Disciplinary Action against Paul J. Cimoch, M.D.
Stephen Barrett, M.D.
In December 2008, the Medical Board of California accused Paul Cimoch, M.D., of gross and repeated negligence; incompetence; failure to maintain adequate and accurate records; and aiding and abetting the unlicensed practice of medicine. Cimoch owns and serves as president of the Center for Special Immunology (CSI) in Fountain Valley, California. CSI's Web site states that the facility provides "the most advanced care for people with immune system disorders." However, the accusation document (shown below) stated:
- From 1998 through 2004, Cimoch's facility administered intravenous gamma globulin (IVIg) infusions to a woman who had immunodeficiency disease.
- He and his staff failed to maintain adequate records and failed to monitor whether the infusions were effective.
- The patient did not receive the amount of IVIg stated in the records.
- Bills submitted to an insurance company falsely stated that Cimoch had supervised the infusions.
The Orange County Register has reported that (a) the patient, whose name was Diane Hasenstaab, sued Cimoch for malpractice and fraud; (b) the suit was settled for $300,000, and (c) Cimoch billed Hasenstaab's insurance company close to $400,000 for her treatments. CSI was founded in 1987 in Florida but relocated to California after Cimoch voluntarily surrendered his Florida medical license in 1990. The Florida Medical Board Web site does not indicate the reason for the surrender.
In October 2009, Cimoch signed a stipulation for settlement under which he was (a) reprimanded for failing to ensure that Hasentaab's treatment was adequately supervised, monitored, and documented and (b) ordered to take courses i medical record-keeping, prescribing practices, and ethics.
EDMUND G. BROWN JR.,
Attorney General of the State of California
STEVEN V. ADLER,
Supervising Deputy Attorney General
BETH FABER JACOBS, State Bar No. 89145
Deputy Attorney General
110 West "A" Street, Suite
1100 San Diego, CA 92101
P.O. Box 85266
San Diego, CA 92186-5266
Telephone: (619) 645-2069
Facsimile: (619) 645-2061
Attorneys for Complainant
MEDICAL BOARD OF CALIFORNIA
DEPARTMENT OF CONSUMER AFFAIRS
STATE OF CALIFORNIA
In the Matter of the Accusation Against:
PAUL JOSEPH CIMOCH, M.D.
Physician's and Surgeon's Certificate No. A46088
Case No. 04-2006-173926
1. Barbara Johnston (Complainant) brings this Accusation solely in her official capacity as the Executive Director of the Medical Board of California, Department of Consumer Affairs.
2. On or about May 15, 1989, the Medical Board of California issued Physician's and Surgeon's Certificate Number A46088 to Paul Joseph Cimoch, M.D. (Respondent). The Physician's and Surgeon's Certificate was in full force and effect at all times relevant to the charges brought herein and will expire on July 31, 2010, unless renewed.
3. This Accusation is brought before the Medical Board of California, under the authority of the following sections of the Business and Professions Code ("Code):
4. Section 2220 of the Code states:
"Except as otherwise provided by law, the Division of Medical Quality1 may take action against all persons guilty of violating this chapter [Chapter 5, the Medical Practice Act]. The division shall enforce and administer this article as to physician and surgeon certificate holders, and the division shall have all the powers granted in this chapter. . . ."
1California Business and Professions Code section 2002, as amended effective January 1, 2008, provides in part that the term "Board" as used in the Medical Practice Act (Business and Professions Code, section 2000, et seq.) means the "Medical Board of California," and that references to the "Division of Medical Quality" and the "Division of Licensing" in the Act or any other provision of law shall be deemed to refer to the Board.
5. Under section 2227 of the Code, a licensee who is found guilty under the Medical Practice Act may have his or her license revoked, suspended for a period not to exceed one year, placed on probation and required to pay the costs of probation monitoring, or have such other action taken in relation to discipline as the Board deems proper.
6. Section 2234 of the Code states:
"The Division of Medical Quality shall take action against any licensee who is charged with unprofessional conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not limited to, the following:
"(a) Violating or attempting to violate, directly or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of this chapter [Chapter 5, the Medical Practice Act].
"(b) Gross negligence.
