03-002690PL Department Of Health, Board Of Medicine vs. James Coker, P.A. Status: Closed Recommended Order on Friday, October 31, 2003.

Summary: Recommend revocation of license for a Physician`s Assistant who prescribed controlled substances and inappropriate medications.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD OF )

MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 03 - 2690PL

)

JAMES COKER, P.A., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a final hearing was held in this case

on September 3 and 4, 2003, in Tampa, Florida, before Susan B.

Kirkland, a designated Administrative Law Judge of the Division

of Administrative Hearings.

APPEARANCES

For Petitioner: Kim M. Kluck , Esquire

Joy L. Doss, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

For Respondent: Jon M. Pellet, Esquire

Barr, Murman, Tonelli,

Slother & Sleet, P.A.

201 East Kennedy Boulevard, Suite 1700

Tampa, Florida 33602

STATEMENT OF THE ISSUES

Whether Respondent violated Subsections 4 58.331(1)(q),

458.331(1)(t), 458.331(1)(nn), 458.347(4), and 456.072(1)(o),

Florida Statutes (2001), and Florida Administrative Code Rule

64B8 - 30.008, and, if so, what discipline should be imposed.

PRELIMINARY STATEMENT

On April 4, 2003, Petitione r, Department of Health

(Department), filed a four - count Administrative Complaint

against Respondent, James Hilton Coker, P.A. (Coker), alleging

that Coker violated Subsections 458.331(1)(q), 458.331(1)(t),

458.331(1)(nn), 458.347(4), and 456.072(1)(o), Fl orida Statutes

(2001), and Florida Administrative Code Rule 64B8 - 30.008. Coker

requested an administrative hearing, and the case was forwarded

to the Division of Administrative Hearings on July 23, 2003, for

assignment to an Administrative Law Judge.

The parties entered into a Joint Prehearing Stipulation in

which they agreed that at all material times relevant to this

proceeding that Coker was a licensed physician assistant with

the added qualification as a prescribing physician assistant in

the State of Florida, having been issued license number PA3151.

Official recognition was taken of Florida Administrative

Code Rule 64B8 - 30.008 (11/13/00 version); Florida Administrative

Code Rule 64B8 - 30.008 (2/15/02 version); Florida Administrative

Code Rule 64B8 - 30. 015 (4/9/01 version); and Florida

Administrative Code Rule 64B8 - 9.013 (12/21/99 version).

At the final hearing, the Department called the following

witnesses: Jaceson Yandell, Theresa Garnett, Margaret Grow,

Heinz Bachman, Donald Bowling, Anthony Bordonar o, and Keith

Arndt. Petitioner's Exhibits 1, 2B, 2C, 2D, 2E, 4A, 4B, 5, 6,

7A, 8, 9A, 9B, 9D, 10C, 10D, 10E, 10F, 11C, 11D, 11E, 11F, 12,

13A, 13B, 13C, 13D, 14A, 14B, 14C, 14D, 15, 16, and 18 were

admitted in evidence.

At the final hearing, Coker called John Barsa, M.D., as his

witness. Respondent's Exhibits 2 through 11 were admitted in

evidence. Coker proffered the transcript of his testimony in

his criminal trial, and the transcript was marked as

Respondent's Exhibit 12.

The parties agreed to the lat e filing of the depositions of

Joanne McGregor, Stephan Mikell, Dan Mathis, and Herly Ramos,

P.A. - C., which depositions are admitted in evidence. Coker

filed the depositions of Joanne McGregor and Stephan Mikell on

September 22, 2003. Respondent's Exhibi ts 13 through 17 were

submitted at the deposition of Ms. McGregor and are admitted in

evidence. The Department filed the deposition of Dan Mathis on

September 15, 2003. Petitioner's Exhibits 3A, 3B, 10A, 10B,

11A, 11B, and 17 were submitted at the deposi tion of Mr. Mathis

and are admitted in evidence. The depositions of Herly Ramos

were filed on September 22, 2003.

The parties agreed to file their proposed recommended

orders within ten days of the filing of the transcript. On

September 29, 2003, the l ast volume of the two - volume Transcript

was filed with the Division of Administrative Hearings. The

parties timely submitted their Proposed Recommended Orders,

which have been considered in rendering this Recommended Order.

All statutory references in thi s Recommended Order are to

the 2001 codification of the Florida Statutes, unless otherwise

indicated.

FINDINGS OF FACT

1. At all material times relevant to this proceeding,

Coker was a licensed physician assistant with an additional

qualification as a pre scribing physician assistant in the State

of Florida, having been issued license number PA3151.

2. A physician assistant is a dependent practitioner, who

practices under a supervising physician. A physician assistant

acts as a supplement or extension of the supervising physician

and is trained to do histories and physicals, to diagnose, and

to treat patients. In Florida, a physician assistant is

permitted to prescribe certain medications after completion of a

prescriptive practice seminar and an applicat ion process.

3. Beginning in June 2001, Coker began working as an

independent contractor for Dr. Rosetta V. Cannata, an

anesthesiologist who practices in pain management. Dr. Cannata

was Coker's supervising physician. Dr. Cannata maintained an

office in Englewood, Florida, and decided to expand her business

to adult entertainment clubs in Tampa, Florida. The purported

purpose was to provide medical services to persons who were

working in the adult entertainment business. She made

arrangements with vari ous clubs to provide space to her at the

clubs for use as examining rooms.

4. Dr. Cannata and Coker began seeing patients at adult

clubs such as the Pink Pony and Diamond's Men's Club. Patients

other than those from the adult entertainment business beg an to

come to the clubs to see Dr. Cannata and Coker. Dr. Cannata

opened an office on Martin Luther King, Jr. Boulevard in Tampa

to take care of the increased business. Coker saw patients at

the new office and also continued to see patients at the adult

clubs.

