Chapter 360-3 INVESTIGATIONS AND DISCIPLINE
The Georgia Composite Medical Board ("Board") is
authorized to deny, revoke, suspend, fine, reprimand or otherwise
limit the license of a physician or physician assistant for all the
grounds set forth in O.C.G.A. § 43-34-8
and to deny, revoke, suspend, fine, reprimand or otherwise limit the
license of a physician pursuant to O.C.G.A. § 43-34-8.
In addition, the Board is authorized to terminate the approval of a
physician's assistant and to revoke the license of a physician's
assistant pursuant to O.C.G.A. § 43-34-107.
O.C.G.A §§ 43-1-19
and
43-34-37
authorize the Board to take disciplinary action against licensees for
unprofessional conduct. "Unprofessional conduct" shall include, but
not be limited to, the following:
| (1) |
Prescribing controlled
substances for a known or suspected habitual drug abuser or other
substance abuser in the absence of substantia l
justification. |
| (2) |
Writing prescriptions for controlled substances for personal use or,
except for documented emergencies, for immediate family members. For
purposes of this rule, "immediate family members" include spouses,
children, sib lings, and parents. |
| (3) |
Prescribing, ordering,
dispensing, administering, selling or giving any amphetamine,
sympathomimetic amine drug or compound designated as a Schedule II
Controlled Substance under O.C.G.A. T. 16, Ch. 13, to or for any
person except in the following situations:
| (a) |
Treatment of any of the
following conditions:
| 1. |
Attention
deficit disorder; |
| 2. |
Drug
induced brain dysfunction; |
| 3. |
Narcolepsy and/or
hypersomnolence; |
| 5. |
Depression or other psychiatric diagnosis. |
| 6. |
Weight loss management, if drug
has been approved by the FDA for that indication. |
|
| (b) |
For clinical investigations
conducted under protocols approved by a state medical institution
permitted by the Georgia Department of Human Services (DHS) with
human subject review under the guidelines of the United States
Department of Health and Human Services. |
|
| (4) |
Pre-signing prescriptions that
have the patient's name, type of medication, or quantity
blank. |
| (5) |
Prescribing
controlled substances (O.C.G.A. T. 16, Ch. 13, Art. 2) and/or
dangerous drugs (O.C.G.A. T. 16, Ch. 13, Art. 3) for a patient based
solely on a consultation via electronic means with the patient,
patient's guardian or patient's agent. This shall not prohibit a
licensee from prescribing a dangerous drug for a patient pursuant to
a valid physician patient relationship in accordance with
O.C.G.A.
33-24-56.4
or a licensee who is on-call or covering for another licensee from
prescribing up to a 30-day supply of medications for a patient of
such other licensee nor shall it prohibit a licensee from prescribing
medications when documented emergency circumstances exist.
This shall also not prevent a licensed physician from
prescribing Schedule II sympathomimetic amine drugs for the treatment
of attention deficit disorder to a patient in the physical presence
of a licensed nurse, provided the initial diagnosis was made and an
initial prescription was issued in accordance with 21 U .S .C. §
829(e), as amended from time to time, including but not limited to
the following:
| (a) |
The
physician has conducted at least one in-person medical evaluation of
the patient; or |
| (b) |
The
physician is covering for a licensee who is temporarily unavailable
and has conducted at least one in-person medical evaluation of the
patient; or |
| (c) |
The
physician is engaged in the practice of telemedicine in accordance
with Board Rule
360-3-.07 and with 21 U.S.C.
§§ 802(54) and 829Ce)(3)(A), including, but not limited to:
| 1. |
Where the patient is being
treated by, and physically located in, a hospital or clinic
registered with the U.S. Drug Enforcement Agency ("DEA"), the
physician is registered with the DEA, and all other requirements of
21 U.S.C. § 802(54)(A) are met; or |
| 2. |
Where the patient is being
treated by, and physically in the presence of, a licensee who is
registered with the DEA, and all other requirements of 21 U .S .C.
