BEFORE THE ·MEDICAL BOARD OF CALIFORNIA.

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

In the Matter of the Petition for an Interim Suspension Order Against:

MARSHAL FICHMAN, M.D.,

Physician's and Surgeon's Certificate No. A 19736,

Respondent.

Case No. 800-2017-031072

OAH No. 4018040459

INTERIM SUSPENSION ORDER

On April 11, 2018, Kimberly Kirchmeyer (Petitioner), Executive Director, Medical Board of California (Board), filed a Petition for Interim Suspension Order (Petition} pursuant to Government Code section 11529, seeking to suspend the Physician's and Surgeon's Certificate issued to respondent Marshal Fichman, M.D., pending a full hearing on the merits.

Matthew Goldsby, Administrative Law Judge with the Office of Administrative Hearings, heard this matter on April 27, 2018, at Los Angeles, California.

Peggie Bradford Tarwater, Deputy Attorney General,, appeared and, represented ~etitioner. Benjamin Fenton, Attorney at Law, appeared and represented respondent.

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After hearing and considering oral argument at the hearing, the administrative law judge read and considered the Petition and accompanying memorandum of points and, authorities, the opposition thereto, and the affidavits and documentary evidence presented by both parties.

The µiatter was submitted on April 27, 2018.

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,_ FACTUAL FINDINGS

·Jurisdictional and Background Facts

1. Petitioner filed the Petition in her official capacity. Respondent filed a timely opposition to the Petition.

2. On July 1, 1960, the Board issue,d to respondent Physician's and Surgeon's certificate number A 19736. Respondent's certificate is active and expires on August 31, 2019. Respondent has no public record of discipline.

3. Respondent earned his medical degree from the University of California, San Francisco, in 1960. He has been in practice for more than 50 years in internal medicine with subspecialties in nephrology and endocrinology.

Suspension of Staff Privileges

4. Respondent had staff privileges at DaVita Century City Dialysis (DaVita), in Los Angeles, California. ·On March 10, 2017, the Chief Executive Officer and the Chief of Medical· Staff at DaVita reported-to the Board that respondent's staff privileges were . summarily suspended as of February 24, 2017, for an indefinite period. The suspension was based on "immediate concerns for patient safety arising from memory problems and cognitive deficits that were reported initially by facility staff and confirmed through DaVita' s internal peer review process and evaluation reports provided by [respondent]." (Ex. 3.)

5. Respondent had staff privileges at Cedars-Sinai Medical Center (Cedars-Sinai), in Los Angeles, California. On June 5, 2017, the Chief Executive Officer.and the Chief of Medical Staff at Cedars-Sinai reported to the Board that respondent's staff privileges were summarily suspended as of May 19, 2017, for an indefinite period. The suspension was based on "the determination that failure to do so may have resulted in imminent danger to Medical Center patients ... [and] on an outside report finding that the physician was unfit for duty based on cognitive deficiencies." (Ex. 3.)

6. Upon receipt of the reports filed by DaVita and Cedars-Sinai, the Board opened an administrative investigatfon against respondent, and assigned Amber Driscoll, an investigator with the Department of Consumer Affairs, Division of Investigation.

UCLA Assessment

7. On or about June 26, 2017, Investigator Driscoll received records from Cedars-Sinai pursuant to subpoena. The records includeq a Neuropsychological Assessment_ Report authored by Shou-Chin Christine You, Ph.D., after respondent participated in testing at the University of California, Los Angeles (UCLA). The assessm~nts took place on July 15, 2016, and July 27, 2016, when respondent was 82 years old. The UCLA rep9rt described the following two events that had been reported concerning respondent:

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(A) The first event occurred in late November 2015 when respondent made attempts to get information about a high-profile patient at Cedars-Sinai with whom he had no treating relationship. Cedars-Sinai determined that respondetrt' s conduct constituted a breach of the hospital's confidentiality policy.