5. In 2001, the Hillsborough Sheriff's Office began an

investigation of Coker's activities in Tampa. Jaceson Yandell

(Yandell) was the lead investigator. Yandell used a

confidential informant (CI) to make contact with Coker. On

July 14, 2001, th e CI took Detective Dan Mathis (Mathis), 1 an

undercover officer, to Diamond's Men's Club to see Coker.

Mathis and the CI were fitted with either recording or

transmitting devices so that their conversations with Coker were

recorded. Yandell was stationed in a nearby vehicle, which

contained devices that could receive and record the transmission

of the conversation between Mathis and Coker.

6. Mathis was introduced to Coker by the CI as Dee Tucker.

Coker asked Mathis to fill out a medical history form. Mathis

filled out the form, indicated no to all the questions, and

stated that he was not currently taking any medication, had no

previous surgeries, and was not allergic to any medications. He

did not list a name for his medical doctor.

7. After asking Mathis his height and weight and whether

he was allergic to any medicine, Coker asked, "What am I seeing

you for today, Dee?," and the following conversation took place:

Mathis: I ain't got nothing wrong with me.

CI: Tell him what you want, shit that's the

only way you're gonna get it.

Mathis: Some Z's. 2

Coker: So you are having some anxiety is

what you're telling me?

Mathis: Yeah, yeah.

CI: Say yes.

Mathis: Yes.

Coker: Has this been going on long?

Mathis: Shit. Well, it's been a long.

I t's been a while. I've been kinda acting

like that.

8. Coker also asked Mathis whether he had ever been in the

military, had a car wreck, or been injured in anyway, including

any football injuries. Coker also asked him whether he had a

family history o r had any surgeries. Mathis replied negatively

to all of these inquiries.

9. Mathis did advise Coker that his mother, who had smoked

for 45 years, had recently died of hypertension and congestive

heart failure at the age of 62. Coker did not check Mat his'

heart, lungs, ears, nose, throat, or glands. Coker took Mathis'

blood pressure and found that it was high, and advised Mathis

that he needed to take medication for the high blood pressure.

He prescribed hydrochlorothiazide for the high blood pressur e

and ordered some laboratory work to rule out causes for the

elevated blood pressure. Coker also advised Mathis to eat more

foods that were high in potassium.

10. Coker had two prescription pads. One pad contained

prescription forms that were pre - signed on the physician's

signature line, and the other pad contained prescription forms

that were not pre - signed. Coker wrote the prescriptions for the

hydrochlorothiazide and the laboratory work on the prescription

forms that were not pre - signed.

11. Coker p rescribed 30 two - milligram bars of Xanax for

Mathis for anxiety. The prescription could be refilled two

times. The prescription was written on one of the pre - signed

prescription forms. During the July 14 office visit, there was

no discussion of the poss ible cause of Mathis' anxiety, no

discussion of a plan of treatment for the anxiety, and no

discussion of alternative treatments for anxiety, such as

counseling. The only discussion of directions of use or

warnings concerning Xanax was that taking Xanax i n the bar,

rather than pill form, could save the patient money, because the

bar could be broken into smaller doses and that Coker would

prefer that a patient not take a whole bar unless it was

necessary.

12. Xanax contains Alprazolam which is a schedule I V

controlled substance.

13. Mathis did not see Dr. Cannata during his July 14

office visit. Coker did not leave the examining room or make

any telephone calls during Mathis' office visit.

14. Mathis paid Coker $50 for the visit. After leaving

the Diamo nd's Men's Club, Mathis went to the vehicle where

Yandell was located and gave Yandell the prescriptions.

15. On August 17, 2001, Mathis returned alone to Diamond's

Men's Club to see Coker. Mathis was wired with a transmitting

device so that the conversa tion between Coker and Mathis was

recorded.

16. Coker took Mathis' blood pressure and found it to be

lower. Other than taking Mathis' blood pressure, Coker did not

perform any physical examination of Mathis. Mathis advised

Coker that he had an injury du e to bench pressing and that he

felt some discomfort when he bench - pressed during a work out.

Coker did not ask Mathis how often he experienced the pain, nor

did he ask Mathis if he was taking any other medication for the

pain. Coker and Mathis discussed the use of anabolic steroids,

and Coker discouraged the use of steroids.

17. During the August 17, 2001, office visit, Coker did

not ask Mathis how the Xanax was working, did not inquire

whether Mathis was still experiencing anxiety, did not discuss

alte rnatives to Xanax, did not discuss the causes of anxiety or

ways to address the anxiety, did not discuss a medical diagnosis

with Mathis, and did not discuss a plan of treatment.

18. On August 17, 2001, Coker wrote Mathis a prescription

for 30 two - milligr am bars of Xanax, which could be refilled two

times, and a prescription for Lortab, which could be refilled

one time. Lortab contains Hydrocodone which is a Schedule III

controlled substance. Coker wrote the prescriptions on

prescription forms which had been pre - signed on the line for the

physician's signature. Mathis did not see Dr. Cannata on the

August 17, 2001, visit, and Coker did not leave the room. Other

than a telephone call to his family, Coker did not talk on the

telephone during Mathis' visit .

19. Mathis paid Coker $50 for the office visit and left

the adult club. He met Yandell at a predetermined location and

turned over the prescriptions to Yandell.

20. On August 21, 2001, Mathis and another undercover

officer, Detective Peggy Grow (Grow) , met with Coker at an

office located on Martin Luther King, Jr. Boulevard in Tampa.

