Medical Negligence & Errors Archives — The Patient Safety League

THE MEDICAL FARCE OF CALIFORNIA

July 22, 2019 / Eric Andrist / Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California, Uncategorized

By Eric Andrist & Marian Hollingsworth
Co-Executive Directors of The Patient Safety League

How many reading this know that California has a Medical Board whose sole purpose is to regulate doctors in order to keep patients safe? Did you know that you can report a complaint about a doctor to the Medical Board? Our organization comes across people all the time who had no idea they could file a complaint against a doctor. Far too many people, unfortunately, put doctors on pedestals and think they can do no wrong, and even more believe that medical errors will never happen to them or a loved one. Think again, it’s happened to both of us, three times for Eric Andrist. More on that later.

Now, how many believe that if you did report a bad doctor to the Medical Board, they would effectively handle the complaint, and protect consumers from further harm?

It is estimated that over 40,000 patients die in California alone each and every year, from preventable medical errors, making it the third leading cause of death behind cancer and heart disease. We’re not talking about accidents, we’re talking about errors that absolutely could have been avoided.

Here’s another stat for you: The Medical Board of California takes in nearly 11,000 complaints every year, but only about 4%* of them end up with any discipline.

[*From the 2017-2018 Annual Report of the Medical Board of California. If you add up the “Administrative Outcomes” in the far right column, it comes to 406, which is about 3.7% of the 10,888 complaints they took in, in the top graphic.]

So what’s going on with the other 96%? That’s what we’d like to know, too, but the Board is protected by laws that allow them to hide their actions from the public. The Board will post disciplines against doctors — but not complaints. Every 4 years, through the Sunset Review the legislature pretends to care about making the Board better and fixing any problems, but there is little real accountability going on. We sent the legislature a 200+ page report detailing problems with the Medical Board, and not one legislator contacted us and thanked us or bothered to ask any questions, they just extended the Board for another 4 years despite what we told them.

IF THE MEDICAL BOARD MOVED ANY SLOWER, THEY’D GO IN REVERSE.

What is even more surprising is that the Medical Board takes on average, 2 1⁄2 to 3 years to complete a full investigation of a doctor and levy a discipline. We’ve even unearthed investigations that took between 4 and 6 years.

20-year-old Alex Smick of Downey was overdosed to death after he checked himself into a hospital after taking too many pain meds for sports injury. Dr. Daniel Headrick gave him a lethal cocktail of medications and then instructed the staff to NOT check on him while he was sleeping. The next morning he was found face down in his bed in a pile of vomit, dead. It had been so long since anyone had checked on him that he was already in rigor mortis. Alex died on February 23, 2012. His family filed a Medical Board complaint against Dr. Headrick on November 6, 2013. The Board couldn’t be bothered interviewing the doctor until October of 2015 almost two full years after the complaint was filed. It took another 8 months for it to be referred to the Attorney General’s office and then another 4 months until an Accusation was filed against the doctor. Then, right before Christmas of 2017, 5 1⁄2 years after Alex’s death, the family received the Medical Board’s decision in the death of their son. Dr. Daniel Hearick was given a “Public Reprimand,” a disciplinary action that is only intended for the most minor of violations, certainly not a death. In total, it took 4 years and 16 days (or 1477 days) for the Medical Board to process the Smick’s complaint. Watch Alex’s parents as they hold the Medical Board accountable at one of their quarterly meetings. Dr. Headrick later went on a public television show, bragging about his lenient discipline from the Board and putting the blame on everyone but himself.

Alex Smick, left, Dr. Daniel Headrick, right.
Photo sources: Tammy Smick and “Inside OC with Rick Reiff”

Some of the complaints that are under review at this moment are from 2013; the Medical Board does not move quickly to resolve complaints even when they involve the death of a patient.

96% DISCIPLINARY FAIL RATE

Ponder this. The Medical Board derives the bulk of its working capital from the license fees of the very doctors that they also have to discipline. How is that not an automatic conflict of interest? If they revoke too many licenses, they’d lose those license fees. The Board complains all the time about not having enough money to pay staff and investigators (even with a budget over $60 million) and that’s with closing 96% of the consumer complaints. If even 50% of those closed complaints are legitimate, how could they possibly investigate them, when they apparently don’t even have enough money to investigate the 4% they do end up disciplining?

On January 22, 1993, the Los Angeles Times published an article detailing how rank and file employees of the Medical Board blew the whistle on their superiors who had been literally throwing consumer complaints in the trash in order to clear their desks of them.

“Among the investigation’s findings was the disclosure that hundreds of Medical Board cases had been improperly dismissed–and in many instances destroyed–in an apparent attempt to reduce a backlog that had prompted criticism from the Legislature. [Whistleblowers] said a three-person management team marched into several key offices in 1990 and began going through files. They said certain files were tagged, indicating that they should be closed and in some cases destroyed. Those that were targeted, they said, seemed to be the cases involving doctors free from previous complaints or patients who had not followed up to see if the board had pursued their complaints. “You would see a stack of files two feet high on a supervisor’s desk one day and by the next hardly any would be left,” recalled one investigator. [Los Angeles Times, January 22, 1993]

It’s hard to not wonder whether this is still happening today.

Annette Ramirez of South Bay was harmed by Dr. James Scharffenberger who sliced her bowel after a routine surgery. For more than 36 hours nurses failed to report her abnormal vital signs and her doctor failed to adequately follow up to check her condition after surgery. An infection rapidly spread through her system causing her to go into septic shock. Gangrene spread to her arms and legs, which led to the amputation of her arms and legs, as well as the excision of flesh from multiple areas of her body.

Annette filed a complaint with the Medical Board only to have them close it down within months without any discipline for the doctor that left her in this condition.

Annette Ramirez. Photo source: CAOC

And lest you think Annette’s story is an exception, we have gathered a number of egregious stories of patients being harmed and the Medical Board closing their complaints, including 2 others with patients who had their arms and legs amputated: Robert Downey, Mario Guzman, Daniela Zelig, Morgan Westhoff, Cali Andrist, Eric Andrist.

DEALS, DEALS AND MORE DEALS!

In April of 2016, the son of TV Judge Glenda Hatchett, Charles Johnson and his wife Kyira, checked into Cedars Sinai to have a baby by repeat elective cesarean delivery in the early afternoon. The procedure was performed by Dr. Arjang Naim.

Dr. Arjang Naim. Photo source Yelp.

Not long after their son Langston was born, blood-tinged urine was seen in Kyira’s catheter. Six hours later, Dr. Naim was notified about a concern for internal bleeding. A massive transfusion was initiated and she was taken to the operating room shortly before midnight. During that surgery, Kyira was found to have 3 liters (or about 4⁄5 of a gallon) of blood in her abdomen. Kyira’s heart stopped on the operating table at 1:15 AM; she was declared dead at 2:20 AM, not being able to survive the massive blood loss. Charles Johnson filed a complaint with the Medical Board and in October of 2018, the Board gave Dr. Naim just 4 years of probation, an amount less than their own minimum guidelines recommend. At our request, Charles flew to San Diego for the Medical Board’s quarterly meeting shortly after the decision was announced, and confronted them about it. His passionate speech can be viewed HERE.

PERVERTED DOCTORS IN THE NEWS

We’ve been working with several news outlets on reports about local area doctors. This past November, 10News in San Diego ran a story on more than 150 area doctors who were disciplined for sexual abuse and other serious violations. In December NBC-LA chronicled the story of Sarah Al-Habib and how she had been sexually assaulted by her doctor, Dr. Zaher Azzawi of Rancho Cucamonga. In February, NBC told the story of three L.A.-area doctors, all of whom are on the Sex Offender Registry, but are still practicing medicine, and how the Medical Board of California makes no effort whatsoever to warn patients about them. Here’s 32 doctors in the state of California who appear on the Sex Offender Registry (most of them are no longer practicing.)

Recently, we discovered the case of a Dr. Robert Stephens, an anesthesiologist in San Diego. Several nurses reported witnessing him sexually assaulting a number of unconscious patients. The case was reported to the California Department of Public Health who in turn should have reported it to the Medical Board of California. We have been unable to find any evidence that they did. The Medical Board verified that he is under investigation, but they refuse to warn the people of this state about him, insisting that the law does not require them to. Oddly, though, their sister agency, the Contractors State License Board does warn consumers when one of their contractors has had a complaint filed against them. Apparently, our legislators think consumers should know about a bad bathroom contractor, but not about a doctor that could sexually assault them the next time they’re in the hospital, unconscious.

To show how bad the laws are that govern the Medical Board, take a look at the case of Dr. Ryszard Chetkowski, who runs a fertility clinic in Berkeley. Chetkowski was accused by at least six women of sexual misconduct. Even after the Medical Board detailed the horrific sexual assaults in seven causes for discipline in an accusation, the Board still only gave him a Public Reprimand. By law, Public Reprimand’s disappear from the Board’s website after 10 years, unlike other documents which remain visible indefinitely. So, if you look up Chetkowski on the Board’s website now, he has a completely clean record; there’s not one mention of the sexual assaults anywhere. It begs the question, were favors done for this doctor so that he was purposely given a discipline that would eventually disappear, even with the severity of the charges? Is no act heinous enough that it can’t be bartered away?

