The Issue Whether the Respondent's paramedic license should be disciplined based upon alleged violations of Sections 401.411(1)(a) and (k), Florida Statutes.
Findings Of Fact Petitioner, HRS, Office of Emergency Medical Services (EMS), is the state agency which certifies and disciplines emergency medical technicians (EMTs) and paramedics in Florida pursuant to Chapter 401, Florida Statutes (F.S.) and Chapter 10D-66, Florida Administrative Code (F.A.C.). Respondent, Joseph L. Riggall, was initially certified as a paramedic in Florida under Section 401.27 and Rule 10D-66.057, F.A.C., in 1990, and was last recertified by EMS for the biennial period December 1, 1992 through December 1, 1994 pursuant to an application he submitted to the department through its agent on October 25, 1992. Respondent Riggall has not filed for recertification as a paramedic in Florida subsequent to the automatic expiration of his certification on December 1, 1994. A paramedic is a medical paraprofessional authorized under Florida law and administrative rules to administer advanced life support treatment with respect to life-threatening medical emergencies. Florida law defines advanced life support to include the use of techniques such as endotracheal intubation, the administration of drugs or intravenous fluids, telemetry, cardiac monitoring and cardiac defibrillation. A paramedic is authorized to perform invasive techniques in order to help save lives threatened by medical emergencies or severe injuries. As a paramedic, Respondent has a responsibility to the public, HRS-EMS and his employer, Polk County Emergency Medical Services, to perform his patient care duties without being impaired by alcohol, habit forming drugs or controlled substances. Respondent was employed by Polk County Emergency Medical Services for a period of time, including March 1994. Respondent was arrested on March 14 1994 in Polk County, Florida, on charges of prescription forgery to obtain controlled substances. HRS-EMS began an investigation of Respondent on March 23, 1994 based upon a complaint. In early March, 1994, Respondent reported to his shift supervisor that on March 11, 1994, while he was on duty as a paramedic, all of the controlled substances (morphine and Valium) had been stolen and were missing from his ambulance stationed at Fort Meade, Polk County, Florida. Respondent's supervisor immediately requested that Respondent submit to a drug test at Polk General Hospital. Respondent complied. Respondent was drug tested at approximately 12:45 a.m., March 12, 1994 at Polk General Hospital. The results of the tests taken at Polk General Hospital, and submitted to Metpath Laboratory for testing on samples from Respondent's serum and blood revealed a very high level of morphine (opiates) in Respondent's bloodstream. The level of opiates in his blood was greater than 1,999 mcg/1 and confirmed by immunoassay by the testing laboratory. Respondent admitted to the use of prescription opiate medication on March 11 and 12, 1994 while on duty as a paramedic. As a result of the drug testing of Respondent conducted the evening of March 11 and continuing the morning of March 12, 1994, and Respondent's arrest on March 14, 1994 on other charges related to improperly obtaining controlled substances or prescription medications, the Polk County EMS Medical Director rescinded Respondent's ability to function under the medical director's medical license. Furthermore, Respondent's employer, Polk County EMS, suspended Respondent without pay from his position as a paramedic with Polk County. Subsequently, Polk County EMS discharged Respondent, after providing a pre- determination conference, on August 26, 1994. HRS-EMS issued an Administrative Complaint, dated July 18, 1994, charging Respondent with a violation of EMS statutes, in particular Section 401.411(1)(a) and (k), Florida Statutes by having tested positive to controlled substances while on duty as a paramedic for Polk County EMS, March 12, 1994. HRS-EMS has adopted an "impaired" EMTs or paramedics policy and program pursuant to Rule 10D-66.0571, F.A.C.. While the administrative complaint tracks the department's impaired practitioner's rule and provided notice to Respondent relative to the rule, Respondent failed to take advantage of this beneficial program. Under the impaired practitioner's rule of HRS-EMS, a paramedic who becomes impaired as a result of drug or alcohol use or addiction may avoid administrative sanction by performing voluntary activities including those listed in the department's administrative complaint against Respondent. Respondent reported for duty as a paramedic while taking a level of controlled substances which impaired his ability to safely provide care to patients.
