The Issue Whether Petitioner is entitled to sit for the examination for licensure as a physician assistant.
Findings Of Fact Petitioner is an applicant to sit for the examination for licensure as a physician assistant in Florida. Petitioner relies on the provisions of Section 458.347(7)(b), Florida Statutes, which provide, in pertinent part, as follows: 1. . . . [T]he department shall examine each applicant who the board certifies: Has completed the application form ... Is an unlicensed physician who graduated from a foreign medical school listed with the World Health Organization ... Has applied for certification as a physician assistant in this state between July 1, 1990, and June 30, 1991. Was a resident of this state on July 1, 1990. . . Petitioner's application to sit for the examination for licensure as a physician assistant was denied by an Order entered by the Board of Medicine on March 12, 1992. The Order cited the following four grounds for the denial: The applicant (Petitioner) does not have a medical degree as required by Sections 458.347(b)1.b. and 458.311(1)(f)3.a., Florida Statutes. The applicant has been unable to provide adequate evidence that he was a resident in Florida on July 1, 1990. The applicant has failed to account for all time and activities on his application from July 1981 - May 1982. The applicant has failed to list all employment activities on his application when compared to the Resume of Qualifications he submitted. Petitioner attended medical school at the Universidad Central del Este (UCE) in the Dominican Republic from 1975 to 1981. Petitioner testified that he completed his assigned curriculum and that he participated in graduation exercises. Petitioner did not receive a diploma or a medical degree from UCE because he owed the university for tuition. In response to an inquiry from Respondent, the Dean of Medicine of UCE provided the following information: ... [W]hile it is true that [Petitioner] completed the curriculum of our School of Medicine, he has other requisites to be completed. Among these is an outstanding debt for registration fees at our University. Until this debt is satisfied he cannot be awarded the degree of Doctor of Medicine, nor can any documents be issued. Petitioner's application and the documentation he initially submitted in support thereof did not establish that Petitioner met the residency requirements of Section 458.347(7)(b)1.d., Florida Statutes. The evidence submitted at the formal hearing established that Petitioner was a resident of the State of Florida on July 1, 1990, and at all other times pertinent to this proceeding since that time. Petitioner, in his application for licensure, failed to set forth his activities between July 1981 and May 1982./1 Petitioner has subsequently provided that information to the Respondent. During that time, Petitioner was unemployed and studying for his medical examinations. Petitioner, in his application for licensure, failed to completely set forth his employment history, including his work as a medical health counselor and as a mental health supervisor. His employment history is required by the application form and should have been included as part of his application package. All information pertinent to his employment has now been provided by Petitioner.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a Final Order denying Petitioner's application on the grounds that he is not a graduate of a medical school recognized by the World Health Organization. DONE AND ORDERED this 28th day of July, 1993, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON 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 28th day of July, 1993.
The Issue The issue in these two consolidated cases is whether disciplinary action should be taken against Luis J. Marti, M. D., hereinafter referred to as "Respondent Marti," and/or Jesus Escar, M.D., hereinafter referred to as "Respondent Escar," based upon the alleged violations of Chapter 458, Florida Statutes, contained in the separate Administrative Complaints filed against each of the Respondents.
Findings Of Fact Based on the stipulations of the parties; on the testimony of the witnesses, and on the exhibits received in evidence at the hearing; I make the following findings of fact. Respondent Escar is, and has been at all times material hereto, a licensed physician in the state of Florida, having been issued license number ME 0034247. Respondent Escar's last known address is 935 West 49th Street, Suite #107, Hialeah; Florida 33012. Respondent Marti is, and has been at all times material hereto, a licensed physician in the state of Florida, having been issued license number ME 0034842. Respondent Marti's last known address is 24355 West Flagler Street, Miami, Florida 33125. Respondent Marti went to medical school in Madrid, Spain. In approximately 1970, while Respondent Marti was in medical school in Madrid, Spain, Respondent Marti met Jose A. Tudela for the first time. At the time, Tudela had come to Madrid, Spain, for the purposes of starting medical school. In approximately 1975, while Respondent Marti was working as a resident at Cedars of Lebanon Hospital, Respondent Marti again saw Jose A. Tudela. At about the same time, Respondent Escar met Tudela for the first time. Tudela's father, Francisco Tudela, a physician, was an attending physician at Cedars of Lebanon Hospital. Respondents Marti and Escar saw Jose and Francisco Tudela in 1975 while on rounds at the hospital. In 1979, while Respondents Marti and Escar were working at Palm Springs General Hospital, Jose A. Tudela came to the hospital to apply for a position as a house physician and saw Respondents Escar and Marti. When Tudela applied for the position of house physician at Palm Springs General Hospital, Respondents Marti and Escar were both residents at the hospital. On the day that Jose A. Tudela came to apply for the position of house physician at Palm Springs General Hospital, Tudela came to the doctors' lounge at the hospital where he spoke with Respondents Escar and Marti. Tudela had with him a diploma which appeared to Respondents Escar and Marti to be authentic and which appeared to have been issued by the Universidad Central del Este. The diploma had on the back what appeared to be official stamps and seals and the signature of the Vice Consul of the United States. Additionally, a translation of the diploma was attached to the diploma. On the date that Tudela came to apply for the position of house physician at Palm Springs General Hospital, Tudela also showed Respondents Escar and Marti what appeared to be a transcript of his grades from the Universidad Central del Este and a letter purportedly from one Victoria Marcial de Gomez. The transcript and letter appeared to Respondents Escar and Marti to be original and authentic. The letter from Gomez, who purportedly was the medical director for the health center of Trujillo Alto Health Department, in the associated Free State of Puerto Rico, appeared to verify the fact that Dr. Jose A. Tudela had worked in the Health Center of Trujillo Alto for seven months. When Respondent Marti reviewed Tudela's documents, he knew it was important that foreign papers be certified because he had had the experience of having to leave Cuba and re-establish himself. Respondent Marti's own diplomas from Spain bear attestations of notarization of a foreign government. Respondent Escar believed that Tudela's documents were originals because of his experience in having seen similar original documents of other residents in the past. On or about August 1, 1979, Jose A. Tudela completed an application for employment as a house physician at Palm Springs General Hospital. The application contained basic personal information about Tudela and listed some of Tudela's education and work experience. According to the application, Tudela went to Belle Glade High School, in Belle Glade; Florida; Warwick High School, in Newport News, Virginia, where he graduated in 1965; and the University of Miami; in Coral Gables, Florida where he graduated in 1970. According to the application, Tudela worked in an unspecified capacity in the Centro de Salud, in Trujillo Alto, Puerto Rico, from 1978 to 1979. The application form does not contain any information about Tudela's medical education. Specifically, it does not contain any mention of University of Santo Domingo, Universidad Central del Este, or U.C.E. On or about August 8, 1979, Jose A. Tudela was employed by Palm Springs General Hospital as a house physician. Jose A. Tudela remained at Palm Springs General Hospital as a house physician until October 29, 1979. Tudela left Palm Springs General Hospital on that date to become a surgical assistant at Miami Children's Hospital. While employed a Miami Children's Hospital, Tudela received the highest score on every item on his employee evaluation form. That hospital never knew of any problem with Tudela's performance or credentials until this case occurred. Between approximately 1979 and 1983, Respondents Escar and Marti practiced medicine together as partners. In 1980, Jose A. Tudela approached Respondent Marti and asked Respondent Marti to sign an affidavit on behalf of Tudela. Therefore, on or about March 13, 1980, Respondent Marti signed a Form B-1 which was addressed to Rafael A. Penalver, M.D., Director, Office of International Medical Education, University of Miami School of Medicine; Miami; Florida. The form B-1 contained the following sworn statement: This is to certify that Jose A. Tudela born in Cuba and a graduate from the University Santo Domingo on 1978 was legally engaged in the practice of medicine from ---- to in Puerto Rico. I have known the applicant since 1975 and was acquainted with him/her during the time he practiced medicine. I was algo (sic) engaged in the practice of medicine in Miami U.S.A. during the years of 1975 and up. At some time after Respondent Marti signed the Form B-1, the abbreviation "(U.C.E.)" was added to the above-referenced sworn statement after the school name, "University Santo Domingo." Respondent Marti did not place the quoted abbreviation on the Form B-1. Prior to signing the subject Form B-1, Respondent Marti reviewed, for verification purposes, the employment application of Jose A. Tudela for Tudela's employment as a house physician at Palm Springs General Hospital. However, the employment application in question does not reflect any attendance by Tudela at any educational institution in the Dominican Republic or Santo Domingo. Furthermore, the employment application does not indicate the capacity in which Tudela worked in the Centro Salud in Trujillo Alto, Puerto Rico, and does not specifically indicate that Tudela practiced medicine in Puerto Rico. In 1980, Jose A. Tudela also approached Respondent Escar and asked Respondent Escar to sign an affidavit for him. Therefore, on or about March 13, 1980, Respondent Escar signed a Form B-1 which contained the following sworn statement: This is to certify that Jose A. Tudela born in Cuba and a graduate from the University of Santo Domingo on 1978 was legally engaged in the practice of medicine from ---- to in Puerto Rico. I have known the applicant since 1970 and was acquainted with him/her during the time he practiced medicine. I was algo (sic) engaged in the practice of medicine in Miami, Fla during the years of 1977 and up. The Form B-1 was addressed to Rafael A. Penalver, M.D., Director; Office of International Medical Education, University of Miami School of Medicine, Miami, Florida. At some time after Respondent Escar signed the Form B-1, the abbreviation "(U.C.E.)" was added to the above-referenced sworn statement after the school name, "University of Santo Domingo." Respondent Escar did not place the quoted abbreviation on the Form B-1. Respondent Escar relied upon Respondent Marti's verification of Tudela's background information in signing the Form B-1 described in the immediately preceding paragraph. Respondent Escar did not personally review Tudela's application for employment at Palm Springs General Hospital but discussed the information contained in the employment application with Respondent Marti. At the time Respondents Marti and Escar signed the Forms B-1, they did not know Tudela very well and did not know very much about his background. Although they both thought Tudela was probably a graduate of a medical school, they did not remember what school he had supposedly graduated from, as evidenced by the fact that they put the wrong school name on the Forms B- 1. Both Respondent Escar and Respondent Marti lacked personal knowledge of the information contained in the Forms B-1 which they signed for Jose A. Tudela. Neither of the Respondents saw or taught Tudela at medical school in the Dominican Republic. Furthermore, neither Respondent Escar nor Respondent Marti was in Puerto Rico at the time Jose A. Tudela allegedly practiced medicine at the Centro Salud in Trujillo Alto, Puerto Rico. Neither of the Respondents had any source of information about Tudela's alleged medical education in the Dominican Republic or his alleged practice of medicine in Puerto Rico other than statements Tudela may have made to them, statements Tudela wrote on the application form at Palm Springs General Hospital, and whatever information could be gleaned from a casual review of Tudela's forged credentials. Jose A. Tudela has never graduated from the Universidad Central del Este, which is located in the Dominican Republic, nor from any other medical school. Tudela enrolled in the Universidad Central del Este (U.C.E.) medical school in August, 1977. There is no evidence in the school records for U.C.E. that Tudela passed any of his courses. In May of 1978 Tudela was no longer at the university. Tudela was given a special concession at U.C.E. so that upon presentation of a pre-medical certificate which Tudela claimed to possess, Tudela could receive credit for the pre-medical program training. However, Tudela never presented the required proof of his pre-medical program. Tudela did not complete any of the twelve semesters at U.C.E. which make up the medical degree program including pre-medical training. Although Respondent Marti first met Tudela in 1970 and Respondent Escar met him in 1975, the Form B-1 signed by Respondent Marti states that he met Tudela in 1975, and the one signed by Respondent Escar states that he met Tudela in 1970. The reason for this error is that both of the forms were prepared by Respondent Marti and the forms were inadvertently switched at the time they were signed. The Forms B-1 signed by Respondents Marti and Escar were submitted to the Board of Medical Examiners by Jose A. Tudela as attachments to an Application for Continuing Medical Education Program, which was submitted as part of Tudela's application for licensure as a physician in Florida. Tudela applied for licensure in Florida under the provisions of a special law which provided that the Board of Medical Examiners would establish continuing education courses designed to qualify for licensure those individuals who were resident nationals of the Republic of Cuba and were residents of Florida on July 1, 1977. In order to qualify for the continuing education program set up by the Board of Medical Examiners for Cuban nationals, an applicant had to demonstrate that he was a graduate from a medical school with a medical degree and that he was a resident national of the Republic of Cuba and a resident of Florida on July 1, 1977. Upon approval of the applicant to participate in the continuing education program set up by the Board of Medical Examiners, the applicant would have to complete the continuing education program. Upon completion of the continuing education program, the applicant would be qualified to take the licensing examination. In or about March of 1980, Tudela submitted an Application for Examination, an Application for Florida State Board of Medical Examiners Continuing Education Program, and the necessary attachments, which included the Forms B-1 signed by Respondents Escar and Marti and copies of what purported to be his diploma and transcript of grades. After successfully completing the continuing medical education program and the licensure examination, Tudela became certified to practice medicine and surgery by the Board of Medical Examiners on August 23, 1982. At the time of Tudela's application for medical license, the staff of the Board of Medical Examiners conducted the initial review and made the initial determination as to whether an individual was qualified to take the continuing education course and to take the licensure examination for certification to practice medicine and surgery in Florida. In making such determinations, consideration is given to all of the information contained in an applicant's file, which includes such things as the applicant's degree or diploma, transcript of grades, and the Forms B-1. At the time Tudela applied for licensure, the staff of the Board of Medical Examiners did not verify the medical education of applicants and conducted no investigation into the school or the graduation of applicants for licensure. Prior to approving Tudela's application, neither the Board members nor the staff independently contacted the Universidad Central del Este to verify whether Tudela actually graduated from medical school. The Board members did not personally review Tudela's application. The staff reviewed the papers and presented the Board with a list of applicants who appeared to be eligible for the continuing education course and the licensure examination. The diploma and the transcript of grades which Tudela showed to the Respondents and filed with the Board of Medical Examiners are forgeries. They are very good forgeries and bear a remarkable resemblance to genuine diplomas and transcripts issued by the Universidad Central del Este. The false documents provided by Tudela to the Board as part of his application, along with the Forms B-1 signed by Respondents Marti and Escar, deceived the staff into recommending Tudela for the continuing education course, the licensure exam, and ultimately for certification to practice medicine. Tudela's application to the Board also contains several letters of recommendation from other physicians who were convinced of Tudela's competence. The Educational Commission for Foreign Medical Graduates granted Tudela a certificate despite his forged documents. In November 1984, an Administrative Complaint was filed against Jose A. Tudela which alleged that Tudela did not graduate from or obtain a degree of Doctor of Medicine from U.C.E., contrary to what Tudela had indicated in his application for licensure examination described above. In March 1985, the Board of Medical Examiners entered an order accepting the surrender for revocation of Jose A. Tudela's license to practice medicine in lieu of further prosecution of the charges contained in the Administrative Complaint which had been filed in November 1984. Tudela is not currently licensed as a physician in the state of Florida. No further action was taken against him for his having fraudulently obtained a medical license in Florida. Respondents Escar and Marti were both aware of the fact that the Forms B-1 which they signed were to be submitted as part of the application for the continuing medical education program which had been established by the Board of Medical Examiners for Cuban nationals as a prerequisite to take the licensure examination. In fact; Respondent Marti became eligible to take the medical licensure examination in Florida by completing the same continuing medical education program. When the Respondents Escar and Marti signed the subject Forms B-1, neither of them had any personal knowledge as to the truth or falsity of the statements therein regarding Tudela's medical education and experience; yet they deliberately certified, under oath, to the truthfulness of matters about which they were distinctly uninformed. When the Respondents Escar and Marti signed the subject Forms B-1, both of them knew the purpose of the forms and both knew that the Board of Medical Examiners would rely on the information in the forms.
