BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter of the Accusation Against: STEVEN K. MANGAR, M.D. Case No. 03-2010-209330 Physician's and Surgeon?s Certi?cate No. A-65476 Respondent DECISION The attached Stipulated Settlement and Disciplinary Order is hereby adopted as the Decision and Order of the Medical Board of California, Department of Consumer Affairs, State of California. This Decision shall become effective at 5:00 p.m. on October 5, 2012. IT IS SO ORDERED: September 6, 2012. MEDICAL BOARD OF CALIFORNIA QM Reginald Low, M.D., Chair Panel KAMALA D. HARRIS Attorney General of California JOSE R. GUERRERO Supervising Deputy Attorney General LAWRENCE MERCER Deputy Attorney General State Bar No. 111898 455 Golden Gate Avenue, Suite 11000 San Francisco, CA 94102-7004 Telephone: (415) 703-5539 Facsimile: (415) 703-5480 Complainant BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA Case No. 03?2010?209330 OAH No. 2012040720 In the Matter of the Accusation Against: STEVEN K. MANGAR, MD. PO. Box 1530 Salinas, CA 93902 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER Physician?s and Surgeon?s Certi?cate No. A65476 Respondent. IT IS HEREBY STIPULATED AND AGREED by and between the parties to the above- entitled proceedings that the following matters are true: 1. Linda K. Whitney is the Executive Director of the Medical Board of California. She brought this disciplinary action solely in her of?cial capacity and is represented by Kamala D. Harris, Attorney General of the State of California, by Lawrence Mercer, Deputy Attorney General. 2. Steven K. Mangar, M.D., is represented in this matter by Belzer, Hulchiy Murray and William J. Murray, Esq, 3650 Mt. Diablo Blvd, Suite 130, Lafayette, CA 94549. 3. On June 5, 1998, the Medical Board of California issued Physician's and Surgeon?s Certificate Number A6547 6 to Steven K. Mangar, MD. (Respondent). At all relevant times, said certificate was current and valid. Unless renewed, the certificate will expire on May 31, 2014. 1 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) R.) 4. Accusation No. 03?2010-209330 was duly filed and served on respondent on July 29, 2011. Respondent timely ?led a Notice of Defense and requested a hearing on the charges against him. A copy of the Accusation is attached hereto as Exhibit A and is incorporated herein by reference. ADVISEMENT AND WAIVERS 5. Respondent has carefully read, fully discussed with his counsel and understands the charges and allegations in the Accusation. Respondent has also carefully read, fully discussed with counsel, and understands the effects of this Stipulated Settlement and Disciplinary Order. 6. Respondent is fully aware of his legal rights in this matter, including the right to a hearing on the charges and allegations in the Accusation; the right to be represented by counsel at his own expense; the right to confront and cross-examine the witnesses against him; the right to present evidence and to testify on his own behalf; the right to the issuance of subpoenas to compel the attendance of witnesses and the production of documents; the right to reconsideration and court review of an adverse decision; and all other rights accorded by the California Administrative Procedure Act and other applicable laws. 7. Respondent voluntarily, knowingly, and intelligently waives and gives up each and every right set forth above. CULPABILITY 8. Respondent admits that he failed to keep adequate and accurate medical records, as more fully set forth in the Accusation, a violation of Business and Professions Code section 2266, and that he has thereby subjected his license to disciplinary action. 9. Respondent agrees that his Physician?s and Surgeon?s Certi?cate is subject to discipline and he agrees to be bound by the Board's imposition of discipline as set forth in the Disciplinary Order below. RESERVATION 10. The admissions made by respondent herein are only for the purposes of this proceeding or any other proceedings in which the Medical Board of California or other 2 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) professional licensing agency in any state is involved, and shall not be admissible in any other criminal or civil proceedings. CONTINGENCY ll. This Stipulation shall be subject to the approval of the Board. Respondent understands and agrees that Board staff and counsel for complainant may communicate directly with the Board regarding this stipulation, without notice to or participation by Respondent or his counsel. If the Board fails to adopt this Stipulation as its Order in this matter, the Stipulation shall be of no force or effect; it shall be inadmissible in any legal action between the parties; and the Board shall not be disquali?ed from further action in this matter by virtue of its consideration of this Stipulation. Respondent also understands and agrees that he will not be able to withdraw or modify this Stipulation while it is before the Board for consideration. 