THE INVESTIGATIVE PROCESS

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THE INVESTIGATIVE PROCESS Powered By Docstoc
					Certified Medical Board Investigator
National Training 2011

THE INVESTIGATIVE PROCESS
Presented by:
                                                 COLUMBUS
Loy C. Ingold , NA 132, CMBI
Senior Investigator
North Carolina Medical Board

Pete Lizanecz, NA 206, CMBI,
Detective                                            2011
Maine Attorney Generals Office



                Sponsored by the Federation of State Medical
                  Boards and Administrators in Medicine
   Interview complainants, licensees, patients,
    medical professionals and witnesses
   Examine records of licensees , complaints
    and patients
   Obtain evidence
   Obtain drug screens
   Obtain voluntary surrenders
    INVESTIGATOR DUTIES
    AND RESPONSIBILITIES
   Serve Orders to Produce, Subpoenas, Demand
    Letters
   Perform PE Checks/Random Audits
   Confer with Medical Director/Experts
   Monitor licensees for Compliance Report
    writing
   Testify before the Board or at other hearings
   The above investigative tools represent a method
    of obtaining:
   Patient charts
   Billing records
   Personnel records
   Complaints/Incidents reported to hospitals
   Hospital credentialing records
   Pharmacy prescriptions/records
   Telephone records
   Admission, History and Physical
   Cover Sheet with Demographics
   Discharge Summary
   Physician‟s Progress Notes
   Physician‟s Order Sheets
   Nurses Notes
   Record of Vital Signs
   Operative Notes
   Pathology Reports
   Anesthesia/Recovery Records
   Consultation and X-Ray Reports
   Hospitals may refuse to comply due to peer review
   The Order to Produce, Subpoena, or Search Warrant should be
    completed by the assigned Investigator
   The OTP, Subpoena, SW should be served on the CFO or
    designee for hospital pt. records and the physician for pt.
    records
   The ordered records should be described with sufficient detail
    to ensure accuracy.
   In most cases, copies are ordered rather than the originals
   The ordered records should reflect a specific date or date
    range.
   The ordered records should reflect a time and place to
    produce with a due date for production.
   In some cases it may be appropriate to remain on site while
    records are copied.
   See Example
An interview is a face-to-face or telephone contact with a
 person for the purpose of obtaining pertinent
 information

Interviewees may include:

   A licensee who is the subject of the investigation
   Complainants
   Patients
   Witnesses
   Others who may have knowledge of the facts
Requirements for face-to-face interviews vary, some
 boards:

   Require face-to-face interviews with complainants,
    witnesses, licensees and other respondents
   Allow non-critical interviews to be conducted by
    telephone
   Mandate that interviews be conducted without the
    presence of a third party
   Allow “non-interfering” third parties such as a
    spouse, friend, co-worker or supervisor to be
    present
   Prohibit the use of audio or video equipment to
    record interviews unless established policy of
    jurisdictional agency/board.
Investigators in any regulatory or law enforcement
  arena need access to attorneys who can answer
  questions and render legal advice

Medical boards generally provide legal assistance
 through in-house, inter-agency or contract
 arrangements

Legal advice may be needed:

   Prior to the initiation of the case
   During the investigation
   At the conclusion of the case
   Before and during a hearing or trial
   Medical review and expert assistance are
    sometimes necessary when conducting Quality of
    Care investigations
   Medical experts should be available „in house‟,
    contracted out or by other special arrangement
   Medical experts may include physicians, physician
    extenders, pharmacists, nurses, forensic scientists
    or other health care professionals
   Investigators may need input from experts prior to
    initiating the case. Never hesitate to ask.
   Some cases will require continued contact with
    physicians or other experts in a specialty area
   Medical experts can be extremely helpful when
    ordering or subpoenaing patient and hospital
    records
   Medical experts can assist in selecting patient
    records that may prove or disprove allegations
   In most Q of C cases medical review of patient and
    hospital records will be necessary
   Medical experts need to provide a comprehensive
    report documenting if the physician met the
    established standard of care
   Medical experts need to be prepared to testify to
    their findings
Evidence may need to be seized during an
  investigation to prove or disprove the allegation or
  issue

Evidence may include:

   Prescription medication
   Prescriptions ( handwritten or computer generated)
   Prescription containers
   Prescription surveys
   Original documents or letters
   Photographs
   Audio/video tape
   Medical records
   Financial records
   Certified court documents
   Drug screens