The Issue The issues to be determined are whether Petitioner meets the requirements for licensure by endorsement pursuant to section 458.313, Florida Statutes (2013), and whether the Board’s interpretation of section 458.311(3), Florida Statutes, is an unadopted rule in violation of section 120.54(1), Florida Statutes (2013).
Findings Of Fact Based upon the stipulations of the parties and the documentary evidence presented, the following facts are found: Petitioner, Leon Rawner, M.D., is a licensed medical doctor in the state of Wisconsin and an applicant for licensure as a medical doctor by endorsement in Florida. The Florida Board of Medicine is the agency charged with the licensing and regulation of allopathic medical doctors pursuant to section 20.43 and chapters 456 and 458, Florida Statutes. Applicants for licensure by endorsement must meet the requirements specified in section 458.313. Those requirements include meeting the qualifications identified in section 458.311(1)(b)-(g) (alternative one) or section 458.311(1)(b)-(e), (g), and (3) (alternative two). Petitioner is over 21 years of age, and has submitted a set of fingerprints on a form and under procedures specified by the Department of Health, along with a payment in an amount equal to the costs incurred by the Department of Health. Petitioner has successfully passed the required criminal background screening. Petitioner’s application for licensure by endorsement demonstrates that he is licensed to practice medicine in another jurisdiction, the state of Wisconsin, and that he has been active in the practice of medicine for at least two of the four years immediately preceding the application. Petitioner has a clean record in his current medical practice in Wisconsin and is not under any investigation in any jurisdiction for an act or offense which would constitute a violation under section 458.331, and has not committed any act or offense in any jurisdiction which would constitute the basis for disciplining a physician pursuant to section 458.331. Petitioner has completed the equivalent of two academic years of pre-professional, postsecondary education, as determined by rule of the Board, which included, at a minimum, courses in anatomy, biology, and chemistry prior to entering medical school. Petitioner received a bachelor’s degree from Brandeis University, an accredited United States university. Petitioner has passed the appropriate medical licensure examinations, the United States Medical Licensing Examination, Step-1, Step-2, and Step-3. Petitioner holds an active, valid certificate issued by the Educational Commission for Foreign Medical Graduates (ECFMG) and has passed the examination used by the Commission. In 2006, Petitioner graduated with a degree of Doctor of Medicine from American University of the Caribbean School of Medicine. Petitioner graduated from an allopathic foreign medical school (American University of the Caribbean School of Medicine) which is recognized by the World Health Organization. Petitioner completed all of the formal requirements for graduation from American University of the Caribbean School of Medicine. Petitioner’s application for licensure demonstrates that he has completed the academic year of supervised medical training prior to graduation as required under section 458.311(3)(d). Petitioner did not graduate from an allopathic medical school or allopathic college recognized and approved by an accrediting agency recognized by the United States Office of Education. Petitioner did not graduate from an allopathic medical school or allopathic college within a territorial jurisdiction of the United States recognized by the accrediting agency of the governmental body of that jurisdiction. Petitioner is not a graduate of an allopathic foreign medical school registered with the World Health Organization and certified pursuant to section 458.314, Florida Statutes, as having met the standards required to accredit medical schools in the United States or reasonably comparable standards. Petitioner has not completed an approved residency or fellowship of at least two years in one specialty area. Petitioner’s application for licensure demonstrates that he does not meet the postgraduate training requirements under section 458.311(1)(f)3. Petitioner completed one year of residency training in the Internal Medicine Program at Mt. Sinai-Elmhurst Hospital Center, Queens, New York. Besides the residency training program at Mt. Sinai– Elmhurst Hospital Center, Queens, New York, Petitioner has not completed any other residency or fellowship training. Petitioner does not have two years of any residency or fellowship training which can be counted toward regular or subspecialty certification by a board recognized and certified by the American Board of Medical Specialties. Since January 24, 2011, Dr. Rawner has been practicing medicine in Wausau, Wisconsin, as a staff physician with Knee Pain Solutions Center. Accordingly, he has been in the active practice of medicine for the two years preceding his Florida application. Dr. Rawner submitted his application for licensure by endorsement on March 13, 2013. Supplemental documentation was filed with the Board by letter dated March 18, 2013. In that letter, Dr. Rawner expressly stated that he was relying on the second alternative for establishing licensure by endorsement, which does not include the requirements identified in subsection 458.311(1)(f). On April 3, 2013, the Board requested additional information, and in response, Dr. Rawner provided a copy of his undergraduate degree and information related to his one year of supervised medical training. Other information requested in the April 3, 2013, letter was sent directly to the Board office by the appropriate agencies, including an official United States medical examination transcript, indicating that Dr. Rawner passed USMLE Steps I, II, and III; a letter from the residency program director, indicating that Dr. Rawner completed one year of residency training; confirmation from the Wisconsin Medical Board confirming his current, valid medical license in the state of Wisconsin; an American Medical Association (AMA) profile letter; and Dr. Rawner’s fingerprints and clear background check. Program Operations Administrator Chandra Prine notified Dr. Rawner by letter dated June 26, 2013, that he was required to appear before the Credentials Committee of the Board. The purpose of the appearance was to discuss: Failure to meet the training requirement pursuant to section 458.313(1)(a), 458.311(1)(f)3.c., Florida Statutes. Failure to complete an academic year of supervised clinical training pursuant to section 458.311(3)(d), Florida Statutes. Dr. Rawner appeared before the credentials committee of the Board of Medicine on August 1, 2013. The committee recommended that his license be denied. On August 22, 2013, the Board of Medicine issued a Notice of Intent to Deny Licensure, stating that it intended to deny Dr. Rawner’s application because Dr. Rawner did not meet the requirements of section 458.313(1), which requires an applicant to meet the qualifications outlined in either section 458.311(1)(b)-(g) (alternative one), or in section 458.311(1)(b)- (e), (g) and (3) (alternative two). The notice stated that with respect to alternative one, Dr. Rawner did not meet the requirements of section 458.311(1)(f)3., because he had not completed an approved residency or fellowship of at least two years in one specialty area. With respect to alternative two, the Board determined that Dr. Rawner did not meet the requirements of section 458.311(3)(c) because, in the Board’s view, the section was inapplicable to Dr. Rawner because he had completed all requirements of the foreign medical school, with none outstanding, and did not meet the requirement of (3)(d) because he had not completed an academic year of supervised clinical training in a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association. Dr. Rawner filed a Petition for Administrative Hearing with respect to the Notice of Intent to Deny, and the matter was reconsidered at the credentials committee’s meeting on October 3, 2013. The credentials committee voted to reconsider the application based on the issues presented in the Petition. On October 22, 2013, the Board issued an Amended Notice of Intent to Deny Licensure. With respect to alternative two, in the Amended Notice, the Board stated: [t]he application file reveals that Dr. Rawner fails to meet subsection (3) for the reasons set forth below. Subsection (3) provides: Notwithstanding the provisions of subparagraph (1)(f)3., a graduate of a foreign medical school need not present the certificate issued by the Educational Commission for Foreign Medical Graduates or pass the examination utilized by that commission if the graduate: Has received a bachelor’s degree from an accredited United States college or university. Has studied at a medical school which is recognized by the World Health Organization. Has completed all of the formal requirements of the foreign medical school, except the internship or social science requirements, and has passed part I of the National Board of Medical Examiners examination or the Educations Commission for Foreign Medical Graduates examination equivalent. Has completed an academic year of supervised clinical training in a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association and upon completion has passed part II of the National Board of Medical Examiners examination or the Educational Commission for Foreign Medical Graduates examination equivalent. Subpart (3)(c) provides in relevant part all of the formal requirements of the foreign medical school, except the internship or social service requirements, and has passed certain examinations. A plain reading of this subpart is that the foreign medical school has an internship or social service requirement and that the internship or social service requirement has not been completed. The application file demonstrates that Dr. Rawner graduated in June, 2006, with a degree of Doctor of Medicine from the American University of the Caribbean School of Medicine. Thus, subpart (3)(c) is inapplicable to Dr. Rawner, because the application file reveals that he completed all of the formal requirements of the foreign medical school and there are no outstanding or pending internship or social service requirements. Based on the foregoing, the Board finds that the Applicant has not demonstrated that he meets the requirements for licensure by endorsement set forth in Section 458.313(1)(a), Florida Statutes. The Amended Notice no longer listed failure to complete an academic year of supervised clinical training as a basis for the denial of Dr. Rawner’s application. There is no persuasive evidence presented that Respondent’s interpretation of the requirements of section 458.311, Florida Statutes, as it applies to this case, is a statement of general applicability.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Florida Board of Medicine enter a Final Order approving Leon Rawner, M.D.’s application for licensure by endorsement. DONE AND ENTERED this 28th day of April, 2014, in Tallahassee, Leon County, Florida. S LISA SHEARER NELSON 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 28th day of April, 2014. COPIES FURNISHED: Donna C. McNulty, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399 Amy W. Schrader, Esquire GrayRobinson, P.A. 301 South Bronough Street, Suite 600 Post Office Box 11189 Tallahassee, Florida 32302 Allison M. Dudley, Executive Director Board of Medicine Department of Health Division of Medical Quality Assurance Boards/Councils/Commissions 4052 Bald Cypress Way Tallahassee, Florida 32399 Jennifer A. Tschetter, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399 Edward A. Tellechea, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399
The Issue Whether Petitioner's application for medical licensure by endorsement has expired and Respondent is therefore without authority to act on the application, as Petitioner claims? If not, whether the application should be denied on the grounds that Petitioner is guilty of violating Section 458.331(1)(a) and (gg), Florida Statutes,1 as Respondent has preliminarily determined.
Findings Of Fact Based on the evidence adduced at hearing, and the record as a whole, the following findings of fact are made to supplement and clarify the factual stipulations set forth in the parties' December 8, 2005, Prehearing Stipulation3: Petitioner is now, and has been since 1998, a Napperville, Illinois anesthesiologist licensed to practice medicine in the State of Illinois. At no time has she resided in Florida or used a Florida mailing address. "[A]t the end of 2002," Petitioner hired US Medical Licensing (USML) to help her obtain licenses to practice medicine in Florida, California, and Nevada, including "put[ting] together the application[s for such licensure] for [her]." In making these arrangements with USML, Petitioner dealt with USML's Melinda Hilterbrand, with whom she spoke over the telephone. Petitioner paid USML by credit card. USML first "charged [Petitioner's] credit card in January" of 2003 (using the credit card number Petitioner had given Ms. Hilterbrand during their telephone conversation). Petitioner provided USML, at USML's request, information and documentation (including a "standard credentialing application [she used in] Illinois") for USML to utilize in "put[ing] together [her Florida, California, and Nevada] application[s]." None of the information and documentation Petitioner provided was, to her knowledge, false or inaccurate. USML "put together the application[s]," as it had agreed to do. It then submitted them to the Florida, California, and Nevada medical licensing agencies without Petitioner's review, approval, or signature, notwithstanding that Petitioner had not given USML authorization to make such submissions. On June 16, 2003, Respondent received the Florida application that USML had "put together" for Petitioner (Petitioner's Florida Application) using the appropriate Respondent-developed form . Petitioner's Florida Application gave Petitioner's mailing address as "5631 Ballybunion Drive, Pace, Florida" (Pace, Florida Address). This was actually USML's mailing address, not Petitioner's. Petitioner's Florida Application gave Petitioner's telephone number as "(850) 994-4646." This was actually USML's telephone number, not Petitioner's. 10. Items 12, 12a., 12b., 15a., and 19b. on the application form on which Petitioner's Florida Application was submitted (Florida Application Form) asked the following questions: 12. Was attendance in Medical school for a period other then the normal curriculum? (If "yes," explain on a separate sheet providing accurate details.) 12a. Did you take a leave of absence during medical school? (If "yes," explain on a separate sheet providing accurate details.) 12b. Were you required to repeat any of your medical education? (If "yes," explain on a separate sheet providing accurate details.) 15a. Have you ever been dropped, suspended, placed on probation, expelled or requested to resign from a postgraduate training program? (If "yes," explain on a separate sheet providing accurate details.) 19b. Have you ever applied for, taken an examination for, or failed to receive specialty board certification or recertification for any reason?" (If "yes," explain on a separate sheet, providing full details). Each of these questions was incorrectly answered "no" on Petitioner's Florida Application. Item 15 on the Florida Application Form asked the applicant to "[l]ist in chronological order from date of graduation from Medical school, to present, all professional/postgraduate training (Internship/Residency/ Fellowship)." In response to this request, Petitioner's Florida Application listed her participation (following graduation from medical school) in programs at the University Medical Center in Las Vegas, Nevada, at the Medical College of Ohio in Toledo, Ohio, at the Advocate Illinois Masonic Medical Center in Chicago, Illinois, and at St. Anthony's Hospital in Chicago, Illinois. No other post-graduate programs were listed, notwithstanding that Petitioner had also received post-graduate training at the Vanderbilt University Medical Center. At the time, Petitioner did not even know that her Florida Application had been submitted, much less that it contained any erroneous information, inasmuch as she had not seen it or been made aware of its contents. As will be discussed in more detail below, it was not until approximately three months later that she first learned of her Florida Application’s submission, and it was even later, at her July 24, 2004, appearance before Respondent’s Credentials Committee, that she first became aware "that there was any incorrect information on [her] application." No one from USML had ever contacted Petitioner and asked her for her responses to items 12, 12a., 12b., 15, 15a., 19b. or any other item on the Florida Application Form. Item 18 on the Florida Application Form was an Affidavit of Applicant, which read, in pertinent part, as follows: I affirm that these statements are true and correct and recognize that providing false information [ma]y result in disciplinary action against my license or criminal penalties pursuant to Sections 456.067, 775.083 and 775.084, Florida Statutes. I hereby authorize all hospitals, institutions, my references, personal physicians, employers (past and present) and all governmental agencies and instrumentalities (local, state, federal or foreign) to release to the Florida Board of Medicine information which is material to my application for licensure. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice Medicine in the State of Florida. * * * Date of Expiration (Signature of Applicant required) 4 (Date Signed required) The Affidavit of Applicant in Petitioner's Florida Application contained what purported to be, but was not, Petitioner's signature. It was dated May 30, 2003. Petitioner had not authorized USML to sign her Florida Application on her behalf or otherwise "submit documents using [her] signature," nor was she "aware that [USML was] going to do [so]." On July 14, 2003, Respondent prepared and sent to the Pace, Florida Address (which, as noted above, was USML’s, not Petitioner’s, mailing address) a notice advising that Petitioner's Florida Application was "deficient" and explaining what needed to be done in order for the application to be considered "complete" (July 14, 2003, Deficiency Notice). The July 14, 2003, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of medical school transcripts from St. George's University Medical School and Ross University Medical School. It appears you transferred to Ross University after your third year. The transcript received from Ross University indicates your third year of medical school was repeated. Please submit a written explanation regarding attend[ing] two medical schools and why you answer[ed] no to question 12 (Was attendance in Medical School for a period other than the normal curriculum?) and 12b (Were you required to repeat any of your medical education?). A letter has been sent to St. George's University to confirm you left the medical school in good standing. Your file has been submitted in for advisement regarding your examination score reports submitted to the board office. It appears question 1 of your licensure application was left blank. However, you should apply by endorsement. Enclosed is a copy of page 1, please check the appropriate box. On page 3, question 10 needs to list the date your medical degree was granted. On page 3, question 15 needs to list the specialty area of training. Please complete the enclosed copy of page 4. Explain why you switched training programs from Medical College of Ohio to Advocate Illinois Masonic Medical Center. Did you leave the program in good standing? Were you offered a contract to continue and complete the program? A letter has been sent to the Medical College of Ohio to retrieve[] further information on your performance. Submit a written explanation on why you started your training programs with Medical College of Ohio and Advocate Illinois Masonic Medical Center off cycle. Please complete the enclosed fingerprint card. Submit a written account of your employment/non-employment activities from 1/89 to 6/92 and 6/93 to 4/94, and 5/96 to 1/97, and 11/98 to 2/99, and 11/02 to Present. Submit a copy of your legal name change document. Explain in writing why the name "Randa Mariana Prochazka" appears on your supporting documentation. The copy of your valid ECFMG certificate submitted to the board office is unreadable. The valid through area is not readable. Please resubmit a copy to the board office. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. Submit two current letters of recommendation, addressed to the Florida Board of Medicine. "To Whom It May Concern" is not acceptable. Recommendation letter(s) must be current, original, personable and from physician(s). We await licensure verification from the Illinois State Medical Board. The National Practitioner Data Bank, self-query has not been received. You may contact the NPDB at (800)767-6732. The AMA Physician Profile sheet has not been received. You may contact the AMA at (312) 484-5199. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -University Medical Center, regarding your Internship, from 6/92 to 6/93 -Medical College of Ohio, regarding your Residency, from 4/94 to 5/96 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 -Valley Ambulatory Surgery Center, verifying your staff privileges and good standing. * * * On August 15, 2003, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (August 15, 2003, Deficiency Notice). The August 15, 2003 Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of medical school transcripts from St. George's University Medical School and Ross University Medical School. It appears you transferred to Ross University after your third year. The transcript received from Ross University indicates your third year of medical school was repeated. Please submit a written explanation regarding attend[ing] two medical schools and why you answer[ed] no to question 12 (Was attendance in Medical School for a period other than the normal curriculum?) and 12b (Were you required to repeat any of your medical education?). We are in receipt of the evaluation form submitted by Valley Ambulatory Surgery Center. They indicate you did not perform competently and you were not regularly appointed. Please submit a written explanation. It appears question 1 of your licensure application was left blank. However, you should apply by endorsement. Enclosed is a copy of page 1, please check the appropriate box. On page 3, question 10 needs to list the date your medical degree was granted. On page 3, question 15 needs to list the specialty area of training. Please complete the enclosed copy of page 4. Explain why you switched training programs from Medical College of Ohio to Advocate Illinois Masonic Medical Center. Did you leave the program in good standing? Were you offered a contract to continue and complete the program? Submit a written explanation on why you started your training programs with Medical College of Ohio and Advocate Illinois Masonic Medical Center off cycle. Please complete the enclosed fingerprint card. Submit a written account of your employment/non-employment activities from 1/89 to 6/92 and 6/93 to 4/94, and 5/96 to 1/97, and 11/98 to 2/99, and 11/02 to Present. Submit a copy of your legal name change document. Explain in writing why the name "Randa Mariana Prochazka" appears on your supporting documentation. The copy of your valid ECFMG certificate submitted to the board office is unreadable. The valid through area is not readable. Please resubmit a copy to the board office. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. Submit two current letter of recommendation, addressed to the Florida Board of Medicine. "To Whom It May Concern" is not acceptable. Recommendation letter(s) must be current, original, personable and from physician(s). The National Practitioner Data Bank, self-query has not been received. You may contact the NPDB at (800) 767-6732. The AMA Physician Profile sheet has not been received. You may contact the AMA at (312) 484-5199. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -University Medical Center, regarding your Internship, from 6/92 to 6/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * It was not until sometime in or around September of 2003, during a telephone conversation (she had initiated) with USML's Ken Carroll, that Petitioner first learned that her Florida Application had been submitted to Respondent. Petitioner was "very surprised" when Mr. Carroll told her about the application's submission because she had thought that she was "going to get to look at the application" and "go over it" before it was sent to Respondent and she had not been given this opportunity. Nonetheless, she did not voice any objections to Mr. Carroll during her telephone conversation with him. Rather, "[she merely] asked him if there were any problems with [the application], and he said that everything was okay." Petitioner assumed, erroneously, that USML had completed the application accurately. She did not, at that time, request a copy of the application to verify the application's accuracy, nor did she do anything to indicate that she did not want Respondent to treat the application as hers. Indeed, until becoming aware of the actual contents of the application, it was her desire that Respondent act on the application and grant her licensure, and her actions were consistent with such a desire. On September 17, 2003, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application remained "deficient" and explaining what needed to be done in order for the application to be considered "complete" (September 17, 2003, Deficiency Notice). The September 17, 2003, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of medical school transcripts from St. George's University Medical School and Ross University Medical School. It appears you transferred to Ross University after your third year. The transcript received from Ross University indicates your third year of medical school was repeated. Please submit a written explanation regarding attend[ing] two medical schools and why you answer[ed] no to question 12 (Was attendance in Medical School for a period other than the normal curriculum?) and 12b (Were you required to repeat any of your medical education?). We are in receipt of the evaluation form submitted by Valley Ambulatory Surgery Center. They indicate you did not perform competently and you were not regularly appointed. Please submit a written explanation. It appears question 1 of your licensure application was left blank. However, you should apply by endorsement. Enclosed is a copy of page 1, please check the appropriate box. On page 3, question 10 needs to list the date your medical degree was granted. On page 3, question 15 needs to list the specialty area of training. Please complete the enclosed copy of page 4. Explain why you switched training programs from Medical College of Ohio to Advocate Illinois Masonic Medical Center. Did you leave the program in good standing? Were you offered a contract to continue and complete the program? Submit a written explanation on why you started your training programs with Medical College of Ohio and Advocate Illinois Masonic Medical Center off cycle. Please complete the enclosed fingerprint card. Submit a written account of your employment/non-employment activities from 1/89 to 6/92 and 6/93 to 4/94, and 5/96 to 1/97, and 11/98 to 2/99, and 11/02 to Present. Submit a copy of your legal name change document. Explain in writing why the name "Randa Mariana Prochazka" appears on your supporting documentation. The copy of your valid ECFMG certificate submitted to the board office is unreadable. The valid through area is not readable. Please resubmit a copy to the board office. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. Submit one current letter of recommendation, addressed to the Florida Board of Medicine. "To Whom It May Concern" is not acceptable. Recommendation letter(s) must be current, original, personable and from physician(s). The National Practitioner Data Bank, self-query has not been received. You may contact the NPDB at (800) 767-6732. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 464-5199. The AMA Physician Profile submitted to the board office indicates you had training with Vanderbilt University in Anesthesiology from 7/93 to 11/93. However, this training is not listed on question 15 of your licensure application. Please submit a written explanation. Also, a training evaluation form will have to be completed. A letter has been sent to the training program to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board office indicates your training with Medical College of Ohio is incomplete. Please provide a written explanation. A letter has been sent to the program to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to . . . our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * On September 26, 2003, Respondent received a letter, dated September 23, 2003, that was addressed to one of its employees, Lakeisha Henderson, and purported to be, but was not, from Petitioner and signed by her (September 26, 2003, Letter). The September 26, Letter, of which Petitioner had no knowledge, read as follows: In answer to your questions in the letter you sent me 9/17/03 [sic], I am providing these answers: I left St. George's because of the war in Grenada. I waited till I was sure the situation was stable and I also took a leave to study for my ECFMG. I was not satisfied with the situation at the school so I transferred/moved to Ross. One course prior to the start of my clinicals was required at Ross before I could start there in the clinical phase. This was a repeat from St. George[']s, but the only one. During this period, I had numerous child care and child health issues with my children which caused me to not be available for work and surgery. Page one is attached. Page three is attached. Page 4 is attached. In answer to question #7, there was a change at Medical College of Ohio. The Program Director left due to illness and subsequently the program started changing, so I finished my second year and then did my third year at another program. I left in good standing, getting credit for everything. I could have continued if I had elected to do so but I declined. In question 8, I started my third year based on what was needed to complete and where the class was. I was having a child and was allowed to start off cycle. Non-Employment Dates: 01/89-6/92-Child Birth and child care, studied for tests. 05/96-01/97-Unemployed 11/98-02/99-Moving and vacation 11/02-04/03-Unemployed 05/03-Present @ Surgical Center of Downers Grove, IL I thought the fingerprint card had been sent to your office (Question #9) Item #11 has been requested. Question #12. I was married for a short period of time and while married took the last name of husband Prochazka. When we divorced I retained my maiden name. Question #18- The program was overfilled with Residents and I elected to leave with no credit as I only attended for a short period of time. Question #19- I was given full credit for my training there, so I do not understand the question. I have attached my diploma. All other items have been requested and will be sent directly to you. On September 30, 2003, Respondent received another letter, also dated September 23, 2003, that was addressed to Ms. Henderson and purported to be, but was not, from Petitioner and signed by her (September 30, 2003, Letter). The September 30, 2003, Letter, of which Petitioner had no knowledge, read as follows: I am sorry I forgot to include the fact that I was arrested for disturbing the peace. I have included all those documents. I forgot till Ken Carroll asked. I thought it was not needed as it was over 10 years ago, sorry to cause any issues. I have also included my divorce papers. Among the documents that were "included" with the September 30, 2003, Letter to Ms. Henderson was a statement in Petitioner’s handwriting, dated June 10, 1996, which provided an explanation of the circumstances surrounding Petitioner’s arrest. This handwritten statement was among the materials that Petitioner had furnished USML for use in the application preparation process. On October 16, 2003, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (October 16, 2003, Deficiency Notice). The October 16, 2003, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. We are in receipt of the letter dated September 23, 2003, [in which] you indicate employment with Surgical Center of Downers [Grove]. Do you hold staff privileges with this hospital? If so, an evaluation form will have to be completed. On page 3, question 10 needs to list the date your medical degree was granted. A letter has been sent to the Medical College of Ohio to confirm your written explanation. Submit a written account of your employment/non-employment activities from 6/93 to 4/94. The copy of your valid ECFMG certificate submitted to the board office is unreadable. The valid through area is not readable. Please resubmit a copy to the board office. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. We are in receipt of the letter of recommendation from Dr. Kianoosh Jafari. Please submit an additional letter of recommendation, addressed to the Florida Board of Medicine. "To Whom It May Concern" is not acceptable. Recommendation letter(s) must be current, original, personable and from physician(s). The National Practitioner Data Bank, self-query has not been received. You may contact the NPDB at (800) 767-6732. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. 19. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * Respondent received, in response to the October 16, 2003, Deficiency Notice, a letter that purported to be, but was not, from Petitioner and signed by her. The letter, of which Petitioner had no knowledge, read as follows: Question #5 from letter of 10/13/03 [sic] I left [the] program after one year to move closer to my husband at the time wh[o] was in the Midwest. I spent the time from 7-93 till 4-94 looking for a program and applying to programs. Petitioner was not married during the time period referenced in the letter. To the extent that the letter suggests otherwise, it is inaccurate. In or around the end of October of 2003, Petitioner received a letter from the Nevada State Board of Medical Examiners (Nevada Board) concerning an application for licensure that USML had submitted to the Nevada Board on her behalf. The letter, which was dated October 28, 2003, read as follows: Dear Dr. Sawan: Please find enclosed a new application for medical licensure for the State of Nevada. You will be required to complete this application without the assistance of a credentialing service. The Nevada State Board of Medical Examiners does not accept any documentation from the credentialing company U.S. Medical Licensing and Credentialing. After receiving this letter, Petitioner telephoned Mr. Carroll and asked him why "this Nevada licensure application . . . was not accepted." Mr. Carroll, in response to Petitioner’s inquiry, explained that "there were some other doctors that did not get their licenses and they were upset with [USML]" and had complained to the Nevada Board. Having received this response to her inquiry, Petitioner "did not dig anymore" into the matter. Petitioner subsequently completed the application form she had been sent by the Nevada Board and then returned it. Approximately, four and a-half months later she received her Nevada medical license On November 17, 2003, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (November 17, 2003, Deficiency Notice). The November 17, 2003, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. We are in receipt of the letter dated September 23, 2003, [in which] you indicate employment with Surgical Center of Downers [Grove]. Do you hold staff privileges with this hospital? If so, an evaluation form will have to be completed. On page 3, question 10 needs to list the date your medical degree was granted. A letter has been sent to the Medical College of Ohio to confirm your written explanation. The copy of your valid ECFMG certificate submitted to the board office is unreadable. The valid through area is not readable. Please resubmit a copy to the board office. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * Respondent received, in response to the November 17, 2003, Deficiency Notice, a letter that purported to be, but was not, from Petitioner and signed by her. The letter, of which Petitioner had no knowledge, read as follows: Question #2 from letter of 11/14/03 [sic] Downers Grover Surgical Center is an out patient center. Not a hospital. Question #5 A copy of my ECFMG is enclosed. On December 19, 2003, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (December 19, 2003, Deficiency Notice). The December 19, 2003, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. On page 3, question 10 needs to list the date your medical degree was granted. A letter has been sent to the Medical College of Ohio to confirm your written explanation. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * The December 19, 2003, Deficiency Notice was accompanied by a letter from Ms. Henderson, addressed to Petitioner at the Pace, Florida Address (December 19, 2003, Deficiency Letter), which read as follows: Your application remains incomplete. Please review the attached update [the December 19, 2003, Deficiency Notice] outlining the remaining deficiencies. Please be advised previous malpractice, criminal charges, discipline, addictions/impairment, unfavorable evaluations, etc. may require that you appear before the Credentials Committee for determination of eligibility for licensure. If your appearance is required, you will be notified in writing once your file is complete. Any information received by this office may require additional explanation and/or documentation to be requested in order to further determine licensure eligibility. After all requested documentation is received, your file will be submitted for a standard supervisory review. Should additional information be required, you will be notified. Once your file is determined complete, it will be presented to the Board for consideration at the next scheduled meeting. As documentation is received in our office, an updated list of deficiencies will be mailed to you. Your application will remain incomplete until all deficiencies are completed. In addition, notify the Board office immediately in writing of any occurrence(s) that would in any way change or affect any answer given in the application or an answer provided in response to any of our direct questions to you. If I can be of any assistance, please contact me at (850) 245-4131 extension 3512 or e-mail me at Lakeisha_Henderson @doah.state.fl.us. On January 22, 2004, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (January 22, 2004, Deficiency Notice). The January 22, 2004, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. On page 3, question 10 needs to list the date your medical degree was granted. A letter has been sent to the Medical College of Ohio to confirm your written explanation. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * On February 24, 2004, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (February 24, 2004, Deficiency Notice). The February 24, 2004, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. A letter has been sent to the Medical College of Ohio to confirm your written explanation. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * On March 24, 2004, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (March 24, 2004, Deficiency Notice). The March 24, 2004, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. A letter has been sent to the Medical College of Ohio to confirm your written explanation. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board office list[s] your graduation year incorrectly. Please have the AMA [Physician Profile] corrected. You may contact the AMA at (312) 484-5199. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to inquiry/evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 -Advocate Illinois Masonic Medical Center, regarding your Residency, from 1/97 to 11/98 * * * The March 24, 2004, Deficiency Notice was accompanied by a letter from Ms. Henderson, addressed to Petitioner at the Pace, Florida Address (March 24, 2004, Deficiency Letter). The body of the March 24, 2004, Deficiency Letter was identical to the body of the December 19, 2003, Deficiency Letter. On March 31, 2004, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (March 31, 2004, Deficiency Notice). The March 31, 2004, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION'S EXPIRATION DATE IS: June 15, 2004 APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. We are in receipt of the training evaluation form from Valley Ambulatory Surgery Center. The evaluation form indicates you resigned and your staff privileges were terminated. It appears you should have answered yes to question 18c. Please submit a written explanation as well [as] explain the no answer given for question 18c. A letter has been sent to Valley Ambulatory Surgery Center to retrieve[] further information. Enclosed for your review is a copy of the evaluation form. A letter will be sent to each training program requesting a copy of your training file. A letter has been sent to the Medical College of Ohio requesting further clarification on the letter submitted from them dated July 22, 2003. A letter has been sent to Vanderbilt University Medical Center to retrieve[] further information on your performance. We await verification of ECFMG examination results, direct from ECFMG, which must be requested by the applicant. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. We await responses to evaluation forms, which were mailed from our office to the following: -Vanderbilt University Medical Center, Department of Anesthesiology, regarding your Residency, from 7/93 to 11/93 * * * The March 31, 2004, Deficiency Notice was accompanied by a letter from Ms. Henderson, addressed to Petitioner at the Pace, Florida Address (March 31, 2004, Deficiency Letter). The body of the March 31, 2004, Deficiency Letter was identical to the bodies of the December 19, 2003, and March 24, 2004, Deficiency Letters. In or around March of 2004, during a telephone conversation with Mr. Carroll, Petitioner inquired as to whether her "talk[ing]" to Respondent "could help expedite" the processing of her Florida Application. Mr. Carroll, in turn, gave Petitioner Ms. Henderson’s name and telephone number and suggested Petitioner call Ms. Henderson. Petitioner followed Mr. Carroll’s suggestion and spoke with Ms. Henderson. Petitioner asked Ms. Henderson "if there [was] any problem with the application" and offered to provide "anything extra that [Ms. Henderson] may need." Ms. Henderson "did not say that there were any problems," but she did indicate "that she would like additional information," which she described for Petitioner. After speaking with Ms. Henderson, Petitioner prepared a handwritten letter, which she sent to Ms. Henderson by facsimile transmission on April 9, 2004. The letter read as follows: You requested an explanation for why staff privileges at Valley Ambulatory Surgery Center were terminated. It has been my understanding from their contract agreement that once I stop working there (resign), the staff privileges are automatically terminated. The following day, April 10, 2004, Petitioner sent to Ms. Henderson by facsimile transmission a handwritten list of references, as well as letters of recommendation (from others about her). Ms. Henderson had not asked Petitioner to provide these materials, but Petitioner sent them anyway, thinking that Ms. Henderson "might like to have them." On May 4, 2004, Respondent prepared and sent to the Pace, Florida Address a notice advising that Petitioner's Florida Application was still "deficient" and explaining what needed to be done in order for the application to be considered "complete" (May 4, 2004, Deficiency Notice). The May 4, 2004, Deficiency Notice read, in pertinent part, as follows: We will consider no application complete for licensure until we receive all requested documentation by the board. The applicant must ensure that the board receives all requested documentation. Verbal responses are inadmissible. * * * YOUR APPLICATION EXPIRATION DATE IS: June 15, 2004. APPLICATION SUBMITTED REMAINS DEFICIENT FOR LACK OF THE FOLLOWING: We are in receipt of the evaluation form from Advocate Illinois Medical Center. The evaluation form indicates they recommend you with some reservation. Please review the enclosed copy of the evaluation and provide a written response. Also, a letter has been sent to Advocate Illinois Medical Center to retrieve[] further information. A letter will be sent to each training program requesting a copy of your training file. A letter has been sent to Medical College of Ohio requesting further clarification on the letter submitted from them dated July 22, 2003. The AMA Physician Profile submitted to the board indicates you have an inactive resident license in Nevada. Please have the Nevada State Medical Board send a license verification letter to our office. * * * The May 4, 2004, Deficiency Notice was accompanied by a letter from Ms. Henderson addressed to Petitioner at the Pace, Florida Address (May 4, 2004, Deficiency Letter). The body of the May 4, 2004, Deficiency Letter was identical to the bodies of the December 19, 2003, March 24, 2004, and March 31, 2004, Deficiency Letters. Petitioner never received the May 4, 2004, Deficiency Notice or the May 4, 2004, Deficiency Letter; nor had she ever received any of the previous deficiency notices and letters. On June 15, 2004, Petitioner’s Florida Application was still incomplete inasmuch as Respondent had not received all of the information it had requested in the May 4, 2004, Deficiency Notice (including the letter from Petitioner requested in item 1 of the notice, the training files from University Medical Center in Las Vegas, Nevada, and Vanderbilt University Medical Center requested in item 2 of the notice, and the "license verification letter" requested in item 4 of the notice, which were all materials that were reasonable for Respondent to have asked for as part of the application review process). On June 28, 2004, Chandra Prine, Respondent’s Program Operations Administrator (and Ms. Henderson’s supervisor), prepared and sent to the Pace, Florida Address a letter addressed to Petitioner (June 28, 2004, Letter) advising her that she was required to make a personal appearance before the Credentials Committee on July 24, 2004, to discuss: Your medical education and your failure to answer yes to questions numbers 12, 12a & 12b on the licensure application. Failure to list your training at Vanderbilt from 7/93-11/93 and your failure to answer yes to question number 15a on the licensure application. In addition, the Committee may inquire into any other issues relating to your application and eligibility for licensure. Petitioner did not receive this letter. In July of 2004, Petitioner telephoned Ms. Henderson to inquire about the status of Petitioner’s Florida Application. She was unable to speak with Ms. Henderson, so she left a message asking Ms. Henderson to return the call. Petitioner subsequently received a telephone message from Ms. Henderson. In her message, Ms. Henderson stated that she thought Petitioner "was going to be going to a hearing" on her Florida Application, but suggested that Petitioner telephone Ms. Prine "just to be sure." Ms. Henderson did not say anything about there being "questions that were answered incorrectly on [the] application." After receiving Ms. Henderson’s message, Petitioner telephoned Ms. Prine and spoke with her. Petitioner told Ms. Prine that Ms. Henderson had left a message about an upcoming hearing concerning Petitioner’s Florida Application and had suggested that Petitioner contact Ms. Prine regarding the matter. Ms. Prine responded, "Yes, we sent you a letter saying you have to show up for this hearing," referring to the June 28, 2004, Letter. Petitioner replied that she had "not received any letter" from Respondent. Ms. Prine then "gave [Petitioner] the address" to which the June 28, Letter had been mailed. Petitioner informed Ms. Prine that this address (the Pace, Florida Address) was not hers. She then "gave [Ms. Prine] her home address for [Ms. Prine] to send [her] another letter." Petitioner asked Ms. Prine during their telephone conversation "what the hearing was going to be about." Ms. Prine's response was that Petitioner should be prepared to answer questions at the hearing regarding certain specific items on her Florida Application, which Ms. Prine identified by number. Petitioner told Ms. Prine that she "had never seen the application," to which Ms. Prine retorted, "Oh, but you signed it." Petitioner insisted that she "didn’t remember signing anything" and asked Ms. Prine to send her, along with the letter concerning the hearing, "a copy of whatever [she supposedly] signed." At no time during the telephone conversation did Ms. Prine tell Petitioner that her Florida Application contained any incorrect information, nor did she reveal to Petitioner anything about those items on the application that Petitioner would be questioned on at the hearing other than what their numbers were and that they pertained to her "schooling and training." It did not come as surprise to Petitioner that the Credentials Committee "wanted to hear from [her]" about her "schooling and training" given the difficulties she had encountered in these areas. Petitioner did not ask Ms. Prine to elaborate any further on what the Credentials Committee would inquire about at the hearing. Two days after her telephone conversation with Ms. Prine, Petitioner received a letter dated July 14, 2004, from Ms. Prine (July 14, 2004, Letter). The July 14, 2004, Letter was addressed to Petitioner at her Naperville, Illinois address and read as follows: This is in further reference to your application for licensure by endorsement. Please be advised that you are required to make a personal appearance before the Credentials Committee of the Board of Medicine to discuss the following: Your medical education and your failure to answer yes to questions numbers 12, 12a & 12b on the licensure application. Failure to list your training at Vanderbilt from 7/93-11/93 and your failure to answer yes to question number 15a on the licensure application. In addition, the Committee may inquire into any other issues relating to your application and eligibility for licensure. Date: Saturday, July 24, 2004 Time: 8:00 a.m. Location: Radisson Hotel 415 N. Monroe St. Tallahassee, FL 32301 (850) 224-6000 The meeting room will be posted in the lobby of the Hotel. Additionally, the Committee's recommendation on your application will be presented to the Board of Medicine, August 6-7, 2004 for final action. Thank you for your continued cooperation. Should you have any question regarding this matter, please feel free to contact me. Along with the July 14, 2004, Letter, Petitioner received from Ms. Prine the signature page of the September 26, 2003, Letter. After reviewing the latter, Petitioner telephoned Ms. Prine and left a message advising Ms. Prine that the signature on that document was not hers. The July 14, 2004, Letter was not accompanied by a copy of Petitioner’s Florida Application. Petitioner made a "personal appearance" before the Credentials Committee on July 24, 2004, as scheduled. As noted above, it was during this appearance that she first learned that her Florida Application contained information that was incorrect. In response to questioning, Petitioner truthfully told the Credentials Committee that she had not "even seen the application" and that it was "not [her] signature" that was on the application in that she did not sign it. The Credentials Committee voted to recommend the denial of Petitioner’s Florida Application, a recommendation that Respondent subsequently followed. On August 2, 2004, following her appearance before the Credentials Committee, Petitioner prepared and sent a letter to Ms. Prine formally requesting, for the first time, a "complete copy of [her] application for the Florida medical license [be] mailed to [her]" at her Napperville, Illinois address. On August 10, 2004, Petitioner prepared and sent to Ms. Prine another letter, which read as follows: I am writing to ask that you do not accept any communication from the USML agency regarding my application. I am not working through them anymore. Please call me directly at (773) 405-3718, or send all mail to: RANDA SAWAN M.D. 1304 Dunrabin Road Naperville, IL 60540 Your assistance with this matter will be greatly appreciated. Thank you. After Petitioner had made several post-Credential Committee hearing requests to Mr. Carroll that he send her copies of "anything [he had] involving [her] application," Petitioner received the following letter, dated September 23, 2004, from Mr. Carroll: I am sorry to inform you but your files along with several hundred other physicians' files were destroyed while in our storage area due to Hurricane Ivan which made a direct hit on Pensacola. Our Pensacola office is operating but has limited phone and no internet or cable. Again I apologize for this inconvenience. Petitioner never received any of the documents she had requested from Mr. Carroll.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that Respondent issue a final order finding that Petitioner's Florida Application expired, without being acted on, one year after it was filed and that it is therefore too late for Respondent to either approve or deny the application. DONE AND ENTERED this 7th day of March, 2006, in Tallahassee, Leon County, Florida. S STUART M. LERNER 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 7th day of March, 2006.
Findings Of Fact The following facts were stipulated by the parties and required no proof at hearing: Petitioner, University Hospital, Ltd., is a Florida limited partnership and is the licensee of University Hospital and University Pavilion Hospital, both located on North University Drive, Tamarac, Florida. Petitioner Sebastian Hospital, Inc., is a Florida corporation, and is the licensee of Sebastian Hospital and SandyPines Hospital. Both hospitals are located on separate premises. Petitioner Haines City HMA, Inc., is a Florida corporation, and is the licensee of Heart of Florida Hospital, Inc. and Palmview Hospital. Both hospitals are located on separate premises. Petitioners timely filed their respective Petitions to determine the invalidity of the proposed rules at issue. Petitioners would be regulated by the proposed rules and are substantially affected parties with standing to challenge the proposed rules at issue. No proof is necessary to prove the standing of these Petitioners. Prior Rule 59C-1.004(2)(i) (the "License Consolidation Rule") required CON application and approval for license consolidations pursuant to Section 395.003, F.S. It was declared invalid in University Hospital, Ltd., et al. v. AHCA, 16 F.A.L.R. 3312 (final order dated July 22, 1994). [This decision is referenced throughout as University Hospital.] Prior to invalidation of the License Consolidation Rule, six CON applicants sought issuance of a single, or consolidated, license to replace former separate licenses held by the same licensee for facilities located on separate premises. Each of these six prior applicants involved a general acute care hospital and a specialty psychiatric hospital. Those applicants resulted in an issuance of CON numbers 7303, 6954, 7712, 7311, 7167, and 7047. Each of those six applications was ulti- mately approved in the form of a single license. When the single licenses were issued, no restrictions were placed on the licensees regarding eligibility for Medicaid reimbursement. As reflected in the respective SAARS, a significant result of approval of each of these applications was that the formerly separately licensed psychiatric hospital became eligible for Medicaid reimbursement for treatment of Medicaid patients. All of these prior applicants had licenses issued and became eligible for Medicaid. Such Medicaid reimbursement was not available to the separately licensed psychiatric facilities prior to issuance of a single, or consolidated, license. Aside from the rules under challenge, there has been no change in pertinent state statutes or rules subsequent to the final order in University Hospital Ltd., v. AHCA 16 F.A.L.R. 3312. After invalidation of the Consolidated License Rule, AHCA's interpretation is that issuance of a single, or consolidated, license for a general acute care hospital and a psychiatric hospital does not result in Medicaid eligibility. Petitioners did not participate in any of the rule workshops conducted on June 22, July 7, and November 2, 1994 or the public hearing held on February 13, 1995. Petitioners did not send in any written comments, questions, or materials, or request an economic impact statement. A holding of the Final Order in University Hospital, was that a Certificate of Need was not required prior to the issuance of a single consol- idated license for multiple premises. University Hospital, 16 F.A.L.R. at 3321. The Agency has no discretion regarding rule- making pursuant to Section 120.535. (Joint Prehearing Stipulation, filed 3/14/95) Approximately eighteen months ago and well before the University Hospital decision, the Agency for Health Care Administration (AHCA) commenced a major rewrite of the hospital license rules that had been promulgated by its predecessor agency, the Department of Health and Rehabilitative Services (HRS). After a series of public workshops, the revisions were noticed in the January 20, 1995, Florida Administrative Weekly. These substantial revisions of rule chapter 59A-3 comprise about fifty pages of the Florida Administrative Weekly. The challenged portions comprise only several paragraphs of the revisions. The challenged portions of the proposed rules are: 59A-3.203 Licensure Procedure. (2) All persons requesting licensure for the operation of a hospital under the provisions of Chapter 395, F.S., shall make application to the Agency, on forms provided, AHCA Form 3130- 8003-January 1995, and AHCA Form 3130-8001-January 1995, and shall receive a regular or provisional license prior to the acceptance of patients for care or treatment. * * * (e) An application for the addition of beds or off-site outpatient facilities to a hospital's license must include: A valid certificate of need or letter of exemption as required by ss. 488.041 - 408.045, F.S., and Approval from the Agency's Office of Plans and Construction. * * * (i) A single license will be issued to a licensee for facilities located on separate premises, upon request of the applicant. The license will specifically state the location of the facilities, their services, and the licensed beds available on each separate premises. Such a license shall also specifically identify the general or specialty classification of hospitals located on separate premises. (6) Each license shall specifically state the name of the licensed operator of the hospital, the class of hospital, and the name and location of the hospital. Any beds in the hospital which are regulated under the certificate of need program, as specified in Chapter 59C-1, F.A.C., shall be listed, including the number of licensed beds by type. The license for hospitals having facilities on more than one premises shall specifically state the location of each facility, their general or specialty classification, their services, and the licensed beds available on each separate premises. * * * Specific Authority 395.003, 395.004, 455.239, F.S. Law Implemented, 395.001, 395.003, 395.004, 395.1005, 408.035, 408.036, 455.239, F.S. History New. (emphasis added) Prior to the decision in the University Hospital case in July 1994, the proposed revisions did not include the requirement that the license for facilities on separate premises identify separately the general or specialty classification of each. That provision was added by the agency because it concluded that when it could no longer require a CON for "consolidated" licenses, then general acute care beds and free-standing psychiatric beds could not be "consolidated" on a single license. It is uncontroverted that the substantial effect of the requirement that each facility retain its prior classification is that a facility classified as a class III (specialty) facility is not eligible for Medicaid reimbursement. The agency agrees that proposed rule is based on, and is compelled by section 395.003(2)(d), F.S., which provides as follows: (d) The Agency shall, at the request of a licensee, issue a single license to a licensee for facilities located on separate premises. Such a license shall specifically state the location of the facilities, the services, and the licensed beds available on each separate premises. If a licensee requests a single license, the licensee shall designate which facility or office is responsible for receipt of information, payment of fees, service of process, and all other activities necessary for the Agency to carry out the provision of this part. (Emphasis supplied). It is immediately obvious from a comparison of the text of the proposed rule and the text of the law implemented that the law does not require that the license state the general or specialty classification for the separate facilities. This distinction was not lost on the agency since it included in its legislative package for the 1995 legislative session a proposed amendment to section 395.003(2)(d), F.S. that would cure the inconsistency by adding the proposed rule language to the statute. (Petitioner's exhibit number 16, p. 25) There is a statute which restricts Medicaid reimbursement for treatment in free-standing psychiatric hospitals. The agency argues that the proposed rules give effect to that statute, section 409.905(5), F.S., which provides, in pertinent part: . . . A licensed hospital maintained primarily for the care and treatment of patients having mental disorders or mental diseases is not eligible to participate in the hospital inpatient portion of the Medicaid program except as provided in federal law. . . . (emphasis supplied). Reliance on Section 409.905(5) is misplaced, however, because it is nowhere cited in the proposed rules as authority or law implemented. Moreover, evidence presented at hearing describes federal policy that when two hospitals are consolidated under one license and have a total capacity that is less than 50 percent psychiatric in nature, the premises are both eligible for Medicaid reimbursement, even though one remains primarily for the treatment of mental disorders. (Petitioners' exhibits number 20-22) The federal policy on Medicaid reimbursement was in effect in 1993, prior to the University Hospital decision and prior to the current version of the proposed rules. Section 409.905(5), F.S. has been in effect since 1991, before the six consolidated licenses referenced in paragraph 1, above, were issued. Section 395.003(2)(d), F.S. has been in effect in its current form at all times material. Nothing in the law has changed to support the agency's contention that, after the University Hospital decision, it can no longer issue a single license with a single license classification for separate premises. No evidence nor specific argument was presented with regard to the alleged invalidity of proposed rule 59A-3.203(2)(e), which on its face relates to the addition of beds or an outpatient facility to a hospital's license. Issues related to that portion of the proposed rule are not the issues invoked in this proceeding with regard to Petitioner's facilities. (See Petitioners' exhibit 26, p. 71, deposition of Tanya Williams)
The Issue Whether Petitioner is qualified to be licensed as a medical doctor in Florida by endorsement.