12. The parties understand and agree that facsimile copies of this Stipulated Settlement and Disciplinary Order, including facsimile signatures thereto, shall have the same force and effect as the originals. 13. In consideration of the foregoing admissions and stipulations, the parties agree that the Board may, without further notice or formal proceeding, issue and enter the following Disciplinary Order: DISCIPLTNARY ORDER IT IS HEREBY ORDERED that Physician?s and Surgeon?s Certificate No. A65476 is revoked. However, the revocation is stayed and Respondent?s certificate is placed on three (3) years probation, on the following terms and conditions: 1. PRESCRIBTNG PRACTICES COURSE: Within 60 calendar days of the effective date of this Decision, Respondent shall enroll in a course in prescribing practices equivalent to the Prescribing Practices Course at the Physician Assessment and Clinical Education Program, University of California, San Diego School of Medicine (Program), approved in advance by the Board or its designee. Respndent shall provide the Program with any information and documents that the Program may deem pertinent. Respondent shall participate in and successfully complete the classroom component of the course not later than six (6) months after respondent?s initial 3 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) 10 ll 25 26 27 28 enrollment. Respondent shall successfully complete any other component of the course within one year of enrollment. The prescribing practices course shall be at respondent?s expense and shall be in addition to the Continuing Education (CME) requirements for renewal of licensure. A prescribing practices course taken oafter the acts that gave rise to the charges in the Accusation, but prior to the effective date of the Decision may, in the sole discretion of the Board or its designee, be accepted towards the ful?llment of this condition if the course would have been approved by the Board or its designee had the course been taken after the effective date of this Decision. Respondent shall submit a certi?cation of successful completion to the Board or its designee not later than 15 days after successfully completing the course, or not later than 15 days after the effective date of this Decision, whichever is later. 2. MEDICAL RECORD KEEPING COURSE: Within 60 days of the effective date of this decision, Respondent shall enroll in a course in medical record keeping equivalent to the Medical Record Keeping Course offered by the Physician Assessment and Clinical Education Program, University of California, San Diego School of Medicine (Program), approved in advance by the Board or its designee. Respondent shall provide the Program with any information and documents that the Program may deem pertinent. Respondent shall participate in and complete the classroom component of the course not later than six (6) months after Respondent?s initial enrollment. Respondent shall successfully complete any other component of the course within one (1) year of enrollment. The medical record keeping course shall be at Respondent?s expense and shall be in addition to the Continuing Medical Education (CME) requirements for renewal of licensure. A medical record keeping course taken after the acts that gave rise to the charges in the Accusation, but prior to the effective date of the decision may, in the sole discretion of. the Board or its designee, be accepted towards the fulfillment of this condition if the course would have been approved by the Board or its designee had the course been taken after the effective date of this decision. 4 STIPULATED SETTLEMENT AND DISCIPLTNARY ORDER (2012040720) Respondent shall submit a certi?cation of successful completion to the Board or its designee not later than 15 days after successfully completing the course, or not later than 15 days after the effective date of this decision, whichever is later. 