ALJDEC decisions subject to certification as final
19A-5631-PAB-RES-2 · Arizona Medical Board · 2020-03-17
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
In the Matter of:
Kimberly A. Hart, PA
Holder of License # 5631,
Respondent.
No. 19A-5631-PAB-RES-2
ADMINISTRATIVE LAW JUDGE DECISION
HEARING: March 4, 2020 and March 5, 2020.
APPEARANCES: Respondent Kimberly A. Hart did not appear. Assistant Attorney General Roberto Pulver appeared on behalf of the Arizona Regulatory Board of Physician Assistants.
ADMINISTRATIVE LAW JUDGE: Velva Moses-Thompson
_____________________________________________________________________
FINDINGS OF FACT
Respondent Kimberly A. Hart is a physician assistant (PA) who holds
Arizona Regulatory Board of Physician Assistants (Board) issued License No. 5631 for the performance of health care tasks in the State of Arizona.
The Board referred this matter to the Office of Administrative Hearings
(OAH), an independent state agency, for an evidentiary hearing.
On December 17, 2019, the Board issued a Complaint and Notice of
Hearing that alleged certain facts, charged Respondent with having committed unprofessional conduct as defined by Ariz. Rev. Stat. § 32-2501(18)(d), (j), (p),(ee), and Ariz. Rev. Stat. § 32-1501(3), and provided notice of a hearing in the OAH on February 4-5, 2020, at 9:00 a.m. The Board sent the Complaint and Notice of Hearing by United States certified and first-class mail to Respondent at her address of record.
A hearing was held on February 4-5, 2020.
Hart did not appear at hearing.
Hart filed a motion to continue the hearing on January 31, 2020.
The motion was denied.
The PA Board presented the testimony of Raquel Rivera, Carol J. Peairs,
M.D., and Michael A. Sucher, M.D., and submitted exhibits 1 through 73.
Testimony of Raquel Rivera
Raquel Rivera is the Investigations Manager for the Arizona Medical Board (Board) and the PA Board. Ms. Rivera has been an investigations manager for four years. Ms. Rivera holds a Master’s degree in Public Health.
On or about November 16, 2015, the PA Board received a complaint from the University of Arizona Health Plans (UAH) against Respondent. See Exhibit 55. UAH alleged that two patients died from an overdose of pain medication prescribed by Respondent. See id.
The PA Board opened an investigation into the complaint.
The PA Board notified Ms. Hart that it had opened an investigation regarding a complaint it received against her involving her care and treatment of patients. The Board requested that Ms. Hart provide a response to the complaint.
On February 6, 2015, Ms. Hart and Irfan Fazil, M.D. entered into a Physician Assistant Supervision Agreement (PA Supervision Agreement) wherein Dr. Fazil agreed to act as Ms. Hart’s Primary Supervising Physician. Dr. Fazil agreed to complete a PA performance evaluation quarterly. The PA Supervision agreement provided, in relevant part, as follows:
Medications:
The physician assistant may prescribe up to 30 days of Schedule II and III controlled substances (as long as allowed by board and the PA has a current DEA registration with matching authority)
For each schedule IV or schedule V controlled substance, a physician assistant may not prescribe the controlled substance more than five times in six month period for each patient.
Prescription-only drugs shall no be dispensed, prescribed or refillable for a period exceeding gone year.
Dr. Fazil was issued a reprimand for over-prescribing concerns.
Ms. Hart treated Patient R.C. during the time period of the delegation agreement.
On May 5, 2016, R.C. died of a multiple drug overdose at the age of 43. R.C. died just 20 days after Hart prescribed additional medication to R.C. R.C.’s death certificate showed that R.C. had a history of hypertension as well as a history of alcohol, tobacco, and drug abuse, under the section called, “Other significant conditions contributing to death but not resulting in the underlying causes given above.”