   Investigators should make every effort to have
    original documents copied, especially medical
    records

   Some Boards discourage the seizure of evidence if
    it can safely be secured by third parties

   An Investigator should avoid receiving or seizing
    any controlled medications or substances that
    could result in a violation of state or federal laws
   Evidence should be sealed
   Evidence should be labeled: case #, date, time,
    names of the Investigator and individual making
    the transfer
   Investigator provides a receipt: case #, date, time,
    names of the Investigator and individual making
    the transfer, description of the evidence
   Evidence Control Log: same info as evidence
    receipt
   Semi-annual inventory witnessed by 2 persons
   Disposition of evidence noted in Control Log
   Examples: Receipts and Evidence Control Log
   Most states have statutes to the effect: a
    practitioner‟s license may be revoked, suspended,
    annulled, or denied for being unable to practice
    medicine by reason of illness, drunkenness, excessive
    use of alcohol, drugs, chemicals or other physical or
    mental abnormality
   Behaviors indicative of substance abuse:
   Personality changes that rapidly evolve
   Withdraw from friends and activities
   Depression
   Mistrust
   Anxiousness/Irritability
   Loss of appetite
   Drowsiness
   Insomnia
   Sleeping during the day
   Deterioration of personal hygiene
   Reduced levels of exercise
   Self-treatment of physical problems
   Communication problems
   Frequent arguments
   Disruptive behavior
   Placing blame on others
   Spouse or child abuse
   Jealousy
   Infidelity
   Family members
   Patients
   Colleagues
   Licensee‟s employees
   Hospital staff
   Physicians health program
   Anonymous
   Licensee self-report
   License application
   Annual registration
   Missed appointments
   Rounds conducted at unusual times
   Inability to locate while on call or other crucial
    times
   Inaccurate charting
   Smell of alcohol
   If the licensee admits to substance abuse, consider a
    request of voluntary surrender
   Report the surrender to the Board for consideration of
    emergency action
   If the licensee refuses to surrender, offer a drug screen
   If positive, report the results and/or the refusal to the
    Board for possible emergency action
   Top priority should be given to substance abuse cases
   The Investigator should keep management informed on
    a continuing basis regarding the status of the case
   Consent Orders, Board Orders, Random Screens on
    licensees with past substance abuse
   Unannounced visits: discreet and inconspicuous
   Some Boards require witnessing the sample
   Refusals reported to the Board
   Example (FP and Surgeon scenario with
    Cocaine/Ecstasy use)
     IMMEDIATE THREATS TO THE PUBLIC RESULT IN
                EMERGENCY ACTIONS

   Impairment / Drugs / Alcohol / Mental Illness
   Diversion of controlled substances
   Boundary violations / Sexual Misconduct
   Felony Arrest
   Felony Arrest : Meet with licensee in custody
   Active Substance Abusers
   Drug Diverters
   Other Professional Misconduct
   Investigators may not predict Board Actions but
    may explain a range of possible actions available
   Voluntary Surrender Form should be read by the
    licensee and witnessed by the Investigator. A copy
    should be provided to the licensee
   At the time of surrender the Investigator should
    explain that the licensee can no longer practice
    medicine or prescribe and must make patient
    records available.
   Example (State of Maine arrest of licensee for child
    pornography led to V/S in NC)
   Sexual misconduct exploits the physician-patient
    relationship, is a violation of the public trust and causes
    immeasurable harm, both physical and mental, to the pt

                      SEXUAL VIOLATIONS
   A sexual violation may include: physician-patient sex
   Engaging in any conduct with a patient that is sexual or
    may be reasonably interpreted as sexual
   Inappropriate touching, or offering to provide practice
    related services such as drugs in exchange for sexual
    favors
SEXUAL IMPROPRIETY
   Sexual impropriety may comprise behavior,
    gestures, or expressions that are seductive,
    sexually suggestive, or demeaning to a patient
   Disrobing/Draping practices: lack of respect and
    privacy
   Deliberately watching a patient dress or undress
   Examining or touching genitalia without the use of
    gloves
   Kissing or hugging
   Making inappropriate comments, sexual comments
SEXUAL IMPROPRIETY
   Inappropriate, non-clinical comments regarding
    sexual performance during an examination or
    consultation
   Requesting details of sexual history not clinically
    indicated
   Soliciting a meeting or date
   Initiating a conversation regarding the licensee‟s
    sexual problems, preferences or fantasies in a
    non-clinical manner
   Giving gifts
   Meeting patients outside the office
   Revealing personal information
   Bartering of services
   Private financial transactions between physicians
    and patients
   Anonymity: difficult if not impossible to grant
   The Investigator should determine if the licensee
    has a past history of boundary violations
   Require a face-to-face interview with the
    complainant
   Interviews may require same gender interviewer
   Interviews should be conducted in private but in a
    public setting
   The complainant may request the presence of a
    third party
   Boundary violation cases should receive high
    priority
 Two categories: a single issue involving a single
  patient or a pattern of practice which may reflect
  care below the acceptable standard
 Protracted investigations