4. NOTIFICATION: Within seven (7) days of the effective date of this decision, the Respondent shall provide a true copy of this Decision and Accusation to the Chief of Staff or the Chief Executive Officer at every hospital where privileges or membership are extended to Respondent, at any other facility where Respondent engages in the practice of medicine, including all physician and locum tenens registries or other similar agencies, and to the Chief Executive Officer at every insurance carrier which extends malpractice insurance coverage to Respondent. Respondent shall submit proof of compliance to the Board or its designee within 15 calendar days. This condition shall apply to any change(s) in hospitals, other facilities or insurance carrier. 5. SUPERVISION OF PHYSICIAN ASSISTANTS: During probation, Respondent is prohibited from supervising physician assistants. 6. OBEY ALL LAWS: Respondent shall obey all federal, state and local laws, all rules governing the practice of medicine in California and remain in full compliance with any court ordered criminal probation, payments, and other orders. 7. QUARTERLY DECLARATIONS: Respondent shall submit quarterly declarations under penalty of perjury on forms provided by the Board, stating Whether there has been compliance with all the conditions of probation. Respondent shall submit quarterly declarations not later than 10 calendar days after the end of the preceding quarter. 8. COMPLIANCE WITH PROBATION UNIT: Respondent shall comply with the Board?s probation unit and all terms and conditions of this decision. 9. CHANGE OF ADDRESS: Respondent shall, at all times, keep the Board informed of ReSpondent?s business and residence addresses, email address (if available), and telephone number. Changes of such addresses shall be immediately communicated in writing to the Board 5 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) IXits designee. Under no circumstances shall a post of?ce box serve as an address of record, except as allowed by Business and Professions Code section 2021(b). 10. PLACE OF PRACTICE: Respondent shall not engage in the practice of medicine in Respondent?s or his patient(s)? place of residence, unless the patient resides in a skilled nursing facility or other similar licensed facility. 1 1. LICENSE RENEWAL: Respondent shall maintain a current and renewed California physician?s and surgeon?s license. 12. TRAVEL OUTSIDE STATE: Respondent shall immediately inform the Board or its designee, in writing, of travel to any areas outside the jurisdiction of California which lasts, or is contemplated to last, more than thirty (30) calendar days. In the event Respondent should leave the State of California to reside or to practice Respondent shall notify the Board or its designee in writing 30 calendar days prior to the dates of departure and return. 13. INTERVIEW WITH THE BOARD OR ITS DESIGNEE: Respondent shall be available in person upon request for interviews either at Respondent?s place of business or at the probation unit office, with or without prior notice throughout the term of probation. 14. NON-PRACTICE WHILE ON PROBATION: Respondent shall notify the Board or its designee in writing within 15 calendar days of any periods of non?practice lasting more than 30 calendar days and within 15 calendar days of Respondent?s return to practice. Non?practice is de?ned as any period of time Respondent is not practicing medicine in California as de?ned in Business and Professions Code sections 2051 and 2052 for at least 40 hours in a calendar month in direct patient care, clinical activity or teaching, or other activity as approved by the Board. All time spent in an intensive training program which has been approved by the Board or its designee shall not be considered non?practice. Practicing medicine in another state of the United States or Federal jurisdiction while on probation with the medical licensing authority of that state or jurisdiction shall not be considered non-practice. A Board-ordered suSpension of practice shall not be considered as a period of non?practice. 6 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) the event Respondent?s period of non?practice while on probation exceeds 18 calendar months, Respondent shall successfully complete a clinical training program that meets the criteria of Condition 18 of the current version of the Board?s ?Manual of Model Disciplinary Orders and Disciplinary Guidelines? prior to resuming the practice of medicine. Respondent?s period of non?practice while on probation shall not exceed two (2) years. Periods of non?practice will not apply to the reduction of the probationary term. Periods of non-practice will relieve Respondent of the responsibility to comply with the probationary terms and conditions with the exception of this condition and the following terms and conditions of probation: Obey All Laws; and General Probation Requirements. 