Hart provided R.C.’s medical records with her response to the Board’s investigation. See Exhibit 64. The medical records showed that R.C. had a history of alcohol and substance abuse. However, the medical records do not show that Hart advised R.C. about the risks of using alcohol and taking controlled substance medications, including opioids. See id.
15. R.C.’s medical records show that R.C. reported to another provider that he drank occasionally but denied alcohol or controlled substance abuse. See Exhibit 64, AMB 9 of 641. However, the medical records related to Hart’s treatment show that R.C. reported no history of drug or alcohol abuse. However, R.C.’s records also show that he tested positive for alcohol. See id at AMB 21.
16. Hart had a patient provider agreement which provided that the R.C. would be discharged from the clinic if a toxicology report showed that R.C. did not take prescribed medication, but other illicit drugs, alcohol, or unprescribed drugs are found in the patient. See AMB 153.
17. R.C. underwent a urine drug screen on March 15, 2015. See Exhibit, 64, AMB 310 of 641. According to the results of the drug screen, R.C. tested positive for
opiates, hydromorphone, hydrocodone, and alcohol and its metabolites.
18. Hart’s last visit with R.C. was April 15, 2015. AMB 306 of 641. On April 15, 2015, Hart prescribed MS Contin and Oxycodone to R.C. Hart did not advise R.C. regarding the positive urine drug screen. According to the patient provider agreement, R.C. should have been no continuation of controlled substance prescribing and R.C. should have either been discharged from pain services or referred to a rehab center or to his PCP.
19. Hart made a note in the communication log that she reviewed the positive drug screen with R.C. at the April 15, 2015 visit, and advised R.C. not to take alcohol with drug medication. Hart also noted, “compliance addressed 20 for better pain control with compliance.” Hart further noted that R.C. reported that he was not taking his prescribed medication regularly.
20. Ms. Rivera explained that it is not normal for a physician or PA to place a warning to a patient the communication log instead of in the actual progress notes.
Ms. Rivera explained that when a patient’s medical records are transferred to a new provider, the communication log does not transfer with the records, only the progress notes.
21. Ms. Rivera explained that two medical experts reviewed Hart’s response. Steve Pummel and Dr. Peairs reviewed the report and although Hart was given the chance to respond to their written findings, she did not respond.
22. The Board issued a Staff Investigation Review Committee (SIRC) report. A SIRC report summarizes the investigation, the Board’s sustained findings,
the medical consultant's findings, any aggravating or mitigating factors, what the PA's response had been thus far, the statutes being sustained against the PA, and a discussion on how the committee members determined their recommended action. With regard to Hart, SIRC recommended that the PA Board revoke PA’s license.
Testimony of Carol Peairs, M.D.
23. Carol Peairs, M.D. has been a licensed physician in the State of Arizona for 34 years. Dr. Peairs has practiced medicine for approximately 38 years. Dr. Peairs is a Diplomate of the American Board of Pain Medicine. Dr. Peairs completed a residency in Anesthesiology. Dr. Peairs is double board certified in Anesthesiology and pain management. Dr. Peairs holds a certificate for the treatment of opioid addiction. Suboxone can only be prescribed for treatment of addition if the provider is certified.
24. Dr. Peairs has served as President of the Arizona Society of Anesthesiology Board of Directors. The Arizona Society of Anesthesiologists (ASA) represents about 700 Anesthesiologists and focusses on issues that impact their patients. At the time that Dr. Peairs served as President, ASA focused on rising problem of opioid prescribing.
25. The Arizona Legislature consulted with Dr. Peairs to obtain her expert advice about the opioid crisis and to use her advice to implement guidelines and rules related to opioid prescribing.
26. Former Arizona Governor Jan Brewer appointed Dr. Peairs to the Arizona Substance Abuse Partnership Governor’s Office for Children, Youth and Family from February 2012 to February 2015.