 Investigative research before case initiation:
  medical terms, surgical procedures, medications,
  diagnostic tests
 Investigator confers with Medical Director or other
  expert who practices in the same specialty field
* (This lecture to be presented by B. J. West, Mgr-
  Investigations- Texas Medical Board)
QUALITY OF CARE
INVESTIGATIONS
   Medical records are an integral part of the
    investigation
   OTP, Subpoenas, Demand Letters, etc.
   Pharmacy surveys
   Expert review of patient/hospital charts
   X-rays are evidence if copies cannot be secured
   Interview licensee after expert review
   Detailed interview with Pharmacist or source
   The Investigator should exercise extreme caution
    in discussing the licensee‟s prescribing patterns
   Establish the extent of prescribing through an Rx
    Survey: local pharmacy or multiple pharmacies
   Select a period of time for patient profile (6 mos. to
    1 year)
   Analyze Rx patterns: unusual or high doses, meds
    outside normal practice/specialized discipline,
    meds or dosage amounts inconsistent with patient
    complaint
   OTP, Subpoena patient records for expert review
   Physicians, having assumed care of a patient, may not
    neglect that patient or fail for any reason to prescribe full
    care in accordance with the standards of medicine
   Physicians have the right to choose patients and terminate
    relationships with notice and continuity of care

   Frequently asked questions in patient abandonment cases:

   When did the physician/patient relationship begin and
    end, and the nature of the termination?
   Did the licensee give notice of termination to the patient?
   How was the patient notified of the termination?
PATIENT ABANDONMENT
   Was the patient given 30 days notice?
   Were provisions for referrals made for continuing
    care?
   Were provisions made to transfer patient records?
   Are there other patients with similar complaints?
   Medical boards generally have a statute that allows a
    practitioner‟s license to be revoked, suspended,
    annulled, or denied for a conviction of a crime involving
    moral turpitude, a felony, or violation of law involving
    the practice of medicine
   Initial reports of criminal violations: self-reported,
    complaints, criminal justice personnel or by the media
   Information provided by the source should include:
    nature of the charge, time, place, and arresting agency
   Interview arresting officer, witnesses, obtain police
    report
   Obtain court records
   Federal. State, or Local jurisdictions may request
    assistance in an investigation of a licensee

   Requests for assistance must be approved by
    management
   Each agency should be aware of each others
    regulations, guidelines and protocols
   Interviews should be conducted together when
    appropriate
   Agreements should be finalized regarding
    reporting
   Investigator should not discuss any prior Board
    Action of a licensee that is not public record
   Law enforcement subpoenas should be forwarded
    to management
   Investigator should not seize any physical evidence
    in a joint investigation
   Determine if the complainant was misled in believing
    that the care received was performed by a licensed
    medical practitioner
   Determine if a diagnosis was made, medication
    dispensed and/or medical treatment rendered
   Obtain all documentations supporting the allegation
   Contact the appropriate law enforcement agency or
    regulatory board for referral or joint investigation
   Refer to Board if a licensee is assisting in the unlicensed
    practice of medicine
   Most states have misdemeanor provisions for criminal
    violations)
    Before a Board revokes, restricts, or suspends a
    license granted by it, the licensee will be given
    written notice of the charges and accusations and
    will be given an opportunity to be heard at a public
    hearing