§ 802(54)(B) are met; or |
| 3. |
Where the physician has obtained
from the U.S. Attorney General a special registration for
telemedicine in accordance with 21 U.S.C. §§ 802(54)(E) and
831(h). |
|
|
| (6) |
Providing treatment via
electronic or other means unless a history and physical examination
of the patient has been performed by a Georgia licensee. This shall
not prohibit a licensee who is on call or covering for another
licensee from treating and/or consulting a patient of such other
licensee. Also, this paragraph shall not prohibit a patient's
attending physician from obtaining consultations or recommendations
from other licensed health care providers. |
| (7) |
Failing to maintain appropriate
patient records whenever Schedule II, III, IV or V controlled
substances are prescribed. Appropriate records, at a minimum, shall
contain the following:
| (a) |
The
patient's name and address; |
| (b) |
The date, drug name, drug
quantity, and patient's diagnosis necessitating the Schedule II, III,
IV, or V controlled substances prescription; and |
| (c) |
Records concerning the
patient's history. |
|
| (8) |
Committing any act of sexual
intimacy, abuse, misconduct, or exploitation of any individual
related to the physician's practice of medicine regardless of
consent. The rule shall apply to former patients where the licensee
did not terminate in writing the physician patient relationship
before engaging in a romantic or sexual relationship with the patient
and/or where the licensee used or exploited the trust, knowledge,
emotions or influence derived from the prior professional
relationship. The Board will consider the physician patient
relationship terminated if the physician has not evaluated or treated
the patient for a period of at least two (2) years. |
| (9) |
Failing to comply with the
provisions of O.C.G.A. Section
31-9-6.1
and Chapter 360-14 of the Rules of Georgia Composite Medical Board
relating to informed consent, which requires that certain information
be disclosed and that consent be obtained regarding any surgical
procedure performed under general anesthesia, spinal anesthesia, or
major regional anesthesia or an amniocentesis procedure or a
diagnostic procedure that involves the intravenous injection of a
contrast material. |
| (10) |
Failing to conform to the recommendation of the Centers for Disease
Control for preventing transmission of the Human Immunodeficiency
Virus, Hepatitis B Virus, Hepatitis C Virus, and Tuberculosis to
patients during exposure-prone invasive procedures. It is the
responsibility of all persons currently licensed by the Board to
maintain familiarity with these recommendations, which the Board
considers the minimum standards of acceptable and prevailing medical
practice. |
| (11) |
Failing to
timely respond to an investigative subpoena issued by the
Board. |
| (12) |
Conducting a
physical examination of the breast and/or genitalia of a patient of
the opposite sex without a chaperone present. |
| (13) |
Practicing medicine while
mentally, physically, or chemically impaired. |
| (14) |
Failing to use such means as
history, physical examination, laboratory, or radiographic studies,
when applicable, to diagnose a medical problem. |
| (15) |
Failing to use medications and
other modalities based on generally accepted or approved indications,
with proper precautions to avoid adverse physical reactions,
habituation, or addiction in the treatment of patients. However,
nothing herein shall be interpreted to prohibit investigations
conducted under protocols approved by a state medical institution
permitted by DHS and with human subject review under the guidelines
of the United States Department of Health and Human
Services. |
| (16) |
Failing to
maintain patient records documenting the course of the patient's
medical evaluation, treatment, and response.
