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Disciplinary Action against Paula Bickle (1998)


In 1996, the Washington Department of Health charged Paula Bickle with practicing medicine without a license in connecion with the Cascade Park Health Group, which she owned and operated. Bickle, who originally was trained as a dental hygienist, was licensed to practice as a health assistant, which meant she could carry out certain tasks under the direction of a licensed physician. The records state that she had independently diagnosed and treated patients and submitted insurance forms under the name of a supervising physician who had not actually seen the patients on the relevant dates. In 1998, she settled the charges with an agreement under which she was assessed $5,000 and could provide various types of nutritional counseling but could not diagnose or prescribe treatment for any disease.


STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SECRETARY OF HEALTH
HEALTH CARE ASSISTANT PROGRAM

In the Matter of the Certification to Practice as
a Health Care Assistant of

PAULA RUTH BICKLE
Certification No. HC00001404,
 
Respondent.

Docket No. 97-06-B-1024HC
 
STIPULATED FINDINGS OF FACT,
CONCLUSIONS OF LAW AND
AGREED ORDER

The Health Care Assistant Program of the Department of Health by and through Alan D. Copsey, assistant attorney general, and Paula Ruth Bickle, health care assistant, represented by George William Cody, stipulate and agree to the following:

Section 1: PROCEDURAL STIPULATIONS

1.1 Paula Ruth Bickle, Respondent was issued a cet1ificate to practice as a health care assistant by the State of Washington in September 1988 and was certified at all times material hereto.

1.2 On December 6, 1996, the Program Manager of the Health Care Assistant Program, acting on behalf of the Secretary of Health, issued a Statement of Charges against Respondent, alleging that Respondent violated RCW 18.130.180(1),(7), (8), (12), and (13), RCW.18.135.010, RCW 18.135.050,RCW 18.135.060, WAC 246-826-{020, and WAC 246-826-030, and engaged in the unlicensed practice of medicine in violation of RCW 18.71.011.

1.3 Respondent understands that the Health Care Assistant Program is prepared to proceed to hearing on the allegations in the Statement of Charges.

1.4 Respondent understands that she has the right to defend herself against the allegations in the Statement of Charges by presenting evidence at a hearing.

1.5 Respondent understands that, should the Health Care Assistant Program prove at a healing the allegations in the Statement of Charges, the Secretary of Health has the power and authority to impose sanctions pursuant to RCW 18.130.160.

1.6 Respondent and the Health Care' Assistant Program agree to expedite' the resolution of this matter by means of this stipulated Findings of Fact, Conclusions of Law, and Agreed Order (Agreed Order).

1.7 Respondent waives the opportunity for a hearing on the Statement of Charges contingent upon signature and acceptance of this Agreed Order by the Health Law Judge.

1.8 This Agreed Order is not binding unless and until it is signed and accepted by the Health Law Judge, acting on designation by the Secretary of Health.

1.9 Should this Agreed Order be signed and accepted, it will be subject to the reporting requirements of RCW 18.130.110 and any applicable interstate/national reporting requirements.

1.10 Should this Agreed Order be rejected by the Health Law Judge, Respondent waives any objection to the participation at hearing of the Health Law Judge who heard the Agreed Order.

Section2: STIPULATEDFACTS

The Health Care Assistant Program and Respondent acknowledge that the evidence, if uncontested at a hearing, is sufficient to justify the following findings of unprofessional conduct:

2.1 At all times material hereto, Respondent owned and operated Cascade Park Health Group, located in Vancouver, Washington and provided health care to patients under the following circumstances:

(a) Respondent was certified as a health care assistant in the State of Washington at all times material hereto and holds a Ph.D. in Applied Nutrition.

(b) Written contracts existed at all times material hereto for a licensed medical physician or osteopathic physician to act as Respondent's delegator and as Medical Director of Cascade Park Health Group. '

(b) Each delegator issued "standing orders" which delegated. specific authority to Respondent o meet with patients during initial intake, take patients' medical history, and to order a predetermined battery of medical tests.

2.2 In February 1995, Respondent or another person employed at Cascade Park Health Group gave a patient a business card which listed Dr. Huemer as the medical director of Cascade Park Health Group. Dr. Huemer was no longer the medical director of Cascade Park Health Group and had not been Respondent's delegator since March 1994.

2.3 On July 31, 1995, Respondent sent written request for lab tests to the Portland manager of National Health Labs, and indicated that, Richard Huemer, MD, had ordered the lab tests for a patient. Dr..Huemer had not seen the patient, did not order these lab tests, and had not been Respondent's delegator since March 1994.

