STATE OF CALIFORMA KAMALA D. HARRIS BOARD OF CALIFORNEA Attorney General of California 22;. JANE ZACK SIMON .. 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 Attorneys for Complainant BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTNIENT OF CONSUNIER AFFAIRS STATE OF CALIFORNIA In the Matter of the Accusation/Petition to Case o. 800-2014?007649 (D1) Revoke Probation Against: STEVEN MANGAR, M.D. ACCUSATION AND PETITION TO PO. Box 1530 REVOKE PROBATION Salinas, CA 93902 Physician?s and Surgeon?s Certi?cate No. A65476 Respondent. Complainant alleges: PARTIES 1. Kimberly Kirchmeyer (Complainant) brings this Accusation and Petition to Revoke Probation (Accusation) solely in her official 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, M.D. (Respondent). At all relevant times, said certificate was current and valid and, unless renewed, it will expire on May 31, 2016. 3. In a disciplinary action entitled ?In the Matter of the Accusation Against Steven K. Mangar, Case No. 03-2010?209330, the Board issued a decision, effective October 5, 2012, in which Respondent?s Physician?s and Surgeon?s Certificate was revoked. However, the revocation was stayed and Respondent?s Physician?s and Surgeon?s Certificate was placed on Accusation and Petition To Revoke Probation Uprobation for a period of three (3) years with certain terms and conditions, including a prescribing practices course and a medical record keeping course. A copy of that decision is attached as Exhibit A and is incorporated by reference. JURISDICTION 4. This Accusation and Petition to Revoke Probation 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. 5. 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. (0) Carrying out disciplinary actions appropriate to findings made by a panel or an administrative law judge. Suspending, revoking, or otherwise limiting certificates after the conclusion of disciplinary actions. Reviewing the quality of medical practice carried out by physician and surgeon Certificate holders under the jurisdiction of the board. . 6. 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. 7. 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.? Accusation and Petition To Revoke Probation 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.? Restrictng 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.? 8. Section 2234 of the Code provides: ?The board 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 5, 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 of the 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. Incompetence.? Accusation and Petition To Revoke Probation 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. 10. Section 2241.6 of the Code authorized the board, in conjunction with professional peer organizations in the field 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. 11. Section 2242(a) of the Code provides: ?Prescribing, dispensing, or furnishing dangerous drugs as defined in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct.? 12. Section 2261 of the Code provides: ?Knowingly making or signing any certificate or other documentation directly or indirectly related to the practice of medicine or podiatry which falsely represents the existence or nonexistence of a state of facts, constitutes unprofessional conduct.? 13. 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.? Accusation and Petition To Revoke Probation \DOOleUl-FIRST CAUSE FOR DISCIPLINARY ACTION (Gross Negligence/Repeated Negligent Acts) (Patient 14. Respondent?s license is subject to discipline and respondent is guilty of unprofessional conduct in violation of Business and Professions Code 2234(b) and/or and/or in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in his patient care and treatment, and respondent failed to maintain adequate and accurate medical records, including but not limited to the following: A. At all relevant times, respondent was a physician and surgeon with a specialization in pain management. B. On or about April 21, 2008, Patient R.M., who was then a 40 year old male, came under respondent?s care and treatment for chronic pain management. R.M. was referred to respondent by a Colorado physician and had a history significant for chronic low back pain resulting from a ruptured disc and degenerative disc disease. The patient reported a past laminectomy and discectomy in 1993. He also stated that his medications included Oxycontin, 80 mg, TID, Oxycontin, 40 mg, TID, Oxycodone, 15 mg, 8/day, Ritalin, 20 mg3, BID, Testosterone IM injections, Valium, 10 mg4, QD. In brief annotations to the patient?s intake questionnaire, respondent entered diagnoses of Failed Back Surgery Low Back Pain, Lumbar Radiculopathy and Chronic Pain Other than vital signs consisting of a blood pressure reading and pulse, no objective findings were obtained or stated. No additional history beyond that provided by the patient was recorded, a physical examination was either not performed or not 1 Patient?s names are abbreviated to protect privacy. Oxycodone is a narcotic analgesic with multiple actions similar to those of morphine. Oxycodone is a schedule 11 controlled substance. It is available in combination with other drugs or alone. When Oxycodone is available by itself, it is Oxycontin. Oxycodone can produce drug dependence and, therefore, has the potential for being abused. Oxycontin is indicated for the management of moderate to severe pain, and is a commonly abused or diverted drug. 3 Ritalin is a central nervous