 until September 21, 1989. The Respondent was employed by the Nova Clinic to perform initial psychiatric evaluations of Nova Clinic patients and to manage the medication of the Nova Clinic patients who required medication. In this capacity, on May 11, 1988, the Respondent performed an initial psychiatric evaluation on a Nova Clinic patient named C. P., who was at that time a 17-year- old female patient. An intake evaluation performed on May 10, 1988, and the Respondent's psychiatric examination on May 11, 1988, reveal that C. P. came to the Nova Clinic with a history of depression and a prior suicide attempt at age 14. She had been hospitalized for the previous month at Fair Oaks Hospital. At the hospital she had received treatment for severe depression which resulted from her obsession with a married high school teacher and the loss of that emotional relationship. When admitted to Fair Oaks Hospital, C. P. had experienced some auditory hallucinations, paranoia, suicidal ideation, and social withdrawal. She reported a dysfunctional family history and intense feelings of rejection by her divorced parents. The three-year obsession with her high school teacher and the realization that it would go nowhere was the precipitating factor in the depression that led to her hospitalization. C. P. consistently contended that there had never been any inappropriate physical or sexual contact between herself and the teacher who was the object of her obsession, although she had fantasies that such might eventually happen. During her hospitalization at Fair Oaks there was a remission of her psychotic symptoms and of her overt depressive symptoms, and by the time of her discharge she was gaining insight into her relationship with the teacher. Her Axis I discharge diagnosis was "Major depression, single episode, with psychotic features." Her Axis II discharge diagnosis was "Personality disorder NOS (non specified) with borderline and dependent features." Upon discharge from Fair Oaks Hospital she was to continue outpatient psychotherapy at the Nova Clinic. C. P. began weekly therapy sessions with Dana Bennett, a child therapist at the Nova Clinic, on May 23, 1988, which continued through June 6, 1989. C. P. continued therapy sessions at Nova Clinic with Mary Bertera, a clinical psychologist, from August of 1989 until February of 1990. During her therapy session with Ms. Bennett, C. P. always denied any physical contact between herself and the teacher who had been the object of her obsession. The only two hallucinations experienced by C. P. during the period of her therapy at Nova Clinic occurred while she was taking Prozac or Stelazine. The hallucinations she described were non-sexual in nature. During the period of her therapy at Nova Clinic, C. P. did not make any suicide attempts. While C. P. was seeing the Respondent for medical management at the Nova Clinic, she developed a growing attraction for him. She mentioned this to the Respondent and he suggested that she speak to Dana Bennett about her feelings. C. P. followed his suggestion. On several further occasions C. P. again mentioned to the Respondent her growing attraction for him. The Respondent told her that he was also attracted to her, but that because he was her psychiatrist he could not pursue any sort of relationship with her. On several occasions C. P. asked the Respondent if they could go out for lunch or dinner. The Respondent told her that although he was attracted to her and would like to do so, he could not. Sometime during the fall of 1988 the Respondent had a conversation with Mary Bertera (who was not C. P.'s therapist at that time) during which he discussed his attraction to C. P. During that conversation he mentioned C. P. by name, stated that she had been leaving cards and letters for him, stated that he was attracted to C. P. and that he would not mind going out with C. P. After an automobile accident on December 12, 1988, C. P. called the Respondent for some medication advice. During the course of that conversation C. P. asked the Respondent when they would be getting together. His reply was to the effect that she should not give up hope, that he was going away for the holidays, but would talk with her shortly after New Year's Day. On January 3, 1989, C. P. had a medication management session with the Respondent. Towards the end of their session the Respondent told C. P. that he was getting off work early that evening and asked if she could meet him. She agreed that she would meet him later that same day. At about 7:30p.m. on January 3, 1989, C. P. drove back to the Nova Clinic parking lot, parked next to the Respondent's automobile, and sat in the car she was driving while waiting for the Respondent. Shortly thereafter, the Respondent walked into the parking lot, got into the car with C. P., and C. P. drove the car to Margate Park. There they shared a bottle of wine C. P. had brought with her. While sitting in the car drinking wine, they kissed for the first time. Then they drove to a restaurant where they had drinks and something to eat. Eventually they drove back to the Nova Clinic parking lot where they sat in the car, talked, kissed, and eventually had sexual intercourse in the car. The sexual