(B) The second event occurred in February 2016 when respondent appeared physically frail with noted weight loss, and his judgment seemed "off." He made "repeated statement~ almost verbatim - as if they had been prepared." (Ex. 3.)

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8. Dr. You noted that, in 2010, respondent was diagnosed with Guillain-Barre' syndrome, a condition that affects the immune system and peripheral nervous system. Respondent was hospitalized for one week and then in rehabilitation at Cedars-Sinai for six weeks. Furthermore, in 2012, respondent receiVed a neuropsychological examination. The results noted, "Cognitive and executive functioning remains intact and generally at a Superior to Very Superior level. ... However, his memory scores (as opposed to working memory) are not commensurate with his high cogniti~e skills. Not only are these scores relatively low, but also the standard scores are age-normed, meaning that his memory scores are low even when compared to others his age." (Ex. 3.)

9. The UCLA report noted results in key findings from testing'to assess respondent's cognitive and mtellectual functioning. Overall, respondent demonstrated superior intellectual functioning, receiving a full-scale intelligence quotient score of 122. Results revealed a significant decline in perceptual reasoning from the superior to average range. All other indices were in the stable or average range. Respondent's working memory was in the very superior range and unchanged from 2012. His overall processing speed was stable from 2012, in the average range.

10. However, respondent displayed a decline in semantic fluency, dropping from the very superior range to the average range in language skills. He exhibited a decline in visuospatial reasoning tasks from the very superior to average range. Respondent had impairments of episodic memory for verbal information. He displayed improvements on verbal set shifting, from the borderline to average range.

11. As a result of the assessment, respondent was diagnosed with Majo-r Neurocognitive Disorder, Unspecified, Without Behavioral Disturbance, Mild. The report concluded "we recommend respondent plan for retirement due to results of significant impairment of memory." (Ex. 3.)

PACE Assessment

12. On or about September 14, 2017, Investigator Driscoll received a Fitness for Duty Evaluation Report from the University of California, San Diego Physician Assessment and Clinical Education program (PACE). Respondent participated in the evaluation on three consecutive days beginning April 5, 2017.

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13. David Bazzo, M.D., performed a history and physical examination on respondent. Respondent was observed to have severe sun-damaged skin, and "a somewhat sloppy appearance and was unevenly shaven." (Ex. 3.)

14. Sean Evans, M.D., performed a neurology evaluation on respondent. After interviewing respondent and conducting an examination, Dr. Evans reported the following · impression/plan:

[Respondent] shows obvious difficulty in casual conversation with self-repetition, difficulty focusing a narrative, and difficulty following commands. He demonstrated multiple frontal release signs, as well as nonspecific basal ganglia motor dysfunction and ataxia. He shows virtually no insight into these difficulties. Without obtaining detailed independent history from informants, his lack of insight into his difficulties makes accurate disease specific diagnosis essentially impossible, but I have very little doubt that neuropsychological testing will show substantial abnormalities in his cognitive function, and my strong perception is that these are sufficient to interfere with his daily activities. As such, I think it is appropriate to characterize him as meeting criteria for a Major Neurocognitive Disorder.

(Ex. 3, subex. D, p. 4.)

15. William Perry, Ph.D., performed a neuropsychological evaluation on respondent. Testing was administered to assess respondent's processing speed, motor skills, language, visuospatial functioning, learning and memory, executive functioning, and emotional functioning. Dr. Perry reported:

The most significant deficits were noted within the cognitive domain of learning/memory. His performance within this domain was consistently impaired and indicative of mild to moderate deficits wben compared to his peer group; deficits were more pronounced when compared to a younger age group. . ..