Findings Of Fact Petitioner Jeffrey Jad Gaier applied for licensure by endorsement in Florida by filing a written application in November of 1983 with the Board of Medical Examiners, which is within the Department of Professional Regulation. He made a personal appearance before the Foreign Graduate Committee of the Board of Medical Examiners in April 1984. After Petitioner's appearance before the Foreign Graduate Committee, the Foreign Graduate Committee made a favorable recommendation regarding Petitioner's application for licensure to the Board of Medical Examiners. However, the full Board of Medical Examiners voted to deny Petitioner's application for licensure. On May 21, 1984, the Board of Medical Examiners rendered an Order denying Petitioner's application for licensure as a physician by endorsement, stating as the grounds: Your application and supporting documentation does not provide sufficient information to demonstrate that you can practice medicine with reasonable skill and safety. See Section 458.331(3), F.S. More specifically, the clinical training you received while attending the American University of the Caribbean as disclosed within your documentation was determined to be insufficient insofar as the clinical training was not received at a hospital affiliated with a medical school approved by the Counsel [sic] on Medical Education of the American Medical Association. The denial of Petitioner's application for licensure by endorsement was taken before the Board of Medical Examiners for reconsideration on February 3, 1985. Counsel for Petitioner was present at the hearing. At that hearing, the discussion by the Board of Medical Examiners of the request for reconsideration clarified the basis for the denial of the medical license as being the overall inadequacy of the clinical training and not specifically because the clinical training was not obtained at teaching hospitals. Except for the purposes of clarifying the issue(s) herein the collegial actions of the board are irrelevant to the instant de novo proceedings. Petitioner received a B.S. degree from Clark University, Massachusetts and a Masters degree in science education from Florida Institute of Technology, August 1978. Petitioner was granted a medical degree by the American University of the Caribbean after being enrolled at that school for less than three years. During that time, Petitioner was on the campus of the American University in Montserrat, British West Indies for only eight months. There the class used prepared slides instead of gross tissue samples. Before that, Petitioner studied at the campus in Cincinnati, Ohio, where the class used rubber cadavers instead of human cadavers. All of the clinical training received by Petitioner as part of the requirements for the completion of the medical degree consisted of preceptorships at hospitals in south Florida which included Florida Medical Center, Plantation General Hospital, University Community Hospital, and Bennett Community Hospital. Dr. Neil Katz, Petitioner's principal expert medical witness, supervised Petitioner for six weeks in a preceptorship in Family Practice. Dr. Katz is a board-certified Family Physician and a fellow of the American Academy of Family Practice. He has been Chairman of the Emergency Room Department, a member of the Credentials and Qualifications Committee, and a member of the Intensive Care Unit Committee at University Hospital, Tamarac, Florida. He has taught both foreign medical students in a clinical setting and has briefly qualified as a preceptor for the University of Florida College of Medicine. Dr. Katz actually supervised Petitioner only for the six-week period at the very beginning of Petitioner's rotations. After that six-week period of time, he only "touched base" with Petitioner, seeing him on an informal basis in the cafeteria or at meetings. During the six weeks formal observation period, Petitioner accompanied Dr. Katz in his work in his office, during hospital rounds, at the emergency room, and for most other activities that Dr. Katz participated in, including committee meetings at the hospital. Petitioner took histories and did physicals on patients under direct supervision. Petitioner displayed enthusiasm and energy in his association with Dr. Katz and the rest of the program. Dr. Katz found Petitioner "barely acceptable" in three of the nine categories for which he was to evaluate Petitioner during the preceptorship. These categories were diagnostic acumen, therapeutics and management, and medical knowledge. In explaining that evaluation, Dr. Katz testified that although Petitioner was able to take a history and a physical examination, he was not able to make a diagnosis. In fact, Dr. Katz testified that Petitioner did not have truly acceptable knowledge at the time as to the various therapeutic modalities available to a physician. He encouraged Petitioner to do more reading. During his preceptorship with the University of Florida Medical School students in their first clinical semester, Dr. Katz also saw problems similar to those exhibited by Petitioner, specifically that the University of Florida students were not "super ready," so to speak, on diagnosing and doing differential diagnoses and therapeutics at that particular stage in medical school because they were still learning. I accept Dr. Katz' opinion that Petitioner had adequate exposure to the major diseases and injuries which are common to Family Medicine, sufficient for Petitioner to go into an internship, but in light of his lack of involvement with Respondent's other preceptorships in several different hospitals after the first six weeks, and in light of his specific testimony that in his professional opinion, American-trained students were far superior to the Caribbean-trained students at the same level in terms of general knowledge (TR-65-66), Dr. Katz' opinion that Petitioner did "quite good" at the end of the year and a half period is without adequate predicate and is not persuasive. Dr. Isidoro Dunn was the primary force in the arrangements for preceptorships. Dr. Dunn talked with each preceptor to work out areas which should be covered in their respective rotations. Each preceptor had a "fair amount of latitude" in deciding how to supervise the students. Petitioner was assigned by his school to do his clinical rotations in Florida. He did 14 weeks in internal medicine, 14 weeks in surgery, 10 weeks in pediatrics, 10 weeks in obstetrics/gynecology, 4 weeks in psychiatry, and 10 weeks in electives. This totals 62 weeks, not even close to two years which is the norm in medical schools in the United States. Petitioner was required to follow patients from admission to discharge in each specialty within each of these clinical rotations. Petitioner had didactic teaching on a daily basis, weekdays. Petitioner represents that he had specific didactic courses in hematology, EKG readings, pathology, orthopedics, cardiology, radiology, and gastrointestinal invasive procedures. In each subspecialty, he had a written examination after completion of the rotation, didactic teachings in each rotation, and was required to read medical journals. On Saturdays, Petitioner was required to participate in case conferences, make case presentations, and complete assigned reading from current medical journals. The case presentations necessitated review of patient records, laboratory tests, x-rays, and pathology slides. On "patient management reviews," the Petitioner was "exposed to" or "spent time in" the dialysis unit, pathology laboratory, intensive care unit, emergency room, gastrointestinal unit, blood lab, catherization department, radiology department, EKG unit, and cardiac surgery unit. Petitioner testified, and Dr. Katz confirmed, that there was an entity called the "Doctors' Club," which had a considerable amount of audiovisual equipment available for use 7 days a week, 24 hours each day. Practicing physicians used this media to obtain continuing medical education approved for credit by the American Medical Association. Petitioner represented that "on several days" he signed out equipment or reading material. There is no precise language in his testimony that he used the equipment or that he read the reading material, but drawing any other inference is straining the clear meaning of Petitioner's unrebutted testimony. Petitioner and the other students were required to use various materials from this service, but there is no evidence that Petitioner or other students were objectively checked by Dr. Dunn or their preceptors to verify that they had actually read or viewed the material assigned. Petitioner specifically testified that there was not necessarily any follow-up by the preceptors. Dr. Katz did talk with Petitioner about the reading assignments he gave. Petitioner was required to pass a competency examination for each rotation. Petitioner's clinical studies evaluation forms in his school records indicate no overall evaluation grades below "Good." Petitioner was required to attend and pass both a written and practical examination for a two-day Advanced Cardiac Life Support Course. This course is required even of board certified emergency room (ER) physicians. In Petitioner's opinion, this course was imperative for medical doctors who might work in an emergency room because they need to be very familiar with how to handle a patient presenting with a cardiac arrest, including the administration of drugs, "cardioversion" and "intubation." To the best of Petitioner's knowledge, Dr. Dunn was to report the students' progress to the dean of the American University of the Caribbean. However, the predicate for that testimony is hearsay, uncorroborated by any direct, credible evidence. As for the relationship with the university, Dr. Katz had no knowledge as to any arrangement between Dr. Dunn and the American University of the Caribbean or any counterpart-sponsoring organization in the United States. He did not know if there was any arrangement whatsoever. Dr. Katims was accepted as an expert physician witness, as an expert teaching fellow witness, and as an expert witness in medical applications and licensure. He testified that in the normal course of medical education in the United States, part of a student's medical education is clinical training, and that experience consists of bedside outpatient treatment and supervised training under the supervision of a faculty selected particularly for their knowledge, background, and interest in education and teaching. Dr. Katz testified unequivocally that a preceptorship is very different from a clinical rotation or a clerkship. A clerkship takes place in a teaching hospital, which is a very structured environment, wherein students make rounds in a very large hospital and are given instruction in an approved clinical structure. In contrast, a preceptorship gives students more knowledge about what private practice is like and it gives students a view of direct patient care, but does not replace a formal teaching setting in clinical medicine. As recognized above, in Dr. Katz' opinion, American-trained students were far superior to the Caribbean-trained students at the same level in terms of general knowledge. In Dr. Katims' opinion, Petitioner's clinical studies consisting of only four semesters were not sufficient for him to practice medicine with reasonable skill and safety. Dr. Katims testified concerning the importance of clinical training in medical education, commenting that clinical training is the sine qua non of the practice of medicine. In the usual clinical rotation, medical students are assigned to a particular area of a hospital and perform under the full-time supervision of attending physicians. In teaching hospitals, faculties are selected for their ability, interest, and dedication to education, as well as to the practice of medicine. The attending staff at a teaching hospital include house physicians, interns, and residents. Dr. Katims himself has served as a preceptor and testified that a preceptorship is one method of obtaining a minor portion of clinical training, but is very unstructured and unsupervised. Dr. Katims testified that preceptorship training is an inferior method of training because the quality of training depends totally on the quality of the physician to whom the student is assigned and the program is unstructured. There was no testimony that any of the preceptors that supervised, or purportedly supervised, Petitioner were faculty members of any medical school, let alone the American University of the Caribbean. Upon the Requests for Admissions and the Joint Pre-Trial Stipulation of the parties, it is found that: the State of Florida Board of Medical Examiners has granted a medical license to a Dr. Flugsrud-Breckenridge and a Dr. Cobb, both having non-teaching clerkships. Three doctors, Adela Fernandez, Andrew Gonzalez, and Manuel E Garcia, did their clerkships principally at the International Hospital (Miami), a non-teaching/non-medical school-associated hospital, and obtained Florida medical licenses. At least 25 foreign graduates received Florida medical licenses within the years 1981-1984 and did their clerkships principally in non-teaching/non-medical school associated hospitals. No further information appears of record by which the undersigned may determine any other similarities or dissimilarities of these licensees to each other and/or to Petitioner. Nor does the record divulge what, if any, other facts may have been considered in these cases. Petitioner is licensed to practice medicine in Georgia and is a resident of Florida. Petitioner passed the first time his Educational Commission for Foreign Medical Graduates' (ECFMG) examination was given in June, 1981. The examination is a prerequisite to acceptance in a medical residency program. The Federation of State Medical Boards of the United States, Inc.'s (FLEX) examination is recognized by all 50 states, including Florida. Petitioner took this examination after completing his rotations in Florida. Petitioner passed the June 1982 FLEX examination with an 84 percentile ranking. Fifty percent of this test is on patient management. This clinical competence examination was taken before Petitioner started his first year of residency. Petitioner had passed the FLEX examination, completed one year of residency, and obtained a medical license in another state, Georgia, by the time of the April 1984 application hearing. In Dr. Katims' opinion, Petitioner's successful passage of the FLEX examination in the 84 percentile does not show Petitioner to have had good clinical rotations, even though the FLEX test consisted of 50 percent on patient management. Dr. Katims did not feel that by the time Petitioner was in his fourth year of residency, this would be curative of deficiencies in the clinical semesters at a non-teaching hospital, but expressed the opinion that if Petitioner passes his internal medicine board examination and becomes board certified, his clinical deficiencies would be cured and Petitioner should then be granted a Florida medical license by endorsement. Dr. Katz opined that Petitioner presently possesses the medical knowledge, judgment and competency to act with reasonable skill and safety in the practice of medicine in Florida. Affidavits of Ira Spiler, M.D. and John R. Middleton, M.D. support similar opinions of these New Jersey medical physicians. Petitioner has completed three years (July 1, 1982 to June 30, 1985) of Internal Medicine residency at Raritan Bay Medical Center, Perth Amboy General Hospital, New Jersey. Petitioner is presently enrolled in a Nephrology Fellowship program, Medical College of Georgia, a teaching hospital located at, and affiliated with, the University of Georgia Medical School. Petitioner is currently eligible for board certification in internal medicine and will be certified in the event he passes the board examination taken September 10-11, 1985. Petitioner has submitted letters of Ira Spiler, M.D. and Salvatore Chiaramida, M.D., both of New Jersey attesting to Petitioner's good moral character, and no contrary evidence was turned up by the Board's investigation. The parties have stipulated that Rule 21M-22.18, Florida Administrative Code, is not applicable to Petitioner's situation.
Recommendation That the Florida Board of Medical Examiners enter a final order denying Petitioner a medical license by endorsement. DONE and ORDERED this 16th day of January, 1986, in Tallahassee Florida. ELLA JANE P. DAVIS Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 16th day of January, 1986.