2.4 On January 31, 1996, Patient Three went for a scheduled appointment at Cascade Park Health Group and was seen by Respondent. Patient Three is identified in the Confidential Schedule attached to the Statement of Charges. The following occurred during this visit:

(a) Respondent reviewed Patient Three's symptoms and performed a review of systems.

(b) Respondent diagnosed Patient Three as possibly having Epstein Barr or chronic fatigue syndrome, thyroid problems, paramenopausal syndrome, an allergy problem, a systemic yeast infection, a low-grade infection due to dental work, and a mineral deficiency.

(c) Respondent reccomended that Patient Three have a CPHaNP panel test performed "to determine liver function, thyroid function, and white blood count; Respondent told Patient Three that if the' test indicated a thyroid problem, Respondent would treat Patient Three with a thyroid supplement

(d) Respondent recommended that Patient Three have a 24-hoUI adrenal test performed; Respondent told Patient Three that if the test indicated a problem, Respondent would put her on a supplement for adrenal glands.

(e) Respondent recommended that Patient Three have her progesterone and
estrogen levels tested; Respondent told Patient Three that lithe test indicated her estrogen level was low, Respondent would provide a natural hormone to correct the condition.

(f) Respondent recommended that Patient Three have Panorex x-rays taken of
her mouth to determine if she had an infection in the root canals; Respondent told Patient Three that if Patient Three's dentist would not perform the x-rays, then Respondent would have "her dentist' perform the x-rays.

(g) Respondent recommended that Patient Three have an allergy test which would be performed by a chiropractor who independently contracted with the Cascade Pacific Health Group.

(h) Respondent recommended that Patient Three undergo tests of her hair, blood, and stool.

(i) Respondent gave Patient Three a billing form to take the receptionist, which had the following items checked under the heading "DIAGNOSES ICD9-CM": "Adrenal Function Imbalance," "Estrogen Deficiency Syndrome," "Mineral Deficiencies," and "Progesterone Disturbance."

(j) Respondent's delegator was not in the office that day, nor was any person present who was qualified to supervise Respondent.

2.5 On February 6, 1996, Patient Three went to Cascade Park Health Group for the allergy test recommended by Respondent The test was performed by a chiropractor and was not authorized by Respondent's delegator.

2.6 On February 14 1996, Patient Three went to Cascade Park Health Group and had her blood drawn pursuant to Respondent's recommendation; Evelyn Van Wmkle, a certified health assistant, performed the blood draw and had Patient Three sign a form authorizing blood tests for progesterone, estradiol, candida AB, IgG, IgA and IgM, and a "Cascade Park Health Screen." There was no signature in the blank for the physician's signature and the tests had not been authorized by Respondent's delegator. Ms. Van Winkle also took a hair sample from Patient Three.

2.7 On February 28, 1996, Respondent reviewed the lab results from the blood tests and hair samples with Patient Three at Cascade Park Health Group, even though the lab results had not been reviewed by Respondent's delegator or another physician, and even though Respondent had not met with or been examined by a physician at Cascade Park Health Group:

(a) Respondent told Patient Three that she did' not have' chronic fatigue
syndrome.

(b) Respondent expressed concern about the health of Patient Three's
thyroid because the anti-thyroid AB was high and the hair sample showed a low level of iodine, but told Patient Three that she probably did not have Hashimoto's disease.

(c) Respondent told Patient Three that her blood was low in iron because her
red blood cell count and ferritin levels were low and her MCV and MCH values were high.

(d) Respondent expressed concern that Patient Three's platelet count and
monocytes were low.

(e) Respondent expressed concern about Patient Three's progesterone level;
she directed Patient Three to do a two-month "therapeutic" trial of progesterone, taking progesterone once a day on days 14-25 of her cycle, and wrote on a prescription pad "progesterone 200 mg"; Respondent told Patient Three that she would. have to see Bert Lies, MD, in Cascade Park Health Group to have the prescription written.

(f) Respondent expressed concern that Patient Three's glucose level was very
high and told her to stop eating sugar; when Patient Three asked if she had diabetes, Respondent said it might indicate borderline diabetes; when Patient Three asked If she would have to take insulin, Respondent said she hoped to avoid that by giving her medication.

(g) Respondent expressed concern that chloride and carbon dioxide levels
indicated Patient Three was acidic and indicated she would give Patient Three something to remedy the problem.