Overall, respondent's pattern and level of performance on testing indi~ates that he is experiencing difficulty with aspects of,· attention, as well as significant difficulty in dexterity/fine motor skills and learning/memory. l;be above noted areas of deficits have relevance for [respondent's] functioning as a physician. In particular, deficits in learning/memory are of great concern as the integrity of these functions are [sic] crucial for physician practice. All aspects of physician practice require the ability to use previously learned information while performing complex tasks (i.e., important decisions are influenced by knowledge and

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experience).· Incorporating past learning and problem solving strategies to novel situations is needed when providing a high quality clinical practice. Attention lapses may render him vulnerable to errors in his practice, as attending to salient and complex details with accuracy under conditions of sustained attention are essential skills for physicians. His dexterity and motor deficits are also of concern as they may render him vulnerable to problems engaging in procedures.

Given the deficits noted it is recommended that [respondent] continue to actively engage in his medical care to monitor and treat his health conditions. At the very least he should be advised to avoid taking on heavy caseloads to minimize cognitive and physical strain, especially over an extended period of time, whi'ch can become taxillg and result in an increased risk of performance issues. While [respondent] has retained excellent verbal mediated skills, his attention and motor deficits combined with difficulties in learning and memory are·concerning and if coupled with performance deficits noted during the remainder of his PACE exam, may suggest that he is not suited for independent practice. [Respondent] should be made aware of his relative deficits and its potential implications for medical practice so that he can make informed decisions regarding his practice and his ability to ensure patient safety.

(Ex. 3, subex. D, pp. 9-10.)

16. Kai McDonald, M.D., performed a psychiatric evaluation on respondent. After conducting a 75 minute interview, and reviewing a self-report questionnaire and documentation from 9ther sources, Dr. McDonald concluded:

[Respondent] has been an exemplary scientist, teacher and physician, and remains extremely dedicated to the intellectual,

·pedagogic and the care giving aspects of medicine.

Sadly, due to a brain-based impairment, it is my opinion that he is currently not fit to practice clinical medicine. I say sadly because he appears to be extraordinarily attached to several aspects of this role, does not appear ready (or perhaps psychologically able) to make a flexible transition to a new role. Nor does he appear to have the insight necessary to understand the importance of this transition for the safety of his patients.

Clinically, [respondent] has an impairing cognitive disorder, which is quite obvious in a relatively short evaluative interview.

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His deficits manifests [sic] in his overall appearance, his discourse, and I imagine, to some degree in the details of his practice. With that said, much of his practice - after 50 years - is likely so routinized that he is able to maintain it without the benefit of some of his clearly impaired cognitive facilities. Aside from the obvious and potentially dangerous effects of his difficulties with the task of keeping up-to-date with clinical practice and all of the other intellectually-demanding aspects of medicine, the more obvious aspects of his forgetfulness and impaired awareness could certainly worry patients. Moreover, his defensiveness, intelligence, and social savoir-farre likely cover some of his manifold cognitive errors: this ability to "cover up" to some extent is often seen in very intelligent, verbal, and adroit older patients with cognitive disorders.

(Ex. 3, subex. D, p. 12.)

17. Dr. McDonald's report found that respondent suffered from significant cognitive deficiencies that interfered with his ability to perform most or all of the duties of his job and that he presented a significant risk to patients. Dr. McJ?onald concluded: "I find respondent unfit for duty due to his cognitive disorder." (Ex. 3, subex.'D, p. 13.) .

Board-Directed Phys~cal Examination

18. On November 15, 2017, Investigator Driscoll contacted respondent by telephone and instructed him to make an appointment with Lawrence Dardick, M.D., for a physical evaluation. After providing respondent with contact information, Investigator Driscoll received two messages from respondent requesting clarification of the appointments.

19. On Dec~mber 11, 201 7, Investigator Driscoll contacted Dr. Dardick to inquire about the physical examination of respondent. Dr. Dardick responded that he had no record ofrespondent, that respondent was scheduled for an appointment on November 28, 2017, but. that he did not appear for the appointment and did not call to cancel the appointment. When Investigator Driscoll inquired with respondent for an explanation, respondent explained that he had seen Dr. Darvish, not Dr. Dardick. As directed by Investigator Driscoll, respondent appeared at the office of Dr. Dardick for a physical examination on December 21, 2017.

