Findings Of Fact The parties have stipulated to the facts in this case as follows: The Respondent, Clifford Fruithandler, D.C. is and has been at all times material hereto [sic] the Administrative Complaint filed in DOAH Case No. 89-7036, (DPR Case Number 0094598) a chiropractor licensed in the State of Florida having been issued license number CH 0004149. The Respondent's address is 5417 West Atlantic Boulevard, Margate, Florida 33063. The Respondent, in his capacity as a licensed chiropractor caused to be published an advertisement in the North West Medical Guide in Broward County. The advertisement was published on September 16, 1987. The advertisement identified the Respondent's chiropractic practice as "Advanced Chiropractic and Pain Control Center". The Respondent has been subject to discipline by the Board of Chiropractic in DPR Case Number 44292, 40777, and 28914. On or about March, 4, 1988, the Department of Professional Regulation wrote a letter to Respondent which stated "Please be advised that the Department has received a complaint based on the enclosed advertisement. The allegations are: (1) Advance Chiropractic implies that you possess skills and or other attributes which are superior to other chiropractors..." Within one week following the receipt of such letter by Respondent, the Respondent changed the name of the clinic and stopped using the name "Advanced Chiropractic and Pain Control". Prior to the receipt of DPR's letter of March 4, 1988, Respondent had received no complaints from DPR, the Board of Chiropractic, or from any patient regarding the use of such name.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Chiropractic Examiners enter a Final Order finding Respondent guilty of the allegations set forth in the Administrative Complaint, issuing a reprimand to the Respondent and assessing a fine against Respondent in the amount $750.00. DONE AND ORDERED in Tallahassee, Leon County, Florida, this 29th day of April, 1991. 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 29th day of April, 1991. COPIES FURNISHED: Michael A. Mone, Esquire Senior Attorney Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Roger W. Calton, Esquire Qualified Legal Representative 30131 Town Center Drive Suite 177 Laguna Niguel, CA. 92677-2040 Patricia Guilford Executive Director Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Jack McRay General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792
The Issue Respondent was charged in a five count Administrative Complaint with making or filing a report which the licensee knew to be false in his capacity of a licensed chiropractic physician; failing to keep written chiropractic records justifying the course of treatment of a patient; submitting to a third party payor a claim for services or treatment which was not actually provided to a patient; submitting to a third party payor a claim for a service or treatment without at the same time also providing a copy of the claim to the insured; and making misleading, deceptive, untrue, or fraudulent representations in the practice of chiropractic.
Findings Of Fact Petitioner Department of Professional Regulation is the state agency charged with regulating the practice of chiropractic pursuant to Section 20.30 and Chapters 455 and 460, Florida Statutes. Respondent is, and at all times material hereto has been, a licensed chiropractor in the State of Florida, having been issued license number CH 0003234. His address of record is 3822 W. Broward Boulevard, Plantation, Florida. This discipline case arose out of a complaint from a patient named Dale McCormick when Respondent put Mr. McCormick's unpaid bill into "collection." On March 17, 1986, Respondent had examined Dale McCormick and began treating him for shoulder/lower back pain. Mr. McCormick did not testify at formal hearing. Therefore, the only testimony as to what examinations and treatments were actually performed by Respondent on Mr. McCormick was that of Respondent. Respondent first testified that the examination he performed was "brief" and included a depression test on each shoulder and circular depression test on the skull, with observation and touching of swelling, edema, and muscle spasm. Respondent did not remember whether he did a range of motion examination on Mr. McCormick and could not discern from the Confidential Patient Case History whether or not he had done so because it is his practice only to record positive findings (i.e. loss of range of motion) and he had recorded no loss of motion. Respondent's own conclusion from this record was that either he had done a range of motion test with no positive findings worthy of recording in his records or he had not done a range of motion test at all. The ambiguity of this chiropractic record, the only one which can be clearly demonstrated to relate to Mr. McCormick (see Finding of Fact 17), demonstrates the inadequacy of the record in that the chiropractor who actually performed the examination. (Respondent) could not recall from his review of that record what had been involved in his physical examination. Respondent's testimony also illustrates the probable confusion that would be experienced by a different health care professional reviewing the same record. See Findings of Fact 19 and 20. Although Respondent subsequently testified that he also considered his examination of Mr. McCormick to be a "comprehensive" examination, he indicated that this appellation depended on the intensity of what any given doctor wanted to do. Respondent conceded that normally he would have given a much more intensive examination but on the day he examined Mr. McCormick he was rushed; that he had intended to get more information from the patient and supplement his records on a subsequent or follow-up visit; and that his records could have been more complete. Respondent diagnosed lumbar strain. Respondent testified that he prescribed phenylalamine for pain, and cold pack for edema and muscle spasm; that he performed traction, muscle stin, spinal adjustment and hot packs as therapy for pain and muscle spasm, and provided a lumbar sacral brace. Phenylalamine for edema, therapy for pain, and a lumbar sacal brace are treatments also listed on a bill which bears Mr. McCormick's name and the Respondent's file number for Mr. McCormick. They are also noted beside Mr. McCormick's name on a sign-in sheet used for every patient Respondent saw on the same day but they are not listed on either chiropractic "record" discussed in Findings of Fact 12-18 infra. The bill also reflects the initials "SAMSHPTR" which was not directly explained by any testimony but which the undersigned infers from the testimony to signify spinal adjustment (SA), muscle stin (MS), hot packs (HP) and traction (TR). Respondent consistently attempted to justify his diagnosis by describing the treatment rendered after the diagnosis as opposed to using his examination to reach a diagnosis and then justifying the treatment rendered by naming the diagnosis. The bill and the sign-in sheet are forms commonly in use by chiropractors but are not normally considered professional "chiropractic records." Mr. McCormick paid $35 