Mathis and Grow were outfitted with transmitting and recording

devices so that the conversations of Mathis, Coker, and Grow

were recorded.

21. Grow was introduced to Cok er as Peggy Lane. 3 As an

undercover officer, Grow played the role of a call girl or

escort. Upon meeting Grow, Coker explained that he was a

physician assistant and worked with Dr. Cannata, who was an

anesthesiologist. He stated that the practice includ ed primary

care, pain management, and management of anxiety and depression.

He asked Grow to fill out a medical history questionnaire. She

checked no to all the questions except for the use of alcohol

and tobacco. Grow did not list the name of her medic al doctor

and told Coker that she had not seen a doctor in a long time.

22. Coker asked Grow the reason for her visit, and the

following conversation took place:

Grow: I just need something to keep going.

I work a lot of hours, you know, sometimes

I'm u p real late and then you know I get up

again and, sometimes, you know, it's hard.

Coker: Okay. Define keep me going 'cause I

don't prescribe any kind of amphetamines or

any speed or anything like

Mathis: I told you doc. He, he, he's

straight. Tell him you want some Zees.

Coker: Tell me . . .

Grow: I want some Zees.

Coker: Xanax. Okay. Xanax is an anti -

anxiety. Okay?

Grow: Will that help like stress and stuff

like that?

Coker: Oh, absolutely.

Grow: Okay. I think that keeps . . .

Coker: Any time dealing with anxiety. It's

actually a wonderful medicine and it works

very well.

Grow: Okay.

Coker: Um, it either can be dosed, you can,

like I always prescribe the bars because you

can break them into four pieces or you can

break them into two pieces or you can take

the whole thing. It just depends on what

your need is.

Grow: Okay.

Coker: Okay? And I have folks, you know, I

tell them take it as needed. Um, but

usually it's just an anxiety kind of thing,

so . . . you know, you got to talk English

to me otherwise I don't understand.

23. The medical records which Coker generated for Grow

contained the following notes, as they related to Grow's

anxiety:

CHIEF COMPLAINT: Describes being tense, on

edge, tremulous, difficulty relaxing,

ta chycardia - palpitations, dyspnea, symptoms

present for "years."

* * *

PLAN: advised Referral - To therapist of

choice for chronic recurring anxiety

Advised If hyper - ventilating, then teach

"brown paper lunch bag" re - breathing

technique.

Avoid caffeine and plan for regular physical

activity. Practicing a relaxation exercise

regularly as well. Discussed stress

reduction.

Grow did not describe the symptoms listed above, and Coker did

not give the advice listed above.

24. Grow told Coker that she had n ever had any surgeries

and that she had taken some of Mathis' Xanax. Coker took Grow's

blood pressure, listened to her heart and lungs, and checked the

glands on her neck. Coker gave Grow a prescription for Xanax

and advised her not to drink, drive, or o perate machinery while

she was taking the Xanax. He told her the prescription included

one refill and not to call him saying that she needed another

refill. He told her to "[g]o get some of his (meaning Mathis)."

Coker wrote the prescription for Xanax o n a prescription form

which had been pre - signed on the physician's signature line.

25. During Grow's visit on August 21, 2001, Mathis asked

Coker about giving him a prescription for Vicodin. Coker

explained that Vicodin was the same medication as the Lor tab,

which he had prescribed to Mathis on Mathis' last visit. Mathis

explained that the Lortab was actually for him, and Coker asked

him for whom was the Vicodin. Mathis replied that it was for

himself, after which the following conversation took place:

Coker: Well, see I can't give them to you

then 'cause I gave script for a hundred on

the 17th.

Grow: How about me?

Coker: Yeah, I can give them for her.

Mathis: Well, do that. Alright, I get, I

get ah Craig hooked up.

Coker: For your, your neck p ain, huh?

Mathis: Yeah.

Coker: After the motor vehicle accident two

weeks ago.

There had been no mention of Grow having any neck pain until

Coker stated that it was for her neck pain. There is nothing in

the recorded conversation between Grow and Co ker from which

Coker could make a determination that Grow had neck pain

resulting from a motorcycle or motor vehicle accident. Coker

invented the symptoms for Grow to give support for a

prescription for pain medication.

26. Coker asked Mathis, not Grow, about the Vicodin

prescription in the following conversation:

Coker: Which Vicodins are we talking about

here, Dee?

Mathis: A stronger one.

Coker: Well, if you want the tens you have

to go really with the Lortabs 'cause you're

going to get generic an yhow.

Mathis: I'm going to get generic?

Coker: Right.

Mathis: As opposed to what?

Coker: Well, if I wrote it for Vicodin HP,

which is not generic, then you pay a lot of

money.

Mathis: I ain't paying it. I ain't worried

about that.

Coker: What I'm saying somebody's going to

pay a lot of money versus . . . the thing

about it is it's no difference than the

generic.

Mathis: Is, I mean, Craig going to be able

to take of that, I'm not as far as . . .

Based on the recorded conversations between Ma this and Coker, it

is clear that Mathis wanted the Vicodin prescription for someone

named Craig, and that Coker was going to prescribe the pain

medication for Grow in order to get around the problem that it

was too soon for Coker to give Mathis another pre scription for

pain medication.

27. On August 21, 2001, Coker gave Grow a prescription for

50 Lortab, which could be refilled one time. The prescription

was written on a prescription form, which was pre - signed on the

physician's signature line. During th e August 21 office visit,

Grow did not see Dr. Cannata; Coker did not leave the room; and

Coker did not make any telephone calls.

