STATE OF TENNESSEE DEPARTMENT OF HEALTH IN THE MATTER OF: BEFORE THE TENNESSEE BOARD OF MEDICAL EXAMINERS DARREL R. RINEHART, M.D., TENNESSEE LICENSE NO. 15431 COLUMBIA, TENNESSEE DOCKET NO: 213' i? ,u -o - FINAL ORDER Tl 3 551 9? t- a: This matter came to be heard before the Tennessee Board of Medical Examiners (Board) beginning on the 1St day of August, 2018 pursuant to a Notice of Hearing and Charges ?led against the Respondent. Presiding at the hearing was the Honorable Elizabeth D. Cambron, Administrative Law Judge, assigned by the Secretary of State. The State was represented by Samuel L. Moore, Assistant General Counsel. The Respondent was present and was represented by counsel, James E. Looper and Nathaniel T. Gorman, of the Nashville, Tennessee Bar. After consideration of the Notice of Hearing and Charges, testimony of witnesses, argument of counsel, and the record as a whole, the Board finds as follows: I. FINDINGS OF FACT Respondent has been at all times pertinent hereto licensed by the Board as a medical doctor in the State of Tennessee, having been granted Tennessee medical license number 15431 by the Board on August 17, 1984, which has a current expiration date of May 31, 2019. In addition to Dr. Rinehart?s active Tennessee Medical license, Dr. Rinehart holds an active Indiana medical license. From at least January 2008 to December, 2016 Respondent provided treatment to multiple patients. The Department conducted an investigation of Respondent?s practice that included the review of thirty?two (32) of the patient records prepared and kept by Respondent wherein the Department?s expert found all of these records to be below the standard of care. Respondent provided treatment that included prescribing narcotics and other medications and controlled substances in amounts and/or durations not medically necessary, advisable, or justi?ed for a diagnosed condition to the following patients (initials used to maintain patient confidentiality): D.A., D.B., M.B.1, M.B.2, K.B., T.C., R.D., B.G., L.G.2, R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., D.R.2, M.R., A.S., J.S., T.S., C.S.1, 08.2, and J.W. Respondent prescribed controlled substances used for the treatment of pain in conjunction with other medications with a high potential for abuse, and did so without conducting a physical examination focused on the source of pain and/or making a clear objective ?nding of a chronic pain source to justify the ongoing and increasing prescribing for the following patients: D.A., DB, M.B.2, K.B., T.C., R.D., R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., J.S., C.S.1, C.S.2, and J.W. Respondent prescribed controlled substances without consulting the Controlled Substance Monitoring Database (CSMD) as required by law for the following patients: D.A., 10. M.B.2, T.C., R.D., B.G., L.G.1, L.G.2, A.M., A.P., C.R., DR. 1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, C82, and J.W. Respondent prescribed controlled substances and other medication without obtaining a thorough history or adequately inquiring into the potential substance abuse history for the following patients and/or failing to document such history: D.A., D.B., M.B.1, M.B.2, K.B., T.C., R.D., B.G., L.G.1, L.G.2, R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., D.R.1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, C.S.2, and J.W. Respondent prescribed controlled substances and other medication without an appropriate written treatment plan with regard to the use of controlled substances and other medication for the following patients: D.A., D.B., M.B.1, M.B.2, K.B., T.C., R.D., B.G., L.G.1, L.G.2, R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., D.R.1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, C.S.2, and J.W. Respondent?s prescribing discussed herein?was non?therapeutic in nature, neither justi?ed nor medically necessary for patients? diagnoses, and not for a legitimate purpose with regards to the following patients: D.A., D.B., M.B.1, M.B.2, K.B., T.C., R.D., B.G., L.G.1, L.G.2, R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.P., V.P., C.R., D.R.1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, C.S.2, and J.W. Respondent prescribed narcotics and/or other controlled substances to persons when the quantity, duration and method was such that the persons would likely become addicted to the habit of taking said controlled substances and failed to make a bona ?de effort to cure the habit of such persons or failed to document any such effort with regards to the following patients: D.A., D.B., M.B.1, M.B.2, K.B., T.C., R.D., B.G., L.G.2, R.G.1, R.G.2, Ll) 11. 12. 13. 