and received a receipt saying he had reduced his account to a zero balance. Nonetheless, he also signed a lien and insurance authorization form by which Respondent was entitled to seek compensation for the treatment rendered from a third party payor, Mr. McCormick's insurance company. In the absence of testimony by Mr. McCormick as to what the financial arrangement was, and considering the logic that liens are not required of persons who have truly paid in full, Respondent's unrefuted testimony that his secretary/clerk issued the "paid in full receipt" to Mr. McCormick in error is accepted. Thereafter, Respondent billed Mr. McCormick's insurance company for $290, the balance of Mr. McCormick's bill claimed due by Respondent. Respondent billed the insurance company for the following: 90020 Initial Exam $150 97260, 97010, 97012, 97014 65 07040 Lumbar/Sacral Belt 50 Therapy for pain 60 Respondent testified that he did not know precisely what each of the insurance claim codes signified because he let his clerk/secretary fill these in. He understood code 90020 to signify however intense an examination he chose to give; 97260 to mean "spinal adjustment," and 97010, 97012, and 97014 to mean traction, muscle stin, and hot packs in one order or another, which order he was unsure. Dr. Robert Butler, accepted as an expert in chiropractic over objection, testified that 90020 meant "comprehensive examination;" he did not opine on what the other codes might mean. There is no independent documentation concerning the insurance codes which would tend to support either witness' "opinion" of what the codes signify. There is no evidence to show whether Respondent did or did not simultaneously provide a copy of the insurance claim to the insured (McCormick) and the third party payor (insurance company). Respondent's chiropractic records relative to this case include only a Confidential Patient Case History Form (P-3) and an Orthopedic Neurological Exam Form (R-1). Both records fail to include basic vital signs or other examination relative to a comprehensive examination as described by Dr. Butler. Respondent's Confidential Patient History Form has left blank several areas of general and specific conditions that normally should be filled in by the patient prior to treatment. There is, in fact, no information covering the history of the onset of the problem or injury for which Mr. McCormick presented himself to Respondent. It merely recites "rt & lt shoulder pain" and "rt and lt. low back pain." Although Respondent's Orthopedic Neurological Exam Form contains blank areas to fill in the date and time of injury and the location of the present complaint, these were not filled in on this form and no information as to overall medical history is recorded thereon. This form contains space to record examination results but none are recorded, including common observations for height, weight, posture, and vital signs. Dr. Butler conceded that if the Orthopedic Neurological Exam Form could be related to McCormick, it would be sufficient written record of justification of an examination being performed for billing purposes and he expressed no opinion as to the appropriateness of the amount charged therefor. From the Orthopedic Neurological Exam Form, Dr. Butler could only conclude that the patient described was a "healthy individual" without any positive findings upon examination, and that although the form also contains information concerning selective tests performed on the patient, none of the tests recorded revealed positive findings to justify Respondent's diagnosis of Dale McCormick. The Orthopedic Neurological Exam Form was not produced by the Respondent in the course of submitting to informal discovery. It was only located by Respondent among his papers in the course of final formal hearing and subsequent to Dr. Butler's initial testimony and Respondent's testimony. It is machine-copied on the back of a copy of the assignment of lien and insurance authorization signed and dated by Mr. McCormick. From the immediately foregoing facts alone, it may be concluded that this particular record was maintained in a haphazard manner and not in conformity with reasonable chiropractic care and practice. Moreover, this form does not have Mr. McCormick's name on its face and does not reflect any other information identifying who the patient was, the date of examination, or any information which would confirm that the form was made out contemporaneously with Respondent's physical examination of Dale McCormick. There is no suggestion it was ever submitted to the insurance company to verify Respondent's treatment of Mr. McCormick. For the foregoing reasons and even though Respondent was permitted to reopen his case so as to present this "newly discovered evidence", admitted as "R-1", the undersigned is not persuaded that this Orthopedic Neurological Exam Form relates to the patient in question, Dale McCormick. Neither report justified the course of treatment rendered by Respondent. Upon the expert testimony of Dr. Butlers it is found that: The single most important aid for a chiropractic physician in evaluating a patient's condition is a comprehensive history. The minimal standards in the chiropractic profession for a comprehensive patient history are obtaining the primary complaint, secondary complaints (if they exist), duration of the problem, the nature of the problem, what has been done for the problem, if any previous accidents or injuries exist, whether the patient is taking any medication for the problem, and if the patient is receiving any other treatment. Patient histories should be recorded to assist the treating chiropractic physician or successive health care professional in subsequent treatment of the patient. The results of examinations should be recorded by the chiropractic physician to assist the treating chiropractic physician or any successive health care professional in subsequent treatment of the patient. It is standard in the profession for chiropractors to maintain a minimal record of proceedings, communications, and findings and procedures relative to the management and care of each patient. Dr. Butler acknowledged that it is possible to treat a patient without obtaining a patient history but insisted it is risky to treat professionally within the confines of the professional standards without knowing what the underlying condition is. While the exact treatment of a patient with shoulder/low back pain may vary, the physician should record his treatment in the chiropractic records for the patient. This was not done in this case by Respondent. In Dr. Butler's opinion, the examination related in Respondent's testimony was insufficient to treat shoulder/low back pain. Respondent has been previously disciplined for violations of Sections 460.413 (1)(d) and (e) Florida Statutes and Rules 21D-15.01 (2)(g) and (i) with regard to advertising, which offenses are unrelated to the one violation proved herein.