Recommendation Based on the foregoing, it is RECOMMENDED as follows: 1. The paramedic certification of Respondent be revoked and an administrative fine of one thousand ($1,000) dollars for the violation of paramedic certification requirements be imposed. It is further RECOMMENDED that should Respondent reapply for certification as a paramedic or EMT in Florida, he be required to submit to, and successfully complete, the conditions set forth in Rule 10D-66.0571(2), Florida Administrative Code, and pay the administrative fine recommended above, prior to recertification. DONE and ENTERED this 15th day of February, 1995, in Tallahassee, Florida. DANIEL M. KILBRIDE 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 15th day of February, 1995. APPENDIX The following constitutes my specific rulings, in accordance with section 120.59, Florida Statutes, on proposed findings of fact submitted by the parties. Petitioner's proposed findings of fact. Accepted in substance: paragraphs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 (in part), 19, 20, and 21. Rejected as subsumed or covered in the Preliminary Statement: paragraphs 12, 13, 14, 15, 16, 17, 18, and 22. Respondent has not submitted proposed findings of fact. COPIES FURNISHED: Robert L. Powell, Agency Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Kim Tucker, Esquire Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Robert P. Daniti, Esquire Emergency Medical Services Department of HRS 1317 Winewood Boulevard Tallahassee, Florida 32301 Joseph L. Riggall 13711 Hatchienha Road Haines City, Florida 33844
The Issue The issue for determination is whether an amount of up to $46,901.85, which Petitioner paid on behalf of eligible aliens for emergency hospital inpatient services that Respondent provided during the period from January 1, 2007, to December 31, 2007, constitutes an overpayment that Respondent must return, on the grounds that the services are not covered by Medicaid, despite having been included in claims of Respondent's that were prior authorized by Petitioner before payment.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that AHCA enter a final order adjudicating Gulf Coast not liable for the overpayment, or any part thereof, alleged in the Final Agency Audit Report dated February 26, 2015. DONE AND ENTERED this 26th day of January, 2016, in Tallahassee, Leon County, Florida. S JOHN G. VAN LANINGHAM 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 26th day of January, 2016
The Issue The issue allegedly presented in this case is whether the Petitioner, Dennis A. Ryan, is eligible for recertification as a paramedic.
Findings Of Fact Prior to November, 1980, the Petitioner was employed as a paramedic with Brevard County Emergency Medical Services, having been certified by HRS on August 31, 1979. The Department determined, and contended at the hearing, that this certification expired on August 31, 1980, and that a certificate holder has a 60 day grace period within which to renew a certificate after its expiration date. This grace period expired on October 30, 1980. HRS received the Petitioner's application for recertification together with the required fee on November 7, 1980. The recertification application and check having been received on a date which HRS contends is not within the prescribed grace period, HRS refused to recertify the Petitioner. Since November of 1980, therefore, he has worked in a clerical position with EMS of Brevard County, not as a paramedic. HRS further contends that under the rules in existence up to and including the date of the hearing in this matter, a paramedic whose certification lapses by more than 60 days is not eligible for recertification, but must meet anew all of the requirements for an initial certification. There was some evidence presented relative to a pending change in the existing rules, designed to relax the recertification requirements, but there is not sufficient evidence in the record to support a finding of fact on this issue. At best, the prospective rule change would reduce, not eliminate, the eligibility requirements for recertification of individuals whose certificates have lapsed. The Petitioner, Dennis A. Ryan, received his Emergency Medical Technician certification after a 156 hour college course and a State examination. This was a prerequisite for the 500 hour paramedic course which was completed at the Brevard County Community College. He also has completed adjunctive courses in life support under the standards of the American Heart Association. He is not certified as an associate instructor of Advanced Cardiac Life Support courses, and as instructor/trainer for CPR, advanced first aid, water safety and standard first aid. Under the evidence presented the Petitioner is highly qualified as a paramedic. The certificate which HRS issued to the Petitioner on August 31, 1979, does not on its face set forth an expiration