stimulant. It is a schedule 11 controlled substance. Ritalin is potentially addictive and presents a likelihood for abuse. Valium (diazepam) is a drug used for the treatment of anxiety disorders. It is a schedule IV controlled substance which can produce and physical dependence. Accusation and Petition To Revoke Probation documented and the treatment plan was limited to a notation that the patient?s reported medications would be refilled. C. Between 2007 and 2011, respondent?s record of patient encounters consisted of the patient?s completed questionnaire, with vital signs noted by a medical assistant and only brief remarks handwritten by respondent. Between 2011 and 2013, respondent utilized an electronic medical record system. Respondent?s handwritten and electronic medical records were frequently incomplete, stating only ?see questionnaire? under review of systems and ?unchanged? for history of present illness. Some records clearly state that the patient was seen only by a medical assistant, while others suggest that no face?to?face encounter took place based upon the lack of a documented examination and/or vital signs. D. During the course of his treatment with respondent, Patient R.M. experienced little improvement in his functioning and quality of life. Patient R.M. also suffered significant adverse side effects related to his opioid regimen, including hypogonadism and opioid induced somnolence. Nevertheless, respondent maintained him on high dose opioid therapy, initially consisting of the Oxycontin/Oxycodone therapy described in Paragraph above, and later replacing Oxycontin with high dose Morphine Sulfate but also continuing to utilize Oxycodone. Despite the patient?s lack of improvement on high dose opioids, respondent failed to consider alternatives to medication or to seek a consultation from an endocrinologist or addiction medicine specialist. E. The patient frequently complained of problems staying awake and requested an increased dosage of Ritalin. Respondent initially noted that the patient was already receiving the maximum dosage of 80 mg/day, but later did increase the dosage to Ritalin, 20 mg, TID, or 120 mg/day, and also added another stimulant, Adderall, to the patient?s medications. When respondent was interviewed by the Board?s investigator regarding Patient R.M., he initially stated that the patient was receiving stimulants for a diagnosis of narcolepsy, but when the absence of that diagnosis in his records was pointed out to him, he stated that the stimulants were prescribed for opioid induced somnolence. Accusation and Petition To Revoke Probation 15. Respondent is guilty of unprofessional conduct and subject to disciplinary action under section 2234, and/or 2234(b) and/or 2234(c) and/or 2234(d) and/or 2266 of the Code in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in the practice of medicine, including but not limited to the following: A. Respondent failed to obtain a complete history and to perform an appropriate examination before prescribing high dose opioid therapy; B. Respondent failed to develop a treatment plan with objectives, to periodically review the effectiveness of the prescribed treatment or to consider alternatives when the patient failed to improve; C. Respondent failed to obtain appropriate consultations; D. Respondent failed to maintain adequate and accurate records. SECOND CAUSE FOR DISCIPLINARY ACTION (Gross Negligence/Repeated Negligent Acts) (Patient KB.) 16. Respondent?s license is subject to discipline and respondent is guilty of unprofessional conduct in violation of Business and Professions Code 2234(b) and/or and/or and/or 2266 in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in his patient care and treatment, and respondent failed to maintain adequate and accurate medical records, including but not limited to the following: A. In or before 2010, Patient K.B., a 43 year old female, came under respondent?s care and treatment for probable rheumatoid arthritis and joint pain in the ankles, knees, hips and wrists as well as the cervical spine. The patient?s initial evaluation is not in respondent?s chart and, due to the chart?s incompleteness, the extent of the initial history and examination is uncertain. Respondent?s subsequent records reveal that the patient had a history of issues, including Major Depression and anxiety, and that she was non?compliant with her medications. The lack of documented medical response to evidence that the patient was not benefitting from the treatment, was abusing some medications and likely diverting others, gives rise to concern that respondent was not in fact having face?to?face encounters with the patient. 