27. Dr. Peairs has treated patients with opioid addiction, with a focus on pain management.
28. Dr. Peairs has worked as an in house medical consultant for the Board. The Board asked Dr. Peairs to review Hart’s records and render an opinion about her performance. Dr. Peairs wrote her opinion and concluded that Hart’s treatment of Patient R.C .fell below the standard of care.
29. The single highest risk for prescription opioid abuse is personal or family history of substance abuse including alcohol abuse. Basic pain management includes obtaining such a history when planning to prescribe opioids. Dr. Peairs concluded that Hart failed to obtain such a history after she reviewed Hart’s file. Hart failed to evaluate R.C.s history even though R.C.’s history of substance and alcohol abuse was in his medical records. Hart ignored, overlooked, or failed to understand R.C.’s behaviors. Hart failed to recognize red flags for preexisting alcohol abuse, and unauthorized dose escalation. Hart failed to obtain a proper medical history from R.C. Hart obtained a neurology consultation for R.C., but failed to recognize the significance of the report.
30. Hart failed to recognize that one of the high risk factors for prescription opioid abuse is a patient’s failure to participate in a multimodal approach. A multimodal approach to pain management is engaging in treatment other than opioids. R.C. failed to participate in physician ordered physical therapy. R.C. declined facet injections offered by a neurologist. R.C. failed to participate in nerve conjunction studies. Hart did recognize this behavior, she did not document it, and she did not address it.
31. Dr. Peairs concluded that hart failed to properly monitor R.C. after prescribing him opioids. Hart administered dose escalation but noted “He’s stable on these medications. I’m not going to make any changes.” Hart ignored or failed to recognize the importance or urine drug testing.
32. R.C.’s medical records (which were provided by Hart to the Board), showed that R.C. was admitted as inpatient and that R.C. had a history of alcohol abuse and needed to take DT precautions due to acute alcohol withdrawal. The inpatient medical history shows that R.C. suffered from drug abuse. Hart did not provide her medical opinion about these conditions, which is below the standard of care. A treating physician must distinguish between chronic pain and a patient who is trying to find a legal source to feed an addiction. Such an analysis is significant to decision making. The physician must evaluate the pain problem and determine how he or she will proceed. There was no evidence that Hart reviewed hospital records or conducted a routine basic pain management evaluation.
33. Hart did not deem it significant to prescribe medication to R.C. for alcohol withdrawal syndrome. Dr. Peairs explained that such actions are beyond rookie mistakes. Dr. Peairs explained that she teachers such protocol to second year medical students at the University of Arizona.
34. Dr. Peairs concluded that Hart made no objective findings of pain before she prescribed opioids to R.C. after her first visit with him on November 10, 2014. See Exhibit 69. During that initial visit, R.C. complained of lower back pain and leg pain. See Exhibit 53. However, a lumbar X-ray and Lumbar MRI showed no acute problems. R.C. suffered from chronic compression fracture @ L1, but it is no painful. Chronic heel compression fracture does not cause chronic pain.
35. Although R.C. suffered from arthritis, but there was no evidence that R.C. suffered from acute disk herniation, protrusion, and there was no evidence that R.C. had a compressor.
36. Dr. Peairs explained that the physician should do a targeted exam to the patient’s pain problem. Dr. Peairs explained that the physical exams that were purportedly conducted by Hart seemed regurgitated, and it did not appear as if Hart actually conducted the exams as described because it would only be possible to see more than a couple of patients every day. Furthermore, Dr. Peairs explained that the physical exams conducted by Hart were not useful. There were no objective findings regarding R.C.’s leg and back pain, but only R.C.’s subjective complaints about tenderness and decreased motion.
37. Hart did not list percocet under current medication. At R.C.’s initial visit, Hart did not administer a urine drug test but prescribed a significant amount of oxycodone to R.C. after his first visit.
38. Dr. Peairs has used opioid agreements similar to the agreement between Hart and R.C. However, Dr. Peairs explained that if illicit drugs were discovered, she would not end treatment but she would consider other treatment options such as physical therapy and injections. Dr. Peairs explained that the intent is not to punish the patient, but to recognize dangerous drug taking behavior and to take immediate action for the patient’s safety.