Dr. Ryszard Chetkowski. Photo source: Sutterhealth.org

By not acting quickly enough (or at all), the Medical Board puts consumers in danger. A great example of this is the case of Dr. Michael Popkin of Granada Hills. According to reports, the Medical Board knew about sexual assault complaints against Popkin as far back as 2001. An accusation was filed against him in November of 2003, but contained no charges of sexual misconduct. It became clear that he had continued to sexually assault patients when he was arrested in 2016. The court issued a court order preventing him from treating female patients in October of 2017 and the Medical Board finally revoked his license in April of 2018, some SEVENTEEN YEARS after first receiving sexual assault complaints about him. Because of the Board’s inaction, more people were harmed.

Dr. Michael Popkin’s mugshot. Photo source: LAPD.

ABSOLUTE POWER CORRUPTS ABSOLUTELY

When we first started doing our in-depth investigation of the Medical Board, one of the first cases we looked into was that of Dr. Hari Reddy, a doctor who had his license revoked over the sexual assault of 4 patients, one of which was a 15-year-old girl. He tried once to petition the Board to get his license back and they denied the request. He applied one more time in 2010. This was shortly before Governor Jerry Brown appointed Reddy’s friend, classmate and co-worker, Dr. Dev GnanaDev to the Medical Board. Long story short (and you can read more about it HERE), on GnanaDev’s very first disciplinary panel case, they voted to give Reddy his license back. Not long after this occurred, Reddy’s brother-in-law, another Reddy by the name of Prem Reddy (CEO of the always-in-trouble Prime Healthcare), donated over $40 million to GnanaDev’s new medical school in the Inland Empire, and now serves as the school’s chairman of the board.

Dr. Hari Reddy, left. Photo source Vimeo.
Dr. Dev GnanaDev, middle. Photo source calmedu.org.
Dr. Prem Reddy, right. Photo source calmedu.org

Recently, the Medical Board and the Attorney General’s Office had to fess up to one of their own medical “experts” (Dr. Aaron Stone) behaving in such a way that the accusation against Beverly Hills plastic surgeon, Dr. Kenneth Hughes, had to be dismissed. Hughes’ attorney basically called the expert a liar and corrupt. So, while the accusation very well could have had legitimate concerns in it, the Board was forced to dismiss the action and now, Hughes’ profile on their website provides no information whatsoever to the public in regard to anything a patient might need to be concerned about. You can watch key portions of the hearing exposing the “corrupt expert” HERE. Hughes has at least two pending court cases in the Los Angeles Superior Court, but you won’t find that information on the Medical Board’s website, either.

In 2014, Eric Andrist, the co-author of this article, was diagnosed with 4 hernias. He went to see a surgeon, (Dr. Kulmeet Sandhu) in 2015 and laparoscopic surgery was performed that fall. A few months later, all of his symptoms returned and he went back to her in 2016. She ran more tests and blamed the reoccurrence on his “bad genes.” He went back in for a re-do surgery in the fall of 2016. A few months later, all of his symptoms returned once again and he again went back to see the surgeon. She ran more tests and found that the hernia was even worse than when he had started out. She was prepared to take him in for a third surgery, but now, not trusting that she knew what she was doing, he went to get a second opinion. The new surgeon ran a battery of tests and told him he was in terrible condition and they needed to do surgery right away, which took place in the fall of 2017. During the surgery, the new surgeon found that Dr. Sandhu had actually sewn his stomach to itself (in a procedure called a Full Nissen Fundoplication), instead of to the esophagus, rendering it useless. To top it all off, the hospital sent him home after the surgery without checking the surgery site. When he got home, he discovered that his eight-inch incision had popped open and he could see into his abdomen. He filed complaints with both the Medical Board (on Sandhu) and the Department of Public Health (on Glendale Adventist Hospital). Both complaints were closed without investigation.

There appears to be a price to pay when someone tries to hold the government accountable.

We started our little nonprofit, The Patient Safety League, so that we can officially try to help victims of medical errors, warn the public about doctors with all degrees of disciplinary actions, and monitor state agencies like the Medical Board of California and the Department of Public Health, both of which are not properly protecting us. We started our website due to the lack of information on the Medical Board’s website. Consumers can check our website HERE. Right now we’re existing hand to mouth, and it often costs us a lot of money from our own pockets to do our job. Ironically, a doctor recently reached out and helped us come up with the money we needed to get us to the upcoming Medical Board meeting in northern California next month. Tax-deductible donations can be made to the Patient Safety League on their website.

This article was originally published in a shorter format on CityWatchLA. Special thanks to them for all the work they do helping people stay informed.

State Task Force Forming to Investigate Stem Cell Clinics

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California

“Unproven but profitable”. That’s the headline of a recent Journal published by the American Medical Association, exploring the explosive growth of stem cell clinics across the country, including here in San Diego County. The clinics offer questionable “breakthrough” cures for a wide range of health problems.

In May, NBC 7 Investigates first reported on these “surgery-free” fixes that were drawing hundreds of local potential buyers to free seminars. In one seminar, attendees were not told that the costly procedures, sometimes costing up to $6,500 per injection, have not been FDA-approved, nor were they told the procedures do not have scientific support for their claims.

The only proof provided to patients are testimonials from patients who say the products were miracle workers.

Investigating Claims Made By Local Stem Cell Clinic

[See video on website.] NBC 7 Investigates went undercover at a stem cell clinic to see if the clinics are promising legitimate results. NBC 7’s Mari Payton reports. (Published Wednesday, May 23, 2018)

Now, the claims made by these clinics have gotten the attention of the California Medical Board and has led to the creation of a task force to review the clinic’s practices. The task force was formed as a result of an inquiry about the industry from the chairman of the U.S. Senate Health, Education, Labor, and Pensions Committee.

Currently, the only stem cell-based products approved by the Food and Drug Administration (FDA) are for transplant procedures. But these clinics are offering something different. Clinics advertising through Stem Cell Health Centers offer stem cell injections that they say are a “cutting edge treatments” that offer “regenerative cures”.

NBC7 Investigates has found newspaper and broadcast advertisements for free seminars running nearly daily in San Diego, making stem cell health claims without providing specific information about what procedures are performed.

Advertisements for Stem Cell Health Center seminars can be seen in the local newspaper nearly daily.

The ads list hotels hosting these seminars from Oceanside to Chula Vista, all centered around how to “restore your pain-free life”.

NBC 7 Investigates spoke with a registered nurse and a patient advocate who agreed to attend two of these stem cell sales presentation seminars, one in Mission Valley and the other in Rancho Bernardo.

Attendees, working with NBC 7 Investigates, walk into a Mission Valley stem cell seminar on September 25, 2018.

At both locations, Chiropractor Doctor Jared Taylor pitched to the crowd stem cell injections, costing at least $5,000 each, through the Create Wellness clinic in La Jolla. After the seminar, Taylor would not comment on the claims and treatments offered in the seminar. Create Wellness is owned by Acupuncturist Roya Nikzad, who did not return NBC 7 Investigates’ calls for comment.

In May, NBC 7 Investigates found another chiropractor, Michael Van Derschelden, using similar sales tactics at a Carlsbad hotel seminar. Van Derschelden told the audience of mostly senior citizens, some in wheelchairs, that he’s a specialist in regenerative medicine at West 2 North Medical Solutions in San Marcos. After the seminar, Van Derschelden refused to answer questions surrounding the claims he made to seminar attendees.

Promises of Pain Relief

For Actor Ed Hollingsworth, pain relief is top of mind. Hollingsworth has serious back, spine, knee and shoulder injuries, so he agreed to attend a stem cell sales seminar in Mission Valley and relay what was said to NBC7 Investigates.

“I heard a lot of anecdotal things,” Hollingsworth said. “[I] didn’t see a lot of proof. It concerns me the fact that it is so expensive. Like for me, with all the different areas, it would cost me conservatively maybe $30,000 to get all the different [treatments].”

His wife, patient advocate Marian Hollingsworth, said the sales pitch included numerous promises for pain relief.

“They talked about an I.V. infusion [offered] for somebody with cystic fibrosis. And that this woman is [now] off her meds,” she said. “Now this is somebody who was turned down for a lung transplant. So that’s a pretty hefty claim.”

NBC 7 Investigates found orthopedic problems are the primary draw for the clinics but not the only claim of relief promised by the chiropractors in the sales seminars.

The underlying “science” of the claims made in these seminars is that the injections “take advantage of your body’s ability to repair itself naturally,” according to the clinic’s advertisements.

“They didn’t really say what is in it exactly, besides stem cells from birth waste,” Marian said. “And that seemed kind of farfetched.”

While Marian and Edward attended the seminar in a hotel conference room, NBC 7 Investigates Producers sat in the hotel lobby. The couple texted Producers about the different claims made by Dr. Taylor. Some of the claims made involved “cures” for a range of ailments, including Alzheimer’s and Parkinson’s disease.

“[They] said only one shot was needed, with pain relief in two to four weeks with no downtime,” one text read.

“Stem cell therapy helps with COPD–lung disease,” Marian Hollingsworth texted. “They claim [to have] FDA clearance.”

Outside of the Mission Valley hotel conference room where the seminar was held, Create Wellness Clinic Director Melody Darvish sat and shared information with attendees as they left the presentation. After attendees left, NBC 7 Investigates asked her what the term “FDA clearance” meant but she would not tell us.

