10 11 12 7-XAVIER BECERRA Attorney General of California STEVEN D. MUNI Supervising Deputy Attorney General DEMOND L. PHILSON Deputy Attorney General State Bar No. 220220 1300 I Street, Suite 125 PO. Box 944255 Sacramento, CA 94244-2550 Telephone: (916) 210-7548 Facsimile: (916) 327?2247 Attorneys for Complainant FILED STATE OF CALIFORNIA . - use IFORNIA 3-1441 .. 2011 I ANALYST BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter of the Accusation Against: Case No. 800-2017-032495 Chandan Deep Singh Cheema, MD. A A I Capital Medical Extended Care 3001 Douglas Ste 325 Roseville, CA 95661 Physician?s and Surgeon?s Certi?cate No. A 47747, Respondent. COmplainant alleges: PARTIES 1. - Kimberly Kirchmeyer (Complainant) brings this Accusation solely in her of?cial Affairs (Board). - capacity as the Executive Director of the Medical Board _of California, Department of Consumer 2. On or. about NoVember 27, 1989, the Medical Board issued Physician?s and Surgeon?s Certi?cate Number A 47747 to Chandan Deep Singh Cheema, M.D. (Respondent). The Physician?s and surgeon?s Certi?cate was in full force and effect at all times relevant to the charges brought herein and will expire on July 31, 2019, unless renewed. 1 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-2017-032495 UJURISDICTION 3. This Accusation is brought before the Board, under the authority 'of the following laws. All section references are to the Business and Professions Code unless otherwise indicated. 4. Section 2234 of the Code, states: - ?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- limitedto, the following: Violating or attempting to violate, directly or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of thischapter. - . 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 constitutesthe negli gent 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 1 standard of care. I I I Incompetence. The cemmission of any act involving dishonesty or corruption which is substantially related to the quali?cations, functions, or duties of a physician and surgeon. Any action or conduct which would have warranted the denial of-a certificate. The practice of medicine from this state into another state or country without meeting the legal requirements of that state or country for the practice of medicine. Section 2314. shall not apply to this subdivision. This subdivision shall become operative upon the implementation of the proposed registration program described in Section 2052.5. 2 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-2017?032495 . The repeated failure by a certi?cate holder, in the absence-0f good cause, to attend and participate in an interview by the board. This subdivision shall only apply to a certi?cate holder- who is the subject of an investigation by the boar 5. Section 2241 of the Code states: A physician and surgeon may prescribe, dispense, or administer prescription drugs, including prescription controlled substances, to an addict under his or her treatment for a purpose other than, maintenance on, or detoxi?cation from, prescriptiondrugs or controlled substances, I A physician and surgeon may prescribe, dispense, or administer prescription drugs or prescription controlled substances to an addict for purposes of maintenance on, or detoxi?cation from, prescription drugs or controlled substances only as set forth in subdivision (0) or in Sections 1 11215, 11217, 11217.5, 11218, 11219, and 11220- 0fthe Health and Safety Code. Nothing in this subdivision shall authorize a physician and surgeon to prescribe, dispense, or administer dangerous drugs or controlled substances to a person he or she knows or reasonably believes is using or will use the drugs or substances for a nonmedical purpose. Notwithstanding subdivision prescription drugs or controlled substances may also be administered or applied by a physician and surgeon, or by a registered nurse acting under his or her instruction and supervision, under the following ?circumstances: Emergency treatment of a patient whose addiction is complicated by the presence of incurable disease, acute accident, illness, or injury, or the in?rmities attendant upon age. Treatment of addicts in state-licensed institutions where the patient is kept under restraint and control, or in city or county jails or state prisons. 7(3) Treatment of addicts as provided for by Section 11217.5 of the Health and Safety Code. I For purposes of this section. and Section 2241.5, ?addict? means a person whose actions are characterized by craving ?in combination with one or more of the following:_ Impaired control over drug use. Compulsive use. Continued use despite harm. .3 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-2017?032495 -P LoNotwithstanding paragraph. (1), a person whosedrug-seeking behavior is primarily due to the inadequate control of pain is not an addict within the meaning of this section or Section 2241.5.? 