encounter on January 3, 1989, initiated an intimate sexual relationship between C. P. and the Respondent which continued until October 14, 1989. During the period from January to October of 1989, C. P. and the Respondent engaged in sexual intercourse in a variety of settings; at the home of C. P.'s mother, at the home of one of C. P.'s friends when C. P. was house- sitting, at C. P.'s father's house, at the Respondent's rental apartment, at the Respondent's private office before it was open, and at various hotels or motels. During the time that the Respondent and C. P. were involved in the sexual relationship the Respondent also maintained a social relationship with C. P. and her family. The Respondent took C. P. out to lunch or dinner on numerous occasions. On numerous occasions the Respondent visited C. P. at her father's house and often picked her up at her father's house to take her out for lunch or dinner. On one occasion the Respondent escorted C. P. to a birthday party held at the home of one of C. P.'s aunts to celebrate the sixteenth birthday of one of C. P.'s cousins. During the time that the Respondent and C. P. were involved in the sexual relationship they were often openly affectionate in public places. They often hugged and kissed in public places. During the time that the Respondent and C. P. were involved in the sexual relationship the Respondent gave C. P. gifts of clothing, jewelry, flowers, money, and cards. The gifts of money totaled several hundred dollars. At various times during the course of the sexual relationship, the Respondent told C. P. that he loved her and discussed future plans for the two of them. On at least one occasion he told her he wanted to divorce his wife and marry C. P. Towards the end of August of 1989 the Respondent told C. P. that he had decided that he could not divorce his wife, primarily because of the Respondent's concerns about the effect a divorce would have on the Respondent's son. C. P. became very angry and upset by the information that the Respondent no longer planned to marry her. On August 30, 1989, the Respondent admitted to Carol Trick that he had been having a sexual affair with C. P. for the previous eight months. During the course of his conversation with Carol Trick, the Respondent described some details of the sexual affair that are corroborated by other evidence. A few days later, Carol Trick told the Director of the Nova Clinic that the Respondent had admitted to her that he was having a sexual affair with C. P. The Respondent and C. P. had a final sexual liaison on October 14, 1989, at a motel in Delray. On C. P.'s birthday, October 27, 1989, the Respondent sent her a gold rope chain and a dozen yellow roses. Although C. P. had been relatively happy during the spring of 1989, following the termination of the sexual relationship with the Respondent she became very depressed and developed eating disorders. C. P. discontinued therapy at the Nova Clinic and began psychiatric therapy with Joel Klass, M. D., on February 20, 1990. As of the date of the formal hearing, C. P. was still a patient of Dr. Klass. Based at least in part on her experiences with the Respondent, C. P. continues to be depressed and is distrustful of psychologists and psychiatrists. This distrust has impeded her progress in therapy. Expert medical testimony in this case establishes that sexual intercourse between a psychiatrist and his patient is a clear violation of acceptable standards of care and is explicitly prohibited by psychiatric standards of ethics. Such conduct is a violation and is prohibited even when the psychiatrist functions only in a supervisory or medical management role. Such conduct is a violation and is prohibited even when the sexual activity is initiated by the patient. Any sexual activity between a psychiatrist and a patient violates the mutual trust between the psychiatrist and the patient. There are no circumstances under which sexual activity between a psychiatrist and a patient is appropriate; such conduct is always a departure from acceptable standards of care. A competent psychiatrist should recognize the symptoms of erotic transference in a patient. Where such symptoms are present, if the psychiatrist also feels an erotic interest in the patient the psychiatrist should note the problem in the patient's records, should attempt to deal with it therapeutically, or should transfer the patient to another therapist. Social entanglement between a psychiatrist and a patient of the type described in Paragraph 11 of these findings of fact is also a departure from acceptable standards of care.
Recommendation On the basis of all of the foregoing, it is RECOMMENDED that the Board of Medicine issue a Final Order in this case concluding that the Respondent is guilty of all three of the violations charged in the Administrative Complaint and imposing a penalty consisting of revocation of the Respondent's license and an administrative fine in the amount of $5,000.00 for each of the three violations, for a total administrative fine of $15,000.00. DONE AND ENTERED this 29th day of June, 1994, at Tallahassee, Leon County, Florida. MICHAEL M. PARRISH, 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 29th day of June, 1994.
