Opinion
No. A-12-336
02-12-2013
SCOTT FASSE, M.D., APPELLANT, v. DEPARTMENT OF HEALTH AND HUMAN SERVICES, REGULATION AND LICENSURE, APPELLEE.
Lisa M. Meyer, of Pansing, Hogan, Ernst & Bachman, L.L.P., for appellant. Jon Bruning, Attorney General, and James D. Smith for appellee.
MEMORANDUM OPINION AND JUDGMENT ON APPEAL
NOTICE: THIS OPINION IS NOT DESIGNATED FOR PERMANENT PUBLICATION
AND MAY NOT BE CITED EXCEPT AS PROVIDED BY NEB. CT. R. APP. P. § 2-102(E).
Appeal from the District Court for Lancaster County: ANDREW R. JACOBSEN, Judge. Affirmed.
Lisa M. Meyer, of Pansing, Hogan, Ernst & Bachman, L.L.P., for appellant.
Jon Bruning, Attorney General, and James D. Smith for appellee.
IRWIN, MOORE, and PIRTLE, Judges.
IRWIN, Judge.
I. INTRODUCTION
Scott Fasse, M.D., appeals an order of the district court for Lancaster County, Nebraska, in which the court affirmed a disciplinary order entered by the Department of Health and Human Services (DHHS). On appeal, Fasse alleges a variety of errors, including assertions that he was denied due process at the administrative level, that there was insufficient evidence adduced at the administrative level to support the discipline imposed, and that the discipline imposed was excessive. We affirm.
II. BACKGROUND
1. PROCEDURAL BACKGROUND
In March 2006, a United Healthcare of the Midlands (UHC) medical advisory committee convened to review Fasse's care of three patients between December 2004 and November 2005. The advisory committee issued a report based upon a case review of clinical studies concerning the three patients. The report suggested that Fasse had subjected the patients to "excessive radiation and injectable exposure" and "substandard care" and that he had incurred "excessive cost" in his treatment of the three. On March 21, UHC submitted a letter to DHHS requesting a DHHS investigation of Fasse.
Fasse testified that he received a letter from UHC on April 21, 2006, concerning its complaint about his treatment of the patients. Fasse testified that he responded with a letter explaining his treatment of the patients. According to Fasse, he then received a letter from UHC indicating that he would be notified within 30 days if any further action was going to be pursued. Fasse did not receive any other communication concerning his treatment of the patients until June 2008, when he heard from a DHHS investigator.
On June 26, 2006, UHC sent a letter to Fasse notifying him that UHC was terminating his "Participation Agreement," making him no longer an authorized provider of healthcare for UHC customers. The letter indicated that UHC would notify Fasse's patients with UHC coverage. Fasse retained counsel, and his counsel sent a letter to UHC notifying UHC that Fasse was seeking arbitration and demanding that UHC send a retraction letter to Fasse's patients. UHC sent a retraction letter to patients, indicating that Fasse remained a participating physician and that the prior letter to patients had been "generated in error."
DHHS assigned the case to one of its investigators, Patricia Lemke, who completed a report of her investigation on June 27, 2008. As part of that investigation, Lemke had Dr. Gerald Luckey review medical records related to the patients and prepare an expert review. Luckey authored a letter to DHHS in which he reported his conclusions and opinions, and he opined that Fasse's care of all three patients fell below the applicable standard of care in a variety of ways. Lemke testified that the "Board of Medicine" met on August 15, that the board reviewed a copy of her report and Luckey's expert review, and that the board recommended a petition be filed seeking discipline against Fasse.
On April 22, 2010, the State filed a petition with DHHS, seeking an order of discipline against Fasse. In the petition, the State alleged that Fasse's treatment of the patients was substandard care and alleged that Fasse's treatment constituted a pattern of negligent conduct and unprofessional conduct. A hearing was held before a DHHS hearing officer on February 9, 2011. The hearing officer received a variety of exhibits, including medical records, investigative reports, and medical literature concerning the treatment Fasse undertook with the patients; heard testimony from Lemke and Fasse; and received Luckey's expert review opinions. The parties submitted written closing arguments to the hearing officer.