"(c) Repeated negligent acts. To be repeated, there must be two or more negligent acts or omissions. An initial negligent act or omission followed by a separate and distinct departure from the applicable standard of care shall constitute repeated negligent acts.
"(1) An initial negligent diagnosis followed by an act or omission medically appropriate for that negligent diagnosis of the patient shall constitute a single negligent act.
"(2) When the standard of care requires a change in the diagnosis, act, or omission that constitutes the negligent act described in paragraph (1), including, but not limited to, a reevaluation of the diagnosis or a change in treatment, and the licensee's conduct departs from the applicable standard of care, each departure constitutes a separate and distinct breach of the standard of care.
"(e) The commission of any act involving dishonesty or corruption which is substantially related to the qualifications, functions, or duties of a physician and surgeon.
"(t) Any action or conduct which would have warranted the denial of a certificate. "
7. Section 2264 of the Code states:
"The employing, directly or indirectly, the aiding, or the abetting of any unlicensed person or any suspended, revoked, or unlicensed practitioner to engage in the practice of medicine or any other mode of treating the sick or afflicted which requires a license to practice constitutes unprofessional conduct."
8. Section 2266 of the Code states: "The failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct."
FIRST CAUSE FOR DISCIPLINE
9. Respondent is subject to disciplinary action pursuant to Section 2234, subdivision (b) of the Code, in that Respondent was grossly negligent in his care, treatment and management of his patient, D.H. The circumstances are as follows:
A. At all relevant times, respondent served as President of the Center for Special Immunology (CSI), the medical practice he owned. Respondent's practice focused on the care of HIV patients, though he also had patients with other immunodeficiencies or autoimmune ailments.
B. In early 1998, D.H., a 40 year female, became a CSI patient. She had a history of several conditions, including but not limited to Hashimoto thyroiditis2, multiple sclerosis, and asthma, and she complained of fatigue, muscle weakness, numbness, eye pain, and poor balance. Dr. F.A., a physician hired by respondent to work at CSI, evaluated D.H. and diagnosed her with an immune deficiency - IgG3 subclass deficiency. Dr. F.A. recommended treatment with a course of intravenous gamma globulin (lVIg) replacement at 15 grams every two weeks beginning in April of 1998. Thereafter, she raised the dose to 20 grams every 2 weeks. Dr. F.A. left her position with CSI in late 2001.3
C. Of the approximately 54 IVIg infusions patient D.H. received at CSI from April, 1998 until on or about June 4, 2004, about 45 IVIg infusions were performed on patient D.H. between December 1, 2001 and June 4, 2004, when respondent was her physician at CSI. All of D.H.’s IVlg infusions were performed by registered nurse, Wendy Fasone, who was also Vice President of CSI. Nurse Fasone performed these infusions without any direct supervision by respondent or any other physician.
2Hashimoto thyroiditis, also referred to as "Hashimoto Disease" is an autoimmune disorder involving infiltration of the thyroid gland with lymphocytes and in part resulting in hypothyroidism (diminished production of the thyroid hormone).
3Allegations pertaining to the care, treatment and management of D.H. prior to December 1, 2001 are informational only. Respondent's conduct with respect to patient D.H. prior to December 1, 2001, is not a basis for discipline.
D. Respondent failed to provide to Nurse Fasone with any protocol, instructions or orders (written or oral) regarding administration of the infusions given at CSI, including those given to patient D.H. In addition, respondent failed to provide any orders or instructions regarding pre-medications, the infusion rate or dose to be given, or procedures to follow in case of an adverse event.
E. On or about May 3, 2001, D.H. had her first IgG blood level test at CSI. Such an IgG blood level would be used to evaluate the effect of the IVIg infusions. Despite respondent having the responsibility to supervise the provision of IVlg infusions, ensure yearly IgG labs, and monitor if such infusions were effective, respondent failed to do so. He also failed to order (or instruct another CSI physician to order) IgG labs for patient D.H. for May 2002, the year following her first IgG level taken at CSI.
F. Respondent's only meeting with patient D.H. was on March 14, 2003. He did not conduct a physical or examine her. He did not discuss the patient with Dr. F.A. While he ordered labs to determine her IgG level, he did not review the patient's infusion records.