7 Accusation and Petition To Revoke Probation gout-IsmsPatient K.B. was initially treated with Hydrocodone, 10/325 mgs, #300, in a regimen which, as of January 2014, was expanded to include Hydrocodone, 10/325, up to 6/day, Ambien, 10 mg, 1-2 HS, Valium, 10 mg, BID, Oxycodone, 30 mg, QD, Dilaudid, 8 mg6, and Dilaudid, 4 mg. A clear treatment plan is absent from respondent?s records. C. Respondent?s periodic review of the effectiveness of the patient?s medication regimen is difficult to follow in that he attempted to taper the patient?s medications at some points and at others increased her medication without a documented rationale. The earliest record in respondent?s chart states that she ?returns early due to last month only received Norco #180.? No patient encounter is documented, but the patient received a new prescription for Norco #300. The patient resisted attempts to taper her medication and, in a letter dated February 4, 2011, complained about her prescribed medications being cut in half: am financially strapped but can afford a fee for a script.? D. The medication regimen prescribed by respondent never achieved its presumed goal of pain control and, in fact, appears to have exacerbated the patient?s underlying depression and suicidal ideation. While she was on the above?described regimen of benzodiazepines and opioids, Patient K.B. underwent four hospitalizations for opiate dependence and depression in 2011-2012. In January, 2012, the patient was brought to the hospital on a 5150 after she was found in a parking lot cutting her wrist. In March 2012, KB. returned to the hospital, stating that she had suicidal thoughts and did not feel safe. The record of that admission states that the patient was having problems managing her pain medications. An inquiry to the patient?s pharmacy revealed that the patient was ?always asking for her medications early, for any various reasons such as going out of town or going to a funeral in Hawaii.? Despite this and other evidence that chronic use of opiates and benzodiazepines was not benefitting her, but was exacerbating her underlying condition and increasing the potential for harm due to increasing suicidal ideation, respondent neither withdrew the patient?s medications nor did he 5 Hydrocodone bipartrate (including the trade name products Vicodin and Norco) is a schedule controlled substance. 6 Dilaudid (hydromorphone hydrochloride) is a potent opioid agonist and a schedule 11 controlled substance. Accusation and Petition To Revoke Probation refer the patient for alternative pain management, such as interventional treatment. Moreover, in respondent?s record of several years of treatment there is no record indicating that he was communicating with the patient?s regarding her status. E. In addition to many indications that K.B. was abusing some of her medications, available laboratory test results beginning in September 2012 show that she also repeatedly tested negative on urine toxicology screens for her prescribed medications (including Oxycodone) and positive for controlled substances (including Suboxone, Klonopin, Cocaine and Methadone) which respondent was not prescribing. These repeated inconsistent results required respondent?s immediate action to stop the apparent drug diversion and substance abuse. Nevertheless, and despite repeated threats of termination, he continued to prescribe for K.B. until finally discharging her from his practice in January 2014. 17. Respondent is guilty of unprofessional conduct and subject to disciplinary action under section 2234, and/or 2234(b) and/or 2234(c) and/or 2234(d) and/or 2266 of the Code in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in the practice of medicine, including but not limited to the following: A. Respondent failed to develop a treatment plan with objectives, to periodically review the effectiveness of the prescribed treatment or to consider alternatives when the patient failed to improve; B. Respondent failed to respond to evidence that the patient?s condition was not benefitting and was actually worsening on the prescribed treatment by weaning and withdrawing her from the treatment; C. Respondent failed to obtain appropriate addiction medicine consultations despite signs that the patient was abusing some medications while apparently diverting others; D. Respondent failed to maintain adequate and accurate records. 9 Accusation and Petition To Revoke Probation THIRD CAUSE FOR DISCIPLINARY ACTION (Gross Negligence/Repeated Negligent Acts) (Patient B.M.) 18. Respondent?s license is subject to discipline and respondent is guilty of unprofessional conduct in violation of Business and Professions Code 2234(b) and/or (0) and/or and/or 2261 and/or 2266 in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in his patient care and treatment, and respondent failed to maintain adequate and accurate medical records, including but not limited to the following: A. On June 26, 2013, the Medical Board received a complaint from Patient B.M., who reported that respondent had discharged him after approximately 10 years of care. B.M. stated that during that time he picked up his prescriptions from respondent?s office every thirty days, but actually had face?to?face meetings with, and examination by, respondent on approximately three visits per year. The patient also complained that respondent?s medical records were inaccurate and that many were missing. B. On May 6, 2002, Patient B.M. was referred to respondent by his neurosurgeon for a pain management consultation. B.M. reported that he had been disabled by chronic back pain since two industrial accidents that occurred in 1999 and had undergone multiple surgeries and procedures without relief. Respondent diagnosed B.M. with Failed Back Surgery and recommended a regimen of pain medications, injections and physical therapy. B.M. was placed on Oxycontin, 10 mg, TID, Trazodone HS, Valium and Baclofen. Respondent stated that if the patient?s pain was refractory to medications and injections, consideration of a spinal cord stimulator would be made in the future. C. Respondent continued to prescribe for Patient B.M. through 2012, at which time B.M. was receiving prescriptions for Fentanyl, 50 meg, 1 48 hrs, and Hydrocodone, 75/500, #180. Although respondent?s initial notes are detailed, usually in the form of reports to Patient workers? compensation carrier and his referring neurosurgeon, the chart produced by him in 7 Fentanyl is a schedule II opioid agonist that is delivered Via transdermal patch. 