28. On August 24, 2001, Grow and another undercover

officer, Detective Heinz Bachman (Bachman), 4 went to Diamond's

Men's Club to see Coker. Both Grow and Bachman were outfitted

with electronic devices that allowed the conversations during

the visit to be monitored and recorded.

29. Grow introduced Bachman to Coker as Hank Richardson.

When Coker asked Bachman the reason for th e visit, Bachman told

him pain. Grow told Coker that Bachman wanted some Vicodin.

30. Coker asked Bachman what kind of pain he had, the

cause of the pain, and the duration of the pain. Bachman told

Coker that he had injured his back a week ago while th rowing a

fish net. Coker asked Bachman if he had had any surgeries, was

on any medication, was allergic to any medicine, or smoked.

Bachman answered all the questions in the negative. Bachman

also filled out a medical history questionnaire, indicating n o

to all the questions. Later, when he told Coker that he had

back pain, the form was changed to reflect that condition.

Bachman did not list the name of his medical doctor.

31. Coker took Bachman's blood pressure and listened to

his lungs and heart wit h a stethoscope. Bachman was requested

to stand up. Coker then palpated Bachman's lower back and asked

if that was where he had pain. Bachman replied that it was.

32. Coker told Bachman that he was going to give him a

prescription for pain medicine and that Bachman should take an

anti - inflammatory, over - the - counter medication and put ice on

his back. Coker advised Bachman that if the pain did not go

away that Bachman should come back for a shot of cortisone.

Coker told him not to drink, drive, operate machinery, or drive

a boat while he was taking the medication.

33. During the visit, Grow asked Coker if he could give

Bachman some Xanax during the following conversation:

Grow: Very cool. While's we're here can,

can you give him one for Zees for me a nd Dee

[Mathis] to take?

Coker: Ah - yi - yi - yi - yi - yi - yi

Grow: Can you give him some Zees?

Coker: Maybe.

Grow: Okay. Okay. (Laughs.)

Coker: (Laughs.)

Grow: Well, you gotta ask, right?

Coker: Ay - yi - yi - yi - yi - yi

Grow: You told me last time to ask .

34. Bachman did not tell Coker that he was experiencing

any anxiety or any symptoms of anxiety or stress. Coker did not

ask what might be causing Bachman to have anxiety or describe a

plan of treatment for anxiety. Coker did tell Bachman that the

Xan ax was for mild anxiety. It is clear that Bachman was not

experiencing anxiety and that the reason for prescribing Xanax

was for Grow's use and not Bachman's.

35. Coker wrote a prescription for Bachman for 50 Lortab

with no refill, and a prescription f or 60 Xanax with one refill.

Both of the prescriptions were written on prescription forms

which had been pre - signed on the physician's signature line.

During the visit, Bachman did not see Dr. Cannata, and Coker did

not leave the room or discuss anything with Dr. Cannata.

Bachman paid Coker $50 for the visit.

36. On September 27, 2001, Grow went to see Coker and

brought along another undercover officer, Anthony Bordonaro

(Bordonaro). 5 Both Grow and Bordonaro were outfitted with

electronic devices that allowed the conversations during the

office visit to be recorded.

37. Grow told Coker that she was there for refills of her

prescriptions. Coker asked her how her back and neck were, to

which she replied the "same." He asked if she were okay with

her me dications and she said "Love 'em."

38. Coker took Grow's blood pressure and listened to her

heart. He felt her neck and palpated her back. Coker found a

knot in her back area, and suggested that she have some massage

therapy, stating that he was also a massage therapist. He wrote

prescriptions for Grow for 45 Xanax with one refill and for 50

Lortab with one refill.

39. Coker asked Bordonaro his height and weight.

Bordonaro stated he was not taking any medications and that he

was allergic to penicillin . He told Coker that he piloted tug

boats, had hurt his arm in a fall on a boat, and had to have

surgery on his arm five years ago, resulting in a screw being

placed in his arm. Bordonaro stated that he had no other

medical problems. He denied smoking, but indicated he did drink

alcohol.

40. When Coker asked Bordonaro what was the purpose of the

visit, Bordonaro said that he wanted some Vicodin, which he had

taken when he had hurt his arm. According to Bordonaro, it was

"some good stuff." Coker's comp uter medical notes for

Bordonaro's visit indicate that Bordonaro was currently taking

pain medication; however, Bordonaro did not indicate that he was

currently taking any pain medications.

41. Coker took Bordonaro's blood pressure and listened to

his lun gs. Coker told Bordonaro that his blood pressure was

high. Bordonaro told Coker that the last time that he had gone

to his doctor in Pensacola, his blood pressure was 112/80.

Coker told Bordonaro that they would keep an eye on his blood

pressure.

42. When Coker asked Bordonaro what he did that caused

pain in his arm, Bordonaro replied, "Like all in, all in here."

Coker had him lift his wrist up and down, spread his fingers

apart and push them together, and touch his thumb and little

finger.

43. C oker wrote Bordonaro a prescription for 50 Vicodin

with one refill. Vicodin contains Hydrocodone, which is a

Schedule III controlled substance. Coker told Bordonaro to

avoid doing anything that would exacerbate the pain and not to

drink, drive, or operat e any machinery while taking the

medication.

44. The prescriptions that Coker wrote for Grow and

Bordonaro on September 27, 2001, were written on prescription

forms which were pre - signed on the physician's signature line.

Dr. Cannata was not present du ring the office visit, and Coker

did not leave the room or make any telephone calls during the

visit. Coker charged Bordonaro $100 for his and Grow's visit.

45. On November 15, 2001, Grow returned to see Coker and

took along undercover officer Donald Bow ling. 6 Both officers

carried electronic devices that allowed the conversations during

the visit to be recorded.