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is recommended that the Board of Chiropractic enter a final order dismissing Counts I, III, IV, and V of the Administrative Complaint and finding Respondent guilty of Count II, a violation of Section 460.413 (1)(n) Florida Statutes, imposing a fine of $1,000, suspending Respondent's license as a chiropractic physician for one month, and imposing a one year period of probation to follow directly upon the completion of the one month suspension, with the period of probation to be reduced in the event the Respondent demonstrates to the Board satisfactory completion of courses in chiropractic record-keeping, the courses to be selected and specified by the Board in its final order. DONE and RECOMMENDED this 27th day of October, 1988, at 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 27th day of October, 1988. APPENDIX TO RECOMMENDED ORDER The following constitute rulings pursuant to Section 120.59 (2) Florida Statutes, upon the parties' respective Proposed Findings of Fact (PFOF). Petitioner PFOF: 1-20 are accepted either in whole or in part. Where not fully accepted, modifications have been made to conform to the greater weight of the evidence as a whole, to distinguish between expert opinion accepted and expert opinion not accepted due to equivocations on the record, or opinions expressed without sufficient predicate to be accepted, or to assess the weight and credibility of the witnesses. Proposal 5 specifically has been modified to more closely conform to the greater weight of the credible evidence as a whole. Proposal 6 is mere recitation of testimony out of context and to the degree it has not been accepted within other findings, is modified and distinguished within the facts as found in FOF 20. Proposal 20 has been accepted but only those matters material have been adopted in FOF 21. Respondent's PFOF and 3 are accepted and adopted except as subordinate or unnecessary. is accepted but is irrelevant and not a disputed issue of material fact. Respondent waived any necessity for a subpoena by offering the materials to the prosecution. Moreover, he complained at formal hearing that the DPR attorney did not pick them up quickly enough. 4-6 are partly accepted in FOF 10 to the extent that Dr. Butler was tendered and accepted as an expert in chiropractic over objection, but the remaining parts of each of these proposals is rejected as mere argument and as merely a recitation of authority. COPIES FURNISHED: PAT GUILFORD, EXECUTIVE DIRECTOR BOARD OF CHIROPRACTIC DEPARTMENT OF PROFESSIONAL REGULATION 130 NORTH MONROE STREET TALLAHASSEE, FLORIDA 32399-0750 RAY SHOPE, ESQUIRE AND CYNTHIA SHAW, ESQUIRE DEPARTMENT OF PROFESSIONAL REGULATION 130 NORTH MONROE STREET TALLAHASSEE, FLORIDA 32399-0750 JOSEPH SMITH, D.C. 3822 WEST BROWARD BOULEVARD FORT LAUDERDALE, FLORIDA 33312 LAWRENCE A. GONZALEZ, SECRETARY DEPARTMENT OF PROFESSIONAL REGULATION 130 NORTH MONROE STREET TALLAHASSEE, FLORIDA 32399-0750 BRUCE D. LAMB, GENERAL COUNSEL DEPARTMENT OF PROFESSIONAL REGULATION 130 NORTH MONROE STREET TALLAHASSEE, FLORIDA 32399-0750
Findings Of Fact At all times pertinent to the Administrative Complaint, Dr. Turner has been licensed as a chiropractor in the State of Florida, holding license CH 1454. He has maintained offices as a chiropractic physician at 7650 South U.S. Highway One, Fort Pierce, Florida 34952 since May 19, 1985. Prior Discipline The Board of Chiropractic Examiners has maintained other prosecutions against Dr. Turner. On August 28, 1972 a Final Order was entered revoking Dr. Turner's license for solicitation for prostitution and giving oral medication and injections to a person, but his licensure was reinstated by Order dated September 11, 1974. Thereafter, on July 14, 1977, his licensure was revoked for a second time. Although the Administrative Complaint which had been filed in the second prosecution had alleged sexual misconduct towards patients and staff, those charges were not sustained. The revocation was imposed for obtaining prescriptions for narcotics, stimulants or habit-forming drugs under false pretenses from medical doctors and dentists in an amount so large as to show either drug abuse by Dr. Turner or the offering and administration of drugs to patients, employees, or other persons without lawful authority to do so. Ultimately, Dr. Turner was relicensed, and reestablished his practice in 1985. Alteration of Records The applicable paragraph of the Administrative Complaint alleges that On or about October 25, 1989 a former employee of the Respondent issued a sworn statement, to the State Attorney's Office. In her statement the former employee stated that the Respondent had her change her therapist's notes on a patient to reflect that certain treatments were not being used. The former employee also stated in this interview that the Respondent frequently had her and "other employees" change patient notes in order to mislead future "attorneys" reviewing said notes. Turner hired Debbie Corderre as a therapist and staff member in 1987, and she remained in his employ into 1989. One of the patients to whom she provided therapy was patient E.M. The physical therapists in Dr. Turner's office are not persons who are graduates of a physical therapy school approved for the educational preparation of physical therapists by an accrediting agency recognized by the Council on Post-Secondary Accreditation or who have passed an examination administered by the Department of Professional Regulation to determine fitness to practice as a physical therapist. See Section 486.031 Florida Statutes (1989). Rather, they are persons who have received brief on-the-job training of two weeks or so to provide such therapy as might be ordered by Dr. Turner as part of his office practice. Ms. Corderre testified that Dr. Turner had ordered her to alter the medical records of E.M. to remove diathermy as a therapy given. Diathermy is the heating of body tissues due to their resistance to the passage of high- frequency electromagnetic radiation, electric currents, or ultrasonic waves. (Dorland's Illustrated Medical Dictionary, 26th Edition 1985). The office therapies included massage, traction, electric muscle stimulation, the use of hot packs and ultrasound treatment. Electric muscle stimulation and ultrasound treatment involved the use of a machine with pads; gel was put on the patient and the pads were attached. Ultrasound was performed using the same machine; lotion was placed on the patient and an instrument attached to the machine was rubbed over the body part being treated. How these treatments differ from diathermy, or what constituted diathermy at Dr. Turner's office, was never adequately explained at the hearing. The office notes maintained for Dr. Turner's patients were broken into four sections, each of which were identical, and permitted notes to be made for four separate visits on one sheet. The notes for each individual visit was made up of five parts. The first included a space for the date and abbreviations for the different therapies next to which a check mark could be placed. These spaces were checked off by therapists for billing purposes. None of these spaces ever were checked in any of the extant records for patient E.M. Below the abbreviations was a larger space for therapists notes, in which the therapist would