011., D.H., M.I-I., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., D.R.1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, C.S.2, and J.W. Respondent provided few modalities of treatment other than the prescription of controlled substances for the following patients: D.A., D.B., M.B.2, K.B., T.C., R.D., B.G., L.G.1, L.G.2, R.G.1, R.G.2, C.H., D.H., M.H., P.H., W.H., K.J., A.K., A.M., A.P., V.P., C.R., D.R.1, D.R.2, M.R., A.S., J.S., T.S., C.S.1, CS2, and J.W. Beginning on or about March 30, 2015, Respondent prescribed patient AM. a daily dose of 90mg of oxycodone for lower back pain. Respondent did not consult the CSMD before beginning this course of treatment. A urine drug screen taken from this patient on or about April 20, 2015 indicated that this patient was taking non?prescribed benzodiazepines, but Respondent did not document counseling the patient about this aberrant result. On or about June 19, 2015, Respondent increased this patient?s daily dose of oxycodone to 120mg but Respondent did not consult the CSMD before beginning this new course of treatment. On or about July 22, 2015, this patient died from a combined drug overdose including oxycodone. Beginning on or about January 28, 2015, Respondent prescribed patient M.B.1 a daily dose of 1mg of alprazolam. Respondent diagnosed this patient with agoraphobia but Respondent?s documentation indicates that the patient showed no and Respondent did not conduct a evaluation of this patient. A urine drug screen taken from this patient by Respondent on or about February 20, 2015 indicates that this patient was taking non?prescribed diazepam in addition to his alprazolam, but Respondent did not document counseling the patient about this aberrant result. On or about March 3, 2015, Respondent increased the patient?s daily dose of alprazolam to 3mg. The patient 14. 15. 16. ?lled this prescription on or aboth March 4, 2015 and died the next day from a combined drug overdose which included alprazolam and diazepam. Respondent prescribed patient D.A. a daily dose of 480mg of morphine and 1,050mg of carisoprodol. This patient also received a prescription of benzodiazepines from another prescriber. Respondent did not document cautioning the patient on the dangers of taking opioids in conjunction with benzodiazepines and carisoprodol. Three urine drug screens of this patient obtained by Respondent between May of 2014 and November of 2015 indicate inconsistencies in this patient?s medication but Respondent did not document counseling this patient on these aberrant results. On or about November 12, 2015, this patient died, three days after ?lling his last prescription from ReSpondent. Respondent signed the death certi?cate for this patient and recorded the cause of death as, ?Acute myocardial infarction.? An autopsy was not performed on this patient. Respondent prescribed patient T.S. Adderall and alprazolam. Respondent failed to consult the CSMD before beginning a course of treatment with benzodiazepines. A urine drug screen taken from this patient by Respondent. on or about November 16, 2015 indicates that this patient was taking non?prescribed hydrocodone in addition to her alprazolam, but Respondent did not document counseling the patient about this aberrant result. The patient died on or about January 21, 2016. Respondent signed the death certi?cate for this patient and recorded the cause of death as, ?Acute myocardial infarction.? An autopsy was not performed on this patient. Respondent prescribed patient R.G.1. morphine sulfate and oxycodone, and later alprazolam and Adderall. Respondent did not consult the CMSD before beginning a course of treatment with any of these controlled substances. A urine drug screen taken from this 17. 18. patient by Respondent on or about October 21, 2015 indicates that this patient was not taking her morphine as prescribed, nor had she been taking the alprazolam or Adder-all prescribed to her by her mental health provider. The results of this drug screen were circled, and the word ?retest? was written, but Respondent did not conduct another drug screen of this patient, nor did he discuss her previous inconsistent test results with her before again prescribing her morphine. After this inconsistent drug screen, Respondent also began prescribing the patient Adderall and alprazolam in place of her mental health provider. The patient filled her last prescription from Respondent on or about December 18, 2015 and died two days later of a combined drug overdose of alprazolam and morphine. Respondent?s prescribing resulted in adverse outcomes for several of Respondent?s patients, including overdoses and overdose deaths. We find that Respondent?s treatment of the patients referenced in paragraphs 1 through 16, supra, was below the statewide standard of minimal competency, pursuant to T.C.A. ?63- We find the testimony provided by Clay Jackson, M.D., the expert presented by the Department, to be credible and consistent. We ?nd that the standard of care in terms of the treatment of chronic pain, anxiety and depression is contained in our rules at 0880? and (7), such that the medical record must demonstrate a documented medical history and appropriate physical examination, including an assessment for the potential for substance abuse, diagnostic and laboratory tests consistent with good care, a written treatment tailored to the individual patient, documented discussion of the risks and bene?ts of the treatment options and periodic review of the treatment plan. Based on the testimony of Clay Jackson, MD. and our own review of the charts, we ?nd that Respondent did not meet this standard. 