15. COMPLETION OF PROBATION: Respondent shall comply with all ?nancial obligations restitution, probation costs) not later than 120 calendar days prior to the completion of probation. Upon successful completion of probation, Respondent?s certi?cate shall be fully restored. 16. VIOLATION OF PROBATION: Failure to fully comply with any term or condition of probation is a Vidlation of probation. If ReSpondent violates probation in any respect, the Board, after giving Respondent notice and the opportunity to be heard, may revoke probation and carry out the disciplinary order that was stayed. If an Accusation, or Petition to Revoke Probation, or an Interim Suspension Order is filed against Respondent during probation, the Board shall have continuing jurisdiction until the matter is ?nal, and the period of probation shall be extended until the matter is final. 17. LICENSE SURRENDER: Following the effective date of this decision, if Respondent ceases practicing due to retirement or health reasons or is otherwise unable to satisfy the terms and conditions of probation, Respondent may request to surrender his or her license. The Board reserves the right to evaluate Respondent?s request and to exercise its discretion in determining whether or not to grant the request, or to take any other action deemed appropriate and reasonable under the circumstances. Upon formal acceptance of the surrender, Respondent shall within 15 calendar days deliver Respondent?s wallet and wall certi?cate to the Board or its designee and Respondent shall no longer practice medicine. Respondent will no longer be subject 7 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (2012040720) mm. 831 7513339 E3 E1 cl Is} 27 28 09:57:32 ELM. 08?07?2012 to the terms and conditions of probation. rcaappiics for a. medical the application shall be treated as a petition for of?a revoked ccni?catc. 18. MONITORING COSTS: Respondent shall pay the costs associated with probation moniwring each and every year of probation, as designated by the Board, which may be adjusted on an annual basis. Such costs shall be payable to the Mcdical Board of Califcmia and delivered to the Board or its designec no later than January 31 of each calendar year. ALICEPTAMZE have carcfully read the Siipulaied Settlement and Disciplinary Order and have fully discussed it with my attorneys. i understand the stipulation and {he effect it will havc on my Physician?s and Certi?cate. 1 enter into this Stipulated Settlement and Disciplinary Order vcimimn?iy, knowingly; and intelligently, and agree to be bound by the Decision and Order of the Medical Board of Califcmia. DATED: L?ggw on . I have read and fully discussed with Respondent Steven K. Mangar, MD. the teams and ccnditicns and other matters contained in the: above Stipulaicd Settlement and Disciplinary Ordcr. I approve ins form and content. BEIKER, MURRAY . ?wa WILLIAM J. imw Attorneys for 7 in?) DATED: 8 awn-Im-r?ram 124%? uric-my 15:11:?le mun {2012040720l l:;l Hit if HUUHWHUN 1:86 :27 SEES: .4. ENDORSEMENT The foregoing Stipulated Settlement and Disciplinary Order is hereby respectfully submitted for consideration by the Medical Board of California. DATED: 4; SF2011201886 40574251.doc KAMALA D. HARRIS Attorney General of California JOSE R. GUERRERO Su 'ng Deputy Attorney General LAWRENCE, ERCER Womey General Attorneys for Complainant 9 STIPULATED SETTLEMENT AND DISCIPLINARY ORDER (20l 2040720) ACCUSATION NO. 03-2010-209330 10 STIPULATED SETTLEMENT AND DISCIPLTNARY ORDER (2012040720) lx.) KAMALA D. HARRIS Attorney General of California Jose R. GUERRERO Supervising Deputy Attorney General LAWRENCE MERCER Deputy Attorney General State Bar No. 111898 455 Golden Gate Avenue, Suite 11000 San Francisco, CA 94102-7004 Telephone: (415) 703-5539 . FacsimiIe: (415) 703?5480 A [tornetas?for amp] amam FILED STATE or: MEDICAL some or: BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter ofthe Accusation Against: Case No. 03?2010-209330 STEVEN K. MAN GAR, M.D. ACCUSATI ON PO. Box 1530 Salinas, CA 93902 Physician?s and Surgeon?s Certificate No. A65476 Respondent. Complainant alleges: PARTIES 1.. Linda K. Whitney (Complainant) brings this Accusation (Accusation) solely in her of?cial capacity as the Executive Director of the Medical Board of California, Department of Consumer Affairs. 2. On June 5, 1998, the Medical Board of California issued Physician's and Surgeon?s Certificate Number A65476 to Steven K. Mangar, MD. (Respondent). At all relevant times, said certificate was current and valid. Unless renewed, the certificate will expire on May 31, 2012. ACCUSATION (Case no. 03-2010?209330) JURISDICTION 3. This Accusation is brought before the Medical Board of California (Board!) under the authority of the following laws. All section references are to the Business and Professions Code unless otherwise indicated. 