39. Dr. Peairs testified to the effect that it was a massive deviation from the standard of care to continue to prescribe opioids to a patient if it is discovered that the patient has an alcohol abuse problem, after signing an opioid agreement.
40. Dr. Pears explained that Hart should have completed a pill count agreement with R.C. Under a pill count agreement, the patient brings in his pill medications for a pill count at random, unannounced times to assess whether the patient still has the amount of pills prescribed for the remaining days. If there are an insufficient amount of remaining pills, it may indicate abuse or misuse, or that the patient is giving the pills away or reselling the pills. A pill count agreement is one way of monitoring the patient’s use of medication.
41. Hart did not enter into a pill count agreement with R.C.
42. Dr. Peairs opined that R.C. was not an appropriate candidate for opioids. Dr. Peairs explained that even if Hart determined that she would prescribe opioids, she should have recognized that R.C. was a high risk candidate and that Hart should taken every precaution and monitored all of his medication. Dr. Peairs explained that combining alcohol with pain medication can be fatal.
43. During Hart’s second visit with R.C. on November 25, 2014, Hart noted that she will would no tchange R.C.’s medications because he was stable. However, Hart escalated R.C.’s narcotics by 150 percent with no basis, no increased pain complains, and no physical exam. See Exhibit 64. Hart reported that R.C. stated that he had improved. Hart increased R.C.’s narcotic medication by 150 percent within two weeks.
44. After Hart’s third visit with R.C. on December 10, 2014, R.C. reported that he had doubled his prescribed dosage of morphine. R.C. was previously directed to follow up within a month but visited Hart on December 10, 2014, two weeks early. R.C. reported that he was only receiving one to three hours relief from percocet. R.C. was taking medication in amount that was twice the amount prescribed, which constitutes an abuse of prescription medication. However, there is no documentation showing that Hart advised R.C. about the danger of self-escalation. Dr. Peairs opined that due to R.C.’s self-escalation, Hart should have ceased prescribing opioids to R.C. At the least, Hart should have assessed why R.C. doubled his prescription. Hart should have prescribed very small quantity of narcotic medication. Hart should have then followed up with R.C. frequently regarding pill counts and urine drug tests.
45. On December 24 2014, R.C. showed up at Hart’s office for a fourth visit, even though R.C. was required to follow up four weeks later. See Exhibit 64. R.C. had previously received medication to last four weeks, and he exhausted his medication after two weeks. Hart did not recognize or document that R.C. self-escalated his dosage and used a 30-day supply in 13 days. However, Hart wrote R.C. a one month prescription of MS Contin 30 mg, as well as a new prescription for Dilaudid, 4mg, two tablet daily. Dr. Peairs opined that R.C. should have been discharged at this time.
See id.
46. On January 8, 2015, R.C. visited a neurologist for an epidural steroid injection. See Exhibit 64, AMB 259 – 641. The neurologist performed a physical exam on R.C. before administering the injection. The physical exam was normal.
47. On January 20, 2015, R.C. did not appear for scheduled physical therapy. See Exhibit 69, AMB3 of 15.
48. On January 20, 2015, Nurse Practitioner Babbitt prescribed Librium to R.C. Librium is almost exclusively used to treat alcohol withdrawal. However, there is no documentation that Hart contacted Babbitt regarding the prescription. Hart was either grossly incompetent or made no effort to protect R.C.
49. During Hart’s fifth visit with R.C. on January 21, 2015, R.C. complained of increased pain after the epidural steroid. See Exhibit 64, AMB 257, 269 through 631. Hart increased his morphine dosage and prescribed opioids. R.C.’s physical exam had not changed. Hart did not discuss the prescription for Librium. Dr. Peairs explained that an increase in pain after an epidural steroid injection is not abnormal but it is not treated with opioids. Furthermore, it is possible that R.C. could have been experiencing pain due to an infection. Hart provided an illegitimate rationale for the increase:
to improve coverage throughout the day.