| (a) |
A physician shall be required
to maintain a patient's complete medical record, which may include,
but is not limited to, the following: history and physical, progress
notes, X-ray reports, photographs, laboratory reports, and other
reports as may be required by provision of the law. A physician shall
be required to maintain a patient's complete treatment records for a
period of no less than 10 years from the patient's last office
visit. |
| (b) |
The
requirements of this rule shall not apply to a physician who has
retired from or sold his or her medical practice if:
| 1. |
such physician has notified his
or her active patients of retirement from or sale of practice by
mail, at the last known address of his or her patients, offering to
provide the patient's records or copies thereof to another provider
of the patient's choice and, if the patient so requests, to the
patient; |
| 2. |
has caused to
be published, in the newspaper of greatest circulation in each county
in which the physician practices or practiced and in a local
newspaper that serves the immediate practice area, a notice which
shall contain the date of such retirement or sale that offers to
provide the patient's records or copies thereof to another provider
of the patient's choice, and if the patient so requests, to the
patient; and |
| 3. |
has
placed in a conspicuous location in or on the facade of the
physician's office, a sign announcing said retirement or sale of the
practice. The sign shall be placed 30 days prior to retirement or the
sale of the practice and shall remain until the date of retirement or
sale. |
| 4. |
Both the notice
and sign required by rule 360-3-.02 shall advise the physician's
patients of their opportunity to transfer or receive their
records. |
|
| (c) |
The period specified in this rule may be less than the length of time
necessary for a physician to protect himself or herself against other
adverse actions. Therefore, physicians may wish to seek advice from
private counsel or their malpractice insurance
carrier. |
|
| (17) |
Continuing to practice after the expiration date of the
license. |
| (18) |
Any other
practice determined to be below the minima l standards of acceptable
and prevailing practice. |
| (19) |
Providing a false, deceptive
or misleading statement(s) as a medical expert. |
| (20) |
Failing to report to the Board
within 30 days of becoming unable to practice medicine with
reasonable skill and safety by result of illness or use of alcohol,
drugs, narcotics, chemicals, or any other type of material, or as a
result of any mental or physical condition, unless the physician has
reported to the Physician Health Program. |
| (21) |
(For a physician) Delegating
the injection of botulinum toxin and/or dermal fillers to medical
assistants. |
The Georgia Composite Medical Board is authorized to
take disciplinary action for violations of laws and rules and
regulations which relate to or in part regulate the practice of
medicine. These laws, rules and regulations include, but are not
limited to, the following:
| (1) |
The Georgia Medical Practice
Act (O.C.G.A. T. 43, Ch. 34); |
| (2) |
The Georgia Controlled
Substances Act (O.C.G.A. T. 16, Ch. 13, Art. 2); |
| (3) |
The Georgia Dangerous Drug Act
(O.C.G.A. T. 16, Ch. 13, Art. 3); |
| (4) |
The Federal Controlled
Substances Act (21 U.S.C. Ch. 13); |
| (5) |
The Georgia Pharmacists and
Pharmacies Act (O.C.G.A. T. 26, Ch. 4); |
| (6) |
The Rules of the Georgia
Composite Medical Board, Ch. 360, Rules and Regulations of the State
of Georgia; |
| (7) |
The Rules
of the Georgia State Board of Pharmacy, Ch. 480, Rules and
Regulations of the State of Georgia, in particular those relating to
the prescribing and dispensing of drugs; |
| (8) |
The Code of Federal Regulations
Relating to Controlled Substances (21 C.F.R. par. 1306);
and |
| (9) |
O.C.G.A. Section
31-9-6.1
and Chapter 360-14 of the rules of the Georgia Composite Medical
Board relating to informed consent. |
For the purpose of this rule person means an
individual that holds a license, certificate, or permit issued by the
Board or who has applied for a license, certificate, or
permit.
| (1) |
The Board may,
require a licensee or applicant to submit to a mental and physical
examination by a physician or evaluation program approved by the
Board. Mental or physical evaluations may be performed on an
inpatient or outpatient basis as directed by the Board. The costs of
the evaluation are the responsibility of the person being
evaluated. |
| (1) |
It shall be grounds for
disciplinary action by the Board if a physician aids or abets another
person in misrepresenting his/her credentials or engaging in
unlicensed practice. Engaging in unlicensed practice includes
delegation by a physician of professional responsibilities to a
person who is not authorized to provide such services. A physician
may delegate the performance of certain medical tasks to an
unlicensed person with appropriate supervision as provided herein.
| (a) |
Medical Assistants
| 1. |
For purposes of this rule, a
medical assistant is an unlicensed person employed by the physician
to whom he or she delegates certain medical tasks.