6. Section 725 of the Code states: . Repeated acts of clearly excessive'prescribing, furnishing, dispensing, or administering of drugs or treatment, repeated acts of clearly excessive use of diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of I the community of licensees is unprofessional conduct for a physician and surgeon, dentist, podiatrist, physical therapist, chiropractor, optometrist, speech-language pathologist, or audiologist. Any person who engages in repeated acts of clearly excessive prescribing or administering of drugs or' treatment is guilty of a misdemeanor and shall be punished by a ?ne of not less than one hundred dollars ($100) nor more than six hundred dollars or by imprisonment fora term of not less than 60 days nor more than 180 days, or by both that ?ne and imprisonment. I i A practitioner who has a medical basis for prescribing, furnishing, dispensing, or administering dangerous drugs or prescription controlled substances shall not be subject to disciplinary action or prosecution under this section. No physician and surgeon shall be subject to disciplinary action pursuant to this section for treating intractable pain in compliance with Section 2241.5.? - FIRST CAUSE FOR DISCIPLINE (Gross Negligence) 7. Respondent is subject to disciplinary action under section 2234, as de?nedby section 2234, subdivision of the Code, in that respondent committed gross negligence in his care and treatment of patient A1. The circumstances are as follows: 1 Thepatient is referred to by letter in order to preserve privacy. The patient?s identity will be disclosed in the discovery provided to the respondent. 4 . (CHANDAN DEEP SINGH CHEEMA, MD.) ACCUSATION NO. 800?2017-032495 28' Patient A 8. On July 18, 2012 patient A was transferred to Rock Creek Care Center. Patient A was a 44 year-old male with a history of non-speci?c joint pain, gout, hyperuricemia, and a known history of accidental opiate overdose in October 2011 and a second overdose on methadone on July 3, 2012. Patient A was admitted to the hospital with acute renal failure with hyperkalemia, benign prostatic hyperplasia and elevated liver enzymes. Patient A was admitted to Rock Creek Care Center by Dr. .V. who cominued his methadone, hydromorphone and hydrocodone with acetaminophen as per the discharge summary from Sutter Auburn Faith Hospital. I I 9. On the next day, July 19, 2018, a nurse practitioner saw patient A because patient A felt that the pain waslnot controlled. The nurse practitioner changed the hydromorphone from an as needed basis to routineand increased the Norco from 5/325 to 10/325 -1?2 tablets every 4 hours as needed. 1 10. Patient A was seen and examined primarily by the nurse practitioners though references were made saw the patient for pain management. Patient A was seen by a podiatrist as a courtesy since podiatry care was not reimbursed by his Medi-Cal insurance. Patient A was also seen by an optometrist and dentist. References in the medical notes were made that patient A was to be seen by a rheumatologist but it is unknown whether the patient was seen by one. 1 1. On July 27, 2012, the Respondentis ?rst Signature was on Patient A?s record when he isi'gned the Re?ll Authorization Request for hydromorphone. Patient A had been admitted to the Rock Creek Care Center nine days earlier by Dr. The admission history and physical by Dr. .V. was. completed by the time Respondent signed the Re?ll Authorization Request. There was no accompanying note documenting the ?rst episode of Respondent?s re?lling of hydrocodone. Although the attending physician of record was Dr. .V., the Respondent signed 16 prescriptions 2 Benign prostatic hyperplasia (BPH) also called prostate gland enlargement is a common condition as men get older. An enlarged prostate gland can cause uncomfortable urinary such as blocking the ?ow of' urine out of the bladder. It can also cause bladder, urinary tract or kidney problems. 5 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-201?7-032495 forathe controlled substances while the patient was at Rock Creek Care Center for a total of 229 I days. 12. On November 6, 2012, Patient A was seen by Respondent for treatment. This was approximately 103 days after patient A?s July 27, 2012, visit. Respondent co-signed the nurse practitioner?s note and added ?See pt every 2 months By this time, Respondent had already signed 9 prescriptions. Respondent had developed and established a duty to the- patient. Since the ReSpondent indicated that the patient should now be seen every 2 months, he made a clinical judgment. Respondent was aware of Patient A?s indication forithe admission to Rock Creek Care Center and was also aware it was for ?rehabilitation and continuation of care? on . September '25, 2012, and ?Continue medication as directed fromthe hospital discharge summary? on July 18, 2012, as indicated in patient A?s medical notes. Respondent also had knowledge of patient A?s two episodes of overdose within the last year as indicated in his medical notes. . 13. Between July 27, 2012, and February 27, 2013, Respondent was the only physician who signed multiple prescriptions for HydromOrphone3, Methadone", and'Dilaudid without documenting what information he relied upon to justify the continuation of the controlled substances. Respondent continued the prescription of the controlled substances without considering adjustments to lower the dosages. Since Respondent developed and established aiduty to this patient and had reasonable information available to adjust the level of physician or nurse practitioner care (or frequency of visits), he also had reasonable information available to proactively reduce the d036, frequency and type of narcotics?prescribed in this patient with known multiple narcotic overdoses. 14. Between July 27, 2012, and February 27, 2013, Respondent was the only physician who signed multiple prescriptions for high doses of Hydromorphone, Methadone, and Dilaudid 3 Hydromorphone, brand name Dilaudid, is a Schedule II controlled substance pursuant to Health and Safety Code section 11055, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. - 4 Methadone IS a Schedule II controlled substance pursuant to Health and Safety Code section 11055, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. 