50. On January 26, 2015, R.C. saw a neurologist who opined that R.C. may be seeking pain medication for reasons other than therapy, or to find a legal source to feed his addiction. See Exhibit 64, AMB 281 to 282 of 641.The neurologist noted that R.C. did not have a dermatomal pattern for his leg pain. R.C. did not have radicular pain. Dr. Peairs believed that the neurologist suggested that R.C. was a pain seeker. See id. The neurologist suggested that R.C. was not being treated for radiculitis and back pain, and that there was some other reason that R.C. was seeking pain medication.
51. Hart ignored, never looked at, or did not understand the neurologist’s opinion. Hart provided the opinion to the PA Board with other medical records.
A prescriber should have conducted a focus examination to determine the cause of R.C.s pain.
52. On February 18, 2015, a urine drug test of R.C. was obtained. The test showed that R.C. had a Vitamin B12 deficiency. Dr. Peairs explained that the single greatest cause of Vitamin B12 deficiency is chronic alcoholism, liver disease. Hart should have inquired with R.C. about his alcohol use and alcohol history.
53. On March 18, 2015, Hart saw R.C. for the fifth time and prescribes one month supply each of Dilaudid 4 mg oral twice a day, and MS Contin 30 mg three times a day. See Exhibit 54, AMB294 to 300. Hart obtained a urine drug test which was negative for the prescribed morphine, but positive for hydrocodone which was not prescribed by Hart. The hydrocodone was positive for high levels of metabolites of alcohol. The results show that R.C. was using alcohol and hydrocodone concurrently. Because Hart sent out for the urine drug test on March 18, 2015, Hart would not expect her to address the results at the March 18th visit. However, Hart would have received the results back within a week. Hart never contacted R.C. to discuss the problem shown by the urine drug test. Such behavior is below the standard of care.
54. On April 15, 2015, Hart conducted her last visit with R.C. See Exhibit 64, AMB 306 to 308 of 641. Hart did not document any discussion of the abnormal urine drug test which she most likely had for two weeks. Hart did not attempt to get an alcohol or substance abuse history. Hart did not assess how R.C. obtained the hydrocodone. Hart noted that R.C. was present for a medication refill. Hart continued to assess R.C. with radiculitis after the neurologist reported that there was no radicular pattern present. Hart prescribed R.C. MS Contin 30 mg three times a day, oxycodone 5mg, two bid prn breakthrough pain. However, Hart noted in a communication log which is outside of the office visit note, “Order is signed off by Hart Kimberly A PA on 4/15/15. Patient toxicology reviewed with patient. Positive for alcohol. Advised not take with pain meds. Patient says not takin pain meds regularly. Compliance addressed for better pain control with compliance.” Dr. Peairs opined that the note in the communication log is an insufficient warning because the warning is given about 18 days after she received Hart results. Dr. Peairs opined that Hart probably receive the results on March 27, 2015. Dr. Pears opined that R.C. could have overdosed by that time. The warning should be at the top of her office visit note.
55. Dr. Peairs opined that it was very predictable that R.C. would die from a multiple drug overdose. Dr. Peairs opined that Hart contributed to R.C.’s dangerous drug taking behavior by prescribing medications in an irresponsible manner.
56. Dr. Peairs opined that Hart lacked the ability to use sound judgment in prescribing opioid medication to a patient, and was medically incompetent to practice as a PA. Dr. Peairs did not believe that Hart should return to practice as a PA. Dr. Peairs believed that Hart’s license should be revoked. Dr. Peairs also stated that it was an aggravating factor that Hart did not follow her own office practice guidelines in prescribing, including the high risk factors for opioid prescribing. Dr. Peairs opined that Hart cannot be regulated and is absolutely irresponsible. Dr. Peairs stated that Hart is a danger to the public and ignores absolute unequivocal data available to her.