“I think you have all the information you need,” Darvish said.

NBC 7 Investigates asked the FDA about the term “FDA clearance” versus “FDA approved”.

Stephanie Caccomo, a spokesperson for the FDA, said the term “FDA Clearance” only applies to medical devices, not treatments. And that the stem cell procedures offered by these clinics are neither approved or cleared.

NBC 7 Investigates also asked Dr. Taylor about the fact that on the day of the Mission Valley stem cell seminar, September 25, his chiropractor license was expired.

Doctor Jared Taylor’s license was expired on September 25, 2018, the day of the Mission Valley stem cell seminar. The license has since been renewed.

Taylor said his license wasn’t suspended and that he had “sent his paperwork through the mail.” According to California’s Department of Consumer Affairs website, Taylor’s license, issued out of Utah, had expired in February after the “licensee failed to pay renewal fees”. NBC 7 Investigates found no previous disciplinary actions are taken on Taylor’s license and since the seminar, his license has been reinstated.

The website for Create Wellness, the La Jolla clinic Taylor works for, states his role is to consult with potential candidates for stem cell therapy and to “utilize functional medicine for customized healthcare.”

Stem Cell Health Centers

NBC 7 Investigates has found a common thread with all of the stem cell seminars and advertisements for these treatments, a group called Stem Cell Health Centers. Stem Cell Health Centers has used similar advertisement campaigns involving chiropractors and acupuncturists in 14 states, including California.

Digital forensic experts confirmed what NBC 7 Investigates found, that Stem Cell Health Centers’ website has done a good job of hiding the creators of its domain. The domain was created in July 2017 with a private registration invoked immediately.

Materials on Stem Cell Health Center’s website link to a 40-year-old Salt Lake City acupuncturist named Regan Archibald.

On the website, an e-book written by Archibald is offered for free and referenced often titled “The Stem Cell Breakthrough”. In the book, he claims Stem Cell Health Centers has seen, “well over 25,000 [stem cell] cases with over a 90% success rate.”

Archibald also states in the book that his own life experiences and injuries led to his discovery that, “stem cell therapy could repair and enhance”.

NBC 7 Investigates contacted Archibald to find out more about Stem Cell Health Centers and he said he has nothing to do with what other clinics are claiming at seminars, including here in San Diego. “This is simply a website where individuals and clinicians can reference many of the studies that I’ve found to be helpful. I’ve been able to learn from Arnold Caplan Ph.D.”

Dr. Arnold Caplan of the Case Western Reserve University and a noted expert in the field of stem cell research told NBC 7 Investigates, “I do not know this guy but am VERY (sic) supportive of your efforts to strip away the unsubstantiated claims made by many online”

When asked about Archibald’s role with Stem Cell Health Centers, the advertising campaign and for proof behind claims made in his book and elsewhere, Archibald stopped responding.

On YouTube, Archibald provides a video tutorial or “how to” for anyone interested in starting a stem cell practice.

Stem Cell Clinics Across the Country

Leigh Turner of the University of Minnesota Center for Bioethics said the rise in stem cell treatment offers here in San Diego can be seen across the country.

“We’re talking about hundreds of these across the United States,” Turner said. “By my count, it’s over a thousand at this point.”

Other experts NBC 7 Investigates spoke with provide similar figures on the number of stem cell clinics.

Turner notes the clinics are expanding rapidly, with different owners and clinic names, all making similar promises. He believes it’s up to both state and federal agencies to investigate this further, but so far they have largely ignored the issue.

“If someone has set up shop in San Diego or San Francisco or somewhere else, that company can market stem cell treatments for years with no evidence behind what they’re doing and no one’s going to come knocking on their door,” Turner said.

But that may be changing, at least here in California. Recently, the California Medical Board announced they are setting up a task force to investigate the claims made by these stem cell clinics, among other things.

Its impetus was a letter from U.S. Senator Lamar Alexander (R-TN) to the Federation of State Medical Boards, in which he voiced concerns that “recent reports indicate some patients have been harmed by unproven or investigational treatments received at stem cell clinics.”

The Federation was asked to create a “best practices” list for state medical boards to review when dealing with these types of clinics. The result is 11 recommendations that range from reviewing a clinic’s marketing materials to physicians being required to support health claims made with documented evidence.

A spokesperson for the California Medical Board said they are now reviewing the Federation’s recommendations but there is no date set for when the task force will get to work.

NBC7 Investigates has learned the California Attorney General and San Diego County District Attorney’s offices have both received information on various stem cell clinics and their practices. Neither office would confirm or deny that any active investigation is taking place.

November 28, 2018 | JW August, Mari Payton, Tom Jones | NBC San Diego

How a multimillion-dollar empire built around urine drug tests exposes flaws in California’s rehab laws

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California

Tammy Smick of Downey, sits in the bedroom of her son, Alex, who died in 2012 from a lethal combination of prescription medications while being treated at an Orange County drug treatment center. (Photo by Nick Agro, Orange County Register/SCNG)

Philip Ganong, his wife and their 34-year-old son built a fast-growing, multimillion-dollar empire on urine.

They collected it from drug addicts at their chain of Southern California sober living homes. They created labs to test it. And they charged insurance companies to analyze it.

But the success story was a scam, according to prosecutors, who have accused the Ganongs of fraud. They say the family used a network of doctors and others to bilk insurers out of as much as $22 million for tests that were unnecessary or never performed.

The Ganongs have pleaded not guilty and are awaiting trial.

But the allegations raised in the Ganong case highlight what a growing number of critics say are chronic shortcomings in the oversight of California’s multi-billion-dollar drug rehabilitation industry.

Among the complaints:

Drug counselors and others can run sober living homes and some types of treatment centers without passing any kind of criminal background check. Even people convicted of drug crimes are allowed, under current state law, to get a license to own and/or operate drug and alcohol rehab centers.
Addicts and families considering rehab have no easy way to check the records of treatment centers, recovery homes or their owners or staff.
The state lags behind others in adopting reforms to crack down on treatment center operators who exploit vulnerable addicts and focus more on profits than on effective care.

California is “the wild, wild west right now,” said Kansas Cafferty, a commissioner with the National Certification Commission for Addiction Professionals.

In a state with about 1,800 licensed recovery centers and an unknown number of unlicensed sober living homes and testing labs, Cafferty is among many who believe California needs to get better at rehab regulation.

“There (are) a lot of places committing crimes that authorities are trying to enforce, but they can’t keep up with it.”

Just following the rules

Marlies Perez, chief of the California Department of Health Care Services’ Substance Use Disorder Compliance Division, which licenses rehab treatment centers, said her agency can only do what the state Legislature allows.

She would not say whether her department needs more authority, or if it is doing a good job protecting consumers.

“We’re not going to quantify our functions,” Perez said. “Our role is to provide oversight. That is, once again, exercise the authority that we have” and work with other regulatory agencies when appropriate.

Carol Sloan, the health department’s spokesperson, said state codes list specific causes for denying a treatment center license. Reasons include prior revocation of a license and failure to comply with fire codes. Other than that, applications from would-be operators and counselors generally aren’t screened by the state.

Drug counselors in California are certified by industry-related agencies to work in recovery programs. And once certified, they’re governed by a code of conduct written by the certifying agency that could make them subject to discipline for such things as sexual misconduct or drug abuse.

But officials and critics say neither the third-party certification organizations, nor the state health services agency, are routinely notified by law enforcement or state officials when treatment center operators or their workers are convicted of crimes or disciplined for license violations.

Stalled in Sacramento

It’s not a new problem, and California legislators have fought about it for years. Still, they’ve made only halting progress in beefing up licensing standards and rehab monitoring. That’s partly because of industry lobbying, and because of fears that tighter rules will raise treatment costs or limit the number of rehab beds just when the nation’s opioid crisis is cranking up demand.

This year, State Sen. Pat Bates, R-Laguna Niguel, introduced a bill to reform the system, but it stalled in committee. Today, she describes the state’s oversight of rehab operators, sober living homes and counselors as “troubling.”

Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)

“There is significant resistance … to looking at a (rehab operator’s) background,” Bates said. “There’s a culture about giving these people a second chance.”

Still, she insists that background checks and tougher licensing requirements for counselors, employees and rehab operators are vital. “It’s something we need to pursue.”

The Ganongs – who ran sober living homes in Los Angeles, Orange and San Diego counties – could face decades in prison if found guilty of running fraudulent urine-testing operations.

Since they were charged in May, the Ganongs apparently have shut down their recovery homes, according to one of their attorneys. Phone numbers for some of their operations are disconnected.

But there are no state rules that required them to do that. And even if they are convicted and sentenced to prison, the Ganongs still could legally own sober living homes in California. There’s no law preventing it.

At least one family member already has worked in the rehab business with a drug-related criminal record.

Prosecutors say William Ganong served as corporate secretary of the family’s sober living homes and a director of one of the drug testing labs named in the county’s fraud case. In 2006 and 2008, records show, he pleaded guilty to two misdemeanors involving being under the influence of a controlled substance and driving under the influence.

William Ganong (Photo courtesy of OCDA)

This summer, when prosecutors charged William Ganong and his relatives with fraud, he faced a series of new misdemeanor charges filed in 2014 and 2015 for allegedly possessing an opium pipe, driving under the influence, speeding and giving false information to police. William Ganong could not be reached, and his attorney did not respond to interview requests.