On February 25, 2011, the State filed a motion seeking to supplement the record before the hearing officer to include two letters sent to Luckey and indicating in detail the materials sent to Luckey for his review. The hearing officer granted the motion on February 28, and the record does not reflect that Fasse was given an opportunity to object or be heard. On April 4, Fasse filed a motion seeking to supplement the record and alleging the need to question Luckey further about the materials he had received and reviewed. The State objected to Fasse's motion, asserting that Fasse had chosen not to depose or subpoena Luckey prior to the administrative hearing. The hearing officer denied Fasse's motion.
On July 15, 2011, the DHHS chief medical officer (CMO) issued an order. In the order, the CMO made factual findings and conclusions of law. The CMO concluded that Fasse's treatment of the patients "constituted multiple instances of negligence and established a pattern of negligent practice . . . constitut[ing] grounds for discipline." The CMO concluded that Fasse's treatment of the patients "evidence[d] a dangerous pattern of practice and reflect[ed] a serious neglect and disregard of the expected standards of care of his profession." The CMO imposed discipline, including censure, a requirement that Fasse have a "practice monitor" for a period of 1 year, a requirement that Fasse complete comprehensive review courses, and a civil penalty of $5,000.
On September 30, 2011, Fasse filed an amended petition for judicial review in the district court. The administrative appeal in the district court was held on December 22, and the court heard argument and received the record of the proceedings made before the DHHS hearing officer. On March 20, 2012, the court entered an order affirming the administrative order of discipline. Although the court disagreed with some of the factual findings made by the CMO, the court found that there had been clear and convincing evidence that Fasse's treatment of the patients constituted unprofessional conduct and a pattern of negligent conduct, and upon the court's de novo review of the administrative agency record, the court affirmed the discipline imposed. This appeal followed.
2. FACTUAL BACKGROUND CONCERNING
THREE PATIENTS
This disciplinary action concerned Fasse's treatment of three different patients between December 2004 and November 2005. Those three patients are identified as A.S., K.U., and R.K.
All three patients presented with sinus-related issues and were diagnosed by Fasse as suffering sinusitis, all were subjected to multiple sinus and chest x rays, and all were treated with antibiotics. In his expert review, Luckey indicated that "[t]reatment of sinusitis with antibiotic therapy is generally ineffective" and that "[m]ost instances of sinusitis are viral." He noted that "[o]bviously, the concern has to do with the development of resistant organisms but also the obvious impact is that having to do with providing treatment that has considerable expense and no documented value." He also noted that, when diagnosing sinusitis, "[s]inus x-rays are generally not indicated."
(a) Patient A.S.
A.S. was a 7-year-old child during the relevant period of time. A.S. had a history of successfully treated leukemia. A.S. was seen by Fasse for repeated complaints of upper respiratory congestion and occasional cough. During the relevant period of time, Fasse performed 10 sinus x rays, performed 3 chest x rays, provided 1 intramuscular antibiotic injection, and treated her with several different antibiotics. A.S. had 17 office or other outpatient visits during the relevant period of time.
In his expert review, Luckey noted that on one occasion, Fasse had obtained a nasal swab culture and "grew pseudomonas" and then treated A.S. with three antibiotics at the same time. Luckey also noted that A.S. was seen in the emergency room on one occasion, that the emergency room physician felt she suffered from a viral problem and recommended an ear, nose, and throat (ENT) consultation, and that no such ENT consult was obtained. Luckey also opined that sinus problems had "at least an 85 percent chance of being viral" and not bacterial.