(h) Respondent expressed concern that Patient Three's calcium level was too high and showed Patient Three the hair analysis to corroborate her conclusion.

(i) Respondent told Patient Three that her cholesterol level was good and that
her heart "was probably not at risk."

(j) Respondent told Patient Three that her magnesium level was too high and
expressed concern about her adrenal gland function.

(k) Respondent expressed 'concern that Patient Three's IgG level was too high,
indicating too much yeast in her system, and told Patient Three that her body was working hard to fight off this invasion."

(l) Respondent told Patient Three that the hair analysis and the allergy testing
Showed that she had "heavy metal toxicity"; Respondent told Patient Three that aluminum can cause neurological problems and to stop using aluminum products.

(m) Respondent recommended that Patient Three take Acidophilus, Beacon4c, Beacon 30I-A, Calcium, Chromium, Potassium, Tri-Magnesium ADP, Boron and Kelp, all of which are non-prescription items.

(n) Respondent told Patient Three to come back in two months for repeat tests
to see how she was doing.

(o) Respondent gave Patient Three a billing form to take to the receptionist,
which had the following items checked WIder the heading "DIAGNOSES ICD9-CM": "Adrenal Funct. Imbalance," "Allergic Reactions," "Candidiasis," "Progesterone Disturbance," and "Thyroid-Hypo."

(p) Respondent's delegator was not in the office that day, nor was any person
present who was qualified to supervise Respondent.

2.8 Between November 1994 and May 1996, Respondent submitted bills to the insurer of at least six patients which indicated or created the impression that the patients were seen by Respondent's delegating physician, when none of the patients were seen by the delegating physician on the dates indicated in the bills.

2.9 Between May 1996 and July 1996, in an exchange of correspondence with
Department of Health Investigator James Rich, Respondent, on advice of and through her attorney, refused to provide patient records requested pursuant to RCW 70.02.050(2).

Section 3: CONCLUSIONS OF LAW

The Health Care Assistant Program and Respondent agree the facts set forth above are sufficient to justify entry of the following conclusions of law:

3.1 The Secretary of Health has jurisdiction over Respondent and over the subject matter herein.

3.2 The facts set forth above constitute unprofessional conduct in violation of RCW 18.130.180(1).

3.3 The facts set forth above in paragraphs 2.2 through 2.7 constitute unprofessional conduct in violation of RCW 18.130.180(7) and (12) and constitute vioIations of RC 18.135.010, RCW 18.135.050, RCW 18.135.060(1), WAC 246-826-020, and WAC 246-826-030.

3.4 The facts set forth above 'in paragraph 2.8 constitute unprofessional conduct in violation of RCW 18.130.180(13).

3.5 The facts set forth above in paragraph 2.9 constitute unprofessional conduct in violation of RCW 18.130.180(8Xa).

3.6 Violations of the statutes and rules set forth in this section are grounds for the imposition of sanctions under RCW 18.130.160.

Section 4: AGREED ORDER

Based. on the preceding Stipulated Facts and Conclusions of Law, Respondent agrees to entry of the following Order:

4.1 Respondent's' certification to practice as a health care assistant in the State of Washington shall be and ls SUSPENDED for a: period off five (5) years from the date this order is signed by the Health Law Judge; PROVIDED, however, that said suspension shall be STAYED for up to five (5) years so long as Respondent complies with the following requirements and conditions set forth in paragraphs 4.2 through 4.13.

4.2 Within 10 days of the date this Order is signed by the Health Law Judge,
Respondent shall deliver her original and current certification, including both wall and wallet copies, to the Health Care Assistant Program, which will forthwith mark the certification "probationary" and return the original wall and wallet copies to Respondent.

4.3 Respondent shall keep in current renewal status her certification to practice as a.health care assistant in the State of Washington for the duration of the stayed suspension set forth in paragraph 4.1. PROVIDED, however, that if at any time during the stayed suspension set forth in paragraph 4.1 Respondent is not eligible for certification as a health care practitioner because she
has no delegator who is licensed in the State of Washington, as required in chapter 18.135 RCW, Respondent agrees to the following:

(a) Respondent specifically consents to continued jurisdiction of the Secretary
of Health under the terms and conditions of this Agreed Order for the full term of the suspension set forth in paragraph 4.1; and

(b) Respondent agrees that any new application for certification as a health care
assistant in the State of Washington, submitted during the stayed suspension set, forth in paragraph 4.1, is subject to the terms and conditions of this Agreed Order.