20. On January 24, 2018, Investigator Driscoll received the report of the physical examination conducted by Dr. Dardick. In his report, Dr. Dardick concluded:

[Respondent] does not have any obvious physical medical problems that would necessarily interfere with his ability to safely engage in the practice of medicine. He does exhibit mild cognitive impairment, primarily age related short term memory recall. A test or assessment of his medical knowledge and

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competency was not performed. His ability to safely engage in the practice of medicine is dependent upon the volume of his practice, complexity of his patients and use,of consultants. It is my opinion, that for him to safely practice medicine, he should limit his practice to situations that allow ample time with each patient and include appropriate use of consultants.

(Ex. 3, subex. H, pp. 2-3.)

2L On January 5, 2018, Investigator Driscoll met personally with respondent at his office to obtain an authorization for the release of medical information from Dr. Darvish, the physician to whom respondent erroneously went for physical examination. After signing his name on the form, respondent was .observed to write the number 12 in the space provided on the form for the date of his signature; then, after looking at his phone, respondent wrote the number 2.5 in front of the number 12. When Investigator Driscoll pointed out respondent's error in dating the document, respondent corrected the year, writing the number 18 over the number 12, but h,e did not correct the month. Accordingly, respondent dated the document "2.5 .18" for a release signed on January 5, 2018. (Ex. 3, p. 4, and subex. F.)

22. On January 17, 2018, Investigator Driscoll received certified records from.the medical office of Dr. Darvish. The medical records reflect that respondent appeared for a checkup on November 28, 2017, and that Dr. Darvish conducted a physical examination. Dr. Darvish noted: "Based on evaluation, [respondent] is medically and clinically stable at this time." (Ex. 3, subex. G, p. 6.)

Board-Directed Mental Examination

23. On December 1, 2017, at the direction of the Board, respondent underwent a comprehensive psychiatric evaluation with Nathan E. Lavid, M.D., Diplomate of the American Board of Psychiatry and Neurology and an Expert Reviewer for the Board since March2007.

24. Dr. Lavid interviewed respondent for over three hours, inquiring about respondent's life and family, educational background, professional experience, and psychiatric, medical, and social histories. He performed a mental status exam and administered psychological testing, including the Folstein Mini Mental Status Examination, Minnesota Multiphasic Personality Inventory-II, and the Beck Depression and Anxiety Inventories; the results of the cognitive screening were normal.

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25. Dr. Lavid reviewed a report from the Controlled Substance Utilization Review & Evaluation System (CURES). 1 The CURES report revealed that respondent had not been prescribed or dispensed any type of scheduled medications. Urine drug and alcohol testing results were negative for alcohol or drugs of abuse.

26. Dr. Lavid diagnosed respondent with Unspecified Neurocognitive Disorder, Moderate. Dr. Lavid conduded that respondent suffers from cognitive impairment, based more ~o on his clinical assessment during the face-to-face interview than on any of the -testing results. Dr. Lavid reported, "As for the etiology of his cognitive impairment, I believe they are more severe than would be expected in an individual who is 84 years old. At 84, he would be expected to have some memory problems and require some redirection and focus during evaluation, however, [respondent's] memory.problems and redirection were more so than would be expected for an 84-year-old individual." (Ex. 2; subex. B, p. 10.)

27. In response to the Board's specific questions, Dr. Lavid made the following psychiatric findings: that respondent has a mental illness or condition that impacts his ability to safely engage in the practice of medicine; that his presentation is possibly due to a physical illness such that a physical examination is necessary; that he is not able to practice medicine safely at this time without any restrictions or conditions; that he is unable to safely practiceJ!ledicine at this time as a result of a mental illness or condition; that hi~ continued practice of medicine poses a present danger or threat to the public health, welfare, or safety; and that there is no effective monitoring, treatment or oversight that would allow him to practice medicine safely in light of the severity of his cognitive impairment. (Ex. 2, subex. B, pp. 1-2.)