write the therapy provided to the patient during that visit. Below the therapist's note area was a space of equal size containing the acronym SOAP, in which Dr. Turner would make his notes when he saw the patient, after his therapist had already completed the therapy. The fourth portion of the record of a visit is a line to note any material dispensed to the patient during the visit, and the fifth portion is a line to note any X-rays that may have been taken. In none of the records for patient E.M. have any of the abbreviations for any of the different types of therapy been checked off, even though Dr. Turner maintains that these notes are the source of billing information (Tr. 240-41). It is incomprehensible that from the period October 27, 1987 through April 12, 1988, over a total of 59 visits, that a therapist never correctly filled out the portion of the patient record which another employee would need in order to render a bill for the service provided that day. By way of contrast, however, the records for another patient entered into evidence, B.S., do for the most part, have check marks in that portion of the record for a visit which would be useful for billing. The inference which is drawn from the absence of any billing entries in the records for patient E.M. over so long a period of time is that the records which purport to be the contemporaneous records for E.M. are in fact records generated after the fact by the therapist, Debbie Corderre at the instruction of Dr. Turner. Dr. Turner's contention that Ms. Corderre failed to keep appropriate records is rejected. Ms. Corderre testified that Dr. Turner had instructed her to remove reference to diathermy given to patient E.M. Dr. Turner counters by noting that the insurance claim forms submitted by his office on behalf of patient E.M. to the Workers Compensation insurance carrier for E. M.'s employer never showed that diathermy was administered. Dr. Turner argues that Ms. Corderre's testimony must be wrong, for the insurance billings would have shown a charge for diathermy, if the testimony of Ms. Corderre were correct. Dr. Turner's point is well taken, but it does not negate the core of Ms. Corderre's testimony. Ms. Corderre had told the State Attorney's office before the hearing that she thought Dr. Turner had instructed her to change the records to remove any reference to having provided patient E.M. with ultrasound therapy. Based upon all the evidence I find that the records for patient E.M. were changed by Ms. Corderre in some significant way at the direction of Dr. Turner. Because the original records were necessarily lost, and all that remains are revised records, it is not possible to determine with certainty in what way the records were altered. On this aspect of her testimony the recollection of Ms. Corderre is faulty. Her testimony that she changed all records for patient E.M. is persuasive, and the absence of any entry in the portion of the records used for billing reinforces this conclusion. Why Dr. Turner wanted to have the records changed and the manner in which he told Ms. Corderre to change them are not particularly significant. Dr. Turner regarded the change as sufficiently important to have Ms. Corderre spend almost a full day of filling out the newly created records. He then manufactured what are supposed to be contemporaneous entries of his own in the portion of the records which are his notes (the SOAP notes). Improper Sexual Touching of a Patient Dr. Turner employed Brenda Stanley, who later became Brenda Sika by marriage, during the period August 1988 to 1989. She was trained as a physical therapist at the office. About a month after she was employed, in September 1988, Brenda Sika was injured in an automobile accident, and had gone to the hospital emergency room. She discussed her condition and her need for treatment with Dr. Turner, who agreed to examine her and treat her. Dr. Turner first saw Brenda Sika as a patient on September 13, 1988. Ms. Sika's principle complaints included back pain over the whole back, but which was worse in the lower back; neck pain, and ankle pain, all of which had resulted from the automobile accident. She also had bruising and tenderness of her chest due to the action of her seat belt in the accident. Ms. Sika contends that while she was lying on her stomach in a treatment room on several occasions Dr. Turner had placed his hand on her ankle, and slid it up until his hand was on her buttocks, and that on one occasion he had placed his hands between her legs while she was lying face down, with the inside of his hands on the inside of her legs and his thumb on the outside. She also alleged that on the Sunday following the initial visit on September 13, she sought additional treatment from Dr. Turner, and in the course of that treatment he requested her to remove her bra, remained in the room while she undressed, and afterwards asked her to stretch out her arms, after which he felt her breasts, including placing his hand around the fleshy part of her breasts. Finally, Ms. Sika alleges that while in the X-ray room, Dr. Turner asked to check if her groin muscle had been pulled, and in the process used his thumb and index finger to squeeze or grip her in the groin. It is difficult to accept the contention that Dr. Turner had engaged in inappropriate and unwarranted sexual touching of Ms. Sika's breasts, buttocks or groin area, in view of the continuing employment relationship. Ms. Sika had only recently been hired when she was injured. It seems unlikely that she would have remained in the employ of someone who had engaged in lecherous touching while she was supposedly being treated. She remained an employee of Dr. Stanley for a substantial amount of time, and only left that employment when she went to Michigan for her wedding. What is more significant, however, is that after she returned to Florida following her wedding, she decided to return to employment with Dr. Turner (Tr. 75). Ms. Sika did not tell other employees such as Deborah Coderre or Tammy Prescott that Dr. Turner had engaged in unwarranted sexual advances or made sexual innunendoes to her at the office. With respect to the accusation of fondling of a breast, after the accident Dr. Turner had conducted an examination which included palpation in the area of the rib cage underneath the breast, where there was a bruise caused by the seatbelt in Ms. Sika's car. That sort of touching in an area of complaint is appropriate. The charge with respect to running Dr. Turner's hands from the ankle to the buttocks is unconvincing. Attempting to determine whether there was involvement of a groin muscle would be appropriate, but the description of the examination given by Ms. Sika would have constituted inappropriate conduct, had the examination occurred as described. As stated above, given her continued employment, and reemployment after she had left work with Dr. Tuner at the time of her wedding, the evidence of sexual misconduct is not convincing.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Board of Chiropractic enter a final order revoking the licensure of Dr. Turner, without right of reinstatement or relicensure. RECOMMENDED in Tallahassee, Leon County, Florida, this 9th day of November, 1990. WILLIAM R. DORSEY, JR. 