10 Accusation and Petition To Revoke Probation response to medical release is disorganized, missing records for large periods of treatment, and consists mainly of questionnaires, with only sparse notes by respondent. Electronic medical records replace the patient?s questionnaire in or about 2010, but they are of doubtful accuracy often lacking vital signs or other indicia that the patient was actually seen and examined by respondent. On August 24, 2012, respondent discharged Patient B.M. from his practice after the patient had an angry confrontation with his staff. In that record, respondent states: ?He was informed that the doctor was not in, and his prescription was not ready and that staff was contacting me because [Patient has not been seen since March 27, 2012.? However, respondent?s chart contains notes for each of the intervening four months, each of which states that the patient was seen for 20 minutes. Moreover, these notes correspond with the dates on which Patient B.M. filled prescriptions for pain medications, indicating that the patient was receiving prescriptions for controlled substances from the office staff, without a medical examination. 19. Respondent is guilty of unprofessional conduct and subject to disciplinary action under section 2234, and/or 2234(b) and/0r 2234(c) and/or 2234(d) and/or 2261 and/or 2266 of the Code in that respondent was grossly negligent and/or committed repeated negligent acts and/or was incompetent in the practice of medicine, including but not limited to the following: A. Respondent prescribed controlled substances to a patient without an appropriate medical examination; B. Respondent created medical records which stated that the patient was seen by him, when in fact there was no face?to?face encounter; C. Respondent failed to maintain adequate and accurate medical records. CAUSE FOR REVOCATION OF PROBATION 20. As stated above, an Accusation was filed before the Board, in which it was alleged that respondent had engaged in multiple departures from the standard of care, including prescribing controlled substances without an appropriate examination, in violation of the above- recited provisions of the Medical Practice Act. The Board and respondent thereafter entered into a stipulated settlement, by which respondent agreed that his certificate would be placed on 11 Accusation and Petition To Revoke Probation \lONUlprobation to the Board with terms and conditions. The stipulated settlement specifically provided that failure to fully comply with any term or condition of probation, including the requirement that respondent obey all laws, would be a violation of his settlement agreement with the Board and would authorize the Board to take action to carry out the disciplinary order that was stayed. A copy of the Decision is attached to this Accusation and Petition to Revoke Probation as Exhibit A and is incorporated in this Petition by reference, as though fully set out herein. A. Respondent is guilty of unprofessional conduct and his probation is subject to revocation based upon his violations of the Medical Practice Act, as set forth in the First, Second and Third Causes for Disciplinary Action. 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 Certificate Number A65476, issued to Steven Mangar, 2. Revoking Respondent Steven Mangar, current probation and carrying out the disciplinary order that was stayed, a revocation of respondent?s license; 3. Revoking, suspending or denying approval of Steven Mangar, authority to supervise physician assistants, pursuant to section 3527 of the Code; 4. Ordering Steven Mangar, M.D., if placed on probation, to pay the Medical Board the costs of probation monitoring; 5. Taking such other and further action as deemed necessary and proper. MM KIMBERLY Executive Director Medical Board of California Department of Consumer Affairs State of California Complainant DATED: November 6, 2014 SF2014-409430 41063632.doc 12 Accusation and Petition To Revoke Probation Exhibit A BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA 1n the Matter of the Aecusation Against: STEVEN K. MANGAR, Ml). 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 pm. on October 5. 2012. IT 18 so ORDERED: September 6. 2012. MEDICAL BOARD OF CALIFORNIA 9w 19w Reginald Low, M.D., Chair Panel Li.) U1 18 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 A {torneysfor Complainant BEFORE TH MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA Case No. 03?2010?209330 OAT-1 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. 1T 18 HEREBY STIPULATED AND AGREED by and between the parties to the above- . entitled proceedings that the following matters are true: I 7 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 byKamala D. Harris, Attorney General of the State of California, by Lawrence Mercer, Deputy Attorney General. 2. Steven. K. Marigar, M.D., is represented in this matter by Belzer, l~luichiy Murray and William J. Murray, Esq, 3650 Mt. Diablo Blvd, Suite 130, Lafayette, CA 94549. 