A lawyer representing Philip Ganong, the 64-year-old family patriarch, did talk.

In what might be a statement about the general weakness of rehab regulation and oversight, Kate Corrigan indicated a key part of her client’s defense could be to cite the law itself.

“There was great effort to comply on his part,” Corrigan said.

“But it’s not an area that has a good definition of what you can do and what you cannot do.”

Who is the doctor?

Tammy Smick lost her 20-year-old son, Alex, nearly six years ago, after he was admitted to an Orange County treatment program. The coroner’s office concluded he died of acute intoxication from the combined effects of several drugs. State records show the drugs were ordered during Alex Smick’s treatment.

Alex Smick and his girlfriend, Tarra. (Photo courtesy of Smick family)

Four years later, following an inquiry, investigators recommended that the state medical board discipline the doctor who ordered the drugs, Daniel Headrick. The formal accusation filed by the state attorney general’s office alleges Headrick engaged in “repeated negligent acts” in connection with the medications he ordered for Alex Smick.

Records also show a nurse was cited and fined $1,000 by a separate state agency because he was late in logging in Smick’s medication records, posting the information a half-hour after he was found dead.

Headrick denies the state’s allegations involving him, said his attorney, Raymond McMahon. The care Headrick provided was proper, McMahon added, and any issues involving Alex Smick’s treatment “relates to nursing care, not physician care.”

State officials declined to comment on the progress of Headrick’s case. Tammy Smick said the attorney general’s office and the Medical Board recently told her they have agreed to settle the case, without providing details. Potential penalties range from suspension or revocation of Headrick’s license to probation or a public reprimand, according to the accusation.

After their son’s death, the Smicks settled a malpractice lawsuit against Headrick, the terms of which weren’t disclosed.

Tammy Smick, center, flanked by her husband, Tim left, and son, Chris, called on the Medical Board of California to crack down on doctors whose overprescribing of medications has led to death or serious injuries during a rally at the Capitol in Sacramento in 2013. (AP Photo/Rich Pedroncelli)

Tammy Smick, a Downey teacher, threw herself into activism after her son’s death, retelling his story and focusing on issues such as overprescription of opioids and California’s cap on medical malpractice payouts, which she argues undercuts doctor accountability.

“Our goal is bringing awareness to medical malpractice (in) the opioid industry and detox centers,” she said.

Since Alex Smick’s death, Headrick has opened a drug treatment center, Tres Vistas Recovery in San Juan Capistrano, where he is listed as owner and medical director.

Addicts or their families considering using that rehab can learn about the state allegations involving Headrick, but only if they know where to look. In October 2016, details of the Headrick case were posted on the Medical Board of California website.

Tammy Smick believes it’s not enough. She says people considering rehab wouldn’t necessarily know to turn to the Medical Board website. She believes there should be an easier, centralized way to get official disciplinary records on rehabs, their operators and key staff.

State health officials say even when a doctor’s license is revoked, he or she can still operate a treatment center and profit from it, though they could not provide medical care to patients.

California lags other states

Smick is not the first to raise the issue of transparency. A state Senate report in 2012 found a host of oversight problems in the recovery industry, including poor monitoring of rehab centers and inadequate information sharing related to treatment center operators.

Other state officials have pointed to financial abuses in the industry that authorities say bleed millions from public and private pockets. Part of the concern is tied to so-called “junkie hunters,” people who recruit addicts from around the country and bring them to rehab centers in California in return for kickbacks.

One area of the rehab industry – sober living homes – has virtually no oversight.

The homes, where addicts often live for a few months after leaving formal rehab, aren’t required to submit any records of their operations. This is true, in part, because operators aren’t claiming to provide medical treatment and the people living in them, recovering addicts, are protected under the Americans with Disabilities Act.

The state’s findings from 2012, and a follow-up report in 2013, have sparked debate about how to regulate the industry. But that debate hasn’t prompted big change, and critics complain that California – which has about 1,800 licensed rehab centers, including more than 1,100 in Southern California – is falling behind other big states in vetting and licensing rehab centers.

“The big issue is, what do the licensure laws look like?” said Michael Cartwright, CEO of American Addiction Centers, one of the nation’s largest for-profit treatment chains. “Are they standard? Do they follow good guidelines other states follow? No, they do not.

“Time and time again, the problems get worse and worse,” Cartwright added. “Progressive states like Massachusetts, Pennsylvania, New Jersey … are making serious progress.”

Some of the biggest changes are taking place in Florida.

Like California, Florida has become a hotbed of out-of-state addict recruitment and scandals related to widespread fraud and dangerous patient care. In June, Gov. Rick Scott signed a package of reforms aimed at cleaning up the industry.

The new regulations call for background screenings for all owners, directors and clinical supervisors of sober homes. They clarify laws to make kickbacks illegal and empower state regulators to make unannounced visits to sober homes. They also allow state prosecutors to use racketeering laws to crack down on patient brokering and fraud networks in the industry.

In addition, licensed treatment centers in Florida have been prohibited from referring addicts to sober living homes that have not met the standards of a voluntary, third-party certification process.

Other states are taking actions as well.

In Pennsylvania, as part of the state’s response to the opioid crisis, lawmakers authorized funding for 45 “Centers for Excellence,” treatment facilities that combine medical, behavioral and job training services for 11,000 addicts. And the governor is pushing for the state to begin regulation of sober living homes.

Coming to America

Tonmoy Sharma worked as a psychiatrist in the United Kingdom before losing his license in 2008 for allegedly dishonest and unprofessional conduct in connection with research involving patients.

With a map of ambitious plans for expansion as a backdrop, Tonmoy Sharma, founder and CEO of Sovereign Health, an addiction treatment company, talks about the recent FBI raid earlier this year in San Clemente. (File photo by Mindy Schauer, Orange County Register/SCNG)

He also was accused of employing titles he did not possess – “Ph.D.” and “professor” among them – and “fell significantly short of the standards to be expected of a medical practitioner undertaking medical research on human subjects,” documents from the United Kingdom show.

Sharma said he believed he had obtained proper ethics clearances when he did his research, and that his course of study was equivalent to a Ph.D. so he was justified in using the title. A spokesman said he no longer practices psychiatry.

After moving to Southern California, Sharma built a chain of drug treatment centers, Sovereign Health, with nine centers in California and four other states with 743 beds. He also has centers that treat people for mental illness.

But before starting his businesses in the United States, Sharma’s background wasn’t widely known to California regulators.

His application to run rehab centers sparked no criminal or disciplinary background check. His application to run mental health care facilities did bring scrutiny from the state’s Department of Social Services, which oversees other types of group homes, and he was allowed to operate. There is no indication that the Dept. of Social Services alerted any other state agency about Sharma’s licensing issues and other problems in the United Kingdom.

Today, Sharma and Sovereign Health are under investigation by the FBI.

Tonmoy Sharma, founder and CEO of Sovereign Health, an addiction treatment center, shows reporters photos from the FBI’s recent raid of his company, He feels he is being unfairly targeted by the government. (File photo by Mindy Schauer, Orange County Register/SCNG)

Sharma says he has done nothing wrong. He contends the FBI investigation was sparked by an ongoing legal battle he’s waging with the insurance provider Health Net.In June, federal agents raided his offices and confiscated records and computers. Documents related to the FBI’s search warrant have been sealed, so the focus of the investigation is not public.

The health care giant has accused Sharma’s company of billing fraud worth more than $33 million. Sharma has responded by accusing Health Net of improperly cutting off payments for patient care.

Separately, the Dept. of Social Services is seeking to revoke Sharma’s license to run group homes for the mentally ill over allegations that proper consent was not given to perform genetic and HIV testing on children, among other problems.

But even as he battles law enforcement, the state and at least one major insurer, Sharma is among those who argue that there is “no quality control” in the state’s rehab industry.

“You will find treatment centers in Orange County like Starbucks,” he said.

“Yesterday, a tire shop; today, a treatment center. You don’t require background checks. You don’t require any skill to do this. That’s the problem.”

Business model

Court documents accuse the Ganongs of creating a network of rehab-industry companies that fraudulently exploited the testing of addicts’ urine.

This, according to prosecutors, is how they did it:

In December 2011, Pamela Mae Ganong, now 61, of La Jolla created Ghostline Labs Inc. to submit urine testing claims to insurance carriers. The next month, Ganong hired physician Suzie Schuder to run the lab, which conducted urine tests.

Suzie Schuder was charged with four counts of insurance fraud and conspiracy to commit insurance fraud. Her maximum sentence would be 17 years, eight months. (Booking mug courtesy of OCDA)

In January 2012, Pamela Ganong, Philip Ganong, and their son, William Ganong named themselves officers of the William Mae Corp., which ran sober living homes in Orange County, Bakersfield, Los Angeles and San Diego.Prosecutors allege some of the tests were not covered by the laboratory’s certification or were not necessary, and that Schuder received $21,884 from 2012 to 2013 to run the laboratory and write prescriptions. Schuder has pleaded not guilty to fraud. Her attorney did not respond to requests for comment.

The company advertised on Craigslist and word of mouth among drug users to get clients, according to a court declaration by the District Attorney’s Office.

