VRP – Letter of Concern – What It Really Means

Licensees call me asking what is the VRP “Letter of Concern.”  “Do I have to do all these things the packet asks me to do?”  Do I have to answer these quesstions. This blog is a refresher of two prior blogs I wrote: VRP Letter of Concern and What is VRP Cooperation.  Let’s go through the first four items the Letter of Concern packet asks of each licensee.

1) Contact Livengrin (or your local) drug and alcohol treatment center for an assessment.

2) Complete the Participation Cooperation Form and Personal Data Sheet;

3) Sign releases;

4) If you successfully complete the VRP evaluation and you do not meet the criteria for a mental and physical valuation, the VRP will close its file but will still notify the Department of State legal divisions of the findings.

1) The PNAP VRP Assessment Process
The assessment is a basic DSM-V, alcohol or drug abuse, questionnaire.  Assessors almost always find criminal interaction (DUI, drug possession, or theft) or work place impact (getting fired) as a basis for a drug abuse diagnosis warranting monitoring.  Workplace positive drug tests for a non-prescription controlled substance also guarantees a drug abuse diagnosis.   VRP “voluntary” participants do not know this.  You think you could get cleared……NOPE.

Once a licensee contacts the PNAP – specified drug and alcohol treatment provider, to be compliant, the expectation is to disclose current and historical drug and alcohol (D/A) use.  Drug rehab assessors (not medical trained professionals) require VRP “voluntary” participants to release their medical records for review.  The assessors use the records in their PNAP “report” to identify whether the licensee is truthful during an assessment.   Now PNAP has your medical and prescription drug use history.

Some assessors may look past minor recreational use of marijuana or alcohol.  However, PNAP and PHMP supervisors sometimes intervene and “reorganize” assessor’s non-impaired conclusions.  By “reorganize” I mean PNAP caseworkers will either require the assessor to change their no-monitoring conclusion or require a second PNAP assessment.  This is the problem being voluntarily compliant with VRP assessments.  You can’t trust the person performing the assessment.  You can’t trust the PNAP or PHMP caseworker to not intervene in the assessment.  Do not disclose your medical care or medication history in an environment lacking in trust or transparency.

2) Complete the Participation Cooperation Form and Personal Data Sheet
PNAP treats the Participation Cooperation Form as a voluntary enrollment contract. Right off the bat, PNAP attempts to enforce this contract as if it were the Nursing Board. It is not.  For example, prior to or during the assessment process (waiting for scheduling, attending the assessment, or receipt of the report – which is always delayed due to receipt of medical records), PNAP may instruct VRP participants to not work.  PNAP participation is voluntary and voluntary means compliance.  PNAP initially tests a licensee’s ability to comply by precluding work.  This is not proper.  Only a formal Board order precluding a licensee from practicing their profession impairs a license and their ability to work.  If you need to work, and PNAP will not let you, consider not going into the VRP.
Absent a formal Board Order PNAP and PHNP do not have any authority to compel licensees to comply with the VRP participation requirements.  PHMP sometimes requires VRP enrollees to participate in an aftercare plan based upon the PHMP approved assessment.  Or, only after attendance in the care plan can the licensee return to work.   This is wrong.  Months could go by without working, expenses are rising, and licensees need to work.
The VRP letter of concern states “failure to comply with the terms of the PHMP agreement will result in the initiation of formal disciplinary process against the license to practice.” PNAP and the PHMP cannot compel disciplinary action. PHMP and PNAP threats for failure to honor the terms of the PHMP participation agreement – compelling disciplinary action – absent a formal nursing board agreement is an empty threat.  Only a Pennsylvania licensing board prosecutor can initiate disciplinary action. The PHMP and PNAP case workers cannot and do not initiate legal action.
PHMP and PNAP do not have the authority to initiate disciplinary action.  Only after a Pennsylvania professional licensing board enters a formal board order accepting a consent agreement – which is different from a PHMP agreement– can disciplinary action be initiated for breach of that order.  Licensees are allowed to work this entire time.  There is no Board order or other restriction on a licensee’s license during this time.  This is part of the PNAP trap.
PNAP’s Participation Cooperation Form language is a threat scaring licensees to not change their mind.  Licensees perceive the VRP assessment process will be quick.  PNAP makes sure it is not.  After signing the Participation Form, PNAP stops returning phone calls, answering questions, and SLOWS DOWN the process, causing licensees great frustration. Assessments are cancelled or reschedule for weeks.  Licensees who are fully compliant, attend the assessments, provide medical records are treated improperly.
PNAP caseworkers start the bait and switch lie tactics. PNAP caseworkers claim licensees can’t back out of the agreement, must comply and not work during the delay in report clearance or they’ll be subject to disciplinary process. PNAP case workers claim PHMP must release the licensee back to work.  PHMP caseworkers claim it is the legal department or the report is not done yet, or another drug test is required. This is not correct. Absent a formal Board Order, a VRP voluntary compliance participant who can change their mind. The threat of “legal review and prosecution” is just that;  A threat – not reality.
3) Personal Data Sheet
Many licensees initially participate in the VRP as a result of receiving a Letter of Concern.  The Letter of Concern is triggered by criminal charges – a single offense DUI,  a public drunkenness – or falling asleep in a job after working too many hours.  The personal data sheet seeks very private and confidential information.   Filling out a personal data sheet provides PNAP and the PHMP very extensive, confidential, and private information.   Many licensees candidly and honestly answer the personal data sheet questions.
Some questions, however, should not be answered.   Questions 22, 23, and 24(a)-(g) are of specific concern.  When confronted with substance abuse questions 22–24, many licensees indicate they do not have a drug or alcohol use condition, have never been diagnosed with such, and are taking prescription medication.  For the one/off DUI case, minor personal recreational use of pot or some mild alcohol use, the addiction questions can not be affirmatively answered.
At first blush licensees seeking to be compliant with the VRP process do not answer these questions because they can not admit to an addiction and/or do not suffer from one.  PNAP or PHMP case workers review the data sheet answers and claim the licensee did not provide proper complete information.  The delay process begins.  PNAP does not accept blank or denials to these addiction questions.  PNAP tells licensees that their version of the truth makes them ineligible for the VRP and the matter can be referred to the prosecutor for review.    SCARE SCARE SCARE.
Licensee don’t want to be eligible for this program. Licensees should not lie on this form and admit an addiction to get into the VRP.  Admissions of addiction form the basis for VRP  participation and eventual professional licensing boards’ consent agreement compelling compliance in the program.  Admission of an addiction, impairment, and inability to practice nursing is a necessary finding of any Board Order. It also stops the licensee from working.
Do not admit possessing a medical condition (drug or alcohol addiction) you do not have.  Make the Board prosecutor prove their case….. Do not admit any addiction.  The answers to questions 22 through 24 give the PHMP and the Board prosecutors the foundation for the consent agreement.  Don’t answer these questions if you are not impaired, do not suffer from an addiction, and have not been diagnosed as suffering from an addiction.
4) Personal Date Sheet Questions about Drug, Alcohol, or Mental Health Care
Questions 25-33 of the Personal Date Sheet focus on drug or alcohol treatment or mental health care. This is private, confidential medical care received based a medical condition for which many licensees receive appropriate care.  The VRP, PNAP, and the PHMP will utilize your own health care needs against the licensee as a reason to determine an impairment exists.  This is even though the care is for a diagnosed medical condition, for which licensees receive proper care,  and treat with lawful dispensed prescriptions.  Do not give PNAP any personal information about you, about your medical condition, about the medications you take. They’re only using it against you.
Please call to discuss your case

 

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Criminal Conviction – Professional License Suspensions and Mitigation Evidence

The Criminal History Record Information Act, 18 Pa. C.S. § 9124(c)(1) (CHIRA), requires Pennsylvania’s licensing boards consider criminal convictions disclosed on license applications or which take place after licensure as a reason to discipline active licensees. Different licensing boards apply CHIRA’s rules differently.