46. Grow indicated that she was there because she wanted

refills on her Lortab prescription. Coker asked her how she was

feeling, to which sh e replied, "Oh, pretty good." When asked

about her neck, Grow told Coker that it was about the same.

Coker asked if ever got any better, and she told him it did, but

that sometimes she slept funny.

47. Coker took Grow's blood pressure, listened to her

h eart, and felt her neck. He asked Grow her weight and height.

Coker indicated that she could get her medications from him,

rather than getting prescriptions and having them filled at a

pharmacy. He gave her a bottle of 100 Hydrocodone and a bottle

of 18 0 one - milligram tablets of Alprazolam, the generic name for

Xanax. He told her to take two of the Xanax instead of one

because the dosage was smaller.

48. When Coker asked Bowling the reason for his visit,

Bowling told him that he had injured his knee in high school and

that the knee would get really sore every now and then. He said

that when he bent his knee he could feel something, but he did

not know how to describe it. Bowling said that someone wanted

to do a "scope thing" on his knee and that he ha d refused.

49. Coker took Bowling's blood pressure and listened to

his heart. Coker had Bowling lie down on the examination table.

While Coker felt around Bowling's knee, he asked where the pain

was. Bowling said that he could feel the pain when he w as

moving in a certain way. Coker had him tighten his muscle and

lift his leg. Coker advised Bowling that his condition was

early wear and tear on the knee, which was common. The

condition, Coker said, would come and go. Coker told Bowling

that in addi tion to taking the pain medication, he should take

over - the - counter, anti - inflammatory medications such as

Ibuprofen and Aleve. He told Bowling to put ice on the knee and

to avoid actions that would tend to make the knee worse, such as

squatting on the kn ee.

50. Coker asked Bowling his height and weight. When asked

by Coker, Bowling said that he had not had any major surgery and

was not allergic to any medication. He told Coker that his

father had recently been diagnosed with colon cancer. Bowling

said that he smoked tobacco and drank alcohol.

51. During the visit Grow told Coker that Bowling wanted

some Zees. After examining Bowling, Coker asked, "You said you

wanted Xanax also?" to which Bowling replied "Yes. Please."

There was no other mention of a reason for giving Bowling Xanax.

In Bowling's medical records, Coker indicated that Bowling had

"Anxiety syndrome (tense or nervous)"; however, Bowling never

said that he had anxiety or was tense or nervous.

52. Coker gave Bowling a bottle of Alpraz olam and a bottle

containing 100 Hydrocodone tablets. Bowling paid Coker $310 for

his and Grow's visit and medications.

53. Dr. Cannata was not present during the visit of Grow

and Bowling on November 15, 2001. Coker did not leave the room

or contact Dr . Cannata during the visit.

54. On December 13, 2001, Bordonaro went to see Coker to

get a refill of his pain medication. Bordonaro carried an

electronic device which allowed their conversation to be

recorded.

55. Even though Coker had told Bordonaro during their last

visit that Bordonaro's blood pressure was high, Coker did not

examine Bordonaro or take his blood pressure. Coker asked

Bordonaro how he was doing, and Bordonaro replied, "Good.

Good." After explaining the difference between Vicodin ES and

Hydrocodone, Coker gave Bordonaro a bottle of 100 Hydrocodone

tablets, and charged Bordonaro $115 for the visit and

medication.

56. On January 11, 2002, Bordonaro visited Coker at an

adult club to get more medication. Again, Bordonaro wore a

device which allowed the conversation to be recorded. He told

Coker that he was having to take more of the Vicodin and asked

if he could get something stronger.

57. Bordonaro also asked if he could get some Xanax. At

first, Coker told him no, but then gave h im a form and told him

to place a checkmark by everything that applied to him.

Bordonaro checked the first three items on the form and gave it

back to Coker. Coker did not discuss with Bordonaro any

symptoms of anxiety that Bordonaro checked on the form or any

plan of treatment for anxiety.

58. Coker did not perform an examination of Bordonaro.

Although Coker's computer - generated medical records for

Bordonaro's January 11 visit indicate that Bordonaro's blood

pressure was taken, it was not.

59. Coker g ave Bordonaro a bottle of 100 tablets of

Hydrocodone/Acetaminophen, and a bottle of 90 Alprazolam bars

for anxiety. Coker did not contact Dr. Cannata during the

visit. The total charge for the visit and medications was $155.

60. On February 12, 2002, B ordonaro returned to see Coker

to get refills of his pain medication. The undercover officer

wore an electronic device which allowed the conversation to be

recorded. Bordonaro told Coker that the pain pills he had

gotten at the last visit were not workin g and asked if he could

get something stronger. Coker told him that he could write a

prescription for Percocet, but that Bordonaro would have to get

it filled at a pharmacy. Coker suggested that he get the

prescription filled at Wal - Mart or Target becaus e those

pharmacies are not computer interconnected as Eckerds and

Walgreens are. Coker gave Bordonaro a prescription for 100

Percocet with no refills. Percocet contains Oxycodone, which is

a Schedule II controlled substance. Coker wrote the

prescription on a prescription form which was pre - signed on the

physician's signature line.

61. Coker did not examine Bordonaro during the visit.

Although Bordonaro complained that the pain medication that he

had been given on his last visit was not working, Coker put in

Bordonaro's medical records that Bordonaro was "[d]oing well

with current medication and treatment plan."

62. Coker asked Bordonaro if he wanted the Xanax

medication refilled, and Bordonaro replied that his girl was out

of town so he did not nee d the Xanax. Bordonaro paid Coker $75

for the visit.