Findings Of Fact Based upon the stipulation filed in this cause, the testimony of the witnesses, and the documentary evidence received at the hearing, the following findings of fact are made: The Respondent, Randall E. Pitone, M.D., is a medical doctor licensed (license number ME 0029098) by the State of Florida since 1976. Respondent is a diplomate in psychiatry having received certification from the American Board of Psychiatry and Neurology. At all times material to the allegations of this case, Respondent was in the practice of psychiatry in the State of Florida. Respondent has been affiliated with or authorized to practice in a number of hospitals in the Pinellas County area. He enjoys a good reputation among the community of practicing psychiatrists and has covered for several of them during the course of his practice. The Respondent became Patient 1's treating psychiatrist in 1982 when the patient was almost 18 years of age. Patient 1 has a borderline personality disorder and other problems for which she required treatment. In order to more effectively provide treatment for borderline patients, Respondent attended at least two courses related to borderline personality disorder during the early 1980s. From September, 1982 through May, 1988, Respondent treated Patient 1 with individual psychotherapy. During this time, Patient 1 was hospitalized on several occasions and Respondent counseled with her within the hospital setting and at his office. Borderline patients are typically very needy, seductive, and manipulative in their approach to others. During her period of treatment Patient 1 frequently attempted to initiate a romantic relationship with Respondent who diplomatically refused her advances. On each of these occasions, Respondent explained to Patient 1 that he could not have a romantic relationship and continue therapy. Also during this period, Respondent was married and devoted to his family. In May, 1988, Respondent and Patient 1 ended their formal physician- patient relationship. Patient 1 was not sincerely pursuing therapy. Additionally, she had a new boyfriend with whom she seemed happy. Respondent encouraged her to seek therapy but she mistakenly believed that she did not need it. Although she would periodically drop by to visit with Respondent, she did not make appointments for therapy. Nor did she obtain therapy from another psychiatrist despite Respondent's encouragement for her to do so. Respondent's wife left him sometime in 1988. Her departure was very difficult for Respondent. The couple divorced in June, 1988, and Respondent's former wife remarried shortly thereafter and moved to Georgia. Respondent's children resided with him until sometime in 1989 when they moved to their mother's home. Subsequently, Respondent allowed Patient 1 to move into his home. She resided with him from June, 1989 until April, 1990. Throughout this period of cohabitation, Respondent included Patient 1 in his family activities. She went to his brother's home with him for Christmas and went on a cruise to Jamaica with his relatives. Respondent did not hide their relationship from his family or friends. During this period Respondent and Patient 1 engaged in sexual intercourse. Patient 1 has been hospitalized on several occasions since 1982. During one such hospitalization, on or about October 30, 1988 (after formal therapy had ended), Dr. Helm consulted with the Respondent regarding Patient 1's suspected drug abuse. Patient 1 has a serious addiction to alcohol, cocaine, and crack cocaine. This addiction dates at least as far back as the summer of 1989, and perhaps earlier. Respondent knew of Patient 1's addiction to cocaine and of her abuse of other substances. Respondent prescribed medications for Patient 1 in a misguided effort to wean her from street drugs. Whenever Respondent refused to give Patient 1 prescriptions, she would become outraged and destructive. On one such occasion, Patient 1 exited the car in which the couple was travelling and bolted in front of an oncoming truck. As a result Patient 1 was hospitalized with a broken pelvis. Between May, 1988, and March, 1990, Respondent wrote or authorized the prescriptions listed in attachment A for Patient 1. These prescriptions were given to Patient 1 despite the fact that she was no longer formally receiving psychotherapy from Respondent. Moreover, many of the prescriptions issued are not of the type generally associated with the treatment of psychiatric patients since they are more commonly associated with pain relief. Amitriptyline is a legend