4. Section 2004 of the Code provides, pertinent part, that the Medical Board shall have responsibility for: The enforcement of the disciplinary and criminal provisions of the Medical Practice Act. The administration and hearing of disciplinary actions. Carrying out disciplinary actions appropriate to ?ndings made by a panel or an administrative law judge. Suspending, revoking, or otherwise limiting certi?cates after the conclusion of disciplinary actions. Reviewing the quality of medical practice carried out by physician and surgeon certi?cate holders under the jurisdiction of the board. . 5. Section 2227 of the Code provides that a licensee who is found guilty under the Medical Practice Act may have his or her license revoked, suspended for a period not to exceed one year, placed on probation and required to pay the costs of probation monitoring, or such other action taken in relation to discipline as the Board deems proper. 6. Section 2228 of the Code provides "that a probation imposed by the Board may include, but is not limited to the following: Requiring the licensee to obtain additional professional training and to pass an examination upon the completion of training. The examination may be written or oral, or both, and may be a practical or clinical examination. or both, at the option of the board or the administrative law judge.? As used herein, the term ?board?? means the Medical Board of California. As used herein, ?Division of Medical Quality? shall also be deemed to refer to the board. ix) W. ACCUSATION (Case no. k) b) Requiring the licensee to submit to a complete diagnostic examination by one or more physicians and surgeons appointed by the board. if an examination is ordered, the board shall receive and consider any other report of a complete diagnostic examination given by one or more physicians and surgeons of the licensee?s choice.? Restricting or limiting the extend, scope, or type of practice of the licensee, including requiring notice to applicable patients that the licensee is unable to perform the indicated treatment, where appropriate.? 7. Section 2234 of the Code provides: ?The Division of Medical Quality shall take action against any licensee who is charged with unprofessional conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not limited to, the following: Violating or attempting to violate, directly or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of this chapter [Chapter the Medical Practice Act]. Gross negligence. Repeated negligent acts. To be repeated, there must be two or more negligent acts or omissions. An initial negligent act or omiSsion followed by a separate and distinct departure from the applicable standard of care shall constitute repeated negligent acts. An initial negligent diagnosis followed by an act or omission medically appropriate for that negligent diagnosis ofthe patient shall constitute a single negligent act. When the standard of care requires a change in the diagnosis, act, or omission that constitutes the negligent act described in paragraph (1 including, but not limited to, a reevaluation of the diagnosis or a change in treatment, and the licensee's conduct departs from the applicable standard of care, each departure constitutes a separate and distinct breach of the standard of care . . DJ ACCUSATION (Case no. 03-20l0w209330} K) 8. Section 2241.5 provides that a physician and surgeon may prescribe for a person under his care for a medical condition dangerous drugs or prescription controlled substances for the treatment of pain or a condition causing intractable pain. However, nothing in that section affects the power of the board to take any action described in Section 2227 of the Code, including, but not limited to, Sections 2234, subsections and and/or Section 2242. 9. Section 2241.6 of the Code authorized the board. in conjunction with professional peer organizations in the ?eld of pain management, to develop standards for review of cases concerning the management of a patient?s pain. in 2007, the board revised its 1994 Guidelines for Prescribing Controlled Substances for Pain, which guidelines were disseminated to all California?licensed physicians and surgeons. Those guidelines recommend that physicians follow the standard of care in managing pain patients, including a history, appropriate examination, treatment plan with objectives, informed consent, periodic review of the treatment, consultation where warranted and accurate and complete medical records. 