   Investigators may be called on by the Board or the
    licensee‟s attorney to answer questions
   No personal opinions or assumptions
   Never present information that can be construed as
    prejudicial
   Present clearly, concisely, and without prejudice
   Medical boards process anonymous information in
    different ways. Some Boards:
   Do not accept anonymous information
   Accept anonymous information in written format only
   Will not accept information alleging boundary violations
    if the patient desires to remain anonymous
   Consider anonymous complainants as non-testifying
    sources and protect their Identity from disclosure
   Require non-patient, anon complainants, who will not
    testify, to supply detailed info sufficient for verification
   Will not provide the anonymous complainant with info
    regarding the status or disposition of the case
   Most states have laws that require hospitals and other
    health care institutions to report any revocation,
    suspension or limitation of a physician‟s practice status
   Sources: CEO or Administrator, Risk Manager, Medical
    Staff Coordinator, Attorney, Chief of Staff or licensee
   Two categories of CISPs: patient care and unrelated to
    patient care (disruptive behavior, substance abuse, etc.)
   OTP/Subpoena served on the appropriate person
   Peer review may not be subject to OTP/Subpoena
   CISP (Change in Staff Privileges) investigations should
    be given high priority
   Example (MD/ performing plastic surgical procedures
    beyond scope of practice and board certification
    yielding patient complications and emergency care)
   Audit/Inspection Programs are established in
    response to concerns that Physician Extenders may
    be practicing without appropriate supervision
   Management selects cases by random sample or
    other defensible method
   Management determines the number of cases to be
    assigned to each Investigator
   Case selection may be based on the distance
    between the supervising physician and the
    physician extender
   Most Boards use some variation of a PE Checklist to
    verify compliance
   Examples
Compliance cases are generated as the result of
 Board Actions, Consent Orders, Board Orders, or
 Re-Entry Agreements/Orders

Issues generating compliance cases:

   Substance abuse
   Boundary violations
   Prescribing issues
   Unprofessional conduct
   Quality/standard of care
COMPLIANCE:
Duties and responsibilities

   Drug screens (Random-announced & unannounced)
   Prescription surveys (Electronic Prescription
    Monitoring)
   Licensee interviews regarding consent order
    conditions
   Verify receipt of reports from psychiatrists,
    psychologists, etc.
   Maintain close contact with Physicians Health
    Program
   Most Boards fund, subsidize or refer impaired
    licensees to some type rehabilitation or physicians
    health program
   Referrals may be made for chemical dependency,
    mental illness, physical illness or aging problems
    that preclude them from caring for patients with
    reasonable skill, attention or safety
   Some Boards require health program participants
    to reimburse the costs of their treatment
   Have you had any action taken against you by any
    licensing board, hospital, medial staff or other
    regulatory organization?
   Have you been denied a license, denied the
    privilege of taking a license examination, or
    withdrawn a license application?
   Have you engaged in the excessive use of alcohol
    or prescription drugs, or the use of illegal drugs, or
    received any therapy or treatment for alcohol or
    drug use?
   Have you been charged with (arrested, indicted, or
    arraigned), convicted or pled guilty or nolo
    contendre?
   Have you become aware of any medical, surgical,
    or psychiatric condition that could possibly impair
    or limit your ability to practice medicine safely?
   Has there been a medical malpractice judgement,
    settlement, or award affecting or involving you
    regardless of whether the judgment, settlement, or
    award was made in your name?
   An investigative agency or organization
    should consider a “Procedures Manual” that is
    approved by their respective board bodies to
    establish the processes by which cases are
    investigated and managed.
    This “Procedures Manual” should be
    reevaluated on an annual basis to reflect any
    policy or statutory changes within the agency
    and/or organization.
     “Investigative Procedures Manual”
    implemented by NC Medical Board and
    developed by Curt Ellis, Director of
    Investigations-NCMB. 9/2011 Edition
   (Copy included in training packet, thumb
    drive)
THANK YOU


Questions
Comments
CONTACT INFORMATION:


Loy C. Ingold , NA 132, CMBI       Pete Lizanecz, NA 206,
Senior Investigator                CMBI
                                   Detective
Charlotte Domicile Office
                                   Investigation Division
North Carolina Medical Board       Maine Attorney Generals Office
P. O. Box 162                      6 State House Station
Concord, NC 28026                  Augusta, ME. 04333
Phone: (704) 721-7981              Phone: (207) 626-8594
                                   Fax:     (207) 287-3120
Fax:      (704) 795-7916
                                   Cell:    (207) 751-6491
Cell:    (704) 467-1007            Email: peter.lizanecz@maine.gov
Email: Loy.Ingold@NCMEDBOARD.ORG

				
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