G. Respondent did not appreciate the nature of the immune problem suffered by D.H. nor the significance of the results of the IgG level he ordered on March 14, 2003. He should have seen that the patient, supposedly getting IgG levels at 30 grams infused twice a month since January 2003, had virtually the same IgG levels as she had when supposedly infused with 20 grams twice a month throughout 2002, and that this was essentially unchanged from her level prior to starting IVlg infusions. The results should have alerted respondent that something with the infusions or treatment course was wrong.
H. Respondent knew or should have known that patient D.H. was not getting the amount of IVlg recorded in CSI records.
I. Respondent's records regarding D.H.’s IVIg infusions were inadequate and poorly documented. They are so flawed that it is impossible to know what amount of IVIg was given to patient D.H. on any specific occasion or how it was administered on any specific occasion. The records do not list the time started nor the time the infusion was completed. On many occasions, the IVIg infusion therapy and nursing notes from a prior visit were photocopied onto the new notes so that with the exception of current vital signs, all prior intonation was brought forward to the record for the current infusion date as though it was true and accurate for that new date. In many cases the lot number for the vial used was incorrect because it referred to a vial number used in a prior infusion on a prior date.
J. Respondent did not chart dose amounts or the rate of infusions, give orders for changes in the dose amounts or the rate of infusion, nor chart any order to change dosage or infusion rate. Nonetheless, in many instances, D.H.’s infusion records were altered by writing over dose amounts given, and dose amounts were changed from 20 grams to 30 grams. The dosing changes were not initialed by the person making the change.
K. Respondent knew or should have known his staff was using photocopied records with false and misleading information regarding the infusion notes, lot numbers for the vials of medication infused and the altered dose amounts.
L. Despite the importance of properly recording the lot numbers of the IGIg bottles used for an infusion so that an adverse reaction can be traced or a problem identified by the manufacturer can be cross referenced to the recipient patient, respondent failed to record, failed to instruct his staff to record, and failed to ensure his staff recorded the exact lot number of the bottles used for the infusion of IVIg in the patient's infusion record.
M. The vial labels for the bottles of IVIg used for patient D.H. were not affixed to the request for payment. To the extent multiple vials were used, neither respondent nor his staff affixed labels from all the vials used to the request for payment.
N. Despite respondent's failure to supervise the patient's infusions, from approximately December 1, 2001 through June 2004, approximately 50 bills were submitted to the insurance company (Excellus Blue Cross/Blue Shield [BC/BS]) for the patient's IVIg infusions, identifying respondent as the patient's physician and/or indicating the infusions were "doctor supervised." Respondent submitted these inaccurate billings, knew they were being submitted on his behalf, or should have known they were being submitted.
10. Respondent committed acts of gross negligence in his care, treatment and management of patient D.H. by reason of, but not limited to, the following:
A. Complainant incorporates by reference the allegations in paragraph 9 and its subparagraphs above as though fully set forth herein.
B. Respondent failed to provide written orders for the IVIg infusions, failed to provide any standard operating procedure for the infusions, including pre-medications and procedures to undertake in case of an adverse event and failed to sign the patient's physician supervised infusion notes.
C. Respondent failed to create or maintain a flow chart of the drugs administered to D.H. including the start and stop time for when she was receiving infusion therapy and failed to instruct his staff to do this.
D. Respondent failed to record in D.H.’s infusion records the exact lot number of the infusion bottles used, and failed to instruct his staff to do this.
E. Respondent knew or should have known his staff was using photocopies of infusion notes from prior visits that were then brought forward to the current date as if the information was true and accurate as to that date.
F. Though Respondent billed for D.H.’s IVIg infusions as her treating physician, Respondent only saw D.H. on one occasion the entire time she had infusions at CSI on March 14, 2003. Between December 1, 2001 and June 2004, Respondent had his staff provide approximately 45 IVIg infusions to D.H. without writing any orders. Respondent never saw D.H. during her infusions, did not review the infusion notes, and failed to create or maintain any records showing such treatment or review.