19. 20. 21. 22. 23. 24. 25. 26. 27. For some of the patients listed above, Dr. Rinehart provided care and treatment that began prior to January 2008. None of the thirty?two (32) patients has been called to testify or have given any form of testimony in this matter. The Department has not presented any medical charts that contain treatment past April 2016. No controlled substance monitoring database reports for any of the thirty?two (32) patients identi?ed by the Department have been entered into evidence. No charts from Dr. Rinehart?s current practice in Indiana have been reviewed by the Department?s expert, nor have any copies been entered into evidence. The state has admitted that these thirty-two (32) charts are not representative of Dr. Rinehart?s practice of medicine. Dr. Rinehart has expressed a desire to remain in and continue practicing in Indiana, where has family. Dr. Rinehart has indicated that he does not intend to return to Tennessee to live or practice. Dr. Rinehart has demonstrated that he is contrite and is willing to undergo additional education, training, and supervision. He has demonstrated that he is no longer treating chronic pain, and now realizes that his practice was not in accord with the applicable standard of care as it existed at the time in question. Dr. Rinehart has practiced in Indiana exclusively for the past one and a half years, and not practiced in Tennessee during that time. Dr. Rinehart received a letter from the management of the hospital that owned his practice and informed him that he had cured the breach of a contract matter outlined in a earlier letter dated April of 2016 related to prescribing controlled substances in his medical practice and that now he was in compliance with the Tennessee Prescription Safety Act. The letter further stated that the MRMC compliance department will continue to monitor his controlled substance prescribing patterns on a routine basis and advise him directly of any noted concerns. II. CONCLUSIONS OF LAW The facts as found in the Findings of Fact are suf?cient to establish that grounds for discipline of Respondent?s medical license exist. Speci?cally, Respondent has violated the following statutes or rules which are part of the Tennessee Medical Practice Act, (TENN. CODE ANN. 63-6?101, et seq.) for which disciplinary action before and by the Board is authorized: 28. 29. The Findings of Fact in Section I, paragraphs 3 through 18, supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. CODE ANN. which authorizes disciplinary action against a Respondent who has engaged in unprofessional, dishonorable or unethical conduct. The Findings of Fact in Section 1, paragraphs 3 through 18, supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. CODE ANN. which authorizes disciplinary action against a Respondent who is guilty of gross health care liability or a pattern of continued or repeated health care liability, ignorance, negligence or incompetence in the course of medical practice. 30. 31. 32. The Findings of Fact in Section 1, paragraphs 3 through 18 supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. CODE ANN. which authorizes disciplinary action against a Respondent who is guilty of dispensing, prescribing or otherwise distributing any controlled substance or any other drug not in the course of professional practice, or not in good faith to relieve pain and suffering, or not to cure an ailment, physical in?rmity or disease, or in amounts and/or for durations not medically necessary, advisable or justi?ed for a diagnosed condition. The Findings of Fact in Section 1, paragraphs 3 through 18, supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. CODE ANN. which authorizes disciplinary action against a Respondent who is guilty of dispensing, prescribing or otherwise distributing to any person a controlled substance or other drug if such person is addicted to the habit of using controlled substances without making a bona ?de effort to cure the habit of such patient. The Findings of Fact in Section 1, paragraphs 3 through 18, supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. CODE ANN. which requires that all healthcare professionals shall check the controlled substance database prior to prescribing opioids or benzodiazepines to a human patient at the beginning of a new episode of treatment and shall check the controlled substance database for that human patient at least annually when that prescribed controlled substance remains part of the treatment. 