63. On April 25, 2002, Bordonaro again visited Coker for

the purpose of getting refills of his medications. Again,

Bordonaro wore a device which allowed the conversation to be

recorded.

64. Coker gav e Bordonaro 120 tablets of Hydrocodone, the

generic for Lortab, and 90 bars of two - milligram Alprazolam for

anxiety. Bordonaro asked if he could double up on his

medication, and the following conversation took place:

Coker: No.

Bordonaro: No?

Coker: That's what I have to tell you.

Bordonaro: Okay.

Coker: Remember with these don't drink,

drive, operate any machinery while you're

taking it. Don't mix with other medicines

or share them with anyone else.

When Coker told Bordonaro that he could not double up on the

medication, Coker winked at Bordonaro.

65. Bordonaro was not examined on the April 25 visit.

Coker charged Bordonaro $165 for the visit and medications.

66. John Barsa, M.D., a board certified physician in pain

medicine, testified as an expert witness on Coker's behalf. Dr.

Barsa practices in the Tampa area. Approximately nine or ten

years ago, Dr. Barsa employed a physician assistant for about

six months to one year. He currently employs three nurse

practitioners.

67. Dr. Barsa gave his opinions on the care that Coker

provided to the undercover officers. However, his opinions were

based in part on the medical records made by Coker. Much of

those medical records do not accurately reflect what occurred

during the visits of the underc over officers.

68. Herly Ramos, P.A. - C., is a physician assistant and has

passed the national board certification examination for general

medicine. He is presently employed as a surgical assistant.

Previously he practiced for nine years with the Orlan do

Orthopedic Center, which is primarily an orthopedic practice.

While with the Orlando Orthopedic Center, Mr. Ramos routinely

took medical histories, performed physical examinations, made

assessments, developed treatment plans, did discharge

evaluations, and wrote progress reports.

69. A large component of the orthopedic practice involves

evaluating patients for complaints of pain. Common orthopedic

ailments include back or neck pain, extremity pain from strains,

sprains, or fractures. The first line o f treatment for such

ailments includes nonsteroidal, anti - inflammatory drugs, muscle

relaxers, and physical therapy. Patients with fresh fractures

or other conditions involving severe pain often require narcotic

analgesics or controlled substances.

70. M r. Ramos credibly opined on the standard of care for

a physician assistant in evaluating a patient on the initial

visit and follow - up visits. It is his opinion that when

performing an initial evaluation of a patient complaining of

pain, a detailed medical history should be taken, and a thorough

physical examination should be conducted. The medical history

should include a personal medical history, social history,

family medical history, allergies, surgical history, name of

current physician, current medic ations, review of systems, and

any diagnoses.

71. According to Mr. Ramos, the initial physical

examination for a patient complaining of pain should include

taking the patient's vital signs (blood pressure, pulse,

respiration, and temperature), heart and l ung examination,

assessment for any obvious abnormalities, examination of the

abdomen, and a detailed examination of the portion of the body

about which the patient is complaining. During the physical

examination, the physician assistant should be looking for

anything that might indicate a cause for the patient's

complaint.

72. A limited examination is a less detailed examination,

and it is Mr. Ramos' opinion that a limited examination is

indicated when the physician assistant is treating the patient

for a recurring complaint and wants to determine if there was

any interval change.

73. Dr. Barsa and Mr. Ramos agree that a physician

assistant could recommend to the supervising physician that

controlled substances be prescribed for a patient, but that a

p hysician assistant could not prescribe controlled substances

for a patient. It is the opinion of Dr. Barsa that a physician

assistant who prescribes controlled substances is practicing

beyond the scope permitted by law for a physician assistant.

74. Acco rding to Dr. Barsa, the prescribing of controlled

substances should be based upon a clear documentation of

unrelieved pain that is unmanageable with simple Tylenol or

aspirin. For example, it would be a violation of the standard

of care to prescribe a con trolled substance for neck pain when

the patient has no complaints of neck pain.

75. Mr. Ramos credibly opined that Coker's treatment of

the undercover officers fell below the level of care, skill, and

treatment which is recognized by a reasonably prudent physician

assistant as being acceptable under the conditions and

circumstances.

CONCLUSIONS OF LAW

76. The Division of Administrative Hearings has

jurisdiction over the parties to and the subject matter of this

proceeding. Sections 120.569 and 120.57, Florida Statutes

(2003).

77. The Department has the burden to establish the

allegations in the Administrative Complaint by clear and

convincing evidence. Department of Banking and Finance v.

Osborne Stern and Company , 670 So. 2d 932 (1996).

78. Section 458.347(7)(g), provides that the Board of

Medicine may discipline a physician assistant for a violation of

Chapter 458. In Count I of the Administrative Complaint, the

Department alleged that Coker violated Subsection 458.331(1)(t),

which provides that th e following act constitutes grounds for a

disciplinary action:

Gross or repeated malpractice or the

failure to practice medicine with that level

of care, skill, and treatment which is

recognized by a reasonably prudent similar

physician as being accepta ble under similar

conditions and circumstances. The board

shall give great weight to the provisions of

s. 766.102 when enforcing this paragraph.

As used in this paragraph, "repeated

malpractice" includes but is not limited to,

three or more claims for me dical malpractice

within the previous 5 - year period resulting

in indemnities being paid in excess of

$25,000 each to the claimant in a judgment

or settlement and which incidents involved

negligent conduct by the physician. As used

in this paragraph, "gros s malpractice" or

the "failure to practice medicine with that

level of care, skill, and treatment which is

recognized by a reasonably prudent similar

physician as being acceptable under similar

conditions and circumstances," shall not be

construed so as to require more than one

instance, event, or act. Nothing in this

paragraph shall be construed to require that

a physician be incompetent to practice

medicine in order to be disciplined pursuant

to this paragraph.