On February 28, 2018 Commonwealth Court decided Bentley vs. BPOA, — A.3d —- (2018).  This cases expounds on how a licensing board abuses its discretion when it disciplines a licensee for criminal conduct not related to their license. In 2013 and 2014, Cosmetologist Bentley was convicted in two separate cases of possession with intent to deliver a controlled substance, forgery, aggravated assault, escape, and attempting to allude the police. Wow.

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Bentley reported the convictions to her Board, which issued a Rule to Show Cause seeking to discipline her license under CHIRA.  At the hearing, the Cosmetology Board prosecutor only presented the certified criminal conviction. This is the typical prosecutor practice.  No witness testified as to the underlying criminal conduct.

It is important to have competent counsel at this hearing.  Counsel should object to inadmissible portions of the certified conviction documents. Objections to hearsay statements in affidavits of probable cause eliminate statements of people not present at the hearing.  The licensee can not cross-examine that witness.   I always have these documents paired down and limited.  My client/licensee’s explanation of the criminal case is the only version of events. Consistent Nguyen v. BPOA, licensees are allowed to explain their role in any multi-defendant criminal case. They may explain a co-defendant’s greater role than their own.

During her hearing, through counsel, Bentley presented significant and appropriate mitigation evidence. Mitigation evidence included the delay of the prosecution versus the time of the criminal act; new and abundant family support; full and complete responsibility for the criminal act; the unique set of factors leading up to the criminal charges and her association with her then boyfriend and now co-defendant.  Most importantly, she described her rehabilitation while in state prison. This rehabilitation included anger management, employment/cosmetology training, and new religious faith. She presented reasonable and appropriate community reputation evidence. This evidence corroborated her claim of being rehabilitated, remorseful for her actions, and turning over a new leaf.

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The hearing officer suspended Bentley’s license for the balance of her parole (probably not long). The Cosmetology Board, as all boards do, issued a notice of intent to review the hearing officer’s decision.  The Cosmetology Board rejected as modest Bentley’s mitigation evidence. The board suspended Bentley’s cosmetology license for three years based upon the criminal convictions. The Board rejected Bentley’s need for licensure to remain employed, her rehabilitation, and need to support herself.

Bentley appealed to the Commonwealth Court.  She claimed the Board abused its discretion when it rejected her mitigation evidence and suspended her license based solely on the criminal convictions.  Bentley alleged that the Board summarily ignored all of her uncontested mitigation evidence, which was not contradicted by any evidence the Commonwealth introduced in the certified criminal conviction. Bentley argued the suspension was manifestly unreasonable because the convictions bore no relation to the practice of cosmetology. Arguing the Board’s conduct capriciously disregarded her mitigation evidence absent explanation was an abuse of discretion.

On review the Commonwealth court agreed. Commonwealth Court defines capricious disregard as “when there is a willful and deliberate disregard of competent testimony and relevant evidence which one of ordinarily intelligence could not possibly have avoided in reaching a result. When strong evidence contradicts contrary evidence, the adjudicator must explain the basis for its determination.” Absent a proper explanation why the adjudicator is rejecting overwhelming critical evidence, the board abuses its discretion.

As with many of my cases the time delay between criminal event, conviction, and disciplinary action may be five or six years. I argue Board delay which allows the licensee to practice of their profession for three or four years renders mute any board allegation that there is an emergent basis for extensive discipline. Suspension or revocation is not warranted if the board took six years to do it.

Also, the Cosmetology Board licensing scheme does not authorize discipline for criminal convictions not related to the profession.   Imposing discipline based upon the convictions was an error of law.  Such also revealed ignorance of Bentley’s mitigation evidence.  The court found Bentley’s mitigation evidence unique and must be considered.
The Commonwealth Court held that the Board’s summary rejection and failure to consider it constitutes a capricious disregard of the evidence. Such is an abuse of discretion for which the Commonwealth Court rejects the board decision and sends the case back to the Cosmetology Board.

This case is an example of licensing boards tightening their belts and implementing a much stiffer enforcement environment. This appellate  decision, and several other recent cases, reveal licensing boards routinely abusing their discretion and ignoring the law that guides their decisions.  Non-law trained licensing board members shoot from the hip regarding the discipline that they want to impose upon their license fees. Many times, there is no legal basis for the discipline.

When licensees take an appeal, they have an appellate, independent, unbiased court review the nature and extent of imposed discipline.  The appellate court rejects this board’s arbitrary and capricious decision. Unfortunately this costs a lot of money. However, in many of my cases I see unfettered discretion punishing hard-working licensees that is far beyond both what is necessary and reasonable and what the licensing statutes allow.
Call me to discuss your case.  A criminal record should not be a bar to getting or keeping a license.
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Jerry’s career took off.  So should yours.

PNAP Case workers — Do Not Trust Them

Medical professionals or their employers call PNAP case workers and intake administrators for numerous reasons.  The initial complaint call against the licensee  generates the “Letter of Concern.”  It is the response call from the licensee to PHMP/PNAP/SARPH/PAP that starts the proverbial ball rolling.  Here are several important facts each licensee should be aware of before calling PNAP.

PNAP/PAP/PHMP caseworkers are told to not tell inquiring licensees the truth. PNAP and PHMP caseworkers are instructed to emphasize the worst possible legal and licensing consequences if there is no cooperation.  PNAP/PHMP caseworkers are instructed to intimidate and scare licensees into the program. PNAP caseworkers are instructed to tell licensees about the costs of the Mental and Physical Evaluation and court fees.  PNAP caseworkers are instructed provide the minimum legal information possible.

PNAP caseworkers do not know the law.  PNAP/PHMP/PAP case workers are not trained in the several health care boards’ regulations.  PHMP/PNAP/PAP case workers do not understand the legal implications of the wrong advice they give. PNAP case workers do not know how to tell the truth.  Some PNAP caseworkers may be in the program too.

 

For every medical professional, agreeing to the initial PNAP assessment is the worst thing you can do. Current conflicts between the DSM-IV and DSM V alcohol use disorder – mild, moderate, or severe – are creating significant issues in determinations of impairment for PNAP assessors.  I have learned that the PNAP assessors could be  calling the PNAP caseworker and managers, who help the assessor diagnosis an impairment. This is improper.