Respondent's Evidence of Fitness to Practice

28. Respondent presented his own declaration in opposition to the petition. He attests that he has never had a malpractice action prevail against him and that he has never been found to have acted below the standard of care in any case. He currently works five half-days per week, mostly seeing patients in his office, and does rounds on dialysis patients at an unspecified dialysis center once or twice per week. He has four-employees in connection with his practice.

29. William Mandel, M.D., wrote that he has known respondent professionally for at least 35 years and has treated him as a patient for the past five years. He describeq · respondent as having a practice presenting "very complex medical problems which he has handled with a high level of skill." (E'x. B.) Dr: Mandel acknowledged that respondent has

1 CURES is a database compiled and maintained by the California Department of Justice (DOJ) of all controlled substances prescribed and dispensed in the State of California. Pharmacies and direct dispensers of controlled substances are required to report prescription drug details to the DOJ, which in turn generates reports based on the reported data to authorized users. ·

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"some problem with chronic fatigue possibly related to Guillain-Barre" and has "some mild. memory loss but this does not interfere with his medical decision-making." Dr. Mandel concludes, "I feel respondent is capable of continuing his out patient medical practice without any concern regarding his medical skills." (Ex. B.)

30. On April 17, 2018, respondent was examined by Brian P. Jacks, M.D., F.A.A.C.P., for a complete and comprehensive psychiatric consultation. Dr. Jacks reported having taken a detailed history and performed formal mental status examinations. Psychological testing included the Minnesota Multiphasic Personality Inventory, Mini Mental Status Examination, and a Bender Gestalt test; the results of these tests were consistent with the results from the tests performed by Dr. Lavid. Dr. Jacks reviewed the medical records and reports described above, and wrote in an unswom letter presented at the hearing:

I would conclude fyom all the evidence from my examination as . well as the written tests that there are several questions still left unanswered. First of all, the changes that .occurred in his cognitive performance have been present since 2012 following the episode of Guillain-Barre syndrome and this was noted in the neuropsychological assessment report from Christine You, Ph.D., 7/27/2016, on page 2, it was mentioned that Dr. Daniel Rovner, neurologist, 2/09/2016 noted that "this patient has been stable and quite within normal limits for some time." The important part is that he has been practicing medicine without incident or problems despite some of these memory difficulties, which appear mainly to be mild. There is also some question for the neuropsychological testing because repeatedly the Mini Mental Status Examination, which is a screening test for cognitive disorders, has been repeatedly within normal limits. This was done by myself on 4/12/2018, by Dr. Lavid in the report of 12/05/2017 and by Dr. McDonald.

[if] ... [if]

[Respondent] had cognitive impairments since the Guillain-Barre syndrome back in 2012. These have remained the same and there have been no issues or problems in his practice such as malpractice cases or danger to patients.

Differential diagnosis needs to be considered. Thls,include [sic] chronic fatigue syndrome since this occurs usually following a flu-like syndrome, which certainly would correspond to his influenza and thenthe Guillain-Barre syndrome, with symptoms of umefreshing sleep, impaired memory or concentration, and he

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certainly indicates to me that he has chronic fatigue, but he can force himself to do things.

[~] ... [~

What is important here as well is that there is no diagnosis that has been made concerning the cause of these memory difficulties. Most probably, a provisional diagnosis would be a very mild

·cognitive disorder following the Guillain-Barre syndrome, but this has existed for at least six years without change and he has been able to safely practice medicine during that time. . ..

Therefore, I do not find that he is unfit from psychiatric or neuropsychological point of view to practice medicine safely, which is adequately demonstrated for the last six years following his boutwith Guillain-Barre syndrome.