3. On .1 one 5, 1998, the Medical Board of California issued Physician's and Surgeon?s Certi?cate Number A65476 to Steven K. Maugar, MD. (Respondent). At all relevant times, said certificate was current and valid. Unless renewed, the certi?cate will expire on May 31, 2014. r; I ff J). JURISDICTION 4. Accusartion No. 03?20] 0-209330 was duly ?led and served on reapondent on July 29, 2m 1. Respondent timely filed a Notice ofDe?fensc 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 compo the attendance of witnesses and the production of documents; the right to reconsideration and court review ofan 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 midst" every right set forth above. I I 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 21266, and that he has thereby subjected his license to disciplinary action. it 9. Respondent agrees that his Physician?s and Surgeon?s Certificate is subject to discipline and he agrees to be bound by the Board?sirnposition 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 Ix.) DJ [0 to l\J Ixprofessional licensing agency in any state is involved, and shall not be admissible in any other criminal or civil proceedings. I CONTINGENCY 1. 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, withoutlnotice 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 wil not be able to withdraw or modify this Stipulation while it is before the Board for consideration. I 12. The parties understand and agree that facsimile cepies 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 ?l?brmal proceeding, issue and enter the following Disciplinary Order: I ORDER lT IS HEREBY ORDERED that Physician?s and Surgeon?s Certi?cate No. A65476 is revoked. However, the revocation is stayed and Respondent?s certi?cate is placed on three years probation, on the following terms and conditions: i. PRESCRIBING PRACTICES COURSE: Within 60 calendar days of the effective date of this Decision, Respondent shall enroll in a course in prescribing practices equivalent to ?u 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 is) 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 oflicensure. A prescribing practices course taken oaftcr 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 ofthis 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 an information and doctrinents that the Program may deem pertinent. Respondent shall participate it: and complete the classrooni 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 he in addition to the Continuing Medical Education (CME) requirements for renewal of licensure. I 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. ixRespondent shall submit a certi?cation of successful completion to the Board or its designer: 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.? i 4. NOTIFICATION: Within seven (7) days of the effective date ofthis decision, the Respondent shall provide a true copy of this Decision and Accusation to the Chi efof Staffer the Chief Executive Of?cer at every hospital where privileges or membership are extended to Respondent, at any other facility where Respondent engage-sin 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. I This condition shall apply to any changets) in hospitals, other facilities or insurance carrier. 5. SUPERVISION OF PHYSICIAN ASSISTANTS: During probation, Respondent is prohibited from supervising physician assistants. OBEY ALL LAWS: ReSpondent shall obey all federal, state and local laws, alt-'3: rules governing the practice of medicine in California and remain in full compliance with anyi-i _7 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. I CHANGE OF ADDRESS: Respondent shall, at all times, keep the Board intonned of Respondent?s business and residence addresses, email address (if available), and telephone, number. Changes of such addresses shall be immediately communicated in writin to the Board; 5 or its designcc. Under no circumstances shall a post office box serve. as an address of record, except as allowed by Business and Professions Code section 2021(b). lO. PLACE OF PRACTICE: Respondent shall not engage in the practice ofmedicinc' in Respondent?s or his place ofresidcnce, unless the patient resides in a skilled nursing facility or other similar licensed facility. it. 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: 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 thedates of departure and return. I l3. INTERVIEW WITH THE BOARD OR ITS DESIGNEE: Respondent shall be . available in perscn upon request for interviews either at Respondent?s place ofbusiness or at probation unit: office, with or without prior notice throughout the term of probation. l4. 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 defined in Business and Professions Code sections 2051 and 2.052 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 Statesl'ori 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 ofnon?practice. ix.) Lu Ui a] In the event Respondent?s period ofnon?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 ofthe Board?s ?Manual oi'Modcl 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 ofnon-practice will relieve Respondent of the responsibility to comply with they: a I 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, COMP OF Respondent shall comply with all ?nancial obligations (erg, restitution, probation cosrs) not later than 120 calendar days priorto the completion of probation. Upon successful completion oi?probation, Respondent?s certi?cate shall- be fully restored. 16, VIOLATION OF PROBATION: Failure to fully COiI?iply with any term or condition of probation is a violation. 