drug. Dalmane is a brand name of flurazepam, a legend drug and controlled substance. Valium is a brand name of diazepam, a legend drug and controlled substance. Xanax is a brand name of alprazolam, a legend drug and controlled substance. Darvocet is a brand name of a compound containing propoxyphene, a legend drug and controlled substance. Tylenol #3 and Tylenol #2 are brand names of acetaminophen or apap with codeine, legend drugs and controlled substances. Percodan is a brand name of oxycodone with aspirin, a legend drug and controlled substance. Percocet is a brand name of oxycodone with acetaminophen or apap, a legend drug and controlled substance. Legend drugs are required by federal or state law to be dispensed only on a prescription. Respondent inappropriately prescribed legend drugs/controlled substances to Patient 1. Respondent prescribed drugs for Patient 1 after they were living together and engaging in sexual relations. The types and quantities of prescriptions written by Respondent for Patient 1 were not justified by examinations and records maintained by the Respondent, were not issued in the course of medical practice, and were clearly excessive. By prescribing the drugs listed in attachment A, Respondent failed to provide Patient 1 with that level of care, skill and treatment, which a reasonably prudent similar physician recognizes as acceptable under the conditions and circumstances of this case. Respondent also failed to seek consultation in connection with his concerns over Patient 1. Instead, Respondent set himself up as her sole provider and savior. This action was medically inappropriate and further evidences Respondent's loss of objectivity in this instance. In effect, Respondent became a patient in need of treatment as a result of his erroneous and misguided efforts to assist Patient 1. On April 11, 1990, an order of emergency restriction of Respondent's license was issued by Larry Gonzalez, acting as Secretary of the Department. That order placed specific restrictions on the Respondent's license which include: -the prescription of controlled substances utilizing sequentially numbered triplicate prescriptions; -the review of each prescription by a supervisory physician; -the prohibition of providing medical services to Patient 1; and -the submission of monthly reports by a monitoring physician which includes specific information regarding Respondent's practice, any problems, a review of prescriptions and patient records. To date, Respondent has complied with the restrictions placed on his license. Additionally, Respondent has sought and obtained psychiatric counseling in connection with his errors in thinking related to his relationship with Patient 1. Respondent developed a rescue fantasy in which he perceived that he alone could assist Patient 1 recover from her illnesses. This was not a medically sound approach to the dilemma within which Respondent became embroiled. As Respondent fell in love with Patient 1, he lost his professional perspective and undertook this ill-fated rescue of her. An examination of Respondent's medical records does not suggest that the activities which gave rise to the allegations of this case have occurred regarding other patients. From the circumstances of this case, it is unlikely another incident or series of incidents of this type will recur. Sexual activity between a psychiatrist and his patient has detrimental effects on the patient. In this instance, that conduct had detrimental effects on both the Respondent and Patient 1. Since Respondent fell prey to Patient 1's manipulative nature, his judgment became impaired and she was able to orchestrate an inappropriate response from Respondent. It cannot be found, however, that Respondent used their relationship to induce Patient 1 to engage in sexual activity.
Recommendation Based on the foregoing, it is RECOMMENDED: That the Department of Professional Regulation, Board of Medicine enter a final order finding the Respondent guilty of violating Sections 458.331(1)(m), (q), and (t), Florida Statutes, and imposing the following penalties: suspension of the Respondent's license for a period of one year during which time the Respondent shall continue counseling, followed by a two year period of probation under the terms set forth in the emergency order issued April 11, 1990, together with an administrative fine in the amount of $5,000.00. DONE and ENTERED this 14 day of November, 1990, in Tallahassee, Leon County, Florida. Joyous D. Parrish Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 14 day of