Findings Of Fact Petitioner, Dr. Winifred Chambers received a master's degree in religion and art in 1957, a second master's degree in 1968 in philosophy with a specialization in ethics and social philosophy and a Ph.D. (with honors) in 1975 in the philosophy of science, all from the University of Chicago. While working on her dissertation, she studied at the Chicago Institute of Psychoanalysis. After working around hospitals and conducting classes and workshops on medical ethics for medical personnel, Petitioner decided to attend medical school. Because her educational training did not include extensive background in certain scientific areas, Petitioner was concerned with her ability to score well on the MCATS, which are the entrance examinations required by all medical schools in the United States. In addition, Petitioner's age (she was in her mid 40's at the time) was considered a negative factor by many medical schools in the United States. As a result, she inquired about attending certain foreign medical schools. She was limited in the schools that she could consider because she did not speak Spanish. Medical Education In 1979, Petitioner applied to the American University of the Caribbean (AUC). AUC taught its medical courses in English and Petitioner was only required to make up a few undergraduate science courses (including physics) in order to enroll in the medical school. Petitioner enrolled in classes at AUC in May of 1980. She actually started classes a few days after the semester began. She completed the first two semesters from May to December 1980 and then went home during the Christmas break. During the break, Petitioner learned that she had received an F in her course in neurosciences. Petitioner met with the professor from that course to discuss the failing grade she received and also met with the President of AUC. As a result of these meetings, it was her understanding that the grade was changed to a passing grade. In January of 1981, Petitioner visited CETEC (another Caribbean medical school located in the Dominican Republic,) and met with officials of the school to discuss transferring from AUC to CETEC. Petitioner applied to CETEC during her visit and, prior to leaving, was informed of her acceptance into medical school at CETEC. Petitioner returned to AUC and completed her third semester at the school. In May of 1981, she officially enrolled at CETEC by initiating clinical rotations at Sharp Hospital in San Diego, California. Even though Petitioner had only completed three semesters at AUC, she was granted status as a fifth semester medical student. She contends that she was granted this status based upon CETEC'S evaluation of her transcript and the number of hours she took at AUC. Prior to her enrollment at CETEC, Petitioner provided CETEC with a transcript indicating she had passed neurosciences at AUC and CETEC gave her credit for the course. From May 4, 1981 to June 6, 1982, Petitioner participated in clinical rotations at Sharp Memorial Hospital in San Diego, California as part of her medical education at CETEC. During this time period, Petitioner also participated in a clinical rotation at Children's Hospital in San Diego, California (from 12/28/81 to 2/20/82). Beginning in 1983, the media and some state licensing agencies began challenging the validity and/or authenticity of the credentials and training of some CETEC medical graduates. CETEC medical school was ultimately closed in 1984. The Dominican Republic government formed an agency to verify and certify the transcripts of CETEC graduates. This agency was called the "Counsel For Superior Education" also referred to by the acronym of CONES. CONES verified and certified the legitimacy of higher education credentials from all Dominican schools submitted to other countries. As part of her pending Florida Application, Petitioner has submitted a certification from CONES dated October 15, 1987 attesting to Petitioner's graduation from medical school at CETEC on June 12, 1982. Petitioner has also submitted a second certification from CONES dated July 8, 1988 confirming her graduation on June 12, 1982. Included as part of the documents submitted by Petitioner from CONES is a Certification of Clinical Rotations dated July 14, 1987 (the "CONES Report") and an academic transcript dated July 14, 1987 (the "CONES Transcript.") The "Education Commission For Foreign Medical Graduates" ("ECFMG") provides a certification of the education of applicants from foreign medical schools who seek licensure in the various United States and offers an examination required by some state licensing boards for licensure of applicants graduating from foreign medical schools. Petitioner passed the ECFMG examination and was certified by the ECFMG in 1982. However, after the CETEC scandal began in 1983, the ECFMG started an investigation of graduates of CETEC (including Petitioner) for the purpose of reverifying their medical training. The ECFMG required clearance from CONES of Petitioner's CETEC education before reverifying her ECFMG certificate. The ECFMG reinstated Petitioner's ECFMG certification on June 26, 1987. The earliest certification from CONES that has been submitted by Petitioner is dated July 14, 1987, approximately two and a half weeks after the ECMFG certification. It is not clear what the ECFMG relied upon in reissuing a certification to Petitioner. While Petitioner contends that CONES had originally certified her CETEC transcript shortly after her graduation in June of 1982, no competent evidence was presented to establish when or if an earlier CONES certification was issued. In any event, Petitioner currently holds a valid ECFMG certificate. In certifying Petitioner's medical degree from CETEC, CONES gave Petitioner credit for courses taken and work done at non-medical schools (i.e., the University of Chicago) prior to entering medical school. These credits are discussed in more detail in Findings of Fact 17. Although the ECFMG has apparently accepted CONES' certification of Petitioner's medical education at CETEC, there are several inconsistencies on the face of the CONES Report. The CONES Report states that during the period from May 4, 1981 to June 6, 1982, Petitioner completed fifty six (56) weeks of clinical rotations. However, in reaching this total the CONES Report provides one week of credit for a rotation (from 5/24/82 to 5/28/82) in obstetrics and gynecology which overlapped with another rotation (from 5/10/82 to 6/5/82) in obstetrics and gynecology. It it also provides double credit for a single two week clinical rotation (from 5/4/81 to 5/16/81) in obstetrics and gynecology. In addition, there are two periods of time (from 2/21/82 to 3/14/82 and from 4/25/82 to 5/9/82, which total approximately five (5) weeks), during which no clinical rotations were taken. Since the period between May 4, 1981 and June 6, 1982 consisted of approximately fifty seven (57) weeks, it does not appear that Petitioner actually completed fifty six (56) weeks of rotations as listed. Deleting the double credit received for the 5/4/81 to 5/16/81 clinical rotation, the CONES Report only appears to certify completion of fifty four (54 weeks) of clinical rotations. Moreover, those fifty four (54) weeks of rotations include one week of credit for five (5) days in obstetrics and gynecology (from 5/24/82 to 5/28/82) which directly overlapped a separately listed clinical rotation in obstetrics and gynecology, and one (1) week of credit for six (6) days in obstetrics and gynecology from 6/1/82 to 6/6/82. Thus, on the face of the CONES Report it appears that Petitioner actually completed only fifty three (53) weeks of rotations at most. This conclusion is bolstered by the fact that, according to the CONES Report, there were approximately five (5) weeks of the fifty-seven (57) week period during which no clinical rotations were taken. Petitioner contends that the CONES Report fails to take into account a five (5) week clerkship in family medicine which she completed at Sharp Hospital and which was accepted by the ECFMG when Petitioner applied for licensure in California. This clerkship is reflected in the CETEC Transcript even though it is not reflected in the CONES Report. It is not clear why this rotation was not included in the CONES Report However, the evidence did establish that Petitioner completed the rotation. One of the five weeks of this family medicine rotation overlaps with an OB/GYN rotation (from 5/4/82 -5/8/82). The time frame of the family medicine rotation roughly coincides with the period of time during which no rotations are reflected in the CONES Report. Thus, this rotation would only add four more weeks to the clerkship total listed on the CONES Report. Even if this four week rotation is added to the fifty three (53) weeks certified in the CONES Report, the Report would still only indicate that Petitioner completed a total of fifty seven (57) weeks of clinical rotations. According to the boiler-plate language on the CONES Report, sixty (60) to seventy-two (72) total weeks of clinical rotations had to be completed by CETEC students who took their clinical rotations outside of the Dominican Republic. Thus, the CONES Report does not reflect completion of the required weeks of clinical rotations even though CONES has issued a certification that purports to certify successful completion of the degree requirements. This discrepancy has not been adequately explained. The CONES Report does not reflect any clinical rotations by Petitioner in psychiatry. However, the CETEC Transcript does indicate that Petitioner was granted eight hours credit for her graduate studies at the University of Chicago from 1971-1973. Petitioner contends she is entitled to at least four hours of clerkship in psychiatry for those studies. However, it appears from the CONES Transcript that the credit she received was applied towards classes in Human Conduct which were a part of the curriculum during the first two years of medical school. There is no evidence to indicate that CETEC or CONES granted or should have granted Petitioner credit for clinical rotations in psychiatry based upon her graduate studies at the University of Chicago. During a three week period (between her second and third semesters at AUC) from December 20, 1980 to January 10, 1981, Petitioner participated in an OB/GYN clinical rotation at Sharp Memorial Hospital in San Diego, California (hereinafter this rotation will be referred to as the "Unsanctioned Rotation.") This rotation is usually not done until after a student completes the third semester of medical school. Petitioner's participation in this Unsanctioned Rotation was not authorized by any medical school and was not a part of any medical school program. Petitioner contends that she satisfied the required sixty (60) clerkship weeks if the Unsanctioned Rotation at Sharp Hospital from December 20, 1980 to January 10, 1981 is added to the undisputed clinical rotations and the family medicine rotation discussed in Findings of Fact 15. However, the Unsanctioned Clerkship was not accepted by CONES and Petitioner has not provided sufficient evidence to establish that it should be counted towards her required clinical rotations. Although CETEC had previously granted Petitioner credit for the neurosciences course at AUC, CONES was not able to verify that Petitioner passed the course and CONES required Petitioner to retake the course in order to obtain the 1987 certification from CONES. Petitioner attended Northwestern University during the spring quarter of 1987 and completed a four credit hour course (based on a quarter system) in neurosciences. This neurosciences course was apparently given five hours ex post facto credit by CONES to fulfill the neurosciences requirement for Petitioner's 1982 CETEC medical diploma. From December, 1987 to March, 1988, Petitioner attended Xochicalco Medical School in Ensenada, Mexico in order to take additional coursework in partial fulfillment of a requirement by the California licensing board in a stipulated agreement for additional medical training before licensure. (Petitioner's stipulation with the State of California is discussed in more detail in Findings of Fact 47-50.) The courses taken at Xochicalco were approved by the California licensing agency and included clinical pathology, pharmacology (two courses) and physiology (two courses). Petitioner successfully passed all of the courses. However, no evidence was presented as to the accreditation status of this school. Petitioner completed a five week rotation in emergency medicine at Cruze Roja Hospital in Mexico in 1988 while she was completing the remedial science classes required by the California Licensing Board. Post-Graduate Training Petitioner completed one year of post graduate training from July 1, 1982 to June 30, 1983 in the family medicine residency program at Holston Valley Community Hospital through East Tennessee State University's Quillen-Dishner College of Medicine. Petitioner has presented a certificate verifying succcessful completion of her first post graduate year of training in this program. Petitioner performed her residency at two hospitals which are part of the East Tennessee State University Quillen-Dishner College of Medicine: Kingsport Family Practice Center and Holston Valley Community Hospital. She saw patients at the Kingsport Family Practice Center for 7 months, one afternoon each week under the supervision of various physicians. The rest of Petitioner's residency was performed at the Holston Valley Community Hospital. Dr. Lee S. Hyde was the program director of the Kingsport Family Medicine Center. Petitioner's contact with Dr. Hyde was limited, but she did have several consultations with him about patients. In an evaluation submitted to the Florida Board of Medicine in connection with Petitioner's application for licensure, Dr. Hyde evaluated Petitioner's diagnostic ability and relationships with patients as poor. He also stated that Petitioner came to the program with a "poor fund of knowledge, clinical habits, and basic medical education". Although he felt Petitioner made progress during the residency program, he did not think it was sufficient. However, his overall evaluation was to recommend with reservations. Dr. Hyde's evaluation of Petitioner to the Board was received by the Board on July 18, 1983. Dr. Hyde noted on the back of the evaluation form that Petitioner was not ready to begin a second year of unsupervised practice. Petitioner was not and would not have been offered a contract for a second year in the residency program. Dr. Hyde also commented that Petitioner demonstrated poor judgment by once going "AWOL" from the program. While Petitioner did take a three (3) day leave over a weekend while assigned to a particular rotation with another physician contrary to the rules of the program, she did so with the permission of her supervisor at the time. Prior to the negative evaluation submitted by Dr. Hyde in July of 1983, Dr. Hyde had previously written a letter dated March 24, 1983 to the Florida Board of Medicine recommending Dr. Chambers for licensure stating that she was in good standing with the program and of reasonable professional competence and excellent moral character. Leslie P. Reynolds, Jr., M.D., was a professor of Family Medicine, assistant Dean, and Director of Medical Education at the Holston Valley Hospital during Petitioner's year of residency. In a June 29, 1983 evaluation form submitted to the Florida Board, Dr. Reynolds, gave an evaluation of Petitioner's performance during the family medicine residency and recommended her as an outstanding applicant. Dr. Reynolds subsequently submitted an affidavit to the Florida Board of Medicine dated October 21, 1987 attesting that Petitioner earned the respect of both her instructors and fellow residents and that the hospital's records suggest that she performed well on all her services and that she was very helpful to other residents. Several other physicians who served as clinical supervisors during Petitioner's residency at Holston Valley have submitted letters of recommendation and virtually all other evaluations of her work were positive. Aside from the letter from Dr. Hyde, (Dr. Hyde did not testify and his letter is hearsay,) no other evidence was presented to demonstrate that Petitioner is incapable of practicing medicine with reasonable skill and safety. The weight of the evidence established that Petitioner is capable of practicing with reasonable skill and safety. Numerous letters from the physicians who have worked with Petitioner over the last several years corroborate to her ability to practice medicine with reasonable skill and safety. Petitioner was employed as a house physician at Jackson Memorial Hospital in Miami from July 11, 1983 to October 31, 1983. Her position was under the supervision of the Department of Family Medicine in the Ambulatory Care Unit of the Emergency Room Department and the Family Medicine Clinical Faculty from the University of Miami. However, the position was not an advanced residency program and the nature of the supervision and training that Petitioner received has not been fully explained. Furthermore, the evidence did not establish the exact nature of her duties and functions. From October 1984 to March 1985, Petitioner participated in a series of clinical rotations at the Wesley Medical Center which is affiliated with the University of Kansas. The exact nature of Petitioner's position is not clear. The position at the Wesley Medical Center was a non-paying position during which Petitioner completed an eight week rotation in Internal Medicine, twelve weeks in General Surgery and four weeks in psychiatry functioning in each rotation at the level of a first-year resident. Petitioner was not officially enrolled as a resident in this program. However, she did receive evaluations from the attending physicians and her evaluations by the supervising physicians in that program were acceptable. In 1988, Petitioner completed an eight month internship at Universal Medical Center in Plantation, Florida Universal Medical Center is an osteopathic teaching institution. This internship was undertaken to satisfy a requirement of the California licensing authority for eight months of "remedial" clinical work. See, Findings of Fact 50. Petitioner was evaluated as performing in a competent and professional manner in this program. At the Universal Medical Center, Petitioner completed thirty three (33) weeks of clinical rotations. The program extended from March 21, 1988 through November 3, 1988. Her duties and responsibilities were similar to other interns in the program. In sum, Petitioner has successfully completed several additional science courses and completed at least thirty eight (38) additional weeks of clinical training beyond her medical school rotations and first post-graduate year residency. Those weeks of training include thirty three (33) weeks at Universal Medical Center which is an approved osteopathic medical training program that was accepted by the California Licensing Agency for purposes of Petitioner's remedial clinical work. Licensure Applications Petitioner passed the FLEX exam in June, 1982 with a score of 78. She also passed the ECFMG exam in January, of 1982 with a score of 76. In addition, she passed an oral examination administered by the California State Licensing Board in 1988. After graduating from CETEC in June 1982, Petitioner initiated efforts to obtain licensure in several states. In her initial attempts at licensure, Petitioner submitted several misleading applications which have backfired into a morass of complications and confusion. In 1982, Petitioner knowingly submitted a fraudulent application to the State of Oregon. Petitioner filed the application with the Oregon licensing authority in order to take the Federal Licensing Examination known as the