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 we" Revoke Probation, or an Interim SUSpension Order is ?led against ReSpondent during probation: the Board shall have continuing jurisdiction until. the matter is final, and the period of probation shall be extended until the matter is ?nal. l7. 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 etennining 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 1 5 calendar days deliver Respondent?s wallet and wall certi?cate to the Board or its designer: and Respondent shall no longer practice medicine. Respondent will no longer be subjec 7 8317513339 F3174 ?cl 2? 28 09:57:32 am. to terms and conditions of?pmbation. I'fRespondan Ire-applies for n. mcdica! Iiccnso, the appHcaticm shall be treated as a petition for reinstatement of'a revoked cc?i?catc._ 18. COSTS: Respondent shall pay the costs associated wilh probation :?nonimring each and every year ofprobation, as designated by the Board, which may be adjusted on an annual basis. Such 503st shall be payable to the: Modical Board of California and delivered to the Board or its designec no later than January 31 of each calendar year. I have curefufly read the Stipulaled and Disciplinary Order and vai: fuily disoussed it with my attorneys. I understand the stipulation and the effect it will have on my Physician?s and Surgeon's Certi?cate. I. enter into this Sti?ulated Settlement and Disciplinary Order voluntarily, knowingly; and intelligcn?y, and agree to bc bound by the Decision and Order of?m Medical Board of California. DATED: Cm? MD. pour f. 1 have read and fully discussmi with Ratspondent Steven K. Mangar, MD. the. terms and conditions and other matters contained in the abovc Settlement and Disciplinary Ordm: I approve its form and cement. BBLZER, HULCHIY 5: MURRAY 03?07?2012 2 i2 -5 DATED: WILLIAM J. Attorneys for 8 1 v_ n'vwru . er?x m-vwm' Amw rum-mm TNAWV (201204072 1 ums an? z-Jmtm HM wommuw 1:00 at 5193?83?an 0 ENDORSEMENT The foregoing Stipulath Settlement and Disciplinary Order is hereby submitted for consideration by the Medical BoardofCaliforuia. KAMALA D. HARRIS Attorney General of California JOSE R. GUERRERO Su "\ng Deputy Attorney General 1 ERCER 56 tomey General Attorneys for Complainant DATED: SF2011201886 40?7425Ldoc Ix.) Lu Ex.) ACCUSATION NO. 03-201 0?209330 IO D. HARRIS Attorney General of California JOSE R. GUERRERO Supervising Deputy AILomey General LAWRENCE NLERCER Deputy Attorney General Slate Bar No. 111898 455 Golden Gate: Avenue, Suite 1 1000 San Francisco, CA 94102?7004 Telephone: (415) 703-5539 Facsimile: (415) 7036480 A amp! cu'ncmr FILED- sr TE 05: owe-0mm MEDICAL some OF CALHFORNLA SACRAMENTO Tu aw avg"? (911w, emems; . BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter ofthe Accusation Againsu CaSe No. 03-2010?209330 STEVEN K. MANGAR, MD. ACCUSATION I Salinas. CA 93902 Physician?s and Surgeon?s Cel'll?caLCNo. A65476 I Reapondent. Complainant alleges: I I PARTIES 1. Linda K. Whitney (Complainant) brings this Accuse?on (Accusation) solely in herE off] eial capacity as the Executive Director oft'ne Medical Board ofCallfomla, Department of Consumer Affairs,_ 1 2. On June 5, 1.998, the Medical Board ofCalifomla issued Physician?s and Surgeon?s: I Certi?cate Number A65476 to Steven K. Mangar, MD. (Respondent). A1 all relevant times, said certificate was current and valid. Unless renewed, the certi?cate will expire on May 31, 2012. ACCUSATION (Ca-mm. 03-20l 020933 i b) Ix) 4: is.) JURISDICTION 3. This .fxccusatiOn is brought before the Medical Board of California (Board'l under the authority of the following laws. All section references are to the Business and Professions Code unless otherwise indicated. 4. Section 2004 ol?t'nc Code provides. pertinent part, that the Medical Board shall have responsibility for: ?(t0 The enforcement ol?t?he 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. I suspending, revolting, or otherwise limiting certi?cates after the conclusion oi disciplinary actions. Reviewing the quality of medical practice carried out by physician and surgeon certi?cate holders under the jurisdiction ofthe hoard. . 5. Section 2227 of the Code provides that a licensee who is found guilty under the Medical PracticeAct may have his or her license revoked, suspended for a. period not to exceed one year, placed on probation and required to pa I the costs of probation monitoring, or such other action taken in relation to discipline as the Board deems proper. I Section 2228 oft?he Code provides that a probation imposed by the Board may include, but is n01 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 ofthe board or the administrative law judge." I As used herein, the term ?board? means the Medical'Boai-d of California. As used herein, ?Division ofMedical Quality" shall also be deemed to refer to the board. l-J .1: "(bi 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 ofthe licensee?s choice.? Restricting or limiting the extend, scepe, or type ol?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 ol? Medical 'Qual i'ty shall take actiOn against any licensee who is charged with tutprofessional conduct. in addition to other provisionsof this article, 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. Tobe 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. 