Yet within a year the company, operating under the name Compass Rose Recovery, mushroomed from 12 employees to nearly 100. That growth sparked interest from insurance giant Anthem Blue Cross, which suspected the company’s sudden success might be a result of something more than smart business, records show.

During this period, the Ganongs also formed Compass Rose Staffing, which referred recovering addicts for temporary jobs with nonprofits. But hundreds of recovering addicts from the Ganongs’ sober living homes also were employed at the Ganongs’ various companies, and prosecutors say those workers were required to take frequent urine tests as a condition of their continued employment.

The staffing company “was just a front to facilitate the collection and testing of urine,” Pamela Angle, an Orange County District Attorney’s Office investigator, wrote in May.

Pamela Ganong and William Ganong also submitted insurance claims worth more than $1 million for testing on their own urine, Angle wrote in a court declaration. The lab charged between $400 and $1,500 for each test.

Records allege that over a three-year period the Ganongs’ urine business billed insurance carriers $22 million and collected $15 million. William and Philip Ganong recruited doctors who treated addiction and allegedly bribed those doctors into writing drug testing prescriptions, according to documents.

Carlos X. Montano, 61, of Newport Beach, was charged with three counts of insurance fraud and conspiracy to commit medical insurance fraud, and his maximum sentence would be 16 years, eight months. (Booking mug courtesy of OCDA)

The Ganongs and other defendants are scheduled to appear in court on Feb. 13.One physician, Carlos X. Montano of Costa Mesa, received a flat fee of $2,000 a month and $150 per prescription, prosecutors allege in court documents. Montano also is charged with fraud. His attorney, John Barnett, declined to comment on the case.

Staff writers Jordan Graham and Teri Sforza contributed to this article.

July 30, 2018 | Tony Saavedra and Tom Scott | Orange County Register

Part of [the] ongoing investigation into the Southern California rehab industry.

California doctors are getting away with sexual misconduct

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California

With the news full of stories about sexual misconduct, it’s worth mentioning the perpetrators who have hidden in plain sight – with the blessing of the Medical Board of California and the Legislature. These are doctors who are allowed to practice even after being found responsible for sexual misbehavior.

The state medical board has disciplined more than 450 doctors in recent years for crossing the line with patients. Surprisingly, board investigators are not required to notify law enforcement of a sexual assault complaint. They can quietly investigate without any warning to the public, and doctors usually stay on the job throughout the investigation, which usually takes about three years.

Some physicians do have their licenses revoked if the accusations are found to be true, but others are discreetly put on probation, ordered to take behavior classes and to have a chaperone in the examination room.

But their patients are never told. They have to look up the doctors’ records themselves.

What is also surprising is that a license revocation is rarely permanent. Doctors can petition for reinstatement within a few years. At least three doctors found responsible for sexual misconduct have had their licenses reinstated, and two of the cases involved underage girls.

In one notable case, Dev Gnanadev, the current board president, sat on the panel that reinstated the license of a physician who had assaulted four women, including a minor. Records show that doctor, Hari Narayana Ma Reddy of Victorville, had also pleaded guilty to misdemeanor battery after being charged with felony sexual battery of the minor.

There was never an inquiry into Gnanadev sitting on the panel by either the state Department of Consumer Affairs, which oversees the medical board. An investigation is not likely now since the new consumer affairs director, Dean Grafilo, used to work for the California Medical Association, the doctors’ lobbying group of which Gnanadev is a former president.

In some cases, the medical board doesn’t bother to follow its own discipline guidelines for sexual misconduct cases, which say that physicians should get a minimum of seven years probation, even when the relationship is consensual. Last year, a physician was given just less than three years on probation for unwanted sexual contact with five female patients.

State legislators have been complicit in the protection of these doctors, due in part to strong-arming by the medical association. In 2016, lawmakers failed to pass Senate Bill 1033, which would have required doctors on probation for egregious cases to notify their patients. Just last summer, an effort to insert a similar requirement failed when legislators watered down the proposal so that only a handful of doctors would be covered.

Will there ever be a bill to protect patients from assault by doctors? Not if the current mindset persists. Until then, patients must look up their doctors on the medical board’s convoluted website before every single appointment. And if there is a problem, patients should go directly to the police.

Marian Hollingsworth, who lives near San Diego, is a volunteer advocate with the Patient Safety Action Committee and Consumers Union. She can be contacted at marian.hollingsworth@yahoo.com.

November 30, 2017 | Marian Hollingsworth | The Sacramento Bee

Doctors on Probation Aren’t Required to Disclose Deadly Medical Mistakes to Patients

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California

May 14, 2017 | Bigad Shaban, Jeremy Carrol and Kevin Nious | NBC Bay Area

If your doctor was disciplined for harming other patients, would you want to know?

In California, the state Medical Board is responsible for protecting patients from dangerous doctors. More than 600 physicians and surgeons across the state are currently on probation for a wide-range of violations including sexual assault, insurance fraud, and medical negligence that has resulted in the deaths of patients. Despite the severity of such violations, the Medical Board does not require doctors to notify their patients of their probation status. According to the board, disclosing such details would “harm the patient-doctor relationship.”

The Medical Board has come under fire in recent months for what some are calling a lack of oversight. In February, several patients and their families gathered at the state capital to express their anger and testify before legislators.

“My sister was dead,” said an emotional Eric Andrist. Overcome with pain and anger, Andrist recounted losing his sister, Cally, to what he described as “poor medical care.”

“She, too, was dead from gross medical errors,” he explained to lawmakers.

Is Your Doctor on Probation?

Nearly 110,990 physicians and surgeons currently practice medicine in California. More than 600 of those doctors are on probation, according to the most recent data available from the Medical Board. Their offenses include deadly medical errors, drug use, and criminal convictions. Probation details for those doctors can be found on the Medical Board’s website, but it’s up to patients to find locate the information since doctors are not required to notify them directly of their probation status.

Click Here to search if your doctor is on probation

“Those doctors have [historically], a 30 percent recidivism rate,” state Sen. Jerry Hill, D-San Mateo, told NBC Bay Area.

Hill chaired the February hearing that centered on the Medical Board. He is now proposing major reforms to boost patient protections. His legislation includes a proposal to require doctors to directly notify their patients if they are practicing while on probation.

Medical Board President Dev Gnanadev, however, believes forcing all doctors to disclose their probation status would do more harm than good.

“If I go to a doctor … and if the person says to me, ‘Oh by the way, I’m on probation,’ there goes whatever trust I had – completely gone,” Gnanadev said during the hearing.

Medical Board Executive Director Kim Kirchmeyer also testified, explaining why her colleagues on the board worry about the implications of forcing all doctors to disclose their probation status.

“They didn’t want it to interfere with the patient-physician relationship,” Kirchmeyer said. “They were afraid it would have an impact on the time frame that the physician would be able to see the patient … because so many questions would come up at that time.”

Still, Sen. Hill found the board’s argument difficult to accept.

“When a doctor goes on probation, they have to notify the hospital they’re affiliated with, they have to notify their insurance company, but they don’t have to notify the most important part of the health care continuum, which is the patient,” Hill said.

Last week, the Medical Board released a letter, revising the agency’s stance, saying it now supports doctors disclosing their probation status to patients in cases of sexual abuse and criminal convictions. But the board’s proposal would not require some doctors who were disciplined for negligence to notify their patients.

Medical Board Letter Supporting Reform Legislation

“It’s speaking out of both sides of their mouths, and it really shows how little physicians at the medical board want patients to be informed.”

“The Medical Board continues to fail in its primary mission, which is patient protection,” Consumer Watchdog Executive Director, Carmin Boulder testified during the hearing.

MEDICAL BOARD AND DOCTOR DISCIPLINE

Despite the board’s revised stance on probation, it continues to face criticism over its process for disciplining doctors.

Each year, the board receives more than 8,000 complaints concerning physicians and surgeons, with only a few hundred of those complaints resulting in discipline. But even when investigators determine a doctor acted inappropriately, it takes an average of 909 days from when a complaint is submitted before a physician faces any kind of penalty. State regulations allow nearly all of those doctors to continue to see patients in the meantime.

“The system was set up to fail,” investigator Michelle Veverka testified. Under the current system, Medical Board investigators work in conjunction with the Attorney General’s Office to bring cases against doctors. However, Veverka says that partnership leads to inaction.

“We had to investigate and prosecute these matters being in two separate agencies,” Veverka said. “It has made it very difficult and very cumbersome.”

NBC Bay Area first exposed the communication breakdown between the Medical Board and the Attorney General’s Office last year when it profiled Mario Gusman.

Runner Treated for Flu, Ankle Injury Leaves Hospital as Amputee

Mario was an avid runner who believes a misdiagnosis by his doctor left him a multiple amputee.

“It’s like they steal your life away from you,” Gusman told NBC Bay Area.

Gusman filed a complaint with the Medical Board who recommended the Attorney General’s office discipline his doctor. However, the Attorney General’s Office decided not to pursue the case, citing “insufficient evidence.”

Hill’s legislation, which includes language to restructure the investigations process and require doctors disclose their probation status, is expected to be the subject of debate during a Senate committee on Monday. A final vote on the bill, however, is likely months away.

“The California Medical Board has really broken down in a number of areas,” Hill said. “In some cases, it could be life or death.”