date. Certificate holders are also issued a wallet-size card on which there does appear an expiration date. Between January 1 and August 1, 1980, HRS gave notice by memo directly to persons whose certificates it determined had expired or were about to expire, advising them of the recertification requirements. However, after August 1, 1980, this practice was discontinued. Instead, notices were placed in various newsletters disseminated among the licensed ambulance providers in the State, advanced life support providers, training centers, etc. But without direct notification, or timely reference to his wallet-size card, the Petitioner did not submit his recertification application within the alleged grace period. Further, until August 1, 1980, HRS engaged in the practice of making exceptions to the rigid paramedic recertification rules, allowing recertification when applied for after what it asserts to be the grace period. This practice was also discontinued after August 1, 1980. Consequently, as a result of the inadvertence of the Petitioner, and the cessation by HRS of its policy of flexibility, the Brevard County area has been deprived of the services of a skilled and experienced paramedic.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Department of Health and Rehabilitative Services advise the Petitioner, Dennis A. Ryan, that his paramedic certification is valid until August 31, 1982, and return to him the recertification application and fee submitted on November 7, 1980. DONE AND ORDERED in Tallahassee, Leon County, Florida, this 15th day of June, 1981. WILLIAM B. THOMAS Hearing Officer Division of Administrative Hearings Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 15th day of June, 1981. COPIES FURNISHED: Kenneth C. Crooks, Esquire Post Office Box 37 Titusville, Florida 32780 Samuel P. Stafford, Esquire Assistant District Counsel HRS Disstrict VII, Suite 912 400 West Robinson Street Orlando, Florida 32801 ================================================================= AGENCY FINAL ORDER ================================================================= STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DENNIS A. RYAN, Petitioner, vs. CASE NO. 81-218 DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, Respondent. /
The Issue The issues in this case are whether Respondent committed the alleged violation and, if so, should his Pinellas County Paramedic Certificate be revoked.
Findings Of Fact At all times relevant to this proceeding, Respondent was employed as a paramedic by the City of Clearwater Fire and Rescue Department ("CFRD"). In this capacity, Respondent worked under the auspices of the medical director for Pinellas County EMS. The Pinellas County emergency protocols are written requirements that paramedics must follow when administering emergency treatment to patients. The protocols are published in a document entitled Pinellas County Medical Operations Manual, commonly called the "MOM Protocols," which are approved by the medical director and distributed to all Pinellas County EMS paramedics. Respondent received a copy of the most recent medical operations manual in January 2005. At all times relevant to this proceeding, Respondent and fellow paramedic, Trevor Murray, were members of CFRD Crew "B" shift for Pinellas County, referred to colloquially as "R49B." Mr. Murray was the "lead medic" according to then- current CFRD nomenclature, meaning that he drove the team's vehicle, operated the vehicle's radio, made decisions regarding appropriate medical treatment to be rendered to a patient, and was responsible for all written reports. The evidence conflicted as to whether the lead medic, Mr. Murray, functioned as Respondent's supervisor. CFRD chief, Jamie Geer, testified that the position of lead medic was merely a designation bargained for by the firefighters' union in order to obtain a pay differential for the additional tasks of driving and filing reports and that the position carried no supervisory responsibility. Respondent testified that, whatever the official view espoused by Chief Geer, the common understanding in the firehouse was that the lead medic supervised the paramedic with whom he rode. Respondent conceded that the lead medic and the paramedic are required to follow the same Pinellas County EMS rules and MOM protocols. Nonetheless, given the list of duties entrusted to the lead medic, it was not unreasonable for Respondent to view Mr. Murray as his supervisor. There was no dispute that the Pinellas County OMD recognizes only the designation "paramedic," meaning a paramedic certified by the State of Florida and certified by the Pinellas County OMD. The Pinellas County OMD took no official notice of the CFRD's distinction between lead and non-lead paramedics.1 During the early morning hours of March 26, 2005, Respondent and Mr. Murray were the crew of R49B. At approximately 5:30 a.m., R49B was dispatched