Luckey opined that Fasse's treatment of A.S. fell below the standard of care in several particulars. Luckey found the treatment based on a nasal swab, the choice of antibiotic therapy for problems that were not documented as bacterial, the failure to refer to an ENT physician, and the exposure of a 7-year-old child to 10 sinus x rays and exposure to unnecessary radiation all fell below the standard of care.
Fasse testified that he used a nasal swab to diagnose the sinusitis in A.S. because she was young, she had a substantial amount of mucous in her nose, and he wanted to determine whether she had "methicillin-resistant staph aureus" (MRSA)--a hospital-acquired bacteria that can live in the nose for a lengthy period of time. He testified that because A.S. had been treated for leukemia, she had been in the hospital receiving chemotherapy and immunosuppression and then had experienced multiple consecutive infections, and those circumstances were the basis for him using a nasal swab. He testified it was less invasive than other methods of ruling out "methicillin-resistant staph aureus."
Fasse also testified about the effects of the chemotherapy treatments A.S. had been subjected to for treatment of leukemia. Fasse testified that he was working in tandem with a pediatric hematology oncologist who was treating A.S. and that the oncologists had been treating her with antibiotics, in part because of the vulnerability of her immune system. He testified that the use of antibiotics was not merely to treat the sinus infections, but also as a "form of coverage" to protect against other more extensive infections.
Fasse testified that he did not seek an additional ENT consultation for A.S. after her emergency room visit because she had been simultaneously treating with the oncologist. Fasse testified that he and the oncologist had been working together to help A.S.' immune system build up resistance to bacteria. Fasse noted that the oncologist had not made any referrals to an ENT specialist "because she knew the problem wasn't an ENT problem. The problem was an immunosuppression problem."
Fasse testified that he used multiple sinus x rays with A.S. "because [he] didn't really have any other indicator of how her infection was going." He testified that drawing blood would not have given any indication of whether the infection was improving. He testified that her immunosuppression history merited monitoring the infection.
Fasse noted that although A.S.' oncologist had treated her concurrently with Fasse, the oncologist had not disapproved of the use of antibiotics or Fasse's treatment. Fasse noted that Luckey did not have access to A.S.' full file and did not have access to the records related to A.S.' concurrent treatment with the oncologist. He also testified that A.S., as of the date of the hearing, was "completely well" and "thriving."
(b) Patient K.U.
K.U. was a 32-year-old female patient. K.U. had previously undergone a procedure to replace a heart valve, had a "mechanical mitral valve," and was on Coumadin therapy. Fasse diagnosed K.U. with sinus infections and pneumonia on several occasions during the relevant period of time. During the relevant period of time, Fasse performed nine sinus x rays, performed eight chest x rays, provided five intramuscular antibiotic injections, and treated her with several different antibiotics. K.U. had 28 office or other outpatient visits during the relevant period of time.
In his expert review, Luckey noted that the patient "had 29 protimes [prothrombin time tests]," "the majority of which were subtherapeutic." Luckey noted the variety of different antibiotic treatments that were utilized to treat the sinus infections and pneumonia. Luckey also noted that K.U. "was a chronic smoker" and that "nothing in the charts . . . indicated that smoking cessation counseling was tried."
Luckey opined that Fasse's treatment of K.U. fell below the standard of care in several particulars. Luckey found that repeated sinus x rays with "no recognized value," excessive use of antibiotic therapy for sinusitis, prolonged use of antibiotic therapy, and failure to refer K.U. for an ENT or pulmonary evaluation all fell below the standard of care.
Fasse noted K.U.'s history of having a heart valve replaced and the increased risk of infections and the severity of infections as a result of that procedure. He testified that the history of heart valve replacement presented a very different challenge in treating sinusitis than for a patient with no such history. He presented medical articles indicating that prophylactic antibiotic treatment was appropriate for such patients. He also testified that K.U.'s sinusitis was not a viral issue, based on having drawn blood samples that revealed a "significantly elevated white [blood cell] count." He opined that not treating K.U. with antibiotics would have been "gross malpractice."