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Bacteria infected 10 infants at UC Irvine hospital, but the public is just finding out

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors

Over the course of eight months, a lethal bacteria infected 10 already critically ill infants in UC Irvine Medical Center’s neonatal intensive care unit – an outbreak that the public is only finding out about now.

None of the infants have died, hospital officials said.

Yet UCI doctors have not found the source of the infections – which continued even after 220 employees used antiseptic soap and ointment to eliminate bacteria on their skin and in their noses.

Orange County health officials have known about the continuing hospital-acquired infections since the middle of December, when lab tests confirmed that five infants had been infected by the same strain of a superbug.

That month, two more babies were sickened. Another tested positive in late February, and two more in March.

County officials said they did not notify the public about the outbreak because they had no evidence that infants being treated at UCI’s neonatal unit were at higher risk than infants admitted elsewhere.

A veil of secrecy shields hospitals where outbreaks occur

UCI officials say they did not believe it was necessary to notify families preparing to have labor and deliveries at the hospital of the ongoing outbreak. They said they had isolated the infected patients in one of the hospital’s two intensive care units for infants. New patients are now only accepted into the other unit, they said.

The 10 babies tested positive for methicillin-resistant Staphylococcus aureus, or MRSA. The superbug is especially dangerous for premature infants. One study found that 26% of infants infected with MRSA while in the ICU died.

The last positive test for MRSA in one of the newborns at UCI was on March 26, according to hospital officials. That baby has since tested negative and none of the infants have active infections, the hospital said.

Hospital officials confirmed the outbreak after questions from The Times. The newspaper learned of the outbreak from Marian Hollingsworth, who filed a complaint about it with the state.

Hollingsworth, who sits on a state advisory committee on hospital-acquired infections, said it appeared UCI and government health officials were trying to quietly handle the outbreak internally.

She learned of the outbreak, she said, from a friend who works in the UCI hospital complex.

Hollingsworth said she believes the hospital should have informed pregnant women being admitted to deliver their infants.

“You never know if your baby will end up in the NICU,” Hollingswroth said, using the shorthand term for the neonatal intensive care unit. “I would have wanted to know.”

UCI officials say they have worked aggressively to try to prevent more infections, using measures that “meet or exceed best industry practices.”

“Our rapid response came the minute we saw the strains were the same,” said Susan Huang, UCI’s medical director of epidemiology and infection prevention.

Huang said that since last month, UCI has been disclosing the outbreak in a letter to parents of all infants in intensive care.

Before that time, she said, staff had been instructed to disclose the MRSA infections to parents as their babies were being tested or treated for the infections.

Huang said the hospital has not been testing patients in other areas of the medical center for the MRSA strain.

The UCI case is not an isolated one. For decades, hospitals have struggled to contain lethal pathogens from spreading in the intensive care units treating premature babies.

The fragile patients are especially vulnerable to infections because of their serious conditions, which often require catheters and ventilators to keep them alive. Their immune systems are still developing.

Besides being potentially deadly, the infections can harm the infants’ brain development and growth in early childhood.

The outbreaks are also costly. A 2010 study found that a MRSA infection extended the infant’s hospital stay by 40 days on average at an additional cost of $160,000.

The federal Centers for Disease Control and Prevention does not track the number of outbreaks or deaths from infections in the neonatal units.

Lisa McGiffert, who directs the safe patient project at Consumers Union, said some outbreaks have been uncovered by media reports or when doctors write about them in medical journals. The public does not learn about an untold number of others, she said.

In January, New Jersey health officials confirmed that an outbreak of MRSA had occurred in a neonatal unit of a Camden hospital after a nurse detailed the infections in a lawsuit. The nurse said in her lawsuit that she had been fired for reporting the hospital’s mishandling of the outbreak.

“A lot of these outbreaks disappear,” McGiffert said.

Experts say the outbreaks can be prevented by proper infection control procedures, including some that can be costly to the hospital’s bottom line. For example, studies have found that infection rates decrease when more nurses are available to care for the infants or when the unit is moved to a larger space.

In 2013, the CDC said it had written guidelines for hospitals in preventing outbreaks in the neonatal units. The agency said then it was preparing to publish the proposed guidelines in the Federal Register. But that did not happen.

The agency restarted the project last year and is now working on a new proposed guideline.

Martha Sharan, a CDC spokeswoman, said Thursday the proposed guidelines were not published in 2013 so that the agency could “carefully evaluate new and relevant scientific articles” on the subject.

In California, state officials who license hospitals are expected to quickly respond to complaints when patients may be in danger.

A state inspector did not visit the UCI Medical Center to investigate the outbreak until March 20, after Hollingsworth’s complaint.

UCI said it had sent a letter to the state describing the infants’ infections in early January.

By then, seven of the 10 infants had been sickened.

In a letter to Hollingsworth, state officials said that their investigation completed on April 3 found that the hospital had not broken any federal or state laws.

Hollingsworth questioned that finding. “If UCI had done everything correctly,” she said, “there would not have been so many babies infected.”

State officials said Thursday that they never received UCI’s letter and that the hospital did not call to follow up.

John Murray, a UCI spokesman, said four employees also tested positive for being colonized with the same strain of MRSA in January. After the use of the antiseptic soap, those employees have now tested negative, he said.

The hospital is continuing to clean all equipment and surfaces throughout the unit, he said. Staff and family members must also wear gowns and gloves while visiting the babies and take other precautions such as placing cellphones in plastic bags.

“Our goal is to ensure the safety of our patients and eradicate the presence of any drug-resistant bacteria in our neonatal intensive care unit,” Murray said.

McGiffert at Consumers Union said the group believes that all outbreaks should be made public so patients can take precautions. The public disclosure would also cause hospitals to work harder to prevent infections, she said.

“Patients have a right to know,” she said.

melody.petersen@latimes.com • Follow @melodypetersen on Twitter

Melody Petersen

CONTACT

Melody Petersen covers biotechnology for the Los Angeles Times. Previously, she wrote about the pharmaceutical industry for the New York Times. She won a Loeb award for reporting about a power company at the San Jose Mercury News. She has also written for the Orange County Register and the Philadelphia Inquirer. She’s the author of Our Daily Meds, a book about the drug industry. She’s a former certified public accountant and grew up on an Iowa farm.

April 13, 2017 | Melody Petersen | Los Angeles Times

Hundreds of California doctors on probation

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, Our Incompetent Medical Board of California

2/24/2017 | Adam Racusin | 10 News San Diego

SAN DIEGO – According to a new report, hundreds of doctors across California are on probation, some accused of serious crimes.

The report comes ahead of a California State Senate committee meeting.

“My fathers death was due to deliberate medical harm,” said patient advocate Marian Hollingsworth.

Hollingsworth says she will be testifying in front of the committee about what happened to her father.

A practicing dentist for more than 50 years, she says her father’s death drove her to become a patient’s safety advocate.

“I think people should have the right to know if their doctor is safe,” she said.

Among the items on the Senate Business, Professions, and Economic Development committee’s agenda, a review of the Medical Board of California.

One of the recommendations being made by the committee staff, “Amended to ensure that patients receive timely notification of their physician’s probationary status, that patients are easily able to obtain understandable information about violations leading to probation, and that MBC makes changes to the disciplinary enforcement information displayed on its website to allow for easier public access and understanding of actions MBC has taken.”

It’s igniting a debate on whether patients should be told if their doctor is on probation.

In 2016 State Senator Jerry Hill proposed SB 1033 which would have taken similar action as what’s being recommend by committee staff, “Requires physicians, podiatrists, acupuncturists and chiropractors on probation for serious offenses such as sexual misconduct, substance abuse, gross negligence, or a felony conviction related to patient care to notify patients of their probationary status before visits take place.”

The bill didn’t pass.

Ahead of Monday’s hearing a report was released with a list of doctors on probation, allowed to continue practicing if they follow certain terms and conditions.

According to the list, 44 of those are in San Diego County.

The Medical Board of California tells Team 10 there are approximately 635 doctors on probation.

It’s less than one percent of the 135,375 current licensed California physicians.

In a statement a spokesperson for the California Medical Associating wrote, “CMA is committed to ensuring patient safety and supports a strong medical board. It’s also paramount that due process is observed. As a result, we have been working with Assemblywoman Anna Caballero, former Secretary of the California Business, Consumer Services and Housing Agency, to sponsor AB 505 which requires the most egregious allegations to go through a full hearing process so that the medical board has a finding effect before deciding upon disciplinary actions. This will protect due process but allow the medical board to appropriately discipline bad actors and protect California patients.”

Marian Hollingsworth believes the system needs an overhaul.

“People will have knowledge and have their own informed consent,” she said. “People can have control over their own health care.”

Right now you can check up on your doctor’s license and check for any disciplinary actions using the states license search site.

In a statement to a spokesperson for the Medical Board of California wrote, “The Board will be providing a response to the issues raised by the Senate and Assembly Business and Professions Committees that were listed in the background paper released February 22, 2017 both at the hearing on February 27, and in writing by March 27, 2017. In regard to patient notification, the Board is still looking into this issue and held an interested parties meeting on January 11, 2017 to discuss potential changes to the disciplinary guidelines regarding patient notification. As you may be aware, the Board took a neutral if amended position on the bill proposed last year, SB 1033, regarding patient notification. The Board will review any legislation introduced this year and take a position at its quarterly Board meeting.”