79. The Department alleged that Coker vio lated Subsection

458.331(1)(t) by failing to perform initial and follow - up

examinations of the undercover officers; failing to document and

evaluate the current treatment plan for the undercover officers;

failing to ascertain the history of the pain of the undercover

officers; failing to obtain past medical records prior to

treating the undercover officers; and inappropriately and

excessively prescribing controlled substances to the undercover

officers.

80. The standard of care for a physician assistant

re quires that the physician assistant do examinations on initial

and follow - up visits of patients. The initial examination

requires that a detailed medical history be taken and a physical

examination be done. The physical examination should include

checkin g the patient's vital signs, heart, and lungs; performing

a general assessment of abnormalities; examining the abdomen;

examining each of the patient's systems; and performing a

detailed examination of the portion of the body about which the

patient is com plaining. On a follow - up examination, the

physician assistant may perform a limited examination to

determine if there is any interval change.

81. The standard of care for a physician assistant

requires the physician assistant to prescribe based on a clea r

documentation of the patient's complaint.

82. On Mathis' initial visit, Coker took Mathis' medical

history, checked his blood pressure, asked him if he had anxiety

and for how long. That was the extent of the examination.

There was no discussion of an xiety symptoms Mathis was

experiencing or a treatment plan for anxiety. Coker fell below

the standard of care on July 14, 2001, in his examination of

Mathis.

83. On Mathis' second visit, Mathis had a new complaint of

pain. The only physical examinatio n that Coker performed was to

take Mathis' blood pressure. There was no discussion of how

often Mathis experienced the pain, and there was no discussion

of Mathis's anxiety. Coker fell below the standard of care on

August 17, 2001, in failing to do a phy sical examination of

Mathis as it related to Mathis's complaint of pain, and in

failing to ascertain the status of Mathis's anxiety.

84. Coker fell below the standard of care in prescribing

pain medication for neck pain for Grow on the August 21, 2001,

vi sit. Grow was not complaining of neck pain. The pain

medication was originally requested by Mathis during the visit,

and when Coker indicated that it was too soon to prescribe any

more pain medication, he concocted a complaint for Grow so that

Mathis cou ld obtain the medications through Grow. Additionally,

the evidence indicated that Mathis wanted the pain medication

for someone other than himself.

85. Coker fell below the standard of care in his treatment

of Bachman during the August 24, 2001, visit. During the visit,

Grow indicated that she wanted some more Xanax and asked if

Coker could give Bachman a prescription for Xanax. Bachman made

no complaints of anxiety or symptoms of anxiety. Coker

prescribed Xanax for Bachman ostensibly for Grow's use an d not

based on any complaints from Bachman.

86. Coker fell below the standard of care in his treatment

of Bowling on November 15, 2001. Coker prescribed Alprazolam

(Xanax) for Bowling for anxiety. Bowling had no complaints of

anxiety and did not indicat e that he was experiencing any

symptoms of anxiety.

87. Coker fell below the standard of care in his

examination and treatment of Bordonaro on December 13, 2001,

January 11, 2002, February 12, 2002, and April 25, 2002. Coker

did not do any examination of Bordonaro on these visits and

continued to prescribe pain medication for Bordonaro.

88. Coker violated Subsection 458.331(1)(t) by failing to

practice medicine with that level of skill, care, and treatment

which is recognized by a reasonably prudent phys ician or

physician assistant as being acceptable under the circumstances.

89. There was no indication by Mathis, Grow, Bachman, and

Bowling that they were currently seeing a physician or that they

had a primary care physician. Bordonaro did indicate that the

last time that he had seen a physician, his blood pressure was

not high; however, Bordonaro did not indicate when that visit

was, what the purpose of the visit was, or the name of the

doctor. Based on the information supplied to Coker by the

undercov er officers, Coker would have no reason to know that

Mathis, Grow, Bachman, or Bowling would have medical records

that could be requested. Bordonaro did not give enough

information to Coker so that Coker could request medical

records.

90. In Count II of the Administrative Complaint, the

Department alleged that Coker violated Subsection 458.331(1)(q),

which provides that the following acts constitute grounds for

discipline:

Prescribing, dispensing, administering,

mixing, or otherwise preparing a legend

drug, including any controlled substance

other than in the course of the physician's

professional practice. For the purposes of

this paragraph, is shall be legally presumed

that prescribing, dispensing, administering,

mixing, or otherwise preparing legen d drugs,

including all controlled substances,

inappropriately or in excessive or

inappropriate quantities is not in the best

interest of the patient and is not in the

course of the physician's professional

practice without regard to his or her

intent.

91. The Department alleged that Coker violated Subsection

458.331(1)(q) by prescribing controlled drugs to the undercover

officers without any medical justification; prescribing

excessive quantities of controlled drugs to the undercover

officers where there was no indication for medical treatment;

and prescribing drugs to the undercover officers without

conducting a physical examination.

92. For the reasons stated in the above - discussion of

violations of Subsections 458.331(1)(t), Coker also violated

Subse ction 458.331(1)(q).