PNAP and PHMP assessments should be performed independently, by appropriately trained medical professionals. PNAP and PHMP supervisors (Simpson and Knipe) should not be consulted on diagnosis. This type of diagnosis cooperation smacks of a pre-ordained determination of an impairment to insure medical professionals go in the program.  Please understand the above is not an anecdote or a hypothetical scenario. I have been told about PNAP supervisors providing supplemental questions and facts to assessors to insure a determination of impairment and a conclusion that the monitoring program is required.  Ethically, any assessor/PNAP consultation is improper.

This tells me that the system of initial communication with PNAP (in which they lie to you) and the read assessment process renders this entire program unacceptable. Be careful.  Call me.

Notice of A Disciplinary Proceeding

Pennsylvania’s licensing boards officially communicate with their licensees only through regular mail or certified mail, return receipt requested.  Licensing boards are not legally authorized to communicate via email any disciplinary correspondence.   This is why every disciplinary board requires licensees, not the board staff,  to update their own mailing address.

There always is a percentage of licensees that after  licensure move throughout the Commonwealth and country.  Many fail to update their licensing board with their new mailing address. Licensees who fail to update their prospective board with their most recent address expose themselves to disciplinary action in their absence.

A new client, over two years ago became divorced, moved out-of-state, and failed to update the Pennsylvania Nursing Board with her new Florida mailing address.  Unbeknownst to her, two years ago the Pennsylvania Nursing Board commenced an investigation and initiated disciplinary proceedings against her license.  Board mail included a Mental and Physical evaluation petition, medical expert appointment scheduling notices, hearing notices, and formal board disciplinary decisions.

For the last two years her disgruntled ex-spouse – who stayed in the marital residence – received all of her mail.  He threw out all her mail, never telling her anything.  Because she was unaware, all appointments, hearings, and decisions took place in her absence. This client was ignorant to all that was taking place against her license in her absence. Her lack of notice is now causing significant long-term detrimental consequences with her license because Nursing Board disciplinary decisions were entered against her.

This client has been working in Florida under a second professional license.  Her most recent employer’s basic regulatory compliance process included an annual subscription to the National Practitioner Data Bank (“NPDB”) automated inquiry process for all licensees. Consequently, her employer was automatically notified of her 2018 Pennsylvania Nursing Board license suspension – of which she had no idea.  She was terminated and can not work until she rectifies her Pennsylvania nursing license disciplinary action.  All other potential employers will see the NPDB disciplinary action.

These disciplinary proceedings transpired over 18 months. Having not updated her formal mailing address, she did not receive the Mental and Physical Evaluation appointments, hearing notices, and formal disciplinary decisions. By the time she became aware of her Pennsylvania Nursing Board license suspension it was too late to take an appeal.

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Her only recourse is to comply with the terms of the license suspension order. This includes now attending the Mental and Physical evaluation, petitioning the Nursing Board for Reinstatement of her license, and attending a hearing in which she must prove she can resume the competent practice of professional nursing with reasonable skill and safety.  This process will take three to six months.  She is unable to practice nursing in her new jurisdiction.  Her State of Florida Nursing Board license may also subject to disciplinary action based upon the Pennsylvania Nursing Board disciplinary action.

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State boards are permitted to engage in disciplinary actions against licensees.  Boards must afford all licensees the opportunity to be heard in accordance with administrative agency law.  This law includes a provision that by regular mailing administrative actions to the licensee’s last known address the Board is affording that licensee reasonable notice of proceedings and is giving the licensee a sufficient opportunity to be heard.

Pennsylvania’s General Rules of Administrative Practice and Procedure (“GRAPP”) authorize service of any proceeding by regular mail, without a return receipt requested.  Email is not authorized.  Due process under both the federal and state Constitutions merely requires licensing boards make a respondent/licensee sufficiently aware of the charges against them and the procedures by which a defense can be presented.  Regular mail of any disciplinary petition or notice satisfies this constitutional obligation.  A licensee/respondent will suffer the consequences if they fail to attend evaluations, respond to petitions, file an answer within the time provided, or does not appear at hearings to challenge the charges against them.

In this client’s matter, having failed to attend a Mental and Physical and Evaluation, case law and board procedure allowed the prosecutor to file a petition Deeming Matters Admitted.  The Board accepts as true all allegations that warranted the Mental and Physical Evaluation.  This means mere suggestions of  drug use, work-related incidents, and/or drunk driving charges warranting an expert evaluation – but not proof of an impairment – become admitted and uncontested facts of an impairment.

This licensee cannot file a motion challenging the validity of the underlying mental and physical evaluation order, the factual findings of an impairment, or the need for monitoring of which the Board concluded after a hearing at which the licensee did not attend. The licensee can not contest the findings of fact or formal disciplinary action, which language the board transmits to the National Practitioner Data Bank.

This licensee’s failure to update her address precipitates a cascade of events that are easily avoided.  Licensing boards throughout the country have set in place this minimal notice and mailing procedure to be able to discipline in and out of state licensees in their absence.  The boards do not have to chase licensees down to discipline them.  Unlike in criminal matters where a defendant must almost always be present, state license boards can strip licensee’s of their property interest in their absence.  This client’s unfortunate predicament is a perfect example of the pitfalls of the failing to update your formal address with your licensing board.

GARLIC — NOBODY LIKES IT — The Case of Robert Garlick, Penn DOT, a DUI Investigation, and a Blood Test Refusal

On July 17, 2017 Robert Garlick was operating his motor vehicle in Erie County Pennsylvania.  A state Trooper investigating his 1 car accident, suspected Mr. Garlick of being under the influence of alcohol.  Garlick was arrested for suspicion of DUI.  At the barracks the Trooper read verbatim the warnings contained in the July 2016 revised Penn DOT DL-26B form.  This form provides the following warnings with regard to a chemical test of blood:

1. You are under arrest for driving under the influence of alcohol or a controlled substance in violation of Section 3802 of the Vehicle Code.

2. I am requesting that you submit to a chemical test of blood.

3. If you refuse to submit to the blood test, your operating privilege will be suspended for at least 12 months. If you previously refused a chemical test or were previously convicted of driving under the influence, you will be suspended for up to 18 months.

4. You have no right to speak with an attorney or anyone else before deciding whether to submit to testing. If you request to speak with an attorney or anyone else after being provided these warnings or you remain silent when asked to submit to a blood test, you will have refused the test.

I and many other attorneys have argued that this language in this DL-26B form fails to comply with the statutory version of §1547(b)(2) in effect at the time; that these drivers are not advised that refusing the chemical test would result in enhanced criminal penalties (i.e. the penalties provided in Section 3804(c)) as § 1547(b) requires. While there is no statutory or other requirement that the DL-26 form contain appropriate warnings, or that the form be read verbatim, it is nonetheless the duty of the police officer to inform the petitioner of the statutorily required warnings. In other words, if the police officer recites the appropriate warnings from memory without the use of any form at all that is perfectly acceptable under the law.  In this case, however, the Trooper confirmed that the only warnings he provided were those contained on the DL-26B Form which he read verbatim. Those warnings are not consistent with the law.