Doctors crossing line should face swift, strong sanctions

November 29, 2018 / Eric Andrist / *Our Advocates, Medical Negligence & Errors, Our Incompetent Medical Board of California

July 16, 2016 | Marian Hollingsworth & Eric Andrist | Atlanta Journal Constitution

We are raised to have the ultimate respect for those in the medical profession. The idea of a doctor harming a patient comes as a surprise to most people, let alone one being charged with sexual misconduct.

Sometimes, though, doctors take advantage of their position in society — and get away with it.

Even as patient safety advocates, we had no idea how widespread this problem was until we obtained a list of more than 4,000 cases of sexual assaults by doctors nationwide. We were constantly shocked as we realized the sheer audacity and arrogance of these doctors who were brought up on charges of sexual abuse. Through these cases, we found some interesting patterns that were repeated in other states. Many of the offending doctors appeared to prey on the poor and those in small towns with high immigrant populations — people who are not as likely to file complaints for fear of losing medical treatment.

The most shocking pattern we found is that doctors are often treated differently from regular citizens when it comes to sexual assault, especially when medical boards investigate.

For example, if a teacher or police officer is accused of sexual misconduct, they are immediately removed from the job and investigated. If found guilty, they serve time, and are never allowed back in that position again.

That’s not always the case when a medical board investigates a physician for sexual misconduct. Most boards are not required to inform police when they receive these complaints, so often no criminal charges are filed. A doctor can be quietly investigated by a medical board while remaining in practice. If found responsible, he can be put on probation discreetly, without ever having to inform his patients.

Even if a medical board revokes a license for egregious sexual misconduct, that doctor can just walk away and never face criminal charges. He can apply for reinstatement within a few years.

Medical boards were created by law to protect the public, not to harbor dangerous physicians. The Georgia Composite Medical Board received 1,550 complaints last year, but only levied 50 public sanctions. The nature of complaints and sanctions is not made public, so patients must look up their own doctors on the board website to check their records.

Doctors are used to being put on a pedestal. It’s that arrogance that often leads them to believe they can get away with almost anything, knowing that their colleagues on the medical boards will protect them.

However, when it comes to sexual assault, doctors should be held accountable like any other citizen. In fact, the punishment should be more severe since physicians take an oath to do no harm.

The hurt and betrayal inflicted from an assault cannot be cured with a pill or operation. Shattered trust is irreparable. Doctors who cross the line should meet with swift and strong sanctions, as well as criminal prosecution.

Marian Hollingsworth is a patient safety advocate living near San Diego. Eric Andrist is a patient safety advocate in Los Angeles.

Activists see link between over-prescribing of opioid painkillers and increase in overdoses

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, MICRA

Tammy and Tim Smick, center, join families of victims of drug abuse, physician overprescribing, and medical malpractice at a California Medical Association convention last year in Anaheim. Barbara Davidson Los Angeles Times

Alex Smick’s agonizing, fateful slide toward death by prescription drugs began with a simple act of kindness: He tried to save a little dog from a big dog.

It was a sunny day in Southern California in 2010, and Alex was riding his skateboard, the family dog loping by his side. A tiny, yapping challenger charged at them, and Alex made a quick turn of his skateboard to block off the little David to his dog’s Goliath. Too quick, it turned out.

He hit the pavement hard. He severely injured his back, ending up with five bulging disks – though he would not learn this for months. The family’s health insurance company denied requests for diagnostic imaging of his spine. Instead, three different doctors over the next two years would put him on a regimen of opioid prescription painkillers that escalated in potency – from Vicodin to oxycodone to morphine. He was 18.

At 20, Alex had not yet been seen by a spinal cord injury specialist. There was no plan for treatment. But he was fed up with the drugs and checked into an Orange County hospital in 2012 to detoxify. There, a fourth doctor put him on a lethal combination of 11 drugs, including more opioids. Alex stopped breathing. Cause of death? Poly-acute drug intoxication.

It’s a wrenching story that his mother, Tammy Smick, a Downey schoolteacher, tells time and again. A parent-advocate fighting for more responsible use of prescription painkillers, Smick has joined a growing number of parents nationwide who’ve lost their children to the same scourge: over-prescribing of dangerously powerful and addictive opioid pain medications.

“Alex wasn’t a drug-seeking kid,” his mother said. “He was my big, beautiful, athletic, kind, handsome son. Alex thought going to the hospital was the safest, smartest way to get off the drugs. But they loaded him up with so many meds, they just put him to sleep. I didn’t know enough about excessive prescribing. I was naive.”

No longer. Smick retraced the steps of Alex’s care. She hit the website Epocrates, educating herself on the drugs Alex was given, including the risk of interaction with other medication. She hired a private pathologist. She sought sanctions against the hospital, doctor and nurses. She speaks out about medical negligence, and how it’s the third-leading preventable cause of death.

In rallies on Capitol Mall in Washington and across the nation, in testimony before legislators, in community meetings and online, parent-activists are trying to make their voices heard. They are armed with statistics such as this shocker from the Centers for Disease Control and Prevention: In 2012, health care providers wrote 259 million prescriptions for painkillers, enough for every adult in the United States to have a bottle of pills.

Their message is spurring action on several fronts. States tallying the highest numbers of prescription drug overdoses are cracking down on the most prolific prescription drug providers – and those who obtain drugs for illegal sale. Elected officials from the U.S. Congress on down are taking notice of a federal research finding that 50 percent of deaths by drug overdose involved prescription drugs; and that 75 percent of those deaths involved legal opioid painkillers.

Law enforcement agencies are deploying narcotics agents to curb street sales of opioids. States are reining in so-called “pill mills,” or pain management clinics that prescribe large quantities of the painkillers. Attorneys general of 29 states signed a letter to the U.S. Federal Drug Administration recommending that the FDA reverse its 2013 approval of a new, highly potent narcotic called Zohydro that can by given at doses as much as 10 times higher than what’s typically prescribed.

A coalition of addiction specialists, doctors and parent-activists called Fed Up! recently demanded the removal of FDA commissioner Margaret Hamburg, noting that it’s been under her watch that the overdoses have escalated to roughly 15,000 a year nationwide.

Some citizen-petitioners are even demanding that the FDA take opioid narcotics off the legal market altogether, stirring up a hornet’s nest of objections from pain management doctors who, for decades now, have argued they have an obligation to ease their patients’ suffering.

FDA chief Hamburg stands with them: “We must meet the very real medical needs of the estimated 100 million Americans living with severe chronic pain or coping with pain at the end of life.”

On Monday, the federal Drug Enforcement Agency tightened restrictions on a class of opioid analgesics called hydrocodone combination products, moving them into a more restrictive controlled substances category called Schedule II, from Schedule III. This means that drugs such as Vicodin or Norco are now classified as having the greatest potential for harm, abuse and dependency.

But it is oxycodone, used in OxyContin – already a Schedule II drug – that the DEA has identified as the most-abused medicine in America. Hydrocodones rank second.

Dr. Timothy Albertson is the UC Davis Medical Center’s chairman of internal medicine for pharmacology, toxicology, anesthesiology and emergency departments. He also serves as the medical director of the Sacramento division of the California Poison Control System.

He applauded the DEA’s action, which no longer allows automatic refills, or faxing or phoning of prescriptions to pharmacies.

“The use of high-dose, chronic opioid treatment creates the environment for drug diversion and drug misadventure for the patients,” Albertson said. “We continue to see the numbers of prescription opioid overdoses increasing in our emergency departments.”

California has set up an electronic database for pharmacists and doctors to check if a new patient has already obtained controlled-substance medications and is simply seeking more drugs, or “doctor-shopping.”

On Sept. 29, the Medical Board of California made a formal recommendation that all California pain-medication prescribers use the database, known as CURES.

Even drug companies have responded to the crisis – in their own way. Purdue Pharma, which manufactures the blockbuster drug OxyContin, came up with a way to add an opioid receptor blocker to a new high-dose oxycodone painkiller, called Targiniq ER.

If the pill is crushed for injection or snorting, the opioid blocker naloxone prevents the enhanced effect abusers seek. But when swallowed, naloxone has no effect.

CDC Director Dr. Thomas Frieden has issued a call for reform of prescribing practices. For anything other than cancer pain or end-of-life suffering, the risks of prescribing opioids outweigh the benefits, he said.

He draws a direct line between over-prescribing and the decadelong pattern of steady increases of drug overdose deaths – now officially the No. 1 cause of accidental deaths nationwide, surpassing fatal car accidents.

“Prescription drug overdose is epidemic in the United States,” Frieden said.

California has already heeded Friedan’s call for a “good Samaritan” law that allows people to dial 911 to report an overdose without getting themselves in trouble.

Recently, the state took a significant step toward helping families or people close to opioid users. Gov. Jerry Brown signed into law a provision allowing people to buy the antidote to opioid overdoses without a prescription to have on hand in case of emergency. When injected or used as a nasal spray, naloxone reverses an opiod overdose. It’s been used in ambulances and emergency rooms for decades.

California is one of the lowest-prescribing states. Still, public health officials are worried about prescription painkillers leading users to heroin, a cheaper option than the pricey oxycodone.

State tallies of death-by-poisoning show California saw a 60 percent increase in drug deaths from 2000 to 2012, largely driven by the opioid overdoses.