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 9th day of November, 1990. APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 90-5707 Rulings on the proposed findings by the Department: Adopted in Finding 1. Adopted in Finding 1. Adopted in Finding 4. Adopted in Finding 4. Adopted in Finding 9. Recounted in Finding 6, but the testimony that the alteration was to remove diathermy is not accepted. Rejected as unnecessary, because not within in the allegations of the Administrative Complaint. Rejected as unnecessary, because not within the allegations of the Administrative Complaint. Rejected as unnecessary, because not within the allegations of the Administrative Complaint. Rejected as unnecessary, because not within the allegations of the Administrative Complaint. Rejected as unnecessary, because not within the allegations of the Administrative Complaint. Rejected because the testimony was not sufficiently specific to establish that other medical records were altered. The testimony with respect to patient E.M. is sufficiently specific. Rejected because the testimony was not sufficiently specific with respect to alteration of records other than those of E.M. Moreover, the charge made in paragraph 3 is not one with respect to purposeful mis-billing. See, Finding 3. See, ruling on Finding 13. Adopted in Finding 12. Adopted in Finding 13. Adopted in Finding 13. Adopted in Finding 14. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony is recounted in Finding 15. The testimony recounted in Findings 19-27 is rejected for the reasons stated in Finding 16. Included in Finding 14. Rejected as irrelevant. Rejected as irrelevant. Rejected as irrelevant to the allegations of the Administrative Complaint. Adopted in Finding 2. Rulings on findings proposed by Dr. Turner: Adopted in Finding 1. Adopted in Finding 1. Rejected as unnecessary, because Dr. Turner's skills are not at issue. Rejected as unnecessary, because Dr. Turner's skills are not at issue. Rejected as unnecessary, because Dr. Turner's skills are not at issue. Rejected as unnecessary, because Dr. Turner's skills are not at issue. Adopted in Finding 12. Adopted in Finding 13. 9 and 10. Rejected as irrelevant. Rejected as unnecessary. Generally accepted for the reasons given in Finding 16. Rejected as unnecessary. Rejected as unnecessary. Rejected as unnecessary. Adopted in Finding 16. Adopted in Finding 17. Rejected as unnecessary. Rejected as unnecessary. To the extent necessary, adopted in Finding 17. Generally adopted in Finding 17. Rejected as unnecessary. Rejected as unnecessary. Rejected as unnecessary. Rejected as unnecessary. Rejected as unnecessary. To the extent persuasive, these arguments are covered in Findings 16 and 17. Accepted in Finding 17. Adopted in Finding 4. Generally rejected as a recitation of testimony, and because the argument that Dr. Turner had not required Ms. Corderre to change records of diathermy is accepted, but the argument that Dr. Turner did not instruct Ms. Corderre to make some significant changes in E. M.'s record is rejected. The testimony is recounted in Finding 10. Rejected as unnecessary. What is significant is that Ms. Corderre changed records at the direction of the doctor, the exact nature of the change is not essential. See, Finding 11. Rejected as unnecessary. Rejected as unnecessary; any motivation Ms. Corderre might have had to be untruthful has been considered in evaluating her testimony. Rejected as unnecessary, any motivation Ms. Corderre might have had to be untruthful has been considered in evaluating her testimony. Rejected as unnecessary, any motivation Ms. Corderre might have had to be untruthful has been considered in evaluating her testimony. Accepted in that the only findings made with respect to Dr. Turner's conducts are made with respect to the records of E.M. Rejected as unnecessary. Rejected. I have accepted most of the testimony of Ms. Corderre. Rejected as unnecessary. No "Taylor" case is at issue here. Rejected. See, especially Finding 9. Rejected as unnecessary. COPIES FURNISHED: Patricia Guilford, Executive Director Department of Professional Regulation Board of Chiropractic 1940 North Monroe Street Tallahassee, FL 32399-0792 Kenneth E. Easley, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Michael A. Mone', Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Elizabeth R. Alsobrook, Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Harold M. Braxton, Esquire 9100 South Dadeland Boulevard Suite 400 Miami, FL 33156-7115 Donald C. Dowling, Esquire 501 East Atlantic Avenue Delray Beach, FL 33483
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: On May 13-16, 1992, petitioner, James S. Moore, a chiropractic physician, was a candidate on the chiropractic licensure examination. Doctor Moore is a recent graduate of Life Chiropractic College and was taking the examination for the first time. The test was administered by the Department of Professional Regulation (DPR) on behalf of respondent, Board of Chiropractic (Board). On July 2, 1992, DPR issued a written uniform grade notice advising petitioner that while he had received passing grades on the X-ray interpretation and technique portions of the examination, he had received a score of 70.5 on the physical diagnosis portion of the test. A grade of 75.0 is necessary to pass this part of the examination. By letter dated September 23, 1992, petitioner requested a formal hearing to contest his score. In his letter, Dr. Moore generally contended that he had been denied licensure without any reason or explanation, and that during the review process his contentions were not given meaningful consideration. As further clarified at hearing, petitioner contended that he should have received higher scores on procedures 1, 2, 7, 10, 15, 17 and 18 of the physical diagnosis portion of the examination, and thus he should have received a passing grade. That portion of the test is a practical examination requiring the candidate to give verbal and demonstrative responses to a series of questions designed to test the candidate's diagnostic skills. Among other things, the candidate is required to perform certain tests and procedures on a volunteer patient. To memorialize a candidate's performance, the examination is videotaped, and a copy of petitioner's performance is found in joint exhibit 1 received in evidence. Petitioner generally contends that he should have received a higher grade on the above questions. To support his position, petitioner testified on his own behalf and presented the testimony of his uncle-employer, a chiropractic physician in Jacksonville, Florida, who has seven years experience in the field. Respondent offered the testimony of a Miami chiropractic physician who has been a grader on the examination for the last twelve years and was accepted as an expert in the field of chiropractic. It is noted that both physicians reviewed petitioner's examination prior to giving testimony. However, respondent's expert did not regrade the examination but rather evaluated the