| (i) |
A physician may delegate to a
medical assistant the following medical tasks: subcutaneous and
intramuscular injections; obtaining vital signs; administering
nebulizer treatments; or removing sutures and changing
dressings. |
| (ii) |
Physicians or physician assistants under basic job description and/or
advanced practice nurses under protocol must be on-site for a medical
assistant to administer subcutaneous and intramuscular injections, to
administer nebulizer treatments, and to remove sutures and change
dressings. It is not required for a physician to be on-site for a
medical assistant to obtain vital signs. |
| (iii) |
Physician shall only allow
medical assistants to provide services for which they have been
properly trained. Physicians shall maintain accurate and complete
records of professional services rendered. |
| (iv) |
Nothing in this rule prohibits
the performance of tasks by medical assistants that would not
otherwise require a license. |
|
|
| (b) |
Polysomnography
| 1. |
Definitions
| (i) |
"Polysomnography" means the
treatment, management, diagnostic testing, control, education, and
care of patients with sleep and wake disorders. Polysomnography
includes, but is not limited to, the process of analysis, monitoring,
and recording of physiologic data during sleep and wakefulness to
assist in the treatment of disorders, syndromes, and dysfunctions
that are sleep related, manifest during sleep, or disrupt normal
sleep activities. Polysomnography also includes, but is not limited
to, the therapeutic and diagnostic use of low-flow oxygen, the use of
positive airway pressure including continuous positive airway
pressure (CPAP) and bi-level modalities, adaptive servo-ventilation,
and maintenance of nasal and oral airways that do not extend into the
trachea. |
| (ii) |
"Polysomnographic technologist" means any person performing
polysomnography services under the supervision of a physician
licensed under this article without the requirement that the
technologist is licensed. |
| (iii) |
"Supervision" means that the
supervising physician licensed under this article shall remain
available, either in person or through telephonic or electronic
means, at the time that polysomnography services are
provided. |
|
| 2. |
Delegation of Duties
| (i) |
Physicians
may delegate to a polysomnography technologist to perform tasks to
treat, manage, control, educate, or care for patients with sleep or
wake disorders or to provide diagnostic testing for patients with
suspected sleep or wake disorders. |
| (ii) |
However, the physician may not
delegate tasks that constitute the practice of medicine. |
|
|
| (c) |
Radiologist Assistant
| 1. |
Radiologist
Assistant means an advanced level certified diagnostic radiologic
technologist who assists radiologists under levels of supervision in
performing advanced diagnostic imaging procedures including, but not
limited to, enteral and parenteral procedures when performed under
the direction of the supervising radiologist and may include
injecting diagnostic agents to sites other than intravenous,
performing diagnostic aspirations and localizations, and assisting
radiologists with other invasive procedures.
| (i) |
Supervision
| (I) |
Radiology assistants shall be
supervised by a physician licensed under O.C.G.A.
43-34 who has experience
in performing advanced diagnostic imaging procedures.
| I. |
Exemptions or Limitations
|
|
|
|
| 2. |
This Code section is for
definitional purposes only and shall not be construed to require any
duties or obligations regarding radiology assistants that did not
already exist as of June 30, 2009. |
|
|
| (1) |
Definitions. As
used in this rule, the following terms shall mean:
| (a) |
"Annual patient population"
shall mean those patients seen by a clinic or practice in a twelve
month calendar year, but shall not include patients that are
in-patient in hospital, nursing home or hospice facilities licensed
pursuant to O.C.G.A. T. 31, Ch. 7. |
| (b) |
"Board" shall mean the Georgia
Composite Medical Board. |
| (c) |
"Chronic pain" shall mean pain
requiring treatment which has persisted for a period of ninety days
or greater in a year, but shall not include perioperative pain, i.e.,
pain immediately preceding and immediately following a surgical
procedure, when such perioperative pain is being treated by a
physician in connection with a surgical procedure. |
| (d) |
"Monitoring" means any method
to assure treatment compliance including but not limited to the use
of pill counts, pharmacy or prescription program verification.