Opioids are chemically similar to opium, derived from the seeds of poppies grown largely in Afghanistan. For centuries, opium has been used as a mind-altering substance in certain cultures. Modern versions include the prescription drugs, heroin, morphine, methadone and codeine.

Prescription painkillers work by binding to receptors in the brain to decrease its perception of pain and introduce a feeling of euphoric well-being. In the process of sedation, the user’s breathing slows and, in cases of overuse, stops altogether.

In Sacramento County, about 2,500 residents were hospitalized for opioid overdoses from 2006 and 2012. Of the state’s 15 largest counties, none had a higher rate of the hospitalizations, according to data from the Office of Statewide Health Planning and Development.

David Sheff is the author of “Clean,” an exhaustive look at addiction as a disease, and “Beautiful Boy,” a best-seller that laid bare his family’s chaotic and emotionally painful home life during his son Nic’s years of addiction.

In an interview, Sheff, who lives in the Bay Area, said not enough is being accomplished to fight addiction disease.

“We are way behind where we should be,” he said. “With more funding, we’d have a renaissance in terms of scientific understanding of addiction and how to treat it. We could be so much further.”

That’s a goal that Alex Smick’s mother pushes for as she repeats her story over and over to different audiences.

The night Alex died, he was left unmonitored for seven hours, even though the nurses’ station was right around the corner from his room, Tammy Smick said. By the time a nurse did check on him, Alex’s body was in full rigor mortis.

“All we want to do is bring about change,” Smick said. “This is about the small percentage of negligent and over-prescribing doctors. Change is not moving quickly enough and many people have died.”

Phillip Reese contributed to this story. Call The Bee’s Cynthia H. Craft, (916) 321-1270.

Tammy Smick comforts her husband, Tim, as he testifies at the joint hearing of the Senate and Assembly Business and Professions Committees in Sacramento in March 2012. Their son Alexander died of a prescription drug overdose.

October 10, 2014 | Cynthia H. Craft | Sacramento Bee

Medical errors kill hundreds of thousands each year in the US

November 29, 2018 / Eric Andrist / *Our Advocates, Making News, Medical Negligence & Errors, MICRA, Uncategorized

November 18, 2013 | Ramon Galindo | RT News

Staggering new numbers are shedding light on a critical problem in the American healthcare system.

A recent report by the Journal of Patient Safety indicates that between 200,000 and 440,000 people are killed each year in the United States from preventable medical errors. These patients aren’t dying from the condition that forced them to go to the hospital in the first place. They’re dying from unintended mishaps.

Eric Andrist is overcome with emotion as he remembers the death of his sister Cali. Andrist cared for his mentally disabled sister day and night, and recalls that once he took her to the emergency room at Providence St Joseph’s in Burbank, California for a stomachache. Days later she was dead.

“My sister was writhing in pain for so long. It just haunts me. The last moments my sister, are just engrained in my head,” Andrist said.

A binder full of medical records shows a long list of possible mistakes healthcare professionals made when treating Cali.

Deadly medical errors can happen at even the most highly rated hospitals. New research shows that up to 440,000 people die every year in America from preventable medical mistakes. That would make it the third leading cause of death in the US, following heart disease and cancer.

“The incidence of people dying of errors in hospitals is abysmal in this country. It’s really a crisis level problem,” said Leah Binder, the president and CEO of Leapfrog Group, a non-profit watchdog group which rates hospital safety in the US.

In 1999, the Institute of Medicine reported that up to 98,000 people a year die because of mistakes in hospitals. In 2013, a study in the Journal of Patient Safety said that number may now be between 210,000 and 440,000 patients: more than the population of Miami, Florida.

Not all medical errors kill, but they can still cause a lifetime of pain.

“When I left the operating room, I had a fever, I was nauseous, I was having chills, and I was told that was probably due to the anesthesia,” said Alicia Cole, a medical error survivor.

Cole, who used to work as an actress and model, went to the hospital for a routine myomectomy to remove two uterine fibroids. She expected to be out in a few days. Instead, she contracted Necrotizing Fasciitis, also known as flesh-eating bacteria.

“You can see this is all eaten out here, and cut out. Here it is going down my thigh,” Cole said as she showed photos of the infection overtaking her body’s midsection.

Years later Cole is still in physical therapy.

Her claim of hospital injury is not isolated.

Shelly Skalicky was diagnosed with Spina Bifida as a child. In 2008, she went into the hospital for elective surgery to relieve some of her symptoms.

Skalicky and her husband Danny Long used to enjoy an active outdoor lifestyle. However, after her trip to the hospital, Skalicky came out a quadriplegic and now requires round the clock care.

Home videos show Long helping his wife to do the simplest tasks.

“We have never been allowed to talk to any doctors. We’re not allowed to talk to the patients’ safety department. We’re not allowed to talk to the ethics department. We’re not allowed to talk to anybody except hospital lawyers,” said Long.

Because some states have caps on malpractice claims, many lawyers refuse to take on cases of medical error.

Despite their frustration with the healthcare system, their love has strengthened during the struggle.

“I rely on her as much as she relies on me. If most guys were honest they would have to admit that too. She is my rock,” said Long.

Many healthcare professionals want to reduce accidents but transparency remains a major barrier.

“It’s long since been time that we have a national conversation about these deaths in hospitals,” said Binder.

A requirement in the Affordable Care Act encourages Medicare providers to report medical errors, but it stops short of requiring all health care providers from participating.

“The best hospitals find ways to create safety nets around the mistakes they expect people to make,” said Binder. “They double-count their sponges, they barcode their sponges, to double check they are not leaving sponges inside a patient. There is barcoding for medication administration now too,” Binder added.

And while technology might help, simple, inexpensive things like good hygiene can prevent infection.

In Alicia Cole’s case, the State Health Department found her hospital had broken several patient safety laws.

“Ask your doctor what the infection rate is for the procedure you’re going to have,” said Cole

“Document everything. Take a little notebook with you and write down every drug they give you. Make sure you have your cell phone with your little camera so you can take pictures of things,” said Andrist.

“It’s not right that in a country as wealthy as the US and with the resources that we have, there’s no reasons patients should have to go through that,” Cole added.

THE MEDICAL FARCE OF CALIFORNIA

State Task Force Forming to Investigate Stem Cell Clinics

Investigating Claims Made By Local Stem Cell Clinic

[See video on website.] NBC 7 Investigates went undercover at a stem cell clinic to see if the clinics are promising legitimate results. NBC 7’s Mari Payton reports. (Published Wednesday, May 23, 2018)

Advertisements for Stem Cell Health Center seminars can be seen in the local newspaper nearly daily.

Doctor Jared Taylor’s license was expired on September 25, 2018, the day of the Mission Valley stem cell seminar. The license has since been renewed.

How a multimillion-dollar empire built around urine drug tests exposes flaws in California’s rehab laws

Just following the rules

Stalled in Sacramento

Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)

William Ganong (Photo courtesy of OCDA)

Who is the doctor?

Tammy Smick of Downey, looks at photos of her son, Alex, who died from a lethal combination of medications while being treated at a Laguna Beach treatment center in 2012. (Photo by Nick Agro, Orange County Register/SCNG)

Dozens signed a poster for Alex Smick during a rally on February 23, 2013. (File photo BILL ALKOFER, ORANGE COUNTY REGISTER/SCNG)

Alex Smick was an avid golfer. (File photo BILL ALKOFER, ORANGE COUNTY REGISTER/SCNG)

California lags other states

Coming to America

Business model

California doctors are getting away with sexual misconduct

Marian Hollingsworth, who lives near San Diego, is a volunteer advocate with the Patient Safety Action Committee and Consumers Union. She can be contacted at marian.hollingsworth@yahoo.com.

Doctors on Probation Aren’t Required to Disclose Deadly Medical Mistakes to Patients

Need to contact our Investigative Unit?

• You can remain anonymous

• Click here to submit tips

• 1-888-996-TIPS

• Bigad.Shaban@nbcuni.com

Bacteria infected 10 infants at UC Irvine hospital, but the public is just finding out

A veil of secrecy shields hospitals where outbreaks occur

Hundreds of California doctors on probation

Doctors crossing line should face swift, strong sanctions

Activists see link between over-prescribing of opioid painkillers and increase in overdoses

Medical errors kill hundreds of thousands each year in the US

Investigating Claims Made By Local Stem Cell Clinic

[See video on website.] NBC 7 Investigates went undercover at a stem cell clinic to see if the clinics are promising legitimate results. NBC 7’s Mari Payton reports. (Published Wednesday, May 23, 2018)

Advertisements for Stem Cell Health Center seminars can be seen in the local newspaper nearly daily.

Doctor Jared Taylor’s license was expired on September 25, 2018, the day of the Mission Valley stem cell seminar. The license has since been renewed.

Just following the rules

Stalled in Sacramento

Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)

William Ganong (Photo courtesy of OCDA)

Who is the doctor?

California lags other states

Coming to America

Business model

Marian Hollingsworth, who lives near San Diego, is a volunteer advocate with the Patient Safety Action Committee and Consumers Union. She can be contacted at marian.hollingsworth@yahoo.com.

Need to contact our Investigative Unit?

• You can remain anonymous

• Click here to submit tips

• 1-888-996-TIPS

• Bigad.Shaban@nbcuni.com

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