questions, petitioner's responses and the grades of the two examiners who graded petitioner to determine if the scores were within acceptable guidelines. As might be expected, the two physicians offered conflicting opinions regarding petitioner's examination scores. In resolving the conflicts in the testimony, the undersigned has accepted the more credible and persuasive testimony, and this testimony is embodied in the findings below. There are two independent chiropractors who grade each candidate on the physical diagnosis part of the examination. Each examiner is given one hour of standardization training prior to the examination, there is no discussion by the examiners during the examination itself, and they grade independently of one another. There is no evidence to support a finding that the two examiners who graded petitioner conferred with each other prior to assigning a grade or otherwise acted improperly in the performance of their duties. In order to preserve the confidentiality of the examination, the questions or information given to a candidate will not be repeated verbatim here but rather only a general description will be given. As to question 1, petitioner was penalized one point (or given a grade of three out of four points) because he stated that the normal range for a particular joint was at 100 degrees. He derived this answer from the American Medical Association Guidelines for Impairment, which is the standard used for disability evaluation. Because impairment standards are not synonymous with a normal range of motion, petitioner's response was incorrect and his score of three should not be changed. In procedure 2, the candidate was given a hypothetical case history of a female patient and was required to choose four appropriate orthopedic tests that related to her condition and to then perform each test. The question noted that if an incorrect test was selected, no credit would be given even if the test was performed correctly. Petitioner selected only two correct tests and accordingly received a grade of two out of four possible points. Respondent's expert confirmed that only two correct answers were selected, and thus petitioner's grade should not be changed. Among other things, procedure 7 required the candidate to use and interpret the Wexler scale, a reflex scale used by chiropractic and orthopedic physicians. Petitioner contended that the Wexler scale is considered zero to five, and he used this range to fashion his answer. Although at hearing respondent asserted that the scale is actually zero to four, it now concedes that petitioner's response was correct and that his grade on this question should be adjusted upward by 1.5 points. Procedure 10 related to diagnostic imaging and generally required the candidate to select the appropriate x-rays to be taken for a given set of facts. Because petitioner failed to take a necessary spot hip x-ray, he did not receive full credit on the question. At hearing, petitioner contended that the omitted x-ray would over-radiate the patient and that the large views taken of the patient would give sufficient detail of the primary complaint area. However, these contentions are rejected as not being credible. Therefore, the request to change the grade on this procedure should be denied. In procedure 15, petitioner was given certain information concerning a patient and was required to make a specific diagnosis to be written in the patient's records. The question also provided that if an incorrect diagnosis was selected, the candidate would receive no credit. In this case, petitioner failed to select the proper diagnosis. His response that the patient suffered from a "sprain/strain" of a particular muscle was incorrect since there is no such thing as a sprain of a muscle. Indeed, only joints and ligaments can be sprained. Although respondent's expert conceded that the correct answer was not "easy" to ascertain, all candidates faced the same level of difficulty on the question and thus no change in petitioner's grade is warranted. Petitioner next contends that he was given an incorrect grade on procedure 17, which required him to identify which physical examination procedures (more than one) he would use based upon a hypothetical patient history. The question provided that unless all procedures were identified, no credit would be given. Because petitioner did not state that he would take the patient's vital signs, a necessary procedure for a new patient, he properly received a zero score. Finally, procedure 18 used the same hypothetical patient history given in procedure 17 and required the candidate to demonstrate on a volunteer patient the necessary examination procedures. Of particular significance was the requirement that the candidate not only correctly perform the procedures, but also demonstrate those procedures in the usual and customary order. Unfortunately, petitioner performed the first of four procedures last, which would affect the reliability of the findings, and thus he received no credit. Therefore, petitioner's grade on this question should not be changed. In summary, with the exception of procedure 7, the scores given to petitioner on each of the challenged procedures are supported by logic and reason, and there is no justification in changing the overall score to a passing grade. In addition, the test was fairly administered in every respect to all candidates, including the provision in some questions that unless the entire question was correctly answered, no partial credit would be given. Thus, petitioner's contention that he should have received partial credit instead of no credit on several questions is without merit.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that respondent enter a final order raising petitioner's grade on the physical diagnosis part of the May 1992 chiropractic licensure examination from 70.5 to 72.0 but denying his petition in all other respects. DONE and ENTERED this 4th day of January, 1993, at Tallahassee, Florida. DONALD R. ALEXANDER 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 4th day of January, 1993. Respondent: APPENDIX TO RECOMMENDED ORDER IN CASE NO. 92-6162 1-2. Partially adopted in finding of fact 5. 3-4. Partially adopted in finding of fact 6. Partially adopted in finding of fact 7. Partially adopted in finding of fact 8. Partially adopted in finding of fact 9. Partially adopted in finding of fact 10. Partially adopted in finding of fact 11. NOTE: Where a proposed finding has been partially adopted, the remainder has been rejected as being irrelevant, unnecessary, subordinate, cumulative, not supported by the evidence, or a conclusion of law. COPIES FURNISHED: Vytas J. Urba, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Dr. James S. Moore P. O. Box 229 Doctor's Inlet, FL 32030 Jack L. McRay, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Diane Orcutt Executive Director Board of Chiropractic 1940 North Monroe Street Tallahassee, FL 32399-0752
The Issue The issues in this case are whether Respondent committed the allegations contained in the Corrected Amended Administrative Complaint, and if so, the penalty that should be imposed.