Monitoring must include a urine, saliva, sweat, or serum test
performed on a random basis. |
| (e) |
"Terminal condition" means an
incurable or irreversible condition, which would result in death in a
relatively short period of time. |
|
| (2) |
O.C.G.A. § 43-34-8
authorizes the Board to take disciplinary action against licensees
for unprofessional conduct, which includes conduct below the minimum
standards of practice. With respect to the prescribing of controlled
substances for the treatment of pain and chronic pain, the Board has
determined that the minimum standards of practice include, but are
not limited to the following:
| (a) |
Physicians cannot delegate the dispensing of controlled substances to
an unlicensed person. |
| (b) |
When prescribing controlled substances, a physician shall use a
prescription pad that complies with state law. |
| (c) |
When initially prescribing a
controlled substance for the treatment of pain or chronic pain, a
physician shall have a medical history of the patient, a physical
examination of the patient shall have been conducted, and informed
consent shall have been obtained. In the event of a documented
emergency, a physician may prescribe an amount of medication to cover
a period of not more than 72 hours without a physical
examination. |
| (d) |
When a
physician is treating a patient with controlled substances for pain
or chronic pain for a condition that is not terminal, the physician
shall obtain or make a diligent effort to obtain any prior diagnostic
records relative to the condition for which the controlled substances
are being prescribed and shall obtain or make a diligent effort to
obtain any prior pain treatment records. The records obtained from
prior treating physicians shall be maintained by the prescribing
physician with the physician's medical records for a period of at
least ten (10) years. If the physician has made a diligent effort and
is unable to obtain prior diagnostic records, then the physician must
order appropriate tests to document the condition requiring treatment
for pain or chronic pain. If the physician has made a diligent effort
and the prior pain treatment records are not available, then the
physician must document the efforts made to obtain the records and
shall maintain the documentation of the efforts in his/her patient
record. |
| (e) |
When a
physician determines that a patient for whom he is prescribing
controlled scheduled substances is abusing the medication, then the
physician shall make an appropriate referral for treatment for
substance abuse. |
| (f) |
When
prescribing a Schedule II or III controlled substance for 90 (ninety)
consecutive days or greater for the treatment of chronic pain arising
from conditions that are not terminal or patients who are not in a
nursing home or hospice, a physician must have a written treatment
agreement with the patient and shall require the patient to have a
clinical visit at least once every three (3) months, while treating
for pain, to evaluate the patient's response to treatment, compliance
with the therapeutic regimen and any new condition that may have
developed and be masked by the use of Schedule II or III controlled
substances. The requirement of a visit at a minimum of once every
three months can be waived and the clinical visit be at least once
per year if the doctor determines there is a substantial hardship and
documents such hardship in the patient's record or if the morphine
equivalent daily dose ("MEDD") is 30 mg. or less. |
| (g) |
When prescribing a Schedule II
or III controlled substance for 90 (ninety) consecutive days or
greater for the treatment of chronic pain arising from conditions
that are not terminal or patients in a nursing home or hospice, a
physician must monitor compliance with the therapeutic regimen.
Patients should be randomly monitored at least annually via bodily
fluid analysis. However, body fluid analysis may be performed more
frequently than once a year, if the provider considers it to be
necessary in his/her patient population, in order to assess and
assure compliance with the prescribed treatment regimen. A clinical
examination should occur once every three (3) months, except for
hardship in certain cases, which must be well documented in the
patient record. |
| (h) |
The
physician shall respond to any abnormal result of any monitoring and
such response shall be recorded in the patient's record. |
| (i) |
When a physician determines
that a new medical condition exists that is beyond their scope of
training, he/she shall make a referral to the appropriate
practitioner. |
| (j) |
Any
physician who prescribes Schedule II or III substances for chronic
pain for greater than 50% of that physician's annual patient
population must document competence to the Board through
certification or eligibility for certification in pain management or
palliative medicine as approved by the Georgia Composite Medical
Board ("Board"). The Board recognizes certifications in pain medicine
or palliative medicine by the American Board of Medical Specialties
or the American Osteopathic Association, the American Board of Pain
Medicine and the American Board of Interventional Pain Physicians. If
the physician does not hold this certification or eligibility he/she
must demonstrate competence by biennially obtaining 20 (twenty) hours
of continuing medical education ("CME") pertaining to pain management
or palliative medicine. Such CME must be an AMA/AOA PRA Category I
CME, a board approved CME program, or any federally approved CME. The
CME obtained pursuant to this rule may count towards the CME required