(Ex. A, pp. 16-18.)

Ultimate Findings

31. The credible evidence presented at the hearing establishes that respondent suffers from cognitive deficits that impair his ability to practiq~ medicine. The impairment is acknowledged by respondent's evidence; Dr. Jacks determined that respondent suffered some impairment in 2012, but characterized it as "memory difficulties, which appear to be mild," and which have remained stable in the six years following his bout with Guillain­Barre syndrome. Dr. Jacks' conclusion that respondent's is not unfit to practice medicine is based on his perceptions that, during this period of cognitive impairment, there have been no issues or problems in respondent's practice, such as malpractice cases or danger to patients, and that a cause for the impairment has not yet been determined.

LEGAL CONCLUSIONS

1. Whenever it appears that a licensee may be unable to practice his or her profession safely, because the licentiate's ability to practice is impaired due to mental illness,

· or physical illness affecting competency, the licensing agency may order the licentiate to be examined by one or more physicians and surgeons or psychologists designated by the agency. (Bus. & Prof. Code,§ 820.)

2. If a licensing agency determines that the licentiate's ability to practice his or her profession safely is impaired because the licentiate is mentally ill or physically ill ~ affecting competency, the licensing agency may take action by revoking or suspending the licentiate's certificate or license. (Bus. & Prof. Code, § 822, subd. (a).)

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3. An administrative law judge may issue an interim order suspending a license "only if the affidavits in support of the petition show that the licensee has engaged in, or is about to engage in, acts: or omissions constituting a violation of the Medical Practice Act ... or is unable to practice safely due to a mental or physical condition, and that permitting the licensee to continue to engage in the profession for which the license was issued will endanger the public health, safety, or welfare.',' (Gov. Code, § 11529, subd. (a).)

4. An administrative law judge may issue an interim suspension order if: (1) There is a reasonable probability that the petitioner will prevail in the underlying action, and (2) The likelihood of injury to the public in not issuing the order outweighs the likelihood of injury to the licensee in issuing the order. (Gov. Code, § 11529, subd. ( e).) The standard of proof is preponderance of the evidence.

5. Petitioner has established by a preponderance of the evidence that respondent suffers from cognitive impairments that render him unable to practice medicine safely. To his credit, respondent has demonstrated a long professional career as an internist with no prior record of discipline and no evidence of any malpractice judgments against him. Moreover, the complaints filed by DaVita and Cedars-Sinai were not based on any episode concerning the quality ofrespondent's treatment of any patient and there was no evidence that caused actual harm to the public, including the high-profile patient with which respondent had an inappropriate fascination.

6. However, complainant will likely prevail in an action to impose discipline, in spite of the evidence that respondent has not yet caused injury. The preventative functions of license discipline include the protection of the public, including the prevention of future harm. To prohibit license discipline until the licensee harms a patient disregards these purposes; it is far more desirable to discipline before a licensee haims any patient than after harm has occurre.d. (Griffiths v. Superior ~Court (2002) 96 Cal.App.4th 757; In re Kelley (1990) 52 Cal.3d 487.)

7. Moreover, contrary to the significance indicated by Dr. Jacks, the Board may impose discipline under Business and Professions Code .section 822 without establishing the cause of a mental or physical illness; the law requires only a determination that the condition impairs the licensee's ability to practice safely.

8. Permitting respondent to continue to engage in the unrestricted practice of medicine will endanger the public health, safety, and welfare. The likelihood of injury to the public in not issuing the order set forth below outweighs the likelihood of injury to respondent in issuing the order. While there is no evidence that respondent's cognitive impairments have in fact impacted his care or treatment of patients, this absence may indicate that the impairment is not so severe as to have impacted respondent's practice of medicine, or it may indicate that substandard care or patient harm have not been detected.