G. It is the standard of care for a patient with humoral immunodeficency requiring IVlg infusions to check the patient's IgG levels several times during the first year of treatment. After the level of IgG has stabilized, levels should be checked at least once a year. Respondent's staff first checked D.H.’s IgG levels on May 3, 2001, three years after she first started infusions of IgG at CSI.4 Respondent should have ensured levels were repeated within a year, by May 2002. He did not do this. Rather, the first time he evaluated the patient in any way was on March 14, 2003, when he ordered new IgG levels taken. He did conduct a physical nor discuss her treatment or care with any prior treating physicians, nor did he consult with a physician with an expertise in immunodeficiency. Respondent's failure to closely monitor the patient's IgG levels contributed to his lack of awareness that D.H.'s IgG levels did not increase as expected. Respondent did not appreciate or understand the red flag raised by D .H.'s blood level remaining essentially unchanged regardless of whether she received 20 or 30 grams twice a month.
4Allegations pertaining to the care, treatment and management of D.H. prior to December 1, 2001 are informational only and are not alleged as a basis for discipline.
H. The standard of care requires a physician to supervise IVlg infusions. Respondent did not supervise patient D.H.'s IVIg infusions. He submitted billings stating he supervised her infusions, but he did not so.
I. Respondent failed to properly supervise his nurse, Wendy Fasone, R.N. As a result, Ms. Fasone was running the CSI infusion center on her own. She used photocopied infusion notes from prior infusions and passed them off as current notes, she gave pre-medications to D.H. without any orders from respondent or any other physician, she gave IVIg infusions to D.H. without proper physician orders, she altered medical records as to the amount of IVIg given during the infusions, and modified D.H.'s doses without physician orders.
J. Respondent knew or should have known that patient D.H. was not getting the amount of IVIg that appeared to be charted and billed to the insurance company.
K. Respondent submitted or knew his staff submitted approximately 50 bills to the insurance company (Excellus Blue Cross/Blue Shield [BC/BS]) for patient D.H.'s IVIg infusions, where respondent identified himself or was identified as the patient's physician, and/or the billings falsely indicated the infusions were "doctor supervised."
SECOND CAUSE FOR DISCIPLINE
11. Respondent is subject to disciplinary action pursuant to section 2234, subdivision (c), in that, respondent committed repeated acts of negligence in his care, treatment and management of patient D.H. as described above in paragraphs 9 and 10, and their subsections, which are incorporated by reference as though fully set forth.
THIRD CAUSE FOR DISCIPLINE
12. Respondent is subject to disciplinary action pursuant to section 2234 subdivision (d), in that respondent was incompetent in his care, treatment and management of patient D.H. as described above in paragraphs 9 and 10, and their subsections, which are incorporated by reference herein.
FOURTH CAUSE FOR DISCIPLINE
(Failure to Maintain Adequate and Accurate Records)
13. Respondent is subject to disciplinary action failure to maintain adequate and accurate records relating to D.H, in violation of Business and Professions Code section 2266, as set forth above in paragraphs 9 and 10, and their subsections, which are incorporated herein.
FIFTH CAUSE FOR DISCIPLINE
(Aiding and Abetting Unlicensed Practice of Medicine)
14. Respondent is subject to disciplinary action pursuant to section 2264 in that he aided and abetted his employee, Wendy Fasone, R.N., to practice medicine without a license and to provide care, treatment and medical management of patient D.H.
A. Paragraphs 9 and 10 and their subsections are re-alleged and incorporated by reference herein.
B. Respondent aided and abetted the unlicensed practice of medicine by permitting and authorizing Wendy Fasone, registered nurse and CSI Vice President, to control all aspects of IVIg infusions at CSI, including determining the dose to be infused, the type of and dose of any pre-medications, determining the rate of infusion, performing the actual infusion, recording all aspects of the infusion for patient D.H. and other patients at CSI, and billing for the infusions under respondent's name.
WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing, the Medical Board of California issue a decision:
1. Revoking or suspending Physician's and Surgeon's Certificate Number A46088, issued to Paul Joseph Cimoch, M.D;
2. Revoking, suspending or denying Paul Joseph Cimoch, M.D. the authority to supervise physician assistants, pursuant to section 3527 of the Code;
3 Ordering Paul Joseph Cimoch, M.D. to pay the Medical Board of California the costs of probation monitoring, should he be placed on probation; and
4 Taking such other and further action as deemed necessary and proper.
DATED: December 1. 2008
Medical Board of California
Department of Consumer Affairs
State of California
This page was posted on February 27. 2010.