4.4 Respondent shall immediately notify the Health Care Assistant. Program by
telephone and in writing of any changes in the identity and/or qualifications of her delegator and any changes in procedures to be delegated.

4.5 Respondent shall notify the Health Assistant Program in writing of any change in employment in the health care field or her place of business; the notification shall be made within 20 days of the change and shall include the complete name and telephone number of Respondent's employer or place of business.

4.6 Respondent shall notify the Health Care Assistant Program and. the Adjudicative Clerk Office in writing of any change in her current address or telephone number; the notification shall be made within 20 days of the change and shall include Respondent's complete new address and telephone number.

4.7 Respondent shall give a copy of this Agreed. Order to each delegator and to each health care practitioner or health care facility that certifies her credentials to the Department of Health.

4.8 All health care provided to patients and consumers in any fashion by Respondent during the term of the suspension set forth in paragraph 4.1 shall be provided according to the following terms:

(a) All health care provided by Respondent to patients and consumers In the
State of Washington shall be provided only under proper delegation and-supervision, as required in chapter 18.135 RCW and chapter 246-826 WAC, by a physician licensed under chapter 18.71 RCW, an osteopathic physician licensed under chapter 18.57 RCW, or a naturopathic physician licensed under Chapter 18.36A RCW.

(b) All health care provided by Respondent to patients and consumers in the
State of Oregon shall be provided only under delegation and supervision commensurate with that required in chapter 18.135 RCW and chapter 246-826 WAC, by a physician or osteopathic physician licensed under chapter 677 of the Oregon Revised Statutes or a naturopathic physician licensed under chapter 685 of the Oregon Revised Statutes.

(c) All health care provided by Respondent to patients and consumers shall be
provided in conformity with the following practice protocoIs:

(1) Before being referred to Dr. Bickle, each new patient will be seen in the clinic by the iicensed physician (MD, DO, or ND) who is Dr. Bickle's delegator or supervisor. The physician will assess the patient's symptoms, order appropriate laboratory tests, perform an' appropriate physical examination, and take an appropriate medical history, all as determined to be necessary in the professional judgment of the physician.

(2) The physician may direct Dr. Bickle to assess the Patient for nutritional deficiency, nutritional education, and possible entry into specific research
protocols and, pro grams, and to make other clinical recommendations to the
physician.

(3) The physician shall determine, in the exercise of his or her professional udgment, whether to implement Dr. Bickle's recommendations. If the physician concurs with Dr. Bickle's recommendation, the physician shall so signify in the patient's medical record and shall have the responsibility to make additions or corrections to Dr. Bickle's recommendation as the physician deems necessary.

(4) The physician may schedule a patient for follow-up visits with Dr. Bickle for any of the following purposes: dietary modification, nutritional supplementation, monitoring of compliance of treatment plans, nutritional educational purposes, and for such further consultations and recommendations as the physician deems appropriate.

(5) It is not within Dr. Bickle's scope of practice to diagnose or prescribe a course of treatment for disease or other physical conditions requiring a
medical diagnosis. However, Dr. Bickle may participate in taking the patient's
physical and medical history and 'may make nutritional recommendations to the patient In addition, Dr. Bickle may make any recommendations to the physician, in the exercise of her professional judgment.

(6) Dr. Bickle shall not administer any drug or medicinal preparation except as specifically authorized and delegated to her consistent with chapter 18.135 RCW and 246-826 WAC. Dr. Bickle shali not undertake to diagnose, care, or treat any disease, ailment, injury, infirmity, pain, or other condition except as specifically authorized and delegated to her consistent with chapter 18.135.RCW and 246-826 WAC.

(d) Any violations of the protocol set forth in paragraph 4.8 may be Cause for an enforcement action by the Secretary of Health, as provided in paragraph 4.15.

4.9 During the term of the suspension set forth in paragraph 4.1, Respondent consents to two (2) compliance practice reviews per year by any agent delegated the authority to conduct a practice review by the Secretary, of Health or his designee; the Health Care Assistant Program reserves the right, at its discretion, to conduct fewer compliance practice reviews than authorized under this paragraph. The Health Care Assistant Program agrees that Respondent shall be given at least three (3) business days' notice of each compliance practice review and agrees that Respondent shall have the right to be present at each and every compliance practice review.

4.10 Repondent shall assume all costs of complying with this Agreed Order, including all reasonable costs associated with the practice reviews provided for in paragraph 4.9.