November, 1990. APPENDIX TO CASE NO. 90-3276 RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY THE DEPARTMENT: Paragraphs 1 through 20 are accepted. With regard to paragraph 21 it is accepted that Respondent provided the prescriptions as described, however, he had formally ended psychotherapy of Patient 1 in May, 1988. It was inappropriate for him to issue the prescriptions. Paragraphs 22A. and 22C. are accepted. Paragraph 22D. is rejected to the extent that it finds Respondent did not maintain appropriate records, otherwise, rejected as contrary to the weight of the credible evidence. Note: there is no paragraph 22B. Paragraph 23 is accepted. Paragraph 24A. is accepted. Paragraphs 24B. and 24C. are rejected as contrary to the weight of credible evidence. With regard to paragraph 25 it is accepted that Respondent prescribed substances for Patient 1 inappropriately and excessively, otherwise the paragraph is rejected as contrary to the weight of the evidence or a conclusion of law. Paragraphs 26, 27, 30 and 31 (because it allowed her to manipulate Respondent into prescribing inappropriately--he should have been the physician not a co-patient) are accepted. Paragraphs 28 and 29 are rejected as contrary to the weight of credible evidence. RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY THE RESPONDENT: Paragraphs 1 through 3 are accepted. To the extent addressed in findings paragraphs 3 through 7, Respondent's paragraphs 4 through 9 are accepted; otherwise rejected as irrelevant or a recitation of testimony. With the exception of the last sentence, paragraph 10 is accepted. The last sentence is rejected as speculative or conjecture--it is accepted that Respondent was in a stress-filled, emotional situation. Paragraphs 11 through 14 are accepted. Paragraph 15 is rejected as irrelevant. Paragraph 16 is accepted but is irrelevant. Paragraph 17 is accepted. Paragraphs 18 through 19 are accepted. Paragraphs 20 through 23 are rejected as recitation of testimony but see findings of fact paragraphs 27, 28, and 29. Paragraphs 24 through 28 are rejected as recitation of testimony. With regard to paragraph 29 it is accepted that the Respondent does not pose a threat to the public under his current circumstances. Otherwise, paragraph 29 is rejected as recitation of testimony or irrelevant. Paragraph 30 is accepted. Paragraph 31 is rejected as recitation of testimony. Paragraph 32 is accepted. Paragraph 33 is accepted. ATTACHMENT A Date Drug Prescribed 5/14/88 Dalmane 6/02/88 Valium 7/15/88 Percodan 7/20/88 Percodan 7/27/88 Xanax 7/27/88 Percodan 8/12/88 Percodan 9/06/88 Percodan 9/13/88 Zantac 9/23/88 Percodan 10/7/88 Darvocet N-100 10/29/88 Xanax 11/18/88 Percodan 01/6/89 Xanax 1 mg 01/09/89 Xanax 1 mg 01/10/89 Percodan 01/11/89 Xanax 01/16/89 Xanax 01/18/89 Xanax 01/21/89 Xanax 01/20/89 Tylenol 3 01/24/89 Tylenol 3 01/25/89 Tylenol 3 01/26/89 Xanax 01/31/89 Xanax 02/02/89 Percodan 02/04/89 Xanax 1mg 02/04/89 Percodan 02/04/89 Xanax 1mg 02/09/89 Percodan 02/10/89 Xanax 02/10/89 Percodan 03/03/89 Xanax 03/03/89 Percodan 03/13/89 Percodan 03/14/89 Xanax 1mg 03/17/89 Percodan 03/20/89 Xanax 03/24/89 Xanax 03/24/89 Percodan 03/27/89 Percodan 03/27/89 Xanax 03/29/89 Percodan 03/31/89 Percodan 04/07/89 Xanax 1mg 04/10/89 Percocet 5mg 04/11/89 Percodan 04/21/89 Percodan 04/24/89 Percodan 04/25/89 Percodan 04/25/89 Xanax 04/26/89 Percodan 04/28/89 Percodan 04/28/89 Xanax 04/29/89 Percodan 05/01/89 Xanax 05/02/89 Percodan 05/04/89 Percodan 05/05/89 Percodan 05/09/89 Xanax 05/11/89 Xanax 05/14/89 Xanax 1 mg 05/18/89 Xanax 1 mg 05/20/89 Xanax 1 mg 06/06/89 Xanax 1 mg 06/08/89 Percodan 06/09/89 Xanax 1 mg 06/09/89 Percodan 06/14/89 Xanax 1 mg 06/14/89 Percodan 06/16/89 Xanax 1 mg 06/23/89 Xanax 1mg 06/24/89 Percodan 06/26/89 Percodan 07/01/89 Xanax 07/07/89 Xanax 1 mg 07/07/89 Percodan 07/10/89 Percodan 07/15/89 Percodan 07/17/89 Percodan 07/20/89 Percodan 07/21/89 Valium 10 mg 07/21/89 Percodan 07/28/89 Percodan 07/30/89 Valium 07/31/89 Percodan 08/02/89 Percodan 08/04/89 Percodan 08/05/89 Valium 10 mg 08/07/89 Valium 10 mg 08/07/89 Percodan 08/09/89 Percodan 08/20/89 Valium 10 mg 09/01/89 Percodan 09/04/89 Valium 09/06/89 Percodan 09/19/89 Percodan 09/22/89 Valium 09/22/89 Percodan 09/28/89 Percodan 10/01/89 Percodan 10/02/89 Percodan 10/02/89 Valium 10 mg 10/04/89 Valium 10 mg 10/04/89 Percodan 10/05/89 Xanax 1 mg 10/06/89 Percodan 10/13/89 Darvocet-N. 100 10/13/89 Valium 10/13/89 Tylenol #2 10/17/89 Tylenol #2 10/19/89 Valium 5 mg 10/20/89 Tylenol #3 10/24/89 Tylenol #3 10/24/89 Valium 5 mg 10/25/89 Tylenol #3 10/26/89 Percocet 10/30/89 Percocet 10/30/89 Tylenol #4 10/30/89 Valium 10 mg 11/03/89 Percodan 11/17/89 Percodan 11/17/89 Valium 10 mg 11/24/89 Valium 10 mg 11/24/89 Percocet 11/27/89 Percocet 11/29/89 Percocet 01/02/90 Valium 10 mg 01/02/90 Percodan 01/12/90 Tylenol #3 01/12/90 Valium 10 mg 01/13/90 Xanax 1 mg 01/17/90 Tylenol #3 02/04/90 Xanax 1 mg 02/17/90 Percodan 02/20/90 Percodan 02/28/90 Percodan 03/10/90 Percodan 03/16/90 Percodan 03/17/90 Percodan COPIES FURNISHED: Bruce D. Lamb Chief Trial Attorney Department of Professional Regulation 730 Sterling Street, Ste. 201 Tampa, Florida 33609 Grover C. Freeman FREEMAN, LOPEZ & KELLY, P.A. 4600 West Cypress, Ste. 500 Tampa, Florida 33607 Dorothy Faircloth Executive Director Board of Medicine Department of Professional Regulation Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792 Kenneth E. Easley General Counsel Department of Professional Regulation Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792
The Issue The issue presented by this case concerns the question of whether the Respondent, State of Florida, Department of Health and Rehabilitative Services has exhausted all treatment for the Petitioner, John P. Wordsman, III, through available sex offender programs administered by the Respondent. See Section 917.20, Florida Statutes (1977).
Findings Of Fact The Petitioner submitted a "Petition for Administrative Determination" to the State of Florida, Department of Health and Rehabilitative Services. In turn, the Department requested the Division of Administrative Hearings to conduct a formal hearing to consider the matters set forth in the petition and this request was received by the Division of Administrative Hearings on January 13, 1981. A final hearing in this cause was scheduled for January 30, 1981, but was not conducted until March 3, 1981, to allow Petitioner to secure representation. In the course of the final hearing the Petitioner testified in his own behalf. The Respondent called as witnesses Lois P. Stevens, Staff Psychologist in the forensic service at the Florida State Hospital and Robert H. Alcorn, Jr., Director of the Mentally Disordered Sex Offender Program at the Florida State Hospital. Petitioner had two exhibits admitted. Respondent's Exhibit No. 1 was admitted into evidence. At all times pertinent to this proceeding, the Petitioner has been in the custody of the Respondent in keeping with the order of the Circuit Court of Duval County, Florida, and the authority of Chapter 917, Florida Statutes (1977). Beginning July 28, 1978, through the present, Petitioner has resided in the Florida State Hospital at Chattahoochee, Florida, where he is undergoing treatment in a hospital program for the benefit of mentally disordered sex offenders. This program and similar programs in other institutions administered by the Respondent require a high degree of motivation on the part of the patient in order to achieve success. Although the Petitioner has made progress in the course of his stay, the Respondent has made a preliminary determination that it has exhausted all appropriate treatment for the Petitioner through the program in which he is enrolled and has additionally concluded that similar programs within the State of Florida do not offer other opportunities for progress. In that respect, the Respondent has exhausted treatment in the affiliated programs. The principal treatment modality in the mentally disordered sex offender program at Florida State Hospital is group therapy. The Petitioner has participated in the group therapy sessions during his current hospitalization but no significant change in his behavior has been observed during this period. His condition has been diagnosed as (1) sexual deviation, pedophilia, (2) homosexuality, and (3) alcoholism. The petitioner has been placed with the Department of Health and Rehabilitative Services following a plea or nolo contendere to the offense of sexual battery, involving an attempted rape. Referring again to the Petitioner's participation in the principal treatment modality, i.e., group therapy, Petitioner has worked in a group headed by a male psychologist, staff worker and subsequently, a group with a female staff worker. The change to the female staff worker was to assist the Petitioner in dealing with his relationship with females. His attitude toward females has been described as Victorian in that he had problems relating to women who fulfilled roles other than child bearing. Through the group discussions, the Petitioner has talked about his preference for homosexual