9(1) An initial negligent diagnosis followed by an act. or omission medically appropriate for that negligent diagnosis ofithe 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 change in treatment, and the licensee's conduct departs from the applicable standard Cleare, each departure constitutes a separate and distinct breach of the standard dram . . If L1.) ix) Jam l0 ll [3 tun?J LI) 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 ofpain or a condition causing intraCtable pain. However, nothing "in that section affects the power ofthe board to take any action described in Section 2227 of the Code, including: but not limited to, Sections 2234. subsections to) and and/?or Section 2242. 9, Section 2241.6 of the Code authorized the board, in conjunction with professional peer organizations in the field of pain management, to develop standards or review of cases concerning the management ofa pettient?s pain. in 2007, the board revised its l994 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 reviei-v of the treatment. consultation where warranted and accurate and complete medical records. I .4 10. Section 2242(a) of the Code provides: ?Prescribing dispensing, or furnishing dangerous drugs as defined in Section 4022 without an appropriate prior examination and a medical indication, constitutes Unprofessional conduct.? I ll. Section 22.66 of the Code provides: ?The failure of a physician and surgeon to maintain adecjuate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct.?_ DRUGS l2. The following dangerous drugs, as defined in Section 4022, are relevant to the cause lor disciplinary action set forth in this Accusation: A. Oxycontin is a semisyn?t?netic narcotic analgesic with multiple actions qualitatively similar to those of? morphine. it is dangerous drug as de?ned in section 4022, a schedule 1] controlled substance and narcotic as de?ned by section '1 subdivision (bxl') olthe Health and Safety. Code. and a Schedule ll controlled substance as defined by Section 1308.12 (MU) of Id U.) LJ) 0\ Title 21 oi?thc Code ol'cheral Regulations. Oxycodone can produce drug dependence ol'the nziorphiue type and, therefore, has the potential for being abused. B. Percocet a trade name for a combination of oxycodone hydrochloride and is a scrnisyuthctic narcotic analgesic with multiple actions qualitatively similar to those of morphine, a dangerous drug as defined in Section 4023, a schedule 11 substance and narcotic as de?ned by section subdivision oithe Health and Safety Code, and a Schedule 1] controlled substance as defined by Section 1308.12 oi'Title El oithe Code olFederal Regulations. Oxycodone can produce drug dependence ofthe morphine type and, therefOrc. has the potential for being abused. Repeated administration of Percocei may result in and physical dependence. ACT l3. . On or about August 28, 2003, Patient 3. 60 year old male patient with a hiStoiy of chronic neck and low hack pain came under respondent?s care at the Center for 33am Manage em in the Conununity Hospital of the Monterey Peninsula 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. l4. At the initial consultation in. August 2003, respondent performed an evaluation which included a physical examination. and medical history, assossmeut of the patieut?s pain) level, his physical and status and function, a history of the patient; 3? 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 thatthe patient was currently drinking an ?uncertain quantity" oi?alcohol on daily basis. This inconclusive assessment \yas never pursued further and the paticul?s alcohol use is not?. referred to in subsequent recordspatient 3 name is abbrewated to his privacy. {Caseno (is-20102093303" 5.) Ch 1:3. BaSod upon the history. physical examination and assessment oi?the patient?s condition, respondent proposed a main-disciplinary treatment plan, including occupational and physical therapy, an EMG/ncrve conduction study, an increase the patient?s dosageofNeurontin and consideration or" transition from the patient?s existing regimen o??ercocet to a long-acting. opiate. i6. 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 Pet'cocet, 5 mg, TH), and that the patient signed a medication agreement consenting to have soiel)? responsible for his medications. 17. In 2004, Patient RB. moved to Alaska and his medications, including Perocet as inentioned above, were prescri ed by an Alaska-licensed physician. .18. On or about December 1, 2005,.respondent examined Patient PB. Thereafter, on April 1 l, 2006, he wrote a letter in which he stated that in his medical opinion Patient PB. 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. Oil), for Patient PB. There are no documented examinations of PB. for these dates in i'eSpondent?s records although respondent?s billing ledger for the patient indicates that the patient was for a medical examination on each date. On January 29, 2007, issued a prescription for a 3-month sapply ofPercocm, 10/325 mg. There is neither a record oi.? examination nor a billing statement to indicate that the patient was seen in the office on that date. On May 2007, another 3-month supply of'Pcrcocet 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 RB. by teSpondent-.. The record of the evaluation consists of' the patien?t?s handwritten answers on a ?Patient Follow- Up Questionnaire." with notations in the margin by respondent. According to the patient, his pair. was 7 on a scale of 10 and he could sit, stand or wall: for only short, i.e. 5-10 'rninute?iong, 6 l-J b} 7: month supply from St periods oftime. A rationale is not clearly documented in the patient"s chart; however. respondent?s notes indicate that he increased the patient?s pain medications by doubling the 3- '0 tablets to 720 tablets. A hriei?note states that '?Oxy? would be added. but a prescription does not appear to have been issued on that date. A 3-month supply of 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 ofan examination. I 2 1. Patient PB. returned on September 62 2007, at which time he reported his pain-to be on a scale of ltli He reported that another physician had administered an epidural. I Respondent?s records indicate that Oxycontin: '20 1mg. 