4.11 Respondent and the Health Care Assistant Program intend that this Agreed Order shall apply to any acts undertaken by Respondent as a health care provider in either the State of Washington or the State of Oregon, and Respondent specifically consents to such application of this Agreed Order. To facilitate this Agreed Order, Respondent agrees that the Health Care Assistant Program shall notify the Oregon Board of Medical Examiners of this Agreed Order, and respondent and the Health Care Assistant Program request that each party be notified by the Oregon Board of Medical Examiners of any complaints received by the Board involving actions taken by Respondent in the State of Oregon which would appear in any way to constitute a violation of this Agreed Order.

4.12 Respondent agrees to remit to the Health Care Assistant Program a fine in the amount of $5,000.00, payable in eight (8) quarterly installments of $625.00. Respondent agrees to payment of these installments on or before following dates: March 31, 1998; June 30, 1998; September 30, 1998; December 31, 1998; March 31, 1999; Jun~ 30, 1999; September 30, 1999; December 31; 1999. Respondent and the Health Care Assistant Program stipulate that this fine
amount, while not a reimbursement, reflects a portion of the costs of investigating and processing the complaint and Statement of Charges underlying this Agreed Order.

4.13 Respondent shall obey all federal, state and local laws and all administrative rules governing the practice of health care assistants in Washington.

4.14 If the Secretary of Health acting through the Health Care Assistant Program deems it necessary to seek injunctive relief or other Court intervention to enforce the provisions of this Agreed Order, Respondent specifically consents to jurisdiction and venue in the Superior Court for the State of Washington for Thurston County and to service of any such legal action by certified mail to the last address provided to the Health Care Assistant Program by Respondent

4.15 This Agreed Order resolves all allegations in the Statement of Charges referenced in paragraph 1.2, above, and the Health Care Assistant Program agrees that no further disciplinary action will be taken with respect to those allegations so long as Respondent complies with the provisions of this Agreed Order. However, if Respondent violates any provision of this Agreed Order in any respect, the Secretary of Health, after giving Respondent notice and an opportunity to be heard, may set aside the stay order and impose the full term of the suspension in paragraph 4.1; impose any sanction appropriate under RCW 18.130.160 to protect the public; and/or may take emergency action ordering summary suspension restriction, or limitation of Respondent's practice as authorized under RCW 18.130.150.

4.16 Upon Respondent's successful completion of this Agreed Order, the Health Care Assistant Program may act to remove conditions and/or reinstate Respondent's certification to practice as a health care assistant in the State of Washington. If the Health Care Assistant Program does not initiate such action upon Respondent's successful completion of this Agreed Order, Respondent may petition the Office of Professional Standards for removal of conditions and/or reinstatement of her certification to practice as a health care assistant in the State of Washington, by filling said petition with the Adjudicative Clerk Office.

4.17 All communication with the Health Care Assistant Program required by this Agreed Order shall be made to the following address or telephone number.

Program Manager
Health Care Assistant Program
Washington Department of Health
PO Box 47870
Olympia, W A 98504-7870
Telephone: (360) 586-6100

4.18 .All communication with the Adjudicative Clerk Office required by this Agreed Order shall be made to the following address or telephone number.

Adjudicative Clerk Office
Washington Department of Health,
PO Box 47879
Olympia, W A 98504-7879

I, Paula Ruth Bickle, Respondent, certify that I have read this Stipulated Findings of Fact, Conclusions of Law and Agreed Order in its entirety; that my counsel of record, if any, has fully explained the legal significance and consequence of it; that I fully understand and agree to all of it; and that it may be presented to the Health Law Judge, on designation by the Secretary of Health without my appearance. If the Health Law Judge accepts the Stipulated Findings of Fact, Conclusions of Law and Agreed Order, I understand that I will receive a signed copy and that it will become binding on me.

Paula Ruth Bickle
Respondent
Date: 1/20/98

George Wm. Cody, WSBA #6582
Counsel of Record for Paula Ruth Bickle
Date: 1/257/98

StipuIated and agreed to on behalf of the Health Care Assistant Program.

Alan D. Copsey, WSBA #23305
Assistant Attorney General
Attorney for the Health Care Assistant Program
Date: 1/28/98

Section 5: ORDER

The Secretary of Health accepts and enters this Stipulated Findings of Fact, Conclusions of Law and Agreed Order.

DATED this 29th day of January, 1998.

STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SECRETARY OF HEALTH
OFFICE OF PROFESSIONAL STANDARDS

Arthur E. Dubusschere, Health Law Judge
Presiding Officer

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