in response to a 911 call for emergency medical assistance at 309 South Maywood Avenue. The caller reported that a sexual assault had occurred. The Clearwater Police Department and the Sunstar Ambulance Service were also dispatched to the stated address. The address, 309 South Maywood Avenue, was immediately recognized by Mr. Murray as the residence of a 41-year-old female who had called 911 approximately 15 times over a two-year period for the same type of complaint. The various patient care reports filed by Pinellas County EMS over the course of two years indicated that the woman had an extensive psychiatric history. She claimed to be the victim of a massive government conspiracy that included the FBI, the CIA, and the DEA. She claimed that then-Attorney General John Ashcroft had entered her residence and sexually assaulted her on many occasions. The reports indicated that she was difficult and combative at times with the police and paramedics who responded to her calls. The record indicates that she had accused at least one emergency responder of a sexual assault. By the time R49B received the call from the dispatcher, officers from the Clearwater Police Department were on the way to the address. Mr. Murray told the dispatcher to have the police officers call back if they arrived and discovered that an actual emergency existed. Mr. Murray then placed R49B back on "available" status, meaning that it was free to respond to other calls. The record indicates that R49B was not called back on the morning of March 26, 2005, concerning 309 South Maywood Avenue. Respondent and Mr. Murray manned an Advanced Life Support Unit ("ALS Unit"). MOM Protocol 3.1k provides, in relevant part: An ALS Unit . . . must continue to the scene of every 911 request for service and determine the need for EMS first hand. Once the 911 system is activated for an EMS call, a County Certified Paramedic must investigate it. An EMS response shall not be canceled by the general public or law enforcement. Chief Geer testified that the quoted protocol means that paramedics have no discretion as to whether to respond to a 911 call, unless there is a possibility of violence. MOM Protocol 6.5 may be invoked to provide for "staging" on a call involving possible violence. Staging essentially provides for law enforcement to secure the area before emergency services personnel enter. There was no indication that the woman at 309 South Maywood Avenue posed a threat of violence, though she had been accusatory and otherwise verbally abusive to EMS personnel. As of March 26, 2005, there were no standing orders to stage on calls from 309 South Maywood Avenue. Chief Geer further testified that 15 calls in one day or week might cause the CFRD to label someone a "problem caller" meriting special treatment, but that 15 calls over a two-year period was insufficient. Chief Geer stated that it is not uncommon for Alzheimer's patients, for example, to dial 911 several times in one day. A caller is labeled a "problem caller" and referred to the Clearwater Police Department when there is evidence of maliciousness. Chief Geer noted that all indications were that the caller at 309 South Maywood Avenue believed she needed medical assistance. In such cases, the paramedics do not have the discretion to ignore a 911 call or to wait for the police to let them know whether the emergency is "real." Dr. Laurie Romig, the medical director for Pinellas County EMS, testified that it is imperative for Pinellas County EMS to have the same response for every 911 call. The fact that a certain address is known and notorious among paramedics is not germane. The caller could be another person at the same address or the same person with a different problem. The only way to be sure that a 911 call is a false alarm is to respond to the call. At the hearing, Respondent conceded that he and Mr. Murray should have responded to the call. He made no attempt to minimize the dereliction of duty involved in failing to respond to a 911 call. Respondent's defense was that Mr. Murray, the lead medic, made the decision not to respond to the call. Respondent testified that he objected to Mr. Murray's decision, but that he considered it a direct order from a superior that he must follow. Respondent did not report the incident to superior officers at the time it occurred. After hearing R49B's radio response to the 309 South Maywood Avenue dispatch, the communications supervisor for the Sunstar Ambulance Service notified David Hudak, the Pinellas County medical communications officer, about the incident. Mr. Hudak initiated a quality assurance review ("QAR"), a process designed to assure that Pinellas County EMS personnel have provided quality care and observed the applicable MOM Protocols. Mr. Hudak also informed the Pinellas County OMD's quality assurance manager, David Lock, of the incident and the initiation of the QAR. Mr. Lock took