1 10. Section 2242(a) of the Code provides: ?Prescribing, dispensing, or furnishing dangerous drugs as de?ned in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct.? 1 11. Section 2266 of the Code provides: ?The failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct.? DRUGS 12. The following dangerous drugs, as de?ned in Section 4022, are relevant to the cause for disciplinary action set forth in this Accusation: A. Oxycontin is a narcotic analgesic with multiple actions qualitatively similar to those of morphine. it is a dangerous drug as defined in section 4022, a schedule 11 controlled substance and narcotic as defined by section 1 1055, subdivision of the Health and Safety Code. and a Schedule 11 controlled substance as defined by Section 1308.12 of ACCUSATION (Case no, 03~2010?209330) Title 2] of the Code ofFederal Regulations. Oxycodone can produce drug dependence oi" the morphine type and, therefore, has the potential for being abused. B, Pereocet a trade name for a combination of oxycodone hydrochloride and acetaminophen, is a narcotic analgesic with multiple actions qualitatively similar to those of morphine, a dangerous drug as de?ned in section 4022, a schedule 11 controlled substance and narcotic as de?ned by section 1 1055, subdivision ofthe Health and Safety Code, and a Schedule 1] controlled substance as defined by Section 1308.12 ot?Title 21 of the Code of Federal Regulations. Oxycodone can produce drug dependence of the morphine type and, therefore, has the potential for being abused. Repeated administration of Percocet may result in and physical dependence. FACTS 13. On or about August 28, 2003, Patient 1313.2, 21 60 year old male patient with a history of chronic neck and low back pain came under respondent?s care at the Center for Pain Management in the Community Hospital of the Monterey Peninsula (CHOMP). The patient had already undergone several surgical procedures to address severe cervical and lumbar stenosis and he informed respondent that he had developed pain in his lower back, which intermittently radiated down his right leg to his foot. 14. At the initial consultation in August 2003, respondent performed an evaluation which included a physical examination and medical history, assessment of the patient?s pain level, his physical and status and function, a history of the patient? 5 prior pain treatments and an assessment of other underlying or coexisting conditions. Although reSpondent apparently did ask the patient about his use of other substances, the social history included only the statement that the patient was currently drinking an ?uncertain quantity? of alcohol on daily basis. This inconclusive assessment was never pursued further and the patient?s alcohol use is not referred to in subsequent records. 2 The patient?s name is abbreviated to protect his privacy. (Case no. 03?20lO?209330) 15. Based upon the history. physical examination and assessment of the patient?s condition, respondent proposed a multi?disciplinary treatment plan, including occupational and physical therapy, an BMG/nerve conduction study, an increase the patient?s dosage of Neurontin and consideration of transition from the patient"s existing regimen of Percocet to a long-acting opiate. 16. Patient PB. elected not to follow up with respondent but to continue treatment with other physicians until October 2003.. At that time, reSpondent?s narrative summary states that he took over the patient?s medications, including Percocet, 5 mg, TH), and that the patient signed a medication agreement consenting to have respondent solely responsible for his medications. I 17. In 2004, Patient PB. moved to Alaska and his medications, including Perocet as mentioned above, were prescribed by an Alaska?licensed physician. 18. On or about December 1, 2005, respondent examined Patient PB. Thereafter, on April 1 1, 2006, he wrote a letter in which he stated that in his medical Opinion Patient P.B. was using his medications appropriately and that these prescriptions should be continued. 