The law in effect in July of 2016 was 75 Pa.C.S.A. § 1547.  Section 1547 of the Vehicle Code in effect on May 24, 2017, provides in pertinent part:

(a) General rule.—Any person who drives, operates or is in actual physical control of the movement of a vehicle in this Commonwealth shall be deemed to have given consent to one or more chemical tests of breath or blood for the purpose of determining the alcoholic content of blood or the presence of a controlled substance if a police Officer has reasonable grounds to believe the person to have been driving, operating or in actual physical control of the movement of a vehicle:

(1) in violation of section 1543(b)(1.1) (relating to driving while operating privilege is suspended or revoked), 3802 (relating to driving under influence of alcohol or controlled substance)….
* * *

(b) Suspension for refusal.—

(1) If any person placed under arrest for a violation of section 3802 is requested to submit to chemical testing and refuses to do so, the testing shall not be conducted but upon notice by the police officer, the [D]epartment shall suspend the operating privilege of the person as follows:
(i) Except as set forth in subparagraph (ii), for a period of 12 months.
* * *
(2) It shall be the duty of the police Officer to inform the person that:

(i) the person’s operating privilege will be suspended upon refusal to submit to chemical testing; and
(ii) if the person refuses to submit to chemical testing, upon conviction or plea for violating section 3802(a)(1), the person will be subject to the penalties provided in section 3804(c) (relating to penalties). 75 Pa. C.S. § 1547(a),(b).

On July 20, 2017, the governor approved Act 30 of 2017 which provides for an amendment to Section 1547(b)(2) removing the language requiring a police officer  to provide the warnings relating to enhanced criminal penalties for refusal. This amendment was not effective on the date of Garlick’s incident.  The fact that the legislature amended it is indicative of its acknowledgement that such an amendment was necessary to effectuate the change required of the warnings pursuant to Birchfield.

Drivers license attorneys and I argue PennDOT’s amended DL–26B form, created post-Birchfield, removes references to §3804 criminal penalties. This form is not consistent with the statutory framework of the motor vehicle code and not consistent with any legislative authority. Various courts have been confronted with post-Birchfield amended O’Connell warnings that do not contain the mandatory/ statutory language of § 1547(b)(2).  These cases do not address the illegality of the DL-26B form and the incorrect recitation of law to the motorists deemed refusing.

Mr. Garlick objected to amended DL 26B reading.  The Erie County Court of Common Pleas judge denied his legal argument.  On appeal to the Commonwealth Court affirmed the trial judge and found PennDOT correctly altered its DL-26B form after the Birchfield case.  As you recall, Birchfield v North Dakota, ––– U.S. ––––, 136 S.Ct. 2160, 195 L.Ed.2d 560 (2016), and Commonwealth of Pennsylvania jurisprudence interpreting it hold that 75 Pa.C.S.A. §1547(b) and Pennsylvania’s enhanced criminal penalties for refusing a chemical blood test are unconstitutional.

The complex criminal versus civil application of Birchfield, is born out in the case of Boseman v. Department of Transportation, Bureau of Driver Licensing, 157 A.3d 10 (Pa. Cmwlth. 2017), and Gray v. Commonwealth , Dep’t of Transportation, Bureau of Driver Licensing, No. 1759 C.D. 2016, 2017 WL 2536439, at *7–8 (Pa. Commw. Ct. June 9, 2017), reargument denied (Aug. 7, 2017). These cases maintain arresting officer’s statutory obligation to inform a motorist of the General Assembly’s defined § 1547(b)’s ramifications of a refusal – not PennDOT’s version.

Garlick v. PennDOT is the first case to decide the exact argument I have raised in several cases.  Garlick rejects, though without explanation, the argument that the PennDOT revised DL-26 form is illegal.  The court  opinion adopts much of my and other defense counsel’s reasoning that; “It is true, as Licensee argues, that the language contained in Section 1547(b)(2)(ii) was mandatory at the time Trooper requested that Licensee submit to a blood test. However, while Section 1547(b)(2)(ii) then “command[ed]” that a warning about enhanced criminal penalties be given the purpose behind that provision is to make a licensee aware “of the consequences of a refusal to take the test so that he can make a knowing and conscious choice.” Dep’t of Transp., Bureau of Traffic Safety v. O’Connell, 555 A.2d 873, 877 (Pa. 1989); see Commonwealth v. Myers, 164 A.3d 1162, 1171 n.12 (Pa. 2017) (plurality) (“purpose of [Section 1547(b)(2)] ‘is to entitle arrestees to the information necessary to assess the dire consequences they face if they fail to consent to chemical testing, to ensure their choice in that regard is knowing and conscious, as we described in O’Connell’”

However, the court proceeds to state “Given our review of the current state of the law, Licensee’s argument that his license must be reinstated because he was not warned that he would be subject to no longer constitutionally permissible enhanced criminal penalties for refusing blood testing is unpersuasive. Trooper specifically and accurately warned Licensee about the consequences of refusing a blood test that remain following Birchfield, that is, the suspension of his license. Therefore, common pleas did not err when it denied Licensee’s appeal.”

This conclusion ignores the realty of the legislative dictate that the law as written and authorized by the General Assembly is the only permitted and regally authorized language Penn DOT can read to licensees.  More appeal will follow because of this specious and ill-informed decision.

Still on the topic of refusals to submit to  a breath or blood test, a new bill introduced into the General assembly in 2018, Senate Bill 553, makes changes to the state’s DUI laws and will take effect Jan. 11.  Among them is a new fee for refusing to submit to a blood-alcohol test, after the U.S. Supreme Court ruled in 2016 that police can’t obtain blood samples without a warrant or consent.  Under the revised law, drivers who refuse a blood-alcohol test but are convicted and lose their license will have to pay a “restoration fee” for their license of up to $2,000 — $500 for the first time a test is refused, $1,000 for the second time and $2,000 for the third and each time after. The law requires officers to inform suspects of the costs when they’re pulled over.

Nurse, Doctors, and Intimate Relationships with Patients

Most health care related professional licensing schemes contain a uniform proscription against engaging in sexual intimacies with clients.  This sexual conduct bar does not depend on consensual or non-consensual acts.     Violating this conduct is the first and surest way to lose your professional license.  Prior relationships with current licensee and current relationships with former patients also creates huge problems.