charge of the investigation. On March 28, 2005, Mr. Lock met with Dr. Romig and Jeff Bernard, the executive director of the Pinellas County OMD, and briefed them on the subject of his investigation. Dr. Romig testified that "my jaw dropped" upon hearing what had occurred, because she had never encountered a situation in which paramedics had not responded to a 911 call. Dr. Romig placed Respondent and Mr. Murray on "clinical suspension," pursuant to Pinellas County EMS Rule XIII.E.1.a., pending the outcome of the QAR. A clinical suspension precludes a paramedic from participating in patient care in any capacity. The QAR process consists of an informal, fact-finding process followed by a formal hearing before the medical director. Mr. Lock initiated the informal stage by reviewing the documentary record, including the written incident reports and copies of the patient care records from previous calls to 309 South Maywood Avenue. Mr. Lock confirmed that Respondent and Mr. Murray were properly dispatched to 309 South Maywood Avenue, that neither Respondent nor Mr. Murray notified their superior officer of their failure to respond to the call, and that Respondent and Mr. Murray admitted that their conduct was in violation of MOM Protocols and Pinellas County EMS rules regarding a paramedic's duty to act. The formal investigatory hearing was held on May 3, 2005, before Dr. Romig. At the hearing, Respondent again admitted to violating MOM Protocols. After the hearing, Dr. Romig decided to revoke Respondent's county certification. Dr. Romig testified that her decision hinged on the question of trust. Dr. Romig oversees approximately 750 paramedics and 750 emergency medical technicians, all of whom work under the authority of her medical license. See Section 401.265, Florida Statutes (2005).2 She was not aware of Respondent's existence until this situation arose. Dr Romig testified as follows: t's been said over and over again today about the basic expectation of the public being that when they call, we come. And when I provide the authority for paramedics and EMTs to work under my license, because we're such a big system, I can't get to know each and every one of them intimately in order to establish, you know, a trust level, so I have to grant them trust to begin with. And my problem is, if I can't trust that they follow such a basic tenet as "you call, you go," how can I trust them to make much more complex decisions such as administering medications or doing procedures that could actually harm somebody as much as help them. . . . I don't have any evidence to say that their skills aren't good, but it's their decision making that I have to call into question and whether or not I can trust them to do what I ask them to do. Dr. Romig testified that in the case of an improperly administered medication, she could require training and testing to ensure that the paramedic does not repeat the error. However, Dr. Romig believed there is no way to remediate her basic trust in a paramedic's judgment once it has been broken. Therefore, she concluded that revocation was the only appropriate remedy. Dr. Romig's testimony is credited, and her conclusion was reasonable. Respondent's claim that he was only obeying the instructions of his superior, Mr. Murray, would be more compelling had Respondent taken any subsequent action to bring Mr. Murray's breach of duty to the attention of their superiors. Respondent's silence at the time of the incident indicates acquiescence, if not approval, of the course of action taken by Mr. Murray. Respondent offered evidence sufficient to establish that the resident of 309 South Maywood Avenue was a nuisance caller, if not a "problem caller" under Chief Geer's criteria. However, Respondent's evidence falls far short of demonstrating that he was justified in not responding to the call from that residence on the morning of March 26, 2005. The Pinellas County OMD must ensure that EMS personnel provide quality care and are not a danger to the safety of the county's residents. As the medical director, Dr. Romig is ultimately accountable for the actions of the paramedics operating under her license. Respondent breached the most basic level of his duty as a paramedic: to respond to every 911 call for emergency medical assistance. Given all the circumstances, Dr. Romig had sufficient cause to revoke Respondent's Pinellas County Paramedic Certification.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Pinellas County Emergency Medical Services, Office of the Medical Director, enter a final order finding Respondent guilty of the violations alleged in the Notice of Revocation dated May 10, 2005, and revoking Respondent's Pinellas County Paramedic Certificate. DONE AND ENTERED this 13th day of March, 2006, in Tallahassee, Leon County, Florida. S LAWRENCE P. STEVENSON 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 13th day of March, 2006.