19. On November 9 and December 15, 2006 and January 10, 2007 respondent wrote prescriptions for Percocet, 10/325 mg. QID, for Patient PB. There are no documented examinations of PB. for these dates in respondent?s records although respondent?s billing ledger for the patient indicates that the patient was billed for a medical examination on each date. On January 29, 2007, respondent issued a prescription for a 3?month supply of Percocet, 10/325 mg. There is neither a record of examination nor a billing statement to indicate that the patient was seen in the office on that date. On May 2007, another 3?rnonth supply of Percocet was prescribed by respondent, without a documented examination, but with a billing record that indicates the patient was billed for a medical examination on that date. 20. On June 7, 2007, there is a documented evaluation of Patient PB. by respondent. The. record of the evaluation consists of the patient?s handwritten answers on a ?Patient Follow Up Questionnaire,? with notations in the margin by respondent. According to the patient, his pain was 7 on a scale of 10 and he could sit, stand or walk for only short, i.e. 5?1 0 minute-long, 6 ACCUSATION (Case no. 03?2010?209330) Ix) L2.) U1 periods oftirne. A rationale is not clearly documented in the patient?s chart; however, respondent?s notes indicate that he increased the patient?spain medications by doubling the 3- month supply from 360 tablets to 720 tablets. A briei? note states that ?Oxy? would be added, but a prescription does not appear to have been issued on that date. A 3wmonth supply ot'Percocet, #720, were prescribed on July 26, although there is no interim note regarding how the patient?s pain had responded to the increased dosage, nor is there any record of an examination. 21. Patient PB. returned on September 6, 2007. at which time he reported his pain to be 5 on a scale of 10. He reported that another physician had administered an epidural. Respondent?s records indicate that Oxycontin, 20 mg. BID, is added to the patient?s medications, although there is no documented rationale for the change in the treatment plan. 22. Patient PB. was next seen by respondent on December 5, 2007. As with the prior documented examinations in June and September, the medical record consists of the patient?s answers to a questionnaire with only brief comments written in the margin by respondent. A review of systems checklist, printed on the reverse side of the questionnaire, is signed by respondent but no positive ?ndings are recorded. Respondent?s note indicates that he increased the dosage of Oxycontin to 40 mg. BID and he prescribed a 3?month supply of that drug. The month supply of Percocet was also increased, to #900, on that date. There is no charted explanation for the increase in medication. 23. On February 4 and April 10, 2008, respondent issued prescriptions for Percocet and Oxycontin to Patient PB. There are no documented examinations of PB. for these dates in respondent?s records, although respondent?s ledger for the patient indicates that the patient was billed for a medical examination on each date. 24. On April 30, 2008, there is a documented evaluation of Patient PB. by respondent. The record of the evaluation consists of the patient?s handwritten answers on a Patient Follow Up Questionnaire, with notations in the margin by respondent. The patient checked boxes indicating that his pain control was poor and that his ability to carry out his activities of daily living had decreased. Respondent later stated to a medical consultant for the Medical Board that the patient was doing ?moderately well? at this point, but that he had concerns about the amount of 7 ACCUSATION (Case no. 03-2010?209330) Id 4; ?Percocet.? At that time, respondent issued another prescription for Percocet, 15 mg. #90, apparently to decrease the amount of acetaminophen in the patient?s medication regime. 25. On June 20, 2008, respondent renewed the patient?s prescriptions. Despite his prior concerns about the amount of acetaminophen that the patient was taking, he returned to the practice of prescribing Percocet, 10/325 mg. #900, in addition to the usual 3?month supply of Oxycontin. There is no documented examination for this date. 26. On October 15, 2008, Patient PB. was seen in respondent?s of?ce. The record of the examination consists ofthe patient?s handwritten answers on a Patient Follow Up Questionnaire, with very brief notations in the margin by respondent. The patient reported that he had recently had a spinal fusion. Respondent renewed the prescriptions for 3?month supplies of Percocet and Oxycontin. 27. Respondent did not have another face?to?face meeting with Patient PB., although he continued to prescribe 3-month supplies of Percocet and Oxycontin to PB. at regular intervals through March 2010. These prescriptions were mailed to the patient at his home address and ?lled by him through an internet/mail service for prescription medications. During this period of time, i.e. October 2008 through March 2010, respondent had only one documented telephone contact with the patient, on December 2, 2009, but the contents of that discussion are not recorded in his chart. 