33. The Findings of Fact in Section 1, paragraphs 3 through 18, sup/fa, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. COMP. R. REG. RULE which authorizes disciplinary action against a Respondent who prescribes, orders, administers or dispenses dangerous drugs or controlled substances without observing Board guidelines.- 34. The Findings of Fact in Section 1, paragraphs 3 through 18, supra, constitute grounds for discipline against Respondent?s license to practice as a medical doctor in the State of Tennessee pursuant to TENN. COMP. R. REG. RULE which authorizes disciplinary action as follows: Except as provided in subparagraph it shall be a prima facie violation of T.C.A. 63?6?214 (1), (4), and (12) for a physician to prescribe or dispense any drug to any individual, whether in person or by electronic means or over the Internet or over telephone lines, unless the physician, or his/her licensed supervisee pursuant to appropriate protocols or medical orders, has ?rst done and apprOpriately documented, for the person to whom a prescription is to be issued or drugs dispensed, all of the following: 1. Performed an appropriate history and physical examination; and 2. Made a diagnosis based upon the examinations and all diagnostic and laboratory tests consistent with good medical care; and 3. Formulated a therapeutic plan, and discussed it, along with the basis for it and the risks and bene?ts of various treatments options, a part of which might be the prescription or dispensed drug, with the patient; and 4. Insured availability of the physician or coverage for the patient for appropriate follow-up care. POLICY STATEMENT The Tennessee Department of Health takes this action in order to protect the health, safety, and welfare of people in the State of Tennessee. 10 IV. ORDER NOW THEREFORE, Respondent, for the purpose of avoiding further administrative action with respect to this cause, agrees to the following: 35. 36. 37. 38. 39. The Tennessee medical license of Darrel R. Rinehart M.D., license number 15431, is hereby SUSPENDED until May 31, 2019 at which time his license will expire. Dr. Rinehart will be prohibited from renewing this license, reinstating this license, or applying for a new license. The Tennessee Board of Medical Examiners will notify the Indiana State Medical Board of this action. It is recommended that Dr. Rinehart successfully complete a course on medical record keeping and prescribing controlled substances. Respondent is assessed and must pay, pursuant to TENN. CODE ANN. ?63?6?214 and Rule of the Of?cial Compilation Rules and Regulations of the State of Tennessee, thirty-two (32) Type Civil Penalties in the amount of one thousand dollars each for a total Civil Penalty of THIRTY-TWO THOUSAND DOLLARS Respondent must pay, pursuant to TENN. CODE ANN. 63-6-214(k) and Rule 0880?02- of the Official Compilation Rules and Regulations ofthe State of Tennessee, the actual and reasonable costs of prosecuting this case to the extent allowed by law, including all costs assessed against the Board by the Division?s Bureau of Investigations in connection with the prosecution of this matter. These costs will be established by an 11 Assessment of Costs prepared and ?led by counsel for the Division. The maximum amount for the assessment of costs shall be one?hundred thousand dollars 40. ReSpondent understands that this is a formal disciplinary action and will be reported to the National Practitioner Data Bank (N .P.D.B.) and/or similar agency. IV. NOTICE 41. Any and all civil penalties and costs shall be paid in full within one hundred eighty (180) of Medical EXaminers at a public meeting of the Board and signed this in! days from the issuance of the Assessment of Costs. Payment shall be made by certi?ed check, cashier?s check, or money order, payable to the State of Tennessee, Department of Health. Any and all payments shall be forwarded to the Disciplinary Coordinator, The Division of Health Related Boards, Tennessee Department of Health, 665 Mainstream Drive, Floor, Nashville, Tennessee 37243. A notation shall be placed on said money order or such check that it is payable for the Costs of Darrel R. Rinehart, Case No. 201601273. This FINAL ORDER was approved by a majority of a quorum of the Tennessee Board 2-0 dayof 2018. a flu/M W. Reeves John?n- Jr. Acting Chairperson Tennessee Board of Medical Examiners Filed in the Administrative Procedures Division, Of?ce of the Secretary of State, this the day of MOWW 2018. IQ. ?c?ud J. Rh:th Collier, Director Administrative Procedures Division 12