93. In Count III of the Administrative Complaint, the

Department alleged that Coker violated Subsection 458.347(4) and

Florida Administrative Code Rule 64B8 - 30.008, and, thus,

violated Subsection 458.331(1)(nn), which provides that

di scipline may be imposed for a violation of Chapter 458 and the

rules adopted pursuant thereto. Subsection 458.347(4)(e)

provides that "[a] supervisory physician may delegate to a fully

licensed physician assistant the authority to prescribe any

medication used in the supervisory physician's practice unless

such medication is listed on the formulary created pursuant to

paragraph (f)." The formulary is codified in Florida

Administrative Code Rule 64B8 - 30.008, which prohibits a

physician assistant from presc ribing controlled substances as

defined in Chapter 893. 7

94. In Count III, the Department alleged that Coker

violated Subsections 458.347(4) and 458.331(1)(nn) and Florida

Administrative Code Rule 64B8 - 30.008 by the following acts:

a. On July 14, 2001, the Respondent gave

[Mathis] a prescription for Xanax.

b. On or about August 17, 2001, the

Respondent, at the Diamonds Club, gave

[Mathis] a prescription for Xanax and

Lortab.

c. On or about August 21, 2001, the

Respondent, in the office, gave [Grow] a

p rescription for Lortab and Xanax.

d. On or about August 24, 2001, the

Respondent at the Diamond's Club gave

[Bachman] a prescription for Lortab and

Xanax.

e. On about September 27, 2001, the

Respondent gave [Grow] a prescription for

Lortab and Xanax.

f. On or about September 27, 2001, the

Respondent gave [Bordonaro] a prescription

for Vicodin.

g. On or about November 15, the Respondent

gave [Grow] and [Bowling] each two factory -

sealed prescription bottles, one containing

100 hydrocodone 10 mg and the ot her

containing 180 Alprazolam 2 mg, for a total

of 200 hydrocodone 10 mg and 360 alprazolam

2 mg.

h. On or about December 13, 2001, the

Respondent gave a factory - sealed

prescription bottle to [Bordonaro]

containing 100 hydrocodone 7.5 mg.

l. On or about January 11, 2002, at the

Diamonds Club, the Respondent gave two

factory - sealed prescription bottles to

[Bordonaro], one containing 100 hydrocodone

10 mg and the other containing 90 alprazolam

2 mg.

j. On or about February 11, 2002, the

Respondent gave a p rescription for oxycodone

to [Bordonaro].

k. On or about April 25, 2002, the

Respondent gave two factory - sealed

prescription bottles to [Bordonaro], one

containing hydrocodone and the other

containing alprazolam.

95. Pursuant to Chapter 893, Alprazolam , which is the

generic name for Xanax; Hydrocodone, which is the generic name

for Lortab, Lorcet and Vicodin; and Oxycodone, which is the

generic name for Percocet, are controlled substances. As a

physician assistant, Coker was prohibited from prescribing

controlled substances. He violated Florida Administrative Code

Rule 64B8 - 30.008 and Subsection 459.331(1)(nn) by prescribing

Xanax and Lortab to Mathis; by prescribing Xanax and Lortab to

Grow; by prescribing Xanax and Lortab to Bachman; by prescribing

X anax, Vicodin, Percocet, Hydrocodone, and Alprazolam to

Bordonaro; and by prescribing Hydrocodone and Alprazolam to

Bowling.

96. The prescriptions were written on prescription forms,

which had been pre - signed. Even if the prescription had been

pre - signed by Dr. Cannata, Subsection 458.347(4) prohibits a

supervising physician from delegating the authority to a

physician assistant to prescribe controlled substances. A

physician assistant may make recommendations to the supervising

physician that controlled substances be prescribed, after which

the supervising physician may accept or reject the

recommendation by signing or not signing the prescription.

Coker did not contact Dr. Cannata during any of the visits of

the undercover officers. Coker was not maki ng a recommendation

to Dr. Cannata; he was prescribing the medications himself.

97. In Count IV of the Administrative Complaint, the

Department alleged that Coker violated Subsection 456.072(1)(o),

which provides that discipline may be imposed for "[p]rac ticing

or offering to practice beyond the scope permitted by law or

accepting and performing professional responsibilities the

licensee knows, or has reason to know, the licensee is not

competent to perform."

98. Coker violated Subsection 456.072(1)(o) by prescribing

controlled substances to the undercover officers.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is

RECOMMENDED that a Final Order be entered finding James

Coker guilty of violating Subsections 458.331(1)(t ),

458.331(1)(q), 459.331(1)(nn), and 456.072(1)(o) and Florida

Administrative Code Rule 64B8 - 30.008, and revoking his license

as a physician assistant.

DONE AND ENTERED this 31st day of October, 2003, in

Tallahassee, Leon County, Florida.

S

SUSAN B. KIRKLAND

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.u s

Filed with the Clerk of the

Division of Administrative Hearings

this 31st day of October, 2003.

ENDNOTES

1/ Detective Mathis is identified in the Administrative

Complaint as UO1.

2/ Zee's or Z's is the street name for the prescription

medicine Xana x.

3/ Detective Grow is identified in the Administrative Complaint

as UO2.

4/ Detective Bachman is identified in the Administrative

Complaint as UO3.

5/ Detective Bordonaro is identified in the Administrative

Complaint as UO5.

6/ Sergeant Bowling i s identified in the Administrative

Complaint as UO4.

7/ The versions of Florida Administrative Code Rule 64B8 -

30.008, which were in effect from July 1, 2001, through

April 30, 2002, prohibited a physician assistant from

prescribing controlled substances as defined in the then current

version of Chapter 893.

COPIES FURNISHED :

Kim M. Kluck, Esquire

Joy L. Doss, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

Jon M. Pellett, Esquire

Barr, Murman, Tonelli, Slo ther & Sleet, P.A.

201 East Kennedy Boulevard, Suite 1700

Tampa, Florida 33602

William W. Large, General Counsel

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

Larry McPherson, Executive Director

Board of Medicine

D epartment of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

R. S. Power, Agency Clerk

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.