The General Assembly, through the Pennsylvania Code defines  Sexual intimacies as romantic, sexually suggestive, sexually demeaning or erotic behavior. Examples of this behavior include the following:

  • (i) Sexual intercourse, or any touching of the sexual or intimate parts of the person for the purpose of arousing or gratifying sexual desire in either person.
  • (ii) Nontherapeutic verbal communication or inappropriate nonverbal communication of a sexual or romantic nature.
  • (iii) Sexual invitations.
  • (iv) Soliciting or accepting a date from a client/patient.
  • (v) Masturbating in the presence of a client/patient or encouraging a client/patient to masturbate in the presence of the licensed marriage and family therapist.
  • (vi) Indecent exposure, kissing, hugging, touching, physical contact or self-disclosure of a sexual or erotic nature.  49 Pa. Code § 48.1
Section 49 Pa. Code § 21.146a, is a catch-all Pennsylvania Code provision setting forth as a procedural matter, not even a substantive violation,  a rule stating:
  • (a)  The consent of the patient to any sexual impropriety or violation is not a defense to any disciplinary charge for violation of the act or this subchapter.
  • (b)  Evidence of specific instances, opinion evidence, or reputation evidence of a patient’s past sexual conduct is not admissible in proceedings brought under §  21.148(b)(9) (relating to standards of nursing conduct).  The Board may consider sexual relationships between the nurse and the patient occurring prior to the professional relationship.
  • (c)  A nurse who attempts to raise as a defense an argument that conduct prohibited as a sexual violation or sexual impropriety was necessary or appropriate to the treatment of a patient shall be required to demonstrate competency in practice which relates directly to the treatment of sexual function or dysfunction. This competence may be demonstrated through educational training and supervised clinical experience. Appropriate discussions of sexual matters between a nurse and a patient shall be fully documented in patient records.

Apparently this conduct is prevalent in the psychology, psychiatry, licensed marriage and family therapist, and LSW and professional counselor professions.  I say this because the language in each of these licensing regulatory schemes is exact, precise, and consistently repeated throughout.   The law is very clear about this topic: 49 Pa.Code § 47.61 states: Sexual intimacies between a licensed social worker or licensed clinical social worker and a current client/patient, or an immediate family member of a current client/patient, are prohibited.  More importantly, licensed social workers and licensed clinical social workers may not accept as client/patients individuals with whom they have engaged in sexual intimacies.  For how long you ask?  Sexual intimacies between a licensed social worker or licensed clinical social worker and a former client/patient, or an immediate family member of a former client/patient are prohibited for 7 years following the termination of the professional relationship.

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Violation of these provision will warrant disciplinary action:

  • (a)  A violation of § §  47.61—47.63 (relating to prohibited conduct; former sexual partners as clients/patients; sexual intimacies with a former client/patient or an immediate family member of a former client/patient) will be deemed unprofessional conduct and will subject the licensed social worker or licensed clinical social worker to discipline under section 11(a)(2) of the act (63 P. S. §  1911(a)(2).
  • (b)   The consent of a former client/patient or immediate family member of a former client/patient to engage in sexual intimacies with the licensed social worker or licensed clinical social worker is not a defense in any disciplinary action brought under § §  47.61—47.63.

Pennsylvania does not recognize, along with all other states, that a mental health professional’s conduct in engaging in a sexual affair with a patient is actionable in tort (a medical malpractice action).  Thierfelder v. Wolfert, 617 Pa. 295, 327, 52 A.3d 1251, 1271 (2012).  However, our Commonwealth court routinely concludes the State Board of Medicine properly orders, and it is within their authority, that psychiatrist’s license to practice medicine be revoked on ground that he had engaged in sexual relations with his patients.  (“Revocation of psychiatrist’s license was reasonable sanction in light of his conduct.) Starr v. State Bd. of Med., 720 A.2d 183 (Pa. Commw. Ct. 1998); Morris v. State Bd. of Psychology, 697 A.2d 1034 (Pa. Commw. Ct. 1997).

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In these cases, the court concludes the Board of Medicine, and other boards, are entitled to deference in their determination of what constitutes “unprofessional conduct” as that term is used in Medical Practice Act (or their licensing schemes) section providing that practitioner may be disciplined for “unprofessional conduct.” 63 P.S. § 422.41(8).  As there is no per say rule of revocation, the regulatory language stated above in the counseling fields is overlapped by the Medical Practice Act.
There, sections 41(8) and (9) of the Medical Practices Act state that the Board shall have the authority to impose disciplinary or corrective measures on a board-regulated practitioner for

  • (8) Being guilty of immoral or unprofessional conduct. Unprofessional conduct shall include departure from or failing to conform to an ethical or quality standard of the profession. In proceedings based on this paragraph, actual injury to a patient need not be established.
    • (i) The ethical standards of a profession are those ethical tenets which are embraced by the professional community in this Commonwealth.
    • (ii) A practitioner departs from, or fails to conform to, a quality standard of the profession when the practitioner provides a medical service at a level beneath the accepted standard of care. The board may promulgate regulations which define the accepted standard of care. In the event the board has not promulgated an applicable regulation, the accepted standard of care for a practitioner is that which would be normally exercised by the average professional of the same kind in this Commonwealth under the circumstances, including locality and whether the practitioner is or purports to be a specialist in the area.
  • (9) Acting in such manner as to present an immediate and clear danger to public health or safety.  63 P.S. § 422.41 (8) and (9).

The Boards and the courts consistently determine that having sexual intimacies with clients breaches ethical standards, standards of care, and constitutes immoral or unprofessional conduct.   “Unprofessional conduct” includes “those breaches of trust, confidence and reliance, necessarily attendant upon the intimate relationship of physician and patient, which amount to gross abuses of the standards of professional conduct generally recognized as essential to the proper practice of medicine and surgery.”  As well, the specific regulations above clearly state that it is of no consequence that intimacies occur either before or after a terminated client relationship.  Importantly,

the professional who, during course of therapeutic relationship, engages in sexual intimacies with client may not absolve himself or herself from professional liability by ceasing to provide therapy while sexual relationship continues, or billing for services and masquerading the sex as a therapy. 49 Pa. Code § 41.61. Giddings v. State Bd. of Psychology, 669 A.2d 431 (Pa. Commw. Ct. 1995).
Call me to discuss your legal issues.
 

 

Alcohol Use Disorder and Self-Help Remedies — Licensees Be Careful

My blog topics sometimes originate from media outlets  discussing issues that impact my professional clients. NPR published an article this week discussing a new National Institute of Health (“NIH”) alcohol use disorder online self- help tool.  The attached link presents a significant web presence on alcohol consumption, alcohol use disorders, and other NIH discussion pieces on a national alcohol abuse epidemic. NPR, NIH Alcohol Use Disorder Article

The website reveals a national problem with alcohol consumption and provides a means for self diagnosis of one’s alcohol use disorder (“AUD”) through a DSM questionnaire.  In prior blogs I discuss the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) as the tool mental health professionals utilize to diagnose mental health conditions.  An Alcohol Use Disorder is one such identified mental health disease.  The DSM-V, the latest and current version, identifies any person meeting two of the following 11 criteria during a 12 month period as suffering from an alcohol use disorder.

  • Had times when you ended up drinking more, or longer than you intended?
  • More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
  • Spent a lot of time drinking? Or being sick or getting over the aftereffects?
  • Experienced craving — a strong need, or urge, to drink?
  • Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
  • Continued to drink even though it was causing trouble with your family or friends?
  • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
  • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
  • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
  • Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
  • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there?