FLEX. Oregon was one of the few states which allowed applicants to take the FLEX examination prior to graduation and also granted applicants some choice in the location of the exam. Petitioner took the FLEX in the Virgin Islands in June of 1982. This was the nearest location to the Dominican Republic where she was attending graduation ceremonies at CETEC around the same time. On the application to take the FLEX exam filed with Oregon, Petitioner falsely stated that she attended AUC from May, 1979 to April, 1981. She actually attended AUC from May, 1980 through April, 1981. In the early part of 1983, Petitioner submitted applications for licensure to South Carolina, California, Georgia, New Mexico, and Florida. South Carolina determined that Petitioner was not eligible for licensure in that state because she had not completed the required post-graduate training. Her application for licensure in that state was returned without action. In her applications to Georgia, California and Florida in 1983, Petitioner misrepresented her attendance at CETEC as having commenced in May, 1979 rather than reporting attendance at AUC starting in May, 1980 and ending in May, 1981 when she transferred to CETEC. Petitioner admits that she falsely stated that she began her medical education in May, 1979 on the Oregon FLEX application, as well as the California, Georgia and 1983 Florida applications. In an attempt to justify these false statements, Petitioner points out that the Dean from CETEC had issued a letter to these licensing agencies stating that Petitioner had completed eight (8) semesters at CETEC from 1979 to 1982. Petitioner claims she completed the misleading applications because she wanted her statements to be consistent with the CETEC Dean's certification of attendance. It would appear that an additional motivation for falsifying the applications was to avoid having to explain that she had received medical education credit for some of her non-medical course work at the University of Chicago approximately ten years earlier. It is unclear why the Dean's certification letters were not accurate. While no evidence was presented to directly link Petitioner to the issuance of these incorrect Dean's letters, the shady circumstances surrounding her involvement with Pedro de Mesones around this same time period (discussed in Findings of Fact 87-95 below) leads to an inference that Petitioner was at least indirectly responsible for these misleading letters. In her February 1983 application to New Mexico, Petitioner accurately stated the dates and locations of her medical school education. No adequate explanation was given as to why the correct dates were listed on this 1983 application but not the other applications filed around the same time in Georgia, Florida and California. Petitioner listed the correct dates of attendance at AUC and CETEC on her 1984 Florida application and the 1988 filing which are discussed in more detail in Findings of Fact 69-72 below. Georgia and New Mexico granted Petitioner licensure based upon the 1983 applications. California initially denied her licensure. However, as described in Findings of Fact 47-51 below, Petitioner challenged that decision. Florida permitted Petitioner to withdraw her 1983 Application rather than go to hearing on the Board's intent to deny licensure. See Findings of Fact 67-68. Petitioner's application for licensure in California was filed in the Spring of 1983. Petitioner received a letter in April of 1983 returning her application without action. Petitioner requested reconsideration of her application which, eventually, resulted in a proposed order of denial dated June 9, 1986. Petitioner requested a hearing on that proposed denial. The proposed denial was resolved without hearing by a stipulation between Petitioner and the California licensing agency in an order dated November 5, 1987 (the "California Stipulation"). The stipulated findings of fact in the November 5, 1987 California Stipulation recognize that the application filed by Petitioner in March, 1983 remained pending without action until the 1987 California Stipulation was entered. The California Stipulation notes that the proposed denial of her application in 1986 was based on the grounds that: (a) Petitioner had not listed on her application her attendance at AUC; (b) she had falsely stated under oath that she began her medical education at CETEC beginning in May, 1979; and (c) her medical education did not conform to California requirements. The California Stipulation provides that it supersedes the reasons set forth in the 1986 proposed denial so long as Dr. Chambers abides by the terms of the Stipulation. The California Stipulation makes no findings of fact or conclusions of law regarding wrongdoing on the part of the Petitioner. The California Stipulation provides that Petitioner would be issued a license to practice medicine in California upon completion of remedial medical education specified in the Stipulation, completion of an additional academic year of clinical training before September, 1990, satisfactory proof of certification by CONES, and passage of an oral examination. The California Stipulation also provides that Petitioner shall take forty (40) hours of continuing medical education within the first two (2) years of licensure in addition to the continuing education classes statutorily required for licensure in California. Petitioner was issued her license to practice medicine in California on November 11, 1988 demonstrating that she satisfied the requirements of the November 1987 California Stipulation. In her application to the State of Georgia in June of 1983, the Petitioner specifically represented that she attended CETEC from May of 1979 to April 1980, attended AUC from April, 1980 to May, 1981 and CETEC again from April 1981 through June, 1982. The Dean of CETEC certified to the Georgia licensing agency that Petitioner enrolled in the school of medicine in May, 1979 and attended eight semesters of 4.2 months each. As discussed in Findings of Fact 43, the basis for this certification by the Dean is unclear. Petitioner obtained a license to practice medicine in Georgia based on her 1983 application and did in fact practice medicine in that state from January, 1984 to August, 1984. On August 17, 1984 the Georgia State Board of Medical Examiners issued a Notice of Hearing to Petitioner setting forth charges against her including failure to meet the standards for licensure and/or intentionally making false statements in obtaining a license to practice medicine. The charges also included an allegation that Petitioner "was denied a license by the Board of Medical Quality Assurance of the State of California based on evidence of making false statements on a sworn application and submitting false and/or inaccurate certificates of education to obtain a license to practice in that state." In fact, in 1984 the California licensing authority had not formally denied Petitioner's application for licensure. The proposed denial of Petitioner's California application was pending, but not acted upon. Indeed, a formal denial of her California application was never finalized. Instead, the issues were resolved by the California Stipulation in November, 1987. On September 22, 1984, Petitioner executed a "Voluntary Surrender" which was approved by the Georgia State Board of Medical Examiners and served as the final order of that agency with respect to the Notice of Hearing discussed in Findings of Fact 54. By voluntarily surrendering her license to practice medicine in Georgia, Petitioner waived her right to a hearing on the charges contained in the Notice of Hearing. The first paragraph of the "Voluntary Surrender" states: "I hereby acknowledge that this surrender shall have the same effect as revocation of my license, and I knowingly forfeit and relinquish all right, title and privilege of practicing medicine in the State of Georgia, unless and until such time as my license may be reinstated, in the sole discretion of the Board." Notwithstanding this language, Petitioner contends the "Voluntary Surrender" should be distinguished from a revocation because she did not admit to any wrongdoing and because she was allowed to seek reinstatement upon application and demonstration of the ability to safely practice medicine. The Voluntary Surrender of the Georgia license contains no specific findings of fact or conclusions of law that establish any wrongdoing on the part of the Petitioner. The "Voluntary Surrender" states that Petitioner did not admit to any wrongdoing and it allows Petitioner to seek reinstatement. The Executive Director of the Composite State Board of Medical Examiners of Georgia certified to the Florida Board of Medicine on August 2, 1988, that Petitioner's Georgia license had been issued in 8/83, surrendered in 9/84 and that license had not been "suspended or revoked." Thus, while disciplinary action was clearly initiated against Respondent in Georgia, her license was not revoked. Petitioner was licensed to practice medicine in the State of New Mexico in November, 1983. On January 10, 1985, the New Mexico Board of Medical Examiners served on Petitioner a Notice of Contemplated Action notifying her of charges including having made misrepresentations in applying for and procuring a license to practice medicine in New Mexico and having her license in Georgia revoked. The New Mexico case was referred to a hearing officer who considered argument and briefs by the parties regarding the nature and effect of Petitioner's surrender of her Georgia license. By an order of the New Mexico State Board of Medical Examiners, Petitioner's New Mexico medical license was revoked in January, 1986. The New Mexico order of revocation treated Petitioner's voluntary surrender of her Georgia medical license as the functional equivalent of a revocation for purposes of the New Mexico licensing statute. In reaching this determination, the New Mexico Board relied upon the wording of the Voluntary Surrender and the Georgia Statutes which both indicate that a voluntary surrender shall have the same effect as revocation. No other specific grounds were cited by the New Mexico Board in its Findings of Fact and Conclusions of Law, Decision and Order. As indicated above, Petitioner's initial application to the Florida Board of Medicine (the "Board") for licensure was filed March, 1983. When the Board proposed denial, Petitioner requested a formal hearing. Prior to hearing, the Board obtained leave from the hearing officer to amend the basis for denial to include grounds relating to information presented to the Board by U.S. Postal Service investigators regarding Petitioner's truthfulness on her application form and the validity of certain documents she utilized in her attempt to obtain a Florida medical license. The Board was granted leave to amend as requested by order dated February 20, 1984. Shortly thereafter, Petitioner filed with the hearing officer a motion to withdraw her application because of the new information presented from the "federal investigation." The Board granted the request to withdraw the 1983 Application in an order rendered May 29, 1984. The Board's proposed denial of Petitioner's 1983 Application was on the basis that the Board had reason to believe that Petitioner, "as a graduate of CETEC, was not capable of safely engaging in the practice of medicine as a result of a report of the California Board of Medical Quality Assurance which indicated gross irregularities in the degree granting process of CETEC University and which raised serious doubts about the adequacy of medical education certified by CETEC." Petitioner filed with the Board a second application for licensure in Florida in December of 1984 (hereinafter referred to as the 1984 Application.) In response to a request for additional information from the Board regarding this second application, Petitioner executed a waiver of the requirement that the Board act upon the application within 90 days. As a result, the 1984 Application was left pending. The 1984 Application was for licensure by endorsement based upon Petitioner's license in New Mexico. As discussed in Findings of Fact 62-66, action was initiated against that New Mexico license in January, 1985 ultimately leading to the revocation of the license in January, 1986. After her New Mexico license was revoked, Petitioner did not hold a valid license to practice medicine in any other state until California issued her a license in November, 1988. On August 1, 1988, Petitioner filed another application with the Board as an update to the 1984 Application. (This August 1988 application is referred to as the "1988 Filing.") In her 1988 Filing, Petitioner included a recertification from ECFMG. At the time she filed her 1984 Florida application, Petitioner's original ECFMG certification had been placed on hold because of the CETEC scandal. Petitioner was required to provide a revalidation of her medical education by ECFMG in order to obtain consideration of her application in Florida. This revalidation was not provided until the 1988 Filing. On September 12, 1988, Petitioner filed a supplement to the 1988 Filing. On November 2, 1988 the Board requested additional information relating to the application. On December 12, 1988 Petitioner filed a response to this request. The Board issued an Order of Intent to Deny on March 3, 1989 stating as grounds for denial in Paragraph 2: You have had licenses in Georgia, New Mexico and California acted against by the licensing bodies of those states. See, Subsections 458.331(1)(b) and 458.311(1)(d), Florida Statutes (1988). The only year of training you received was in 1982-1983 at Holston Valley Community Hospital and the Kingsport Family Practice Center through the auspices of East Tennessee State University Quillen-Dishner College of Medicine. You were recommended less than favorably by both hospitals and you were not permitted to return for a second year of residency training by the College of Medicine. Your poor performance in your only year of medical training evidences your inability to practice medicine with reasonable skill and safety. See, Sections 458.301 and 458.331(4), Florida Statutes (1988). There are material discrepancies between answers and information provided in your 3 different applications and supporting documents submitted to the Board; and you have provided fraudulent information and misrepresented or concealed information regarding your medical education. See Subsections 458.311(1)(c) and 458.331(1)(a) and (hh), Florida Statutes (1988). Inconsistencies in the Application There are several discrepancies between Petitioner's 1983 Florida Application, her 1984 Application, and her 1988 Filing. On the 1984 Application, Petitioner reported her participation in the Unsanctioned Rotation at Sharp Memorial Hospital from December 20, 1980 to January 10, 1981 as part of her clinical clerkships. The Unsanctioned Rotation is not listed on the 1988 Filing. Petitioner contends that it was not until after submission of the 1984 Application that she found out that CONES refused to recognize the clerkships taken in 1980 because Petitioner was not enrolled as a student at CETEC at the time. Therefore, Petitioner deleted those unapproved clerkship weeks from the 1988 Filing. However, while specific reference to the clerkship was deleted in 1988, Petitioner admitted at the hearing that she counted the Unsanctioned Rotation as part of sixty (60) weeks of clerkships claimed in the 1988 Filing. The 1988 Filing states Petitioner completed sixty (60) weeks of clinical clerkships as part of her medical education at CETEC. However, as discussed in Findings of Fact 13 through 18, Petitioner's submitted a CONES verification of clinical rotations that only details fifty six (56) weeks (including duplicate and overlapping credit) of clinical clerkships. In the 1988 Filing, Petitioner did report the actions taken against her medical licenses in Georgia and New Mexico and mentioned her problems obtaining licensure in California. On the 1984 Application, Petitioner responded to the question "Have you ever been notified to appear before any licensing agency for a hearing on a complaint of any nature, including, but not limited to, a charge or violation of the medical practice act, unprofessional or unethical conduct?" by stating "after my voluntary surrender, notice of hearing in Georgia, [sic] charging denial and Flafalse documents re licensure (both false)." Both the Notice of Hearing and the Voluntary Surrender in Georgia were issued prior to the completion of Petitioner's 1984 Florida Application. Thus, while Petitioner did disclose the voluntary surrender, she only provided a brief and somewhat misleading explaination. The 1984 Application does not mention Petitioner's application in South Carolina (which was returned without action) nor does it discuss Petitioner's licensure difficulties in California other than to say she had been denied a license because of "informal deficiencies." The 1984 Application also omits Petitioner's licensure problems in New Mexico which is understandable since the Notice of Contemplated Action in that case was not filed until January, 1985. The application form requires the applicant to list all universities or colleges where the applicant "took classes/received training." Petitioner listed her training at the University of Kansas, Wesley Medical Center under the medical education section of her 1984 Application. In the 1984 application, she refers to it as a "externship". That position is also listed in the medical education section of the 1988 Filing with an explanation indicating that she was not actually a resident. As discussed in Findings of Fact 30, her position at the Wesley Medical Center is not easily described due to the unusual circumstances that led to her participating in the program. She was repeating clerkships in certain areas in accordance with the stipulation reached with the California licensing agency. Although Petitioner was not officially enrolled in classes or a residency program in that position, she considers it as part of her medical education and training and, therefore, listed it as such. In her 1984 Application, Petitioner listed time spent at Jackson Memorial Hospital (University of Miami) and Wesley Medical Center (Unversity of Kansas) on a sheet entitled graduate and post-graduate education. On her 1988 Filing, she listed both positions as post-graduate training. Both of these positions were actually house staff positions rather than part of the training programs of the affiliated medical schools. In the 1984 Application, Petitioner listed her dates of training at the Wesley Medical Center as October, 1984 to April 1985 (which was her projected completion date.) The 1984 Application was filled out and filed with the Board in December 1984, four months prior to the projected completion date of the Wesley position. In the 1988 Filing, Petitioner listed her actual completion date of March, 1985, which was approximately two weeks earlier than the projected completion date referred to in the 1984 Application. From January 1984 to August 1984, Petitioner worked for Spectrum Emergency Care in emergency rooms and free-standing clinics in Georgia. Petitioner listed different dates of service with Spectrum on the 1984 Application and the 1988 Filing. Petitioner contends the differences are due in part because the 1988 Filing included employment at Spectrum in New Mexico in December 1984 and January 1985 after submission of the 1984 Application. However, the 1988 Filing states that Petitioner was continuously employed by Spectrum from January 1984 - January 1985. In fact, she was not employed during the months of August, September, October and November, 1984. Moreover, her employment with Spectrum in New Mexico in December, 1984 and January, 1985 overlaps with her "externship" at the Wesley Medical Center/University of Kansas which took place from October, 1984 through March, 1985. Apparently, this overlap was possible because her work for Spectrum in December, 1984 consisted of one weekend and a holiday and in January, 1985 consisted of one weekend. In sum, the 1988 Filing significantly overstates her actual experience with Spectrum. The 1988 Filing contains several inconsistent statements regarding Petitioner's employment as a ship's physician. Under the practice/employment section of that Filing, she states she was a ship's physician for SeaEscape from April, 1985 to September, 1985 and a ship's physician for Commodore Cruise Lines from February, 1986 to September, 1986. Later in the application, under postgraduate medical training and work experience, she states she was a Chief Medical Officer for cruise ships from April, 1985, through September, 1986. However, according to the previously cited information, for at least a four month period during that time frame, she was not employed. In another portion of her application, Petitioner lists under clinical medicine that she worked on the two ships from April, 1985 through September, 1987. Even assuming that there is a typographical error and Petitioner meant September, 1986 as indicated in the other listings, by deleting any reference to the four months that she was not employed, an impression is created that Petitioner has more clinical experience than was actually true. There is a conflict between the AUC transcript that Petitioner submitted with the 1988 Filing and earlier versions of the transcript that appear in her records. The course titles are consistent in the transcripts, but the numbers of some of the courses are different. Only the last digit of the course numbers are different. Whether a course is listed in the 100 series, 200 series and 300 series is consistent in all of the transcripts. The series numbers reflect first semester, second semester and third semester courses respectively. The AUC transcript submitted with the 1988 Filing was the most recent one obtained by Petitioner from AUC. That transcript was prepared in June, 1986 and reflects a failing grade in the neurosciences course. However, as discussed in Finding of Fact 4, that grade was changed to a passing grade as reflected in a 1981 transcript from AUC which was submitted to CETEC when Petitioner transferred to that school. No adequate explanation has been given to explain why the 1986 AUC transcript is not consistent with the earlier one. Postal Investigation The confusing circumstances surrounding Petitioner's medical education are further complicated by her involvement with Pedro de Mesones. The circumstances surrounding her involvement with Pedro de Mesones have not been fully explained. While Pedro de Mesones' exact status or position is unclear, Petitioner believed him to be a representative of CETEC. He has subsequently been convicted of mail fraud in connection with selling medical diplomas and has been sentenced to a federal prison term. Between July, 1981 and January, 1982, while Petitioner was conducting her clinical rotations in San Diego, she attempted to get information and documentation from CETEC, but she had trouble getting responses to her repeated telephone calls, letters and telegrams. Petitioner sought the help of Pedro de Mesones in getting cooperation and/or responses from CETEC regarding transcripts and other documents necessary for the loan applications and residency applications which she had to file prior to her anticipated medical school graduation date of June, 1982. Another reason Petitioner hired Pedro de Mesones was to get confirmation that CETEC would give her credit towards her medical degree for her prior work on her Ph.D. at the University of Chicago. These credits were necessary for Petitioner to graduate in June of 1982 as she anticiapted. Petitioner was advised by others familiar with the school that Pedro de Mesones could help her in her dealings with CETEC. She first contacted Pedro de Mesones by telephone in February, 1982. She agreed to pay him a total of more than $8,000 for his services. Petitioner explains her payments to Pedro de Mesones as a $3000 fee, plus the next two (2) semester's tuition payments totaling an additional $5000.00 plus a $100.00 graduation fee. Pedro de Mesones advised Petitioner that she had to pay CETEC's tuition totalling $5,000 for two (2) additional semesters even though she did not have to take any classes at CETEC because she was given credit for her work at the University of Chicago. At one point during her dealings with Pedro de Mesones, Petitioner signed a false transcript from a Mexican medical school at Pedro de Mesones' request. This transcript reflected work which Petitioner never completed. No adequate explanation was given as to why these false transcripts were ever prepared. While Petitioner contends that she asked Pedro de Mesones not to use the false Mexican transcript for any purpose, it appears that these transcripts were prepared in the event that Petitioner could not secure two semesters credit from CETEC for her Ph.D. work at the University of Chicago. Ultimately, CETEC decided to give her credit for some of the Ph.D. course work she completed at the University of Chicago. As a result, Petitioner was able to graduate in June of 1982 from CETEC without having to use the false Mexican transcripts. It does not appear that the fraudulent Mexican transcript were ever used by Petitioner in any of her applications. Petitioner provided Pedro de Mesones with two false transcripts regarding her AUC medical education. It is clear that she intended for him to use those transcripts, if necessary, to get a dean's certification from CETEC. One of the false AUC transcripts she prepared made its way into the records of CETEC. It is not clear how CETEC obtained that transcript. Because Petitioner was given credit for her graduate work at the University of Chicago, she did not need the extra credits reflected on the false AUC transcripts. Petitioner subsequently wrote the Dean of CETEC requesting removal of the false AUC transcript after she saw it in her CETEC records during a visit to CETEC to obtain a letter from the Dean showing her to be in good standing. Petitioner asked Pedro de Mesones to provide her with letters signed by the CETEC Dean showing her to be in good standing and on track for graduation in June, 1982. She intended to use these letters in applying for licensure for residency programs. Petitioner felt that she was on track to graduate and indicated to Pedro de Mesones that because of time pressures, she felt it would be acceptable for him to forge the signature of the Dean on the letters required by the various state licensing agencies. However, there is no indication that he did so. While none of the false transcripts prepared by Petitioner were directly submitted by her in any of the applications for licensure filed with any state licensing authorities, it is clear the Dean's certification letters included in Petitioner's 1983 Applications in some of the states were false. See Findings of Fact 39-44. No direct connection has been drawn between the false Dean's certification letters submitted with Petitioner's applications in Georgia and California and Pedro de Mesones. However, the circumstances surrounding Petitioner's dealings with Pedro de Mesones raise a question as to how the certifications were obtained. More importantly, it is clear that Petitioner was aware that the representations contained in the Dean's certifications and the dates of attendance at medical school listed on her 1983 Applications were false. Nevertheless, she still submitted the applications. Petitioner's dealings with Pedro de Mesones ended on June 14, 1982, two days after her graduation ceremonies at CETEC. Practice Experience Petitioner has at various times practiced medicine in Georgia and New Mexico prior to surrendering or losing her license in those states. She has also worked on cruise ships as a ship's doctor for several months. She is currently licensed and practicing in California. She has been licensed in that state since November, 1988. She has practiced emergency medicine at various hospitals and has been practicing as a primary care physician for Castle Air Force Base in California since December 1988. There is no indication that she has been deficient in carrying our her professional duties in any of these positions.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Board of Medical Examiners enter a Final Order granting Petitioner's application for licensure as a physician in the State of Florida subject to a probationary period of two years upon such terms and conditions as the Board deems appropriate. DONE AND ORDERED in Tallahassee, Leon County, Florida, this 2nd day of July, 1990. J. STEPHEN MENTON 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 2nd day of July, 1990. APPENDIX Both parties have submitted Proposed Recommended Orders. To the extent that the proposed findings of fact can be isolated, they are addressed below. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or Reason for Rejection. 1. Adopted in substance in Findings of Fact 37, 46-50 and 67. 2. Aubored in substance in Findings of Fact 67 and 68. 3. Adopted in substance in Findings of Fact 69. 4. Adopted in substance in Findings of Fact 70. 5. Adopted in substance in Findings of Fact 71. 6. Adopted in substance in Findings of Fact 72. Adopted in substance in the preliminary statement. Adopted in substance in Findings of Fact 73. Adopted in substance in Findings of Fact 73. Adopted in substance in Findings of Fact 1. Subordinate to Findings of Fact 2-4 and 6. Adopted in substance in Findings of Fact 5. Subordinate to Findings of Fact 6. Suborindate to Findings of Fact 6 and 8. Adopted in substance in Findings of Fact 20. Adopted in substance in Findings of Fact 96. Adopted in substance in Findings of Fact 9. Subordinate to Findings of Fact 9. Adopted in substance in Findings of Fact 10. Adopted in substance in Findings of Fact 11 and 33. Subordinate to Findings of Fact 87. Subordinate to Findings of Fact 87 and 88. Subordinate to Findings of Fact 88. Subordinate to Findings of Fact 89. Subordinate to Findings of Fact 90-94. The first sentence is rejected as constituting argument. The second sentence is subordinate to Findings of Fact 94. Adopted in substance in Findings of Fact 95. Subordinate to Findings of Fact 35. Subordinate to Findings of Fact 35. Subordinate to Findings of Fact 35. Adopted in substance in Findings of Fact 36. Subordinate to Findings of Fact 36 and 39- 42. Adopted in substance in Findings of Fact 45. The first sentence is adopted in Findings of Fact 87. The remainder is rejected as irrelevant. Rejected as irrelevant. Rejected as irrelevant. Adopted in substance in Findings of Fact 73. Subordinate to Findings of Fact 47-66. Adopted in substance in Findings of Fact 47. Adopted in substance in Findings of Fact 48. Adopted in substance in Findings of Fact 50. Adopted in substance in Findings of Fact 51. Adopted in substance in Findings of Fact 49. Subordinate to Findings of Fact 54. Adopted in substance in Findings of Fact 55. Subordinate to Findings of Fact 57, 59-60. Subordinate to Findings of Fact 58. Suborindate to Findings of Fact 61. Adopted in substance in Findings of Fact 59. Subordinate to Findings of Fact 62-66. Subordinate to Findings of Fact 66. Subordinate to Findings of Fact 66. Adopted in substance in Findings of Fact 73. Adopted in substance in Findings of Fact 73. Subordinate to Findings of Fact 20-30. Adopted in substance in Findings of Fact 73. Adopted in substance in Findings of Fact 22 and 27. Adopted in substance in Findings of Fact 23. Subordinate to Findings of Fact 24. Adopted in substance in Findings of Fact 23. Subordinate to Findings of Fact 25-26. Adopted in substance in Findings of Fact 27. Subordinate to Findings of Fact 24 and 25. Adopted in substance in Findings of Fact 73. Subordinate to Findings of Fact 27. Adopted in substance in Findings of Fact 73. Subordinate to Findings of Fact 74. See proposed findings 26-30 above. Subordinate to Findings of Fact 79-80. Subordinate to Findings of Fact 81. Subordinate to Findings of Fact 82-83. Subordinate to Findings of Fact 38. Subordinate to Findings of Fact 78. Subordinate to Findings of Fact 83. Subordinate to Findings of Fact 77. Rejected as irrelevant. Rejected as irrelevant. Rejected as irrelevant. Rejected as irrelevant. Subordinate to Findings of Fact 78. Subordinate to Findings of Fact 84. Addressed in Findings of Fact 12-18. Rejected as irrelevant. Subordinate to Findings of Fact 12-19. The Respondent's Proposed Findings of Fact Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or Reason for Rejection. Adopted in substance in Findings of Fact 1. Subordinate to Findings of Fact 2. Subordinate to Findings of Fact 3. Subordinate to Findings of Fact 4. Adopted in substance in Findings of Fact 5. Adopted in substance in Findings of Fact 6. Adopted in substance in Findings of Fact 7. Subordinate to Findings of Fact 9 and 13. Subordinate to Findings of Fact 13 and 14. Subordinate to Findings of Fact 16. Subordinate to Findings of Fact 18. Subordinate to indings of Fact 35. Adopted in substance in Findings of Fact 37. Adopted in substance in Findings of Fact 48. Adopted in substance in Findings of Fact 39. Adopted in substance in Findings of Fact 44. Subordinate to Fndings of Fact 46-52 and 67- 68. Adopted in substance in Findings of Fact 69. Subordinate to Findings of Fact 78. Subordinate to Findings of 78. Subordinate to Findings of Fact 76. Adopted in substance in Findings of Fact 70. Subordinate to Findings of Fact 76, 77 and 78. Adopted in substance in Findings of Fact 71. Adopted in substance in Findings of 72. 26. Adopted in substance in the preliminary statement. 27. Adopted in substance in Findings of Fact 73. 28. Adopted in substance in Findings of Fact 73. 29. Adopted in substance in Findings of Fact 54. 30. Adopted in substance in Findings of Fact 56. 31. Adopted in substance in Findings of Fact 78. 32. Adopted in substance in Findings of Fact 63. 33. Adopted in substance in Findings of Fact 65. Subordinate to Findings of Fact 47-51. Adopted in substance in Findings of Fact 22. Subordinate to Findings of Fact 24-26. Adopted in substance in Findings of Fact 27. Adopted in substance in Findings of Fact 25. Subordinate to Findings of Fact 31 and 79- 81. Subordinate to Findings of Fact 29. Adopted in substance in Findings of Fact 12 and 17. Adopted in substance in Findings of Fact 19. Subordinate to Findings of Fact 87-95. Adopted in substance in Findings of Fact 20. Adopted in substance in Findings of Fact 97. Subordinate to Findings of Fact 87-95. Rejected as not supported by competent substantial evidence. Adopted in substance in Findings of Fact 40. Rejected as not supported by competent substantial evidence. Subordinate to Findings of Fact 47-68. Rejected as constituting argument. Rejected as constituting argument. Copies furnished: Paul Watson Lambert, Esquire Attorney at Law 1355 Mahan Drive P. O. Box 31 Tallahassee, Florida 32308 Allen R. Grossman, Esquire Assistant Attorney General Suite 1602 - The Capitol Tallahassee, Florida 32399-1050 Dorothy Faircloth Executive Director Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Kenneth E. Easley General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792
The Issue Whether the Petitioner is entitled to be licensed as a physician assistant.
Findings Of Fact Petitioner sat for the physician assistant licensure examination administered by Respondent October 6 - 9, 1995. Petitioner passed all portions of the examination except for the “Clinical Exam” part of the examination. Because he did not pass the Clinical Exam, Petitioner failed the licensure examination. Thereafter, Petitioner requested the opportunity to review the scoring of his examination and the video that was made of the performance. Petitioner was given ninety minutes for that review. The clinical exam required the candidate to physically examine “patients” with stated vital signs and presenting symptoms. The “patients” were healthy models. The candidate's examination of each patient was closely viewed by two examiners who separately graded various components of the candidate’s performance. The performance was video taped. The video tape included audio so that the verbal instructions to the candidate and the candidate's explanation of his examination could be heard. The Petitioner challenged the scoring of 17 components of the examination. Upon review of Petitioner’s challenge, Respondent gave him additional credit for 10 of the challenged components. That additional credit raised his score from 425 to 500, still short of the 600 points needed for a passing grade. Respondent established that Petitioner was given all the credit he deserved for his performance on the clinical examination. Even if Respondent had given additional credit for all 17 components he challenged, the Petitioner would not have achieved a passing score. This test was not arbitrary or capricious. The questions used were consistent with the instructions given the candidates and similar in nature to those used in other clinical examinations. Petitioner failed to establish that he was entitled to additional credit for his performance on the Clinical Exam portion of the physician assistant licensure examination.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a final order dismissing Petitioner’s challenge to the scoring of his performance on the clinical exam portion of the physician assistant examination administered in October 1995. DONE AND ENTERED this 11th day of June, 1997, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 11th day of June, 1997
The Issue Should the certificate of registration of Petitioner, Professional Pain Management, Inc., License No. PMC 296, as a privately-owned pain management clinic, be revoked?
Findings Of Fact Petitioner, Professional Pain Management, Inc., License No. 296, is a pain management clinic (PMC) subject to the requirements of sections 458.3265 and 459.0137, Florida Statutes (2010).1/ PMC 296 is not wholly-owned by medical doctors (M.D.s), osteopathic physicians (D.O.s), or a combination of M.D.s and D.O.s. PMC 296 is not a health care clinic licensed under chapter 400, part X, Florida Statutes. PMC 296 has three equity shareholders. Their names and percentages of ownership interests are: Robert Ciceles (20 percent); Terra Hom (40 percent), and Erez Cohen (40 percent). None of the three equity shareholders is a physician, M.D. or D.O. Erez Cohen is, and at all pertinent times, has been president of PMC 296. He is not an M.D. or a D.O. Since at least August 2010, the owners and officers of PMC 296 were aware of the requirement that it be wholly physician-owned, effective October 1, 2010. PMC 296 was, at all times pertinent to this proceeding, not wholly-owned by physicians, M.D.s, D.O.s, or a combination of M.D.s and D.O.s. A dispute among the shareholders arising out of a dissolution of marriage proceeding has prevented PMC 296 from establishing ownership by a M.D., a D.O. or a combination of M.D.s and D.O.s. Management of PMC 296 plans to transfer ownership to physicians at an unspecified future date once the shareholder dispute is resolved. There was no evidence of any exemption from the operation of sections 458.3265 and 459.0137 presented at the hearing.
Recommendation Based on the foregoing Findings of Fact and Conclusion of Law, it is RECOMMENDED that the Department of Health issue a final order revoking the certificate of registration of Professional Pain Management, Inc., License No. PMC 296. DONE AND ENTERED this 30th day of September, 2011, in Tallahassee, Leon County, Florida. S JOHN D. C. NEWTON, II 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 30th day of September, 2011.