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 luneand September, the medical record consists of the patient?s answers to a quesdonnaire with only brief comments written in the margin by respondent. A review of systems checklist, printed on the reverse side or" the questionnaire, is signed by respondent but no positive ?ndings are recorded, Respondent: 3 note indicates that he increased the dosage of Oxycontin to 40 mg. BID and he prescribed a 3~rnonth supply of that drug. The 3' month supply ot?Percocet was also increased, to #900, on that date. There is no charted explanation for the increase in medication. I 23. I On li?ebruary 4 and April-10: 2008; respondent issued prescriptions for Percocet and Oxycontin to PatientRB. There are no documented examinations of RB. for these dates in rcspon ent?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 RB. by respondent. .The record ot?the evaluation consists oi?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 medicai consultant for the Medical Board that the patient was doing ?moderately well? at this point, but that he had concerns about the amount of . ?1 Id IA. ?l?crcocct.? 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 patieiit"s prescriptions. Despite his A. prior concerns about the amount ofacctaminophcn that the patient was taking, he returned to the practice of prescribing Pcrcocct, 10525 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 office. The record of the examination consists of the pationt?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 P.B., although he continued to prescribe 3?month supplies of Percocct 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 internist/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 at that discussion are not recordet 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, Pcrcocet 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 borne in 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 period. Respondent also reported that he was in content with other treating physicians and 3 .st letter indicating that the patient was he produced i'our letters received during 2009 (the consuming up to a bottle of wine each day and was possibly suffering from alcohol-induced neuronaithy); however, there is no documentation that respondent consulted with these. physicians r- grinding his continued prescribing for Patient P.B., nor any evidence that he re-eveluuted his 5., (3 treatment plan based on information that he received horn them. Respondent assured the Board?s representatives that his practice was to prepare 'ri complete narrative report on his patients annually, although there is not a narrative report for Patient PB. from the time he returned to eSpondent?s care, in or about early 2007'. through 2010. CATUSES FOR DISCIPLINE (Gross Negligence/Repeated Negligent acts) 30. ReSpondeut is subject to disciplinary action under section 2234, including subsections arid/or 22420;) and/or 2266 in that respondent was grossly negligent and/or rel eatedly negligent in his care and treatment ofPetient P.l3., 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 rcsnondent?s initial note indicated that the patient was drinking alcohol clan uncertain quantity on. a daily basis, there is no documented discussion with the patient regarding the effects oi?nlcohol use in combination with opioid treatment then or at any later date. C. Between November 2006 and May 2007, ondent? repeatedly issued long?term prescriptions for large amounts of narcotic pain medications to BB. without a documented, appropriate physical examination, interim history and determination that there continued to be a medical indication for the pain medications. .U 1/ (Case no. 034010209330) Id L1.) .53 a) IQ u: to Beginning in Line 200.7 and continuing through October 2008, respondent's chart . notes consisr 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, ccinditions or his current need for Opioid treatment. Es Respondent?s billing ledger for Patient PB. shows charges for multiple office visits for which there is no corresponding medical record. Ft Respondent prescribed for Patient PB. from 2006 through 2010 without documenting a treatment plan. Respondent faiied to obtain and/or failed to docuinent the patient?s informed censent to opioid therapy for chronic pain. it. Beginning in approximately November 2006, respondent failed to periodically review the patients treatrnent at appropriate intervals and, after October 2008: he ceased to do so entiter PRAYER WHEREFORE, complainant prays that a hearing be held and that the Board issue an order: it Revotting or suspending Physician?s and Surgeon?s Certi?cate number issued to Steven K. Manger, Prohibiting Steven K. Manger: MD, from supervising a Physician Assistant; 2g 3g Ordering Steven K. Manger, M.D., if piaced on probation, to pay the costs of . probation monitoring,v'l 1/ .r 4 Taking such other and further action as may redeemed rope and apprOpria?te. . July 29, 201.1. LINDA K. WHITNEY Executive Director Medical Board ot'Cali?yia epartment of Consom "Affairs State of California Complainant SFBOE lZOl 886 2tl483t325tdoc