As an an attorney representing medical or other licensed professionals possibly suffering from AUD, or other DSM-V criteria disorders, you’re wondering why I’m writing this blog.  The NIH web page, marketing campaign, and DSM assessment tool are very helpful for life correcting and treatment of a medical condition.

However,  licensed professionals should not seek treatment as a result of a self-help assessment in an on-line article, not conducted by a professional.  Such an endeavor could create significant potential professional license exposure. Obviously your health is a paramount concern.  Seek help if you need it.  But before doing so, understand there could be significant legal and professional ramifications.

Licensed professionals who self diagnose themselves and then seek drug and alcohol treatment through any number or type of treatment facilities opens a Pandora’s box of medical records and mental health disclosure issues and potential employment and license reporting responsibilities.   The wrong treatment facility could seek employment related information. Thereafter, under various state and federal regulations, these drug or alcohol treatment facilities (whom the licensee sought for help and stress reduction) become mandatory reporters to state professional licensing boards – causing huge stress. This creates the scenario where someone seeks inpatient treatment and the treatment provider reports a person’s drug or alcohol use to their professional licensing board. This exposes the professional licensee to a disciplinary process.

Self disclosure to any drug or alcohol treatment facility becomes a medical record subject to mandatory disclosure to a licensing board if a petition for a Mental and Physical Evaluation is ordered. By this I mean, once a treating facility reports a licensed professional as suffering from a drug or alcohol use disorder (without any type of criminal or workplace related event), the licensee’s words become the basis for disciplinary action.  Petitions to Compel Mental and Physical Evaluations require disclosure of the medical records from the self-help treatment facility.  The licensee’s words become the proverbial nail in the coffin of any disciplinary action.

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Before you proceed through an NIH or other self-help drug and alcohol use disorder assessment and then contact an inpatient treatment provider (which really just wants your money) please call to discuss the legal ramifications of your need for medical care. While your health and welfare are paramount, take into consideration the broader range of factors, including the status of your ability to work, maintain gainful employment, and practice your profession.  If your life is already full or stress (from family, marriage, work,  finances, and life), causing professional downfall, legal fees, or disciplinary action will just add to the current stress level. Eliminating additional stress is a huge factor in maintaining sobriety, maintaining confidence, and psychological stability.

Drug Act, Automatic Suspensions, and the Time Period for Reinstatement

In November, I wrote a blog about  McGrath v. Bureau of Prof’l & Occupational Affairs, No. 5 WAP 2017, 2017 Pa. LEXIS 3109, at *12-13 (Nov. 22, 2017). Felony Convictions and License Reinstatement This case has now been interpreted in a second license revocation appeal. Joseph Thomas Acri, D.O., Petitioner v. Bureau of Professional…, — A.3d —- (2018). Acri, a D.O., medical license was suspended due to prescription fraud.   The State Board of Osteopathic Medicine (Board), automatically suspended his license to practice osteopathic medicine and surgery pursuant to section 14(b) of the Osteopathic Medical Practice Act (Act) based upon his felony convictions under The Controlled Substance, Drug, Device and Cosmetic Act (CSA), 35 P.S. §§ 780-101—780-144.   He appealed his 10 year ineligibility for license reissuance.

In McGrath, the key holding focuses on the 10 year license ineligibility after a Drug Act felony conviction.  The Court there ruled that the statute evidenced irreconcilable ambiguities regarding whether an individual must wait ten years before applying for reinstatement after having his or her license suspended for violating the CSA. In so holding, the Court noted that a general provision in the Law granted the licensing board with authority to reissue a suspended license, irrespective of a time frame; the section providing for a ten-year waiting period applied to “applicants;” the section dealing with a five-year waiting period concerned the “revocation” and not the “suspension” of a license; and the provisos relating to the “restoration” or “reissuance” of a license made it unclear through which provision the licensing board should consider an application for reinstatement.

After applying the general rules of statutory construction, the Court in McGrath determined that the statutory language remained ambiguous, and because the Law was penal in nature, the court construed it strictly and in favor of the individual. Therefore, the court reversed the licensing board’s order to the extent it imposed a license suspension for a mandatory period of not less than ten years and concluded that the licensing board should process any application for reissuance in accordance with the general, discretionary provision of the Law granting it the power to reissue a suspended license.

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McGrath’s nursing license was automatically suspended – not revoked – when she was convicted of violating the Drug Act (it seems a felony).  McGrath petitioned for reinstatement of her nursing sometime shorter than 10 years.  McGrath argued the Nursing Act’s provision for reinstatement allowed for the Board to grant such application within its discretion at any time, not earlier then 10 years stated under a separate provision of the Nursing Act.  The Court agreed, stating it is within the Board’s discretionary provision of the Law granting it the power to reissue a suspended license.

 

Acri argued the same logic and reasoning applied to the statutes and Board regulations applicable to license doctors under the Osteopathic Act, 63 P.S. § 271..2 and 14a.  Acri maintained the Board’s order automatically suspending his licenses for a period of not less than ten years was in error.  The Court agreed!   Importantly, at oral argument before the appellate court, the Board conceded that there were no statutory time constraints placed upon Petitioner and that he could apply for reinstatement or reissuance when he so desires.  This is the ruling of McGrath!

 

The Acri Court, however,  admonishes the Osteopathic Board and all other licensing Boards to implement this procedure.  “However, this concession does not alter the fact that the Board’s order strongly suggests otherwise, or is at least ambiguous. Although we have no doubt that, in the future, the Board will fulfill its promise to interpret and apply its order in the way that it said it would, this Court nevertheless has an obligation to address the legal issue presented to it.”

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Here the court is saying to the licensing boards, fix your Board disciplinary orders and remove the time period of disqualification for petitions for reinstatement.   The Court’s language is very instructive. “Therefore, pursuant to our decision in McGrath, we modify the Board’s order insofar as it imposed a mandatory five or ten year suspension on Petitioner’s license. In accordance with this memorandum opinion, any reissuance request from a suspension for violating the CSA shall be processed and reviewed under section 15(c)(6) of the Act.”

These two decisions continue in the process of allowing for license reinstatement or reissuance sooner, and not under and specific time period of preclusion.  The difficult legal issue now will be that an appeal of any board order denying license reinstatement for felony Drug Act conviction will be based upon an abuse of discretion standard and not an error of law standard.  The abuse of discretion standard is viewed in light of the general rule that all licensing boards are charged with the responsibility and authority to oversee the profession and to regulate and license professionals to protect the public health and safety. Barran v. State Board of Medicine, 670 A.2d 765, 767 (Pa .Cmwlth.1996), appeal denied 679 A.2d 230 (Pa.1996).