November 7, 2016 Complaint
57. On or about November 7, 2016, the PA Board received a complaint from Patient A.K. that Hart appeared to be under the influence of a substance and attempted to confiscate A.K.’s mediations while A.K. was receiving pain management treatment from Hart.
58. On November 10, 2016, the PA Board opened an investigation into the complaint.
59. On November 29, 2016, the PA Board requested that Hart respond to A.K.’s complaint.
60. In December of 2016, Hart provided a response to the complaint.
61. On February 6, 2017, Hart took a flight to New Mexico. Hart reported to the Yuma International Airport (Yuma Airport) that her missing purse had been returned to her after she boarded her flight. Hart reported to the authorities at the Yuma Airport that her wallet, keys, and prescription pad were missing from her purse.
62. On February 16, 2017, the PA Board retrieved a CSPMP report that showed that Hart was prescribed unusually large amounts of controlled substances, and some of those controlled substances were prescribed by Hart’s former supervising physician.
63. On February 17, 2017, the PA Board interviewed Hart with her attorney present. During the interview, Hart denied that she confiscated A.K.’s medication, or that she was under the influence of any substance while attending to A.K. Hart claimed that she was not present during any patient pill counts, nor does she have any contact with a patient’s medications.
64. During the interview, Hart admitted that she failed to inform Yuma Airport that her medications were also stolen from her purse. Hart explained the stolen prescription pad could not be used to prescribe medications because it was out of date and that she used the prescription pad as a scratch pad. Hart was at Yuma Airport to travel to New Mexico for a continuing education course.
65. Hart explained at the interview that she took oxymorphone, oxycodone for break through pain, Modafinil, Ambien, and prednisone. Hart stated she had a medical condition and had been prescribed prednisone for several years, which prednisone usage has contributed to her history of breaking bones multiple times and caused her bones to be like crackers.
66. Based on the interview and the information obtained, the PA Board issued an Interim Order for a Physician Health Program (PHP) Assessment to Hart with the PA Board’s contractor or PHP. Hart accepted the Interim Order and promised to comply with it.
67. The Interim Order required Hart to “undergo and successfully complete an assessment with the PA Board’s private contractor....” Further, “[f]ailure to comply with any aspect of the assessment or with the recommendation of the Contractor may be considered an act of unprofessional conduct under the Physician Assistance Practice Act. A.R.S. section 32-2501(18)(z). It is also an act of unprofessional conduct to violate or attempt to violate a PA Board Order. A.R.S. section 32-2501(18)(k).”
68. Hart decided to forgo the assessment with the PA Board’s contractor and submit to a comprehensive, multidisciplinary assessment conducted by the Positive Sobriety Institute (Institute) in Chicago, Illinois.
69. On March 14-15, 2017, the Institute administered a comprehensive, multidisciplinary assessment of Hart. The assessment included: (a) initial psychiatric interview; (b) medical assessment; (c) psychiatric assessment; (d) psychological testing; (e) CNS vital signs neurocognitive screening, (f) substance use assessment; (g) collateral information assessment; and (h) laboratory screening or testing of hair, alcohol, and drugs.
70. The Institute’s assessment of Hart disclosed: (a) she met seven criteria for opiate, barbiturate and stimulant use disorder-severe in the DSM V; (b) she admitted to drinking daily, which resulted in a positive Phosphatidylethanol Testing; (c) she drank while taking mood-altering substances which is contraindicated; and (d) she responded to certain questions which raised troubling concerns for the examines such as:
“When asked to comment about her supervising physician also prescribing Modafini and Ambien for her, Ms. Hart stated, ‘I had been on that for 30 years. I don’t even thinking about it as a medicine.”
“Regarding psychotropic medications, Mr. [sic] Hart disclosed ‘I put myself on Bupropion in 1997 to stop smoking... I only smoked for 3 months.’ When asked how long she continued Bupropion, Ms. Hat replied, ‘I’m still on it.”