Findings Of Fact The Parties Petitioner Department of Health has regulatory jurisdiction over licensed chiropractic physicians such as Respondent. In particular, Petitioner is authorized to file and prosecute an administrative complaint, as it has done in this instance, when a panel of the Board of Chiropractic Medicine has found probable cause to suspect that the chiropractic physician has committed one or more disciplinable offenses. At all times relevant to this proceeding, Respondent was a chiropractic physician licensed in the State of Florida, having been issued license number CH 2363. Background / Arrangement with Dr. Wagner In or around 1975, Respondent completed his training at the National University of Health Sciences and began to practice chiropractic medicine shortly thereafter. Some 15 years later, Respondent and an acquaintance—— Dr. Joseph Wagner, also a licensed chiropractor in the State of Florida——matriculated at a medical school in the Dominican Republic. Although both Respondent and Dr. Wagner ultimately earned Doctor of Medicine ("MD") degrees in the mid 1990s, Respondent was not licensed in Florida to practice as an MD until early 2006. Significantly, Dr. Wagner never obtained licensure as a medical doctor. In 2007, Respondent and Dr. Wagner entered into a joint venture designed, in the words of Respondent, to "expand" Dr. Wagner's chiropractic practice. At that time, and for the duration of their business agreement, Respondent's principal place of business was located in Palm Beach County, while Dr. Wagner practiced chiropractic medicine in Daytona Beach. Under the joint venture (which continued until August 2011, when both their offices were raided by the Federal Bureau of Investigation), Respondent traveled to Daytona Beach several times each month and interacted with Dr. Wagner concerning some, but not all, of Dr. Wagner's chiropractic clients (hereinafter "joint-venture clients" or "JVCs"). From what can be gleaned of the credible portions of Respondent's deposition and final hearing testimony, it appears that Respondent's activity with respect to JVCs included a review of client files, and, in some cases, a determination that one or more medications——including narcotics——should be prescribed. Indeed, Respondent's level of participation was so minimal that his face-to-face interaction with JVCs consisted, at most, of an initial introduction, and on no occasion did Respondent personally examine——or perform treatments upon——any JVC. At the conclusion of an office visit, Dr. Wagner——and Respondent, if the JVC was seen on a day when Respondent was present in the Daytona office——dictated medical notes that Dr. Wagner usually transcribed at a later time. Respondent has acknowledged, both at the final hearing and during his deposition, that he provided Dr. Wagner with blanket authority to create claim forms and medical notes in connection with each JVC. Incredibly, Respondent also granted Dr. Wagner complete authority to affix his (Respondent's) signature to claim forms and submit them——without Respondent looking at the forms beforehand——to insurance carriers for reimbursement. This was accomplished not by the use of a stamp, which medical professionals often provide to their subordinates to expedite business affairs, but by Dr. Wagner manually signing, in cursive, "John P. Christensen" inside the box of the claim form labeled "signature of the physician or supplier." Another unusual aspect of the business arrangement between Respondent and Dr. Wagner was the manner in which they dealt with reimbursement checks from insurance carriers. By agreement, reimbursement checks for claims that related to JVCs were received by mail at Dr. Wagner's place of business in Daytona Beach. Upon their receipt, Dr. Wagner deposited the checks into a SunTrust checking account for which Respondent had sole signatory authority. At the end of each month, Respondent would transfer the entire balance of the SunTrust account into his business account at PNC Bank. Shortly thereafter, Respondent would draft a check on the PNC account to Dr. Wagner in an amount equal to 50 percent of the monthly proceeds.2/ Against the foregoing backdrop, the undersigned will turn to the specific allegations enumerated in the Complaint, namely: that Dr. Wagner, in connection with JVCs, submitted claims to an insurance carrier for services that were never provided——i.e., he overbilled——and that Respondent approved, authorized, and/or knew or should have known of the misconduct (as charged in Counts One and Three); and that the Respondent and Dr. Wagner's billing practices with respect to the four JVCs constituted fraudulent, deceptive, or untrue representations related to the practice of a profession (Count Two). The undersigned will begin with a discussion of the facts relating to Count Two. Deceptive Billing Practices In or around August 2009, three individuals——S.J., J.J. (S.J's cousin), and L.J. (S.J's mother)——were involved in an automobile accident. Thereafter, in late 2009 and early 2010, S.J., J.J., and L.J. presented themselves on a number of occasions for chiropractic services at Dr. Wagner's office in Daytona Beach. Roughly one year earlier, patient C.H. was likewise involved in a car accident. C.H. was subsequently referred to Dr. Wagner for chiropractic treatment by her personal injury attorney, Joshua Wagner, who happens to be the son of Dr. Joseph Wagner. It appears from the record that C.H. was treated at Dr. Wagner's clinic on multiple dates. Pursuant to the parties' Joint Prehearing Stipulation, it is undisputed that S.J., J.J., L.J., and C.H. each had personal injury protection (PIP) insurance from Direct General Insurance Company ("DGIC"). PIP insurance coverage allows a medical or chiropractic provider to treat insured persons and then submit a reimbursement claim to the insurance company for the service(s) provided. Beginning with the claims associated with C.H., Respondent has consistently maintained that C.H. was not a joint-venture client, that he had no knowledge of C.H., and that any claim submitted by Dr. Wagner in connection with C.H. was without his knowledge or authorization. The undersigned credits this portion of Respondent's testimony; thus, any bills that relate to C.H. cannot sustain a finding of a deceptive or fraudulent practice. However, the cases of S.J., J.J., and L.J. are another matter. Based upon Respondent's deposition testimony, the undersigned is persuaded that Dr. Wagner, with Respondent's knowledge and authorization, submitted reimbursement claims to DGIC in connection with S.J., J.J., and L.J. that bear the following dates: January 30, 2010 (S.J.); January 30, 2010, and March 13 and 27, 2010 (L.J.); and April 10 and 24, 2010 (J.J.).3/ While the exact services billed to DGIC varied by JVC and date, the content of each of these claim forms represented unambiguously that the examinations and/or treatments——e.g., a trigger point injection for L.J. on March 27, 2010——were performed by Respondent and no other. This was unquestionably deceptive in light of Respondent's consistent testimony that he never physically conducted medical examinations or treatments in connection with any joint-venture client. Alleged Overbilling In contrast to Count Two, the charges that relate to overbilling (Counts One and Three) cannot be sustained merely by proof that claims for reimbursement——i.e., the claims identified in paragraph 16 above, which Respondent authorized——were submitted for services that Respondent did not perform. Rather, it is incumbent upon Petitioner to demonstrate that the services billed were not performed at all. In this regard, the deposition transcripts of L.J. and S.J., which consist entirely of hearsay, are the only evidence that the billed services were not performed by anyone. While the deposition testimony of L.J. and S.J. is credible, there is a complete absence of non-hearsay evidence as to what procedures or services were never provided to these specific patients during their office visits. All that was proven——based upon Respondent's admissions and supplemented by the hearsay testimony of the JVCs——is that Respondent did not perform the billed services, which, as explained in greater detail in the Conclusions of Law of this Recommended Order, is insufficient to satisfy Petitioner's burden. Ultimate Findings of Fact It is determined, as a matter of ultimate fact, that Respondent engaged in deceptive, untrue, or fraudulent representations in or related to the practice of his profession. It is further determined, as a matter of ultimate fact, that Petitioner failed to demonstrate that Respondent submitted to a third-party payor a claim for a service or treatment that was not actually provided to a patient. Finally, as a matter of ultimate fact, it is determined that that Petitioner failed to prove that Respondent, in connection with a personal injury protection claim, intentionally submitted a bill or claim for reimbursement for services that were not rendered.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Board of Medicine: Dismissing Counts One and Three of the Corrected Amended Administrative Complaint; Finding that Respondent violated section 456.072(1)(m), Florida Statutes, as charged in Count Two; Suspending Respondent's license to practice chiropractic medicine for a period of one year; Placing Respondent on probation for a period of two years, with conditions deemed appropriate by the Board; and Imposing a fine of $10,000. DONE AND ENTERED this 16th day of March, 2012, in Tallahassee, Leon County, Florida. S EDWARD T. BAUER 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 16th day of March, 2012.