An abuse of discretion is generally defined as a misapplication of the law, a manifestly unreasonable exercise in judgment, or a final result that evidences partiality, prejudice, bias, or ill-will. Allegheny County v. Golf Resort, Inc., 974 A.2d 1242 (Pa.Cmwlth.2009); Pastorius v. State Real Estate Commission, 466 A.2d 780 (Pa.Cmwlth.1983). When reviewing the exercise of discretion by an administrative agency, the Court may not, in the absence of bad faith, fraud, capricious action or abuse of power, inquire into the wisdom of the agency’s action or into the details or manner of executing agency action. Slawek v. State Board of Medical Education and Licensure, 526 Pa. 316, 586 A.2d 362 (1990); Blumenschein v. Pittsburgh Housing Authority, 379 Pa. 566, 109 A .2d 331 (1954). Appellate courts may interfere in an agency decision only when there has been a manifest and flagrant abuse of discretion or a purely arbitrary execution of the agency’s duties or functions.  Although the Commonwealth Court is required to correct abuses of discretion involving penalties and sanctions imposed by a licensing board, the appeal court may not substitute its discretion for that of the board, which is an administrative body endowed with expertise in matters subject to its jurisdiction. Burnworth v. State Board of Vehicle Manufacturers, Dealers, and Salespersons, 589 A.2d 294 (Pa . Cmwlth.1991).

Call me to discuss your case on appeal.

 

 

 

Disciplinary Action – Scope of Practice Certified Registered Nurse Practitioners

Certified Registered Nurse Practitioners (“CRNP”) can prescribe medication, examine patients, diagnose illnesses, and provide treatment, much like physicians do. In fact, nurse practitioners have what’s referred to as “full practice authority” in 20 states, meaning that they do not have to work under the supervision of a doctor. In the Pennsylvania, however, while CRNPs still have more authority than RNs, they must have a medical doctor sign on certain patient care decisions.

Nurse practitioners are increasingly becoming integral to medical teams as more and more hospitals and healthcare facilities are utilizing their expertise. Their experience as working nurses gives them a unique approach to patient care, while their advanced studies qualify them to take on additional duties that are usually left to physicians.

There are many different ways CRNP are exposed to practicing outside the scope of their practice.  Dispensing medications incorrectly or without a prescription is the first and foremost.  CRNPs are especially vulnerable to disciplinary action as they hold prescriptive authority to dispense Schedule II and other non-scheduled medications.  This blog will address CRNP’s legal duties.

CRNP’s must collaborate with a physician who holds a current license to practice in the Commonwealth.  When acting in collaboration with a physician in a “collaborative agreement” within the CRNP‘s specialty, the CRNP may perform comprehensive assessments of patients and establish medical diagnosis, perform and supervise diagnostic tests, institute referrals, develop treatment plans, establish prescriptive authority approvals for pharmaceutical treatments, complete admission and discharge summary’s, and order various supplemental therapeutic medical care. Supplemental medical care includes dietary plans, home health care and hospice, durable medical equipment, physical therapy and dietitian referrals, respiratory and occupational therapy referrals, and perform initial assessments of methadone treatment evaluations.

Methadone treatment and evaluations can be accomplished in conjunction with approval of a physician in the Pennsylvania methadone treatment regulations.  In this time of opioid crisis, CRNP’s prescribing methadone is a huge issue. CRNPs have sought clarification of their authority and qualifications to prescribe Suboxone.  63 PS § 21.283(c) of the Pennsylvania Code sets forth CRNP’s prescriptive authority.

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Every two years CRNP must complete 16 hours of board approved CE credits in pharmacology.  Initially, CRNPs require 45 hours of coursework specific to advanced pharmacology through the a professional nurse education program within five years before initial prescriptive authority approval. Board prescribing and dispensing schedule II restrictions include only 30-day supply authorizations and only in conjunction with a collaborative agreement setting forth such authorization by the physician in the agreement.

CRNP are limited to prescribing 90-day supplies of schedule III and IV controlled substances, which physician based authority is identified in the collaborative agreement. CRNP may not delegate prescriptive authority to other RNs working in the practice. CRNPs may not issue pre-signed prescriptions, must receive a national provider identifier number, and all prescriptions must include the CRNP’s name, title, and Pennsylvania CRNP certification number.  All labeling, packaging, dispensing, administering, and prescribing must be done in compliance with all other federal and state regulations and Pennsylvania Department of Health chapter 28 code of regulations.

CRNPs must register with the DEA and follow DEA minimum standards when prescribing, administering or dispensing controlled substances.  DEA federal regulations require the CRNP to properly conduct and documents their initial evaluation, physical examination, receipt and review the patient’s medical and medication history.  The physical evaluation includes examining the heart, lungs, vital signs, pain level, and body functions that relate to the patient specific complaint. Re-evaluation‘s and follow up should follow accordingly.

Patient counseling and medical records review are warranted to properly document symptoms observed and reported, diagnosis of any condition for which the controlled substance is being given, and the directions for administration. If the CRNP continues to prescribe the controlled substance, medical records must reflect changes to symptoms observed and reported and modification, alteration, or a limitation of any diagnosis of the condition for which the controlled substance is being given and the directions given to the patient.

The CRNP may dispense emergency, short-term prescriptions in conjunction with examination, evaluation, and proper diagnosis if such is then documented in the patient’s medical record.  Any emergency prescription must be delivered to the pharmacist within three days, and the emergency prescription may not be refilled or issued consecutive to an emergency prescription unless there is a follow-up physical examination.

Compliance with the terms and conditions of CRNP prescriptive authority is not necessarily compliance with Nursing Board scope of practice or standards that are acceptable and the prevailing practice.  Compliance with the above PA Code minimum standards does not restrict Nursing Board disciplinary action CRNPs based upon violations of the Drug Act or any other nursing licensing regulation.

Federal and State Drug Act issues address improper prescription dispensing, improper charting, failing to chart, or performing medical malpractice in the course of acting outside the scope as a CRNP.   Mere compliance with PA Code rudimentary medical practice and charting responsibilities and basic medical care giving duties does not shield the CRNPs from scope of practice and other claims.

CRNP scope of practice is governed by the collaborative agreement by and between the supervising physician and CRNP along with any large scale institutional employment job position limitations. Improperly administering medications earlier than the time set forth in a prescription and refilling daily, weekly, or 30 day prescriptions will well necessary trigger employment or board based disciplinary issues.

This is why the prescriptive authority established in the collaborative agreement between a physician and a CRNP  must satisfy very specific requirements. The collaborative agreements must be in writing, identifying the category of drugs this specific CRNP is allowed to prescribe as per their certified practice.   The collaborating physician obviously must sign the agreement and a copy must be submitted to the Bureau Professional and Occupational Affairs.

The agreement must be updated every two years, or whenever the agreement is changed, and must identify the professional liability insurance limits the physician’s policy provides.  Anytime the prescriptive authority in the collaborative agreement is updated or terminated, the CRNP (and no one else) shall notify the Board in writing of such changes. The CRNP is allowed to advertise or publicly display sign identifying their participation in a medical practice. A licensed CRNP may include such nomenclature after their name on any letterhead, business cards, and practice advertising.