6 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-2017?0324?95 10_18_ 28_ without documenting what information he relied upon to justify the continuation of the controlled Substances. 7 15. In February-2013, a month prior to patient A?s discharge from Rock Creek Care Center, he was referred to a pain specialist at UC Davis Pain Service, but they could not accommodate the referral. 16. . On March 4, 2013, patient A was discharged from Rock Creek Care Center: Patient A was supposed to follow up with-his primary care physician Dr. P.C. after he was discharged. There are no copies of medical records available re?ecting patient A?scare after he was discharged. However, according to available CURES reports, patient A was prescribed lower doses of Norco and had 2 prescriptions of Percocet 5/325 by a variety of prescribers. Patient A?s first preseription by Dr. PC. was September 2013. There were no prescriptions for methadone in patient A?s CURES report after he was discharged from Rock Creek Care Center. On March 2, .2013, the last methadone listed as ?lled was prescribed by Respondent for 90 pills. 17. On November 25, 2013, patient A died due to acute methadone toxicity. The patient died 8 months after he was discharged from Rock Creek Care Center. This was his third and last overdose. - 18. There were multiple instances when Respondent?s signature was on ?Continuation of Schedule 11 Medication Therapy? forms with the prescription either not entered le? blank) or incompletely filled out. The handwriting of these forms varied considerably and did not appear to' have been written by'one person or by Respondent consistently. It is not the standard of care for physicians to allow pre-signed prescriptions in the prescribing of controlled substances. It is also not the standard of care for physicians to Sign prior to the prescriptions for controlled subStances to be ?lled out appropriately. . I 19. Respondent committed gross negligence in his care and treatment of patient A, which includes, but is not limited to, the following: Respondent departed from the standard of care by failing to minimize ?or avoid the prescribing of opiates in a patient who was at high risk for or had multiple risk factors for opioid- associated overdose. The patient had two recent opioid overdoses with complications, and was on 7 (CHANDAN DEEP SINGH CHEEMA, MD.) ACCUSATION NO. 800-2017-032495 .28 multiple opioids and methadone. Respondent understood the signi?cance of this patient?s high Morphine Equivalent Dail'y Dosage yet continued to repeatedly prescribe controlled substances to the patient without attempting to reduce it. Therewere multiple missed opportunities during the 7.5 months that Respondent treated the patient, and multiple-visits under his supervision or his face-to?face visit, to collaboratively minimize or avoid prescribing opiates. 20. Respondent?s conduct, as described above, constitutes gross negligence in the practice of medicine in violation of section 2234(b) of the Code and thereby provides cause to discipline Respondent?s license. I SECOND CAUSE DISCIPLINE (Repeated Acts, of Negligence) 21. Respondent is subject to disciplinary action under section 2234, as defined by section 2234, subdivision (0), of the Code, in that respondent committed repeated negligent acts in his care and treatment of patient A. The circumstances are as follows: Patient A 22. Paragraphs 9 through 21? as more particularly alleged above, are hereby incorporated by reference and realleged as if fully set forth herein. 23. Respondent committed acts of repeated negligence in his care and treatment of patient - A, which included, but are not limited to, the following: Respondent departed from the standard of care by failing to write and sign prescriptions for controlled substances in a safe manner by multiple occurrences with multiple missed opportunities to correct the practice of p're-signing. A 24. Respondent?s conduct, as described above, constitutes repeated acts of negligence in the practice of medicine in violation of section 2234(0) of the Code and thereby provides cause to discipline Respondent?s license(CHANDAN DEEP SINGH CHEEMA, MD.) ACCUSATION NO. 800-2017-03 2495 THIRD CAUSE FOR DISCIPLINE (Excessive Prescribing) 25. Respondent 18 subject to disciplinary action under section 725 of the Code, in that respondent excessively prescribed controlled substances 1n his care and treatment of patient A, as more particularly alleged 1n paragraphs 9 through 19 above, which are hereby incorpOratevd by reference and realleged as if fully set forth herein. PRAYER WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing, the Medical Board of California 13sUe a decision. 1. Revoking or suspending Physician and Surgeon? 5 Certi?cate Number A 47747, issued to Chandan Deep Singh Cheema, 2. Revoking, suspending or denying approval of Chandan Deep Singh Cheema, authority to supervise physician assistants and advanced practice ?nurses; 3. Ordering Chandan Deep Singh Cheema, M.D., if placed on probation, to pay the Board the costs of probation monitoring; and 3 4. Taking such other and further action as deemed necess ry and proper. DATED: - - January 3, 2019 KIMBERLY MIRCHMEYER Executive ector Medical Board of California Department of Consumer Affairs State of California Complainant SA201 8303 604 33700671 .docx 9 (CHANDAN DEEP SINGH CHEEMA, M.D.) ACCUSATION NO. 800-2017-03?2495