9, Absent evidence of actual substandard care or patient harm, the complete suspension ofrespondent's license before a full hearing will not be ordered. However, given

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the established impairment and the potential of such impairment to affect respondent's practice of medicine, restrictions on respondent's practice, including practice monitoring, will be ordered to protect the public.

10. Cause exists to restrict respondent's physician's and surgeon's license · pursuant to Government Code section 11529 in conjunction with Business and Professions

Code section 822. (Factual Findings 7-31.)

ORDER

1. The Petition for Interim Suspension Order is granted, in part. Physician's and Surgeon's Certificate number A 19736 issued to Marshal Fichman, M.D., is restricted as set forth below.

2. Pending' a full determination of respondent's fitness to practice medicine, respondent shall be subject to the following terms and restrictions: ·

(A) Respondent shall practice medicine no more than~four hours per day, five days per week. This order shall not reactivate any staff privileges previously suspende4.

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Within 10 calendar days ofreceipt of this order, respondent shall submit to the Board or its designee for prior approval as a practice monitor, the name and qualifications of one or more licensed physicians and surgeons whose licenses are valid and in good standing, and who are preferably American Board of Medical Specialties (ABMS) certified. A monitor shall have no prior or current business or personal relationship with respondent, or other relationship that could reasonably be expected to compromise the ability of the monitor to render fair and unbiased reports to the Board, including but not limited to any form of bartering, shall be in respondent's field of practice, and must agree to serve as respondent's monitor. Respondent shall pay all monitoring costs.

(C) Respm.}dent shall provide the Board-approved monitor with a copy of this order and a Board..:approved proposed monitoring plan consistent with the terms and conditions of this orde~ Within 15 calendar days of receipt of the order and proposed monitoiing plan, the monitor shall submit a signed statement that the moriitor has read the order, fully understands the rol~ of a monitor, and agrees or disagrees with the proposed monitoring plan. If the monitor disagrees with the proposed monitoring plan, the monitor shall submit a revised monitoring plan with the signed statement for approval by the Board or its designee.

(D) Within 30 calendar days ofreceipt of this order, and continuing until the order is modified, respondent's practice shall be monitored by the approved monitor. Respondent shall make all records available for immediate inspection and copying on the premises by the monitor at all times during business hours and shall retain the records for the entire term the order is in effect. ·

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(E) If respondent fails to obtain approval of a monitor within 30 calendar days ofreceipt of this order, respondent shall cease the practice of medicine within three calendar days after receiving such notification from tlle Board or its designee. Respondent shall not resume the practice of medicine until. a monitor is approyed to provide monitoring responsibility.

(F) The monitor shall submit a monthly written report to the Board or its designee which includes an evaluation of respondent's performance, indicating whether respondent's practices are within the standards of practic~ of medicine, and whether respondent is practicing medicine safely. It shall be the sole responsibility ofrespondent to ensure that the monitor submits the monthly written reports to the Board or its designee within 10 calendar days after the end of the preceding month. ·

(G) If the monitor resigns or is no longer available, respondent shall, within five calendar· days of such resignation or unavailability, submit to the Board or its designee, for prior approval, t_he name and qualifications of a replacement monitor who will be assuming that responsibility within 15 calendar days. If respondent fails to obtain approval of a replacement monitor within 30 calendar days of the resignation or unayailability of the monitor, respondent shall cease the practice of medicine within three calendar days after receiving such notification from the Board or its designee. Respondent shall not reslime the practice of medicine until a replacement monitor is approved and assumes monitoring responsibility.

3. If an accusation is not filed and served within 30 days of this order, the order shall be dissolved pursuant to Government Code section 1.1529, subdivision (f).

4. Except as otherwise provided hereinabove, all terms and restrictions of this order shall remain in full force and effect until a decision is rendered on a timely-filed accusation or this matter is otherwise resolved.

DATED: May 7, 2018

(":DocuSlgned by:

c::~:!;_te41.r. MATTHEW GOLDSBY Administrative Law Judge Office of Administrative Hearings

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