CRNP must undertake and only engage in their specific practice area and only perform procedures in which they have necessary knowledge, preparation, experience and competency to properly execute.  CRNP practice is limited in scope to only their specialty and consistent with their CRNP collaborative agreement. This is the scope of practice provision that allows for the allegation CRNP prescribing medication drugs or other items outside the scope of their practice.

Certification as a CRNP may be suspended, revoked, or otherwise subjected to remedial measures when, after notice of and an opportunity for a hearing, the board finds that a CRNP has engaged and performed medical functions and tasks beyond the scope of practice permitted for a CRNP, that CRNP specially, or in violation of the collaborative agreement.  This is the general, catchall provision, for a potential penalty, based upon the allegation that a CRNP performed a medical function for which the CRNP does not have the necessary knowledge, preparation, experience and competency to perform properly or is not qualified under the CRNP Act.

Call me to discuss your case.

PHMP versus RAMP: A Big Difference

I write blogs about Pennsylvania professional licensing legal developments.  I am also licensed to practice law in New Jersey. I routinely counsel Pennsylvania professionals concerned about their NJ licenses.  There is a huge difference between Pennsylvania’s PHMP and New Jersey’s RAMP (“Recovery and Monitoring Program “).  RAMP was established in 2003 as an Alternative to Discipline program, managed by the Institute for Nursing for the New Jersey Board of Nursing. http://njsna.org/ramp/

Pennsylvania medical professionals who live in New Jersey or Pennsylvania residents also licensed in NJ, but only use their PA  licenses, are exposed to RAMP.  (Obviously also are NJ licensees working in NJ.)  Any Pennsylvania medical professional, who is also licensed in NJ – who receives Pennsylvania PHMP letter – must consider how RAMP will respond if Pennsylvania restricts their professional license.  Any Pennsylvania disciplinary action based upon an alleged impairment of alcohol and drugs will come to NJ’s RAMP attention. Also, NJ licensees must carefully respond to RAMP communications.

A recent NJ appellate case reveals just how different RAMP is from Pennsylvania’s PHMP.  On November 16, 2017 a New Jersey appellate court decided In The Matter of the license of Kevin Rafferty, RN.  He was a certified registered nurse anesthetist and an Advanced Practice Nurse.  Mr. McCafferty‘s licensing problems began in 2013 when three co-workers smelled alcohol on his breath during work.  They levied anonymous complaints to the Nursing Board, which contacted RAMP. This was the only evidence against him.

RAMP contacted  Rafferty via letter, setting forth the allegations that he may have problems related to mental health and or substance-abuse that could affect his ability to practice his profession.  RAMP offered him a private letter agreement and enrollment for a minimum of 90 days.  During this time RAMP requires random observed drug tests, monthly self evaluation reports, and regular attendance in peer support meetings.  Post-enrollment, RAMP then requires an initial intake evaluation.  In my experience this evaluation typically  finds the professional needs to be in RAMP for 12 months.  The 90-day initial RAMP invite is a fraud!

It is this context (which the McCaffrey case reveals)  that RAMP’s enrollment process is distinctly different from Pennsylvania’s PHMP.  RAMP’s initial letter of invite is not really an offer, but an order to each licensee.  PHMP’s initial “Letter of Concern” is a non-mandatory offer for help and does not constitute a demand to enroll.

RAMP’s initial 90-day evaluation period is not based upon a medical expert assessment or determination the licensee suffers from a drug or alcohol addiction that renders them an impaired professional. That assessment comes only after RAMP enrollment and signing of the RAMP 90-day contract.  The licensee is then stuck.

The RAMP evaluation takes place after enrollment, when the agreement sign requires compliance with the terms and condition of the program.  Licensee thinking they are just going to get the 90 days meet the expert, who determines more time in RAMP is required. Now they are stuck and can’t break the agreement.

PHMP’s letter of concern offers an assessment and voluntary disclosure to determine in an impairment exists.   PHMP requires either a finding of an impairment or a voluntary admission of such before enrollment in the program.  Pennsylvania Voluntary Recovery Program (“VRP”) questionnaire includes a provision that the licensee admit to suffering from an impairment.  This is the voluntary admission part of the VRP contract.  I counsel against signing this agreement.  NEVER ADMIT you are an impaired professional.Wait for the Board to file a formal petition to Compel and Mental and Physical Evaluation.  (See my other blogs.)

McCaffrey did not respond the the initial 90 day RAMP letter.  He was determined to be “non-compliant“ with RAMP.  RAMP notified the Nursing Board that “it could not insure the board or the public that McCaffrey was safe to practice.”  The Board subpoenaed McCaffrey to appear before a committee of the Board to answer questions about  appearing at work smelling of alcohol.  McCaffrey appeared, denied the allegations, and brought numerous letters of reference.  The Board still concluded he should enroll in RAMP and proposed a 2nd private letter agreement requiring McCaffery participate.  He refused.

The Board issued a provisional order of discipline compelling McCaffrey to submit to an evaluation and monitoring to determine whether his continued practice may jeopardize the safety and welfare of the public.  This is a distinct different legal standard and burden of proof compared to Pennsylvania’s impairment burden of proof.

NJ’s licensing boards and Courts have long recognized a “community care-taking responsibility” as legal justification that allows government license restriction.  The NJ Nursing Board thereafter issued a final order compelling McCaffrey to enroll in RAMP. The Board determined such was required to satisfy its “mandate to protect the public.” McCaffrey‘s failure to comply with this final order was reported to the national practitioner data Bank. Still no medical determination of any impairment!

McCaffery appealed claiming there was no medical or legal basis to compel RAMP and that absent such, a general order requiring such denied him due process of law.   The appellate court reviewed McCaffrey’s objections to the Board’s order. The appellate court determined the Board maintains oversight over professional licensing for nurses pursuant to the Nursing Law.  Because the New Jersey professional nursing law requires an applicant not be a “habitual user of drugs and alcohol”, McCaffrey‘s potential for alcohol and drug abuse rendered him suspect of meeting the legal requirements of both the Nursing Licensing and Nurse Anesthetist laws.  The court found the Board had the authority even absent a medical conclusion of any impairment.

McCaffrey complained that absent an expert determination that he was impaired or suffered from a chemical dependency, he met the requirements for licensure.  The Board rejected this argument. The court determined the Nursing Board was within its statutory authority based upon the factual allegations, even without even an expert evaluation, that the Board was within its authority to compel McCaffrey to participate in the 90 day private letter RAMP program.  The decision was handed down in 2017.  McCaffrey’s work place situation occurred in 2013.

For the many licenses that practice in Pennsylvania, these procedural differences between the PHMP and RAMP are significant and should be respected. Pennsylvania’s regulatory and statutory framework allow for licensee participation in and evaluation by a board chosen medical expert before mandatory enrollment in the PHMP.  NJ does not allow for this pre-enrollment evaluation, compels participation, and then subjects the licensee to a bait and switch disciplinary monitoring program.

Please call me to discuss either of these programs and any letters you receive from your licensing board.

 

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