The Issue Whether Petitioner is entitled to additional credit for the answer he gave in response to Question 21 on the physical diagnosis portion of the November 1999 chiropractic licensure examination.
Findings Of Fact Based upon the evidence adduced at hearing and the record as a whole, the following findings of fact are made: Petitioner took the chiropractic licensure examination administered in November of 1999. The practical examination consisted of three parts: "technique," "physical diagnosis," and "x-ray interpretation." The minimum passing score for each part was 75. Petitioner passed the "technique" and "x-ray interpretation" portions of the examination; however, he failed the "physical diagnosis" portion of the examination (PD Test), with a score of 68. On this portion of the examination, candidates demonstrated their knowledge of "physical diagnosis" by responding to test questions, in the presence of two examiners, verbally and/or, where appropriate, by demonstrating on a "patient." Their responses were independently evaluated and graded by the two examiners. A candidate's final score was the average of the two examiners' scores. Prior to the administration of the PD Test, all examiners were provided with instructions regarding their role in the examination process and the standards they should follow in grading the candidates' performance. Candidates were provided with a Candidate Information Booklet (CIB) in advance of the licensure examination. Among other things, the CIB listed, by category ("acupuncture," "physical diagnosis," "technique," and "x-ray") reference materials that could "be used to prepare for the examination." The list was preceded by the following advisement: The list is not to be considered all- inclusive. Thus, other comparable texts may be used to prepare for the examination. Under the category of "x-ray" the following "references" were listed: Eisenburg, Gastrointestinal Radiology- A Pattern Approach, Hagerstown, MD: Lippencott, Second Edition, 1989. Paul & Juhl, Essentials of Radiologic Imaging, Hagerstown, MD, Lippencott, Sixth edition, 1993. Taveras & Ferrucci, Radiology: Diagnosis- Imaging-Intervention, Hagerstown, MD: Lippencott, 1986. Five-volume set, loose- leaf renewed in July 1994. Yocum, T. R., & Rowe, L. J., Essentials of Skeletal Radiology, Baltimore: Williams & Wilkins, First Edition 1986. Not on the list under "x-ray" or under any other category was Dr. Robert Percuoco's Radiographic Positioning for the Chiropractor (Dr. Percuoco's Publication), the text book used by Dr. Percuoco in the radiology classes he teaches at the Palmer College of Chiropractic in Davenport, Iowa (Palmer). Palmer was the nation's first college of chiropractic, and is accredited by the Council of Chiropractic Education. Petitioner graduated from Palmer and was taught radiology by Dr. Percuoco. Question 21 on the PD Test was an eight-point "diagnostic imaging" question (with no provision for partial credit) that asked the candidates to "demonstrate a Lateral Thoracic view." Among the six items the candidates had to address in answering the question was the central ray. Page 54 of the Dr. Percuoco's Publication describes what, according to the author, needs to be done to obtain a view of the lateral thoracic spine. It provides, in pertinent part, as follows (Dr. Percuoco's Approach): Center the central ray to the film. The vertical portion of the central ray should pass posterior to the head of the humeri. In responding to Question 21 on the PD Test, Petitioner relied on the foregoing excerpt from Dr. Percuoco's Publication. He told the examiners that the central ray should be centered to the film and that the vertical portion of the central ray should pass one inch posterior to the head of the humerus. The two examiners evaluating his performance both gave Petitioner an "A" (or no points) for his response to Question 21. In so doing, they acted reasonably and in accordance with the grading instructions they had received prior to the administration of the PD Test. Dr. Percuoco's Approach (upon which Petitioner relied) is not generally accepted in the chiropractic community. A reasonably prudent chiropractor, in taking an x-ray of the lateral thoracic spine, would do what was necessary to have the central ray pass, not "posterior to the head of the humeri," but "approximately 3 inches inferior to [the] sternal angle," as Drs. Yocum and Rowe, two of the most respected radiologists in the country today, instruct in their text, Essentials of Skeletal Radiology, which was one of the reference materials listed in the CIB (Dr. Yocum's and Dr. Rowe's Approach). Dr. Yocum's and Dr. Rowe's Approach yields a more exact and complete view of the lateral thoracic spine than does Dr. Percuoco's Approach. Because Petitioner failed to incorporate Dr. Yocum's and Dr. Rowe's Approach in his response to Question 21, the examiners were justified in determining that Petitioner did not answer all six parts of the question correctly and that he therefore should be awarded an "A" (or no points) for his response.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered rejecting Petitioner's challenge to the failing score he received on the physical diagnosis portion of the November 1999 chiropractic licensure examination. DONE AND ENTERED this 7th day of November, 2000, in Tallahassee, Leon County, Florida. 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 November, 2000.