71. According to the Institute’s assessment, Hart was previously assessed by the Institute in 2007 due to a request from the Kentucky PA Board of Medical Licensure. Hart told an Instate examiner, “that one of the physicians she met with during her previous assist in 2007, while working in Kentucky, told her, ‘you’re addicted to the [sic] Adderall, you should be careful about that.”
72. Hart informed an Institute examiner that she experienced muculosketal pain that relied on steroids and opioids. Her serologic findings do confirm her claim that she has a certain medical condition, but she could not provide details to the examiner on her disease activity or severity. Moreover, Hart had not followed through with her primary car provider’s referrals to see certain specialists. It appeared that Hart “dose[s] herself with opioids and steroids, which is outside the standard of care for a patient with [her claimed medical condition].”
73. The Institute notified the PA Board that Hat was advised to immediately discontinue the practice of medicine and be admitted to a treatment program for professionals with dual diagnoses of substance use order and chronic pain due to medical problems. Hart was advised by the Institute to follow all recommendations from the treatment program, and after successful disgorge, be monitored by the PHP. The Institute gave ten treatment recommendations to Hart.
74. Based upon the Institute’s assessment, the PA Board offered Hart an Interim Consent Agreement (ICA).
75. On April 10, 2017, Hart signed the ICA. The ICA placed, among other things, these obligations: (a) prohibited from practicing as a physician assistant; (b) required her to complete a 90-day inpatient treatment regimen; (c) required her to follow any treatment recommendations from the PA Board’s PHP Contractor; and (d) prohibit her from requesting a release or modification of the ICA until she completed the inpatient treatment regimen and a post-treatment evaluation from the PA Board’s PHP Contractor.
76. On April 11, 2017, Hart’s employment as a physician assistant with the Bio Family Clinic was terminated.
77. On July 14, 2017, Hart sent a letter to the PA Board’s PHP Contractor asking the contractor to assess her because she disagreed with the Institute’s assessment. She complained that the Institute’s report was a “scathing” 40 page assessment peppered with “untruths” and “inconsistences.”
78. On August 10, 2017, the PA Board notified Hart that her request was denied due to the ICA. The PA Board also notified Hart that she could abide by the Institute’s recommendations or obtain approval of an evaluation at a second facility.
If Hart chose not to follow one of the two options listed above, she could meet with the PA Board’s PHP Contractor for a final recommendation regarding any treatment or monitoring.
79. On August 16, 2017, the PA Board sent an email to hart explaining that her case would be sent to SIRC because she had no responded to the PA Board’s August 10th email.
80. On December 6, 2017, Hart started a 90 day inpatient treatment regimen at the Florida Recovery Center (Center). However, she did not complete the impatient treatment regimen due to financial difficulties and left the Center on January 30, 2018.
81. The Preliminary Discharge Summary from the Center had these recommendations to Hart: (a) she “struggled to reach any acceptance of her misuse or substances or that it had affected her ability to practice medicine:; (b) she is unwilling to consider opiate blockade medications”; (c) she needs “psychiatric med management by [a] provider well versed in addiction”; and (d) she is no safe to return to practice as a physician assistant.
82. On April 23, 2018, Hart sent an email to PA Board staff requesting that her ICA be modified to allow her outpatient treatment in Kentucky, due to her move to that state to be with her husband and family.
83. On May 3, 2018, the Executive Director of the PA Board denied Hart’s request for modification of the ICA.
84. On July 2, 2018, PA Board staff sent an email to Hart. The email informed Hart the case investigation report was completed and she had an opportunity to provide a response to the investigation report and provide any other information for the PA Board’s review. Hart provided her response to the report.
Testimony of Michael A. Sucher, M.D.