28. In mid?2010, family members became concerned about his marked decline in functioning. They learned that PB. was taking BuSpar and Ativan for anxiety, Percocet and Oxycontin (prescribed by respondent) for pain and was also consuming 1?2 bottles of wine/day. PB. was hospitalized at CHOMP for detoxi?cation, after which he entered a treatment program at the Betty Ford Clinic to wean him from his prescription medications and alcohol. 29. i a subsequent interview with a Board investigator and medical consultant, respondent stated that the reason that he did not examine PB. after October 2008 was the patient?s insistence that he could not make the drive from his home in Monterey to respondent?s office in Salinas. Respondent claimed that he ?was speaking on the phone to him albeit as stated above) there is only one documented telephone conversation between them during this 8 (Case no. 03?2010-209330) period. Respondent also reported that he was in contact with PB. ?s other treating physicians and he produced four letters received during 2009 (the last letter indicating that the patient was consuming up to a bottle of wine each day and was possibly suffering from alcoholainduced neuropathy); however, there is no documentation that respondent consulted with these physicians regarding his continued prescribing for Patient P.B., nor any evidence that he reweval?uated his treatment plan based on information that he received from them. Respondent assured the Board?s representatives that his practice was to prepare a complete narrative report on his patients annually, although there is not a narrative. report for Patient PB. ?om the time he returned to respondent?s care, in or about early 2007, through 2010. CAUSES FOR DISCIPLINE (Gross Negligence/Repeated Negligent acts) 30. Respondent is subject to disciplinary action under section 2234, including subsections and/ or 2242(a) and/or 2266 in that reSpondent was grossly negligent and/or repeatedly negligent in his care and treatment of Patient P.B., and also failed to keep adequate and accurate records relating to the patient, including but not limited to the following: A. Complainant incorporates paragraphs 13 through 29 in this cause for disciplinary action as though fully Set out herein. B. Although respondent?s initial note indicated that the patient was drinking alcohol of an uncertain quantity on a daily basis, there is no documented discussion with the patient regarding the effects of alcohol use in combination with opioid treatment then or at any later date. C. Between November 2006 and May 2007, respondent repeatedly issued long-term prescriptions for large amounts of narcotic pain medications to P.B. without a documented, appropriate physical examination, interim history and determination that there continued to be a medical indication for the pain medications. ACCUSATION (Case no. 03?2010?209330) k) I D. Beginning in June 2007 and continuing through October 2008, respondent?s chart notes consist of a patient questionnaire, without a documented, appropriate physical examination, and with only scant medical information regarding other relevant matters, such as the patient?s interim history. his current physical and status, an assessment the patient?s other underlying or coexisting conditions or his current need for opioid treatment. B. Respondent?s billing ledger for Patient P.B. shows charges for multiple office visits for which there is no corresponding medical record. F. Respondent prescribed for Patient PB. from 2006 through 2010 without documenting a treatment plan. G. Respondent failed to obtain and/or failed to document the patient?s informed consent to opioid therapy for chronic pain. H. Beginning in approximately November 2006, respondent failed to periodically review the patient?s treatment at appropriate intervals and, after October 2008, he ceased to do so entirely. PRAYER WHEREFORE, complainant prays that a hearing be held and that the Board issue an order: 1. Revoking or suspending Physician?s and Surgeon?s Certi?cate number A65476, issued to Steven K. Mangar, 2. Prohibiting Steven K. Mangar, M.D., from supervising a Physician Assistant; 3. Ordering Steven K. Mangar, M.D., if placed on probation, to pay the costs of probation monitoring; 4. Taking such other and further action y/ July 29, 2011. DATED: K. WHITNEY Executive Director Medical Board of Califor ia Department of Consum Affairs State of California Complainant SF20l120l886 20485625doc ACCUSATION (Case no. 033?2010209330)