life style and his problem with alcoholism. Wordsman has not discussed his problems with pedophilia. In the group sessions, his "feedback" under discussion of his life's circumstance is confusing and his motivation in those sessions is not genuine. In this connection, the Petitioner's attitude has been described as one of playing "head games," especially with his principal advisor and therapist, Lois Stevens. This attitude in essence means the Petitioner has feigned sincere participation. His explanation for this tactic is to the effect that he wanted the treatment but that he did not feel that he was up to the occasion of sincerely applying for it. The Petitioner does not wish to engage in specific topics in the group therapy sessions and is distrustful of people, to the extent that he would not confide in others. When pressed to give specific responses during the course of the group therapy sessions, the petitioner becomes stressful and will not give answers to the questions posed. The form of treatment in the sex offender program requires honesty in the responses of the participants and the Petitioner has difficulty complying with this standard. In the course of the group sessions and in dealing with the subject of his crime, the Petitioner would not give specific responses other than to say that he remembers events around the time period of the act; however, he indicates that he may have been on alcohol when it occurred. The only brief progress that the Petitioner has shown in relating to his problems in the group therapy sessions occurred immediately after he had been told that the staff was recommending his return to the committing court. At that juncture, he became more sincere in the first session, but immediately reverted back to a superficial and shallow manner of dealing with the treatment form. The Petitioner has been involved in other therapy activities to include music, leather and wood therapy, a program for alcoholics, and occupational therapy. Petitioner is an accomplished musician and has performed well in that form of therapy and in addition has made notable progress in occupational therapy. Notwithstanding the progress in these therapy areas, his failure to make satisfactory progress in the group therapy sessions, which sessions are the primary agent for change in the underlying condition of the patient, has lead the hospital staff to the conclusion that it has exhausted treatment of those conditions. Continued success in the other related therapy does not have a significant effect in alleviating his condition. This opinion is expressed in the most recent staffing summary of December 10, 1980, a copy of which has been admitted as Respondent's Exhibit No. 1. In addition to the staffing achieved by Florida State an interdepartmental screening was conducted of the Petitioner's condition and the question of exhaustion of treatment in the sex offender programs and it was the opinion of the unit directors of the sex offender programs within the Respondent Department's organization that the overall Department had exhausted treatment for the Petitioner in the sex offender programs. It is the opinion of the Department that the Petitioner continues to meet the definitions of sex offender within the meaning of Chapter 917, Florida Statutes. Wordsman feels that he has made progress in dealing with people around him and that he gets along better than he did before his commitment to the program. He has expressed concern that the staff is "out to get him" and that the group therapy sessions are not adequate to deal with his problem. He prefers to be placed in a program for behavior disorders with specific emphasis on drug abuse, in that he feels his problems arise when he becomes intoxicated. His reaction to the current program In which he is placed is summed up by his remark that he does net "understand what the staff wants from him."
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby, RECOMMENDED: That a final order be entered by the Department of Health and Rehabilitative Services finding that it has exhausted all appropriate treatment for John P. Wordsman, III, and that said John P. Wordsman, III, be returned to the committing court for further disposition. DONE and ENTERED this 19th day of March, 1981, in Tallahassee, Florida. CHARLES C. ADAMS, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 19th day of March, 1981 COPIES FURNISHED: Gerry L. Clark, Esquire Florida State Hospital Chattahoochee, Florida 32324 J. Craig Williams, Esquire 335 East Bay Street Jacksonville, Florida 32201