85. Michael A. Sucher, M.D. is an addiction medicine physician.
86. The practice of addiction medicine is the evaluation, diagnosis, treatment, and posttreatment monitoring or individuals, primarily health professionals with addictive and substance use orders. Dr. Sucher was originally certified by the American Society of Addiction Medicine in 1986. Dr. Sucher was recertified in 1996, and certified by the American PA Board of Addiction medicine in 2009. Dr. Sucher carries an active case load. Dr. Sucher is licensed to practice medicine in Arizona, California, and Nevada.
Dr. Sucher works with Community Bridges, a mental health and substance use disorder network. Dr. Sucher stated that Community Bridges is the largest network in Arizona for mental health and substance use disorder. Dr. Sucher explained that the PHP for the Arizona Medical PA Board, the Regulatory PA Board of Physician Assistants, and the Arizona State PA Board of Dental Examiners is operated through Community Bridges. The PHP is a program authored by state statue to allow for the assessment, evaluation, referral to treatment, and monitoring to ensure that individuals with substance use disorders or mental health disorders are safety to practice.
87. Hart did not originally receive an assessment through the PHP because she believed that Dr. Sucher and Dr. Greenberg, (the second doctor who operated the PHP) were “too tough.” Therefore, Hart sought an assessment from the Institute.
88. Dr. Sucher explained that the program at the Institute is a very good program and he knows the medical physicians who operate the program.
89. Dr. Sucher explained that an assessment is typically a one – to two hour interview, but comprehensive evaluation includes a psychiatric evaluation, a medical evaluation, a meeting with the medical director, a psychological assessment, and psychological testing, neurocognitive screen for executive function and memory and logic, and a substance use assessment.
90. Dr. Sucher read the Institute’s findings and agreed with the diagnoses and recommendations. Dr. Sucher explained that the Institute found that Hart met seven of eleven criteria for opioid, barbiturate, and stimuli use disorder, which placed Hart in the severe category. Dr. Sucher agreed that Hart should not return to the practice of being a PA until her substance use disorders are treated.
91. Dr. Sucher also opined that it was completely inappropriate for Hart to receive her medications, some of them controlled substances, from a supervising physician. Dr. Sucher explained that a patient should not have a social, friendly, or romantic relationship with a treating physician.
92. Based upon the Institute’s report, Hart was not able to perform as a PA from a neurocognitive perspective. Dr. Sucher opined that Hart is not safe to practice as a physician assistant ant that her substance abuse issues impair her judgment to practice.
93. Dr. Sucher explained that after the Institute’s report, Hart approached him and stated that she wanted to come and see him. However, Dr. Sucher declined to admit Hart to the PHP because the program does no assess people without the expressed authorization of the PA Board. Dr. Sucher explained that after reviewing
Ms. Hart’s request for a modification of the interim consent agreement, he concluded that Hart had not accepted that she has substance abuse disorders.
CONCLUSIONS OF LAW
The PA Board is the duly constituted authority for licensing and regulating the practice of physician assistants in the State of Arizona. This matter lies within its jurisdiction.
The PA Board bears the burden of proof to establish cause to sanction Respondent’s physician’s assistant license by a preponderance evidence. “A preponderance of the evidence is such proof as convinces the trier of fact that the contention is more probably true than not.”
The PA Board therefore established by a preponderance of the evidence that Respondent has exhibited unprofessional conduct as defined under Ariz. Rev. Stat. §§ 32-2501(18)(d), (j), (p),(ee), and Ariz. Rev. Stat. § 32-1501(3).
The PA Board therefore has established cause to revoke Respondent’s PA license under Ariz. Rev. Stat. § 32-2551(J).
RECOMMENDED ORDER
Based on the foregoing, it is ordered revoking Respondent Kimberly A. Hart’s License No. 5631 for the Performance of Health Care Tasks in the State of Arizona.
In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be five days from the date of that certification.
Done this day, March 17, 2020.
/s/ Velva Moses-Thompson
Administrative Law Judge
Transmitted electronically to:
Patricia E. McSorley, Executive Director
Arizona Medical PA Board