for license renewal. |
|
| (a) |
Under O.C.G.A. §§ 43-34-8
and
43-1-19,
the Board is authorized to take disciplinary action against licensees
for unprofessional conduct, and in connection therewith, to establish
standards of practice. Except as otherwise provided, in order for a
physician to practice within the minimum standards of practice while
providing treatment and/or consultation recommendations by electronic
or other such means, all the following conditions must be met:
| (1) |
All treatment and/or
consultations must be done by Georgia licensed
practitioners; |
| (2) |
A
history of the patient shall be available to the Georgia licensed
physician, physician assistant or advanced practice registered nurse
who is providing treatment or consultation via electronic or other
such means; |
| (3) |
A Georgia
licensed physician, physician assistant or advanced practice
registered nurse either:
| 3.a. |
Has
personally seen and examined the patient and provides ongoing or
intermittent care by electronic or other such means; or |
| 3.b. |
Is providing medical care by
electronic or other such means at the request of a physician,
physician assistant or advanced practice registered nurse licensed in
Georgia who has personally seen and examined the patient;
or |
| 3.c. |
Is providing
medical care by electronic or other such means at the request of a
Public Health Nurse, a Public School Nurse, the Department of Family
and Children's Services, law enforcement, community mental health
center or through an established child advocacy center for the
protection for a minor, and the physician, physician assistant or
advanced practice registered nurse is able to examine the patient
using technology and peripherals that are equal or superior to an
examination done personally by a provider within that provider's
standard of care; or |
| 3.d. |
Is able to examine the patient using technology or peripherals that
are equal or superior to an examination done personally by a provider
within that provider's standard of care. |
|
| (4) |
The Georgia licensed physician,
physician assistant or advanced practice registered nurse providing
treatment or consultations by electronic or other means must maintain
patient records on the patient and must document the evaluation and
treatment along with the identity of the practitioners providing the
service by electronic or other means, and if there is a referring
practitioner, a copy of this record must also be provided to the
referring physician, physician assistant or advanced practice
registered nurse; |
| (5) |
To
delegate to a nurse practitioner or to supervise a physician
assistant doing telemedicine, the physician must document to the
board that that the provision of care by telemedicine is in his or
her scope of practice and that the NP or PA has demonstrated
competence in the provision of care by telemedicine. |
| (6) |
Patients treated by electronic
or other such means or patient's agent must be given the name,
credentials and emergency contact information for the Georgia
licensed physician, physician assistant and/or advanced practice
registered nurse providing the treatment or consultation. Emergency
contact information does not need to be provided to those treated
within the prison system while incarcerated but should be provided to
the referring provider. For the purposes of this rule, "credentials"
is defined as the area of practice and training for physicians, and
for physician assistants and advanced practice registered nurses,
"credentials" shall mean the area of licensure and must include the
name of the delegating physician or supervising physician; |
| (7) |
The patient being treated via
electronic or other means or the patient's agent must be provided
with clear, appropriate, accurate instructions on follow-up in the
event of needed emergent care related to the treatment. In the case
of prison patients, prison staff will be provided this information if
the consult is provided to an inmate; and |
| (8) |
The physician, physician
assistant or nurse practitioner who provides care or treatment for a
patient by electronic or other such means must make diligent efforts
to have the patient seen and examined in person by a Georgia licensed
physician, physician assistant or nurse practitioner at least
annually. |
|
| (b) |
This rule should not be interpreted to interfere with care and
treatment by telephonic communication in an established
physician-patient relationship, call coverage for established
physician-patients relationships, or telephone and internet
consultations between physicians, nurse practitioners, physician
assistants, other healthcare providers or child protection
agencies. |
| (c) |
This rule
does not authorize the prescription of controlled substances for the
treatment of pain or chronic pain by electronic or other such means.
All treatment of pain or chronic pain must be in compliance with Rule
360-3-.06. |
| (d) |
Nothing in this rule shall
excuse a physician, nurse practitioner or physician assistant from
ordering appropriate laboratory or other diagnostic tests needed to
make diagnoses within the minimum standard of care. |
| (e) |
Nothing in this rule shall
supersede any requirements provided for by other rules or
laws. |
| (f) |
Licensees
practicing by electronic or other means will be held to the same
standard of care as licensees employing more traditional in-person
medical care. A failure to conform to the appropriate standard of
care, whether that care is rendered in person or via electronic or
other such means, may subject the licensee to disciplinary action by
the Board. |