Fasse testified that he did make referrals for K.U. to see specialists, including both a hematology referral and a cardiology referral. He testified that he did not make a referral to an ENT specialist because K.U. was already treating with a hematologist and a cardiologist.
Fasse testified that he performed multiple sinus x rays on K.U. in an attempt to determine a focus of infection, based on her elevated white blood cell counts, and to ensure that the infection was not in K.U.'s heart valve. According to Fasse, for K.U., the x rays allowed him to see that the infection was in the sinuses and not the heart valve.
Fasse testified that contrary to Luckey's suggestion, he had consulted K.U. about smoking cessation. He testified that her progress notes included mentions of it on numerous occasions. He testified that he "did everything [he] could to help her stop smoking."
Fasse testified that as of the date of the hearing, K.U. was "doing wonderfully."
(c) Patient R.K.
R.K. was a 29-year-old male patient. Fasse treated R.K. for sinus issues, pneumonia, and low testosterone levels during the relevant period of time. During the relevant period of time, Fasse performed 13 sinus x rays, performed 15 chest x rays, provided 5 intramuscular antibiotic injections, treated him with several antibiotics, and provided 10 testosterone injections. R.K. had 28 office or other outpatient visits during the relevant period of time.
In his expert review, Luckey noted that antibiotic therapy as opposed to inhaled nasal steroids was not consistent with "[c]urrent therapy." Luckey also noted that the "current standard of care" for treating low testosterone levels was to conduct additional evaluation to "search for a pituitary problem" and to treat with "topical testosterone products" instead of injections. Luckey also noted that despite the multiple diagnoses of pneumonia, R.K. had not presented with an elevated temperature, the x rays were "not referred out for an official read," and "on a number of occasions when [R.K.] was doing much better follow-up x-ray studies were done."
Luckey opined that Fasse's treatment of R.K. fell below the standard of care in several particulars. Luckey found that repeated sinus x rays, multiple and prolonged doses of antibiotic therapy for sinusitis, testosterone injections without a trial of a topical treatment, multiple chest x rays, and the choice of antibiotic therapy all fell below the standard of care.
Fasse testified that he performed chest and sinus x rays on R.K. because of R.K.'s persistent inability to breathe and restrictive lung disease demonstrated by a CT scan and a pulmonary function test. Fasse testified that R.K.'s sinusitis was not a viral matter and that the antibiotics and subsequent x rays were necessary to treat and monitor progress.
Fasse testified that he did make referrals to specialists for R.K., including a pulmonologist and an allergy/immunology specialist. In addition, R.K. ultimately underwent sinus surgery from an ENT specialist. According to Fasse, none of the specialists R.K. was referred to expressed any concern about Fasse's treatment of R.K.
Fasse testified that he treated R.K. with testosterone injections because R.K. suffered from male hypogonadism and had a low testosterone level. Fasse testified that R.K. had previously been treated with corticosteroids and prednisone on numerous occasions and that one of the side effects of those treatments was a loss of bone density. Fasse testified that he had treated R.K. with a topical testosterone, but that the injections were more efficacious for him because the injections could also benefit R.K.'s bone density. He presented a medical article in support of his conclusion. He also testified that the topical testosterone treatment could be cost prohibitive.
III. ASSIGNMENTS OF ERROR
In this appeal, Fasse has assigned a total of 18 errors. We have consolidated and restated these as four. First, Fasse asserts that the district court erred in not finding that Fasse's due process rights were violated by the investigative process of DHHS. Second, Fasse asserts that the district court erred in not finding that Fasse's due process rights were violated when the hearing officer allowed the State to supplement the record after the disciplinary hearing but denied Fasse's request to do the same. Third, Fasse asserts that the court erred in finding that sufficient evidence was adduced to support the CMO's findings that Fasse's treatment of the patients fell below the standard of care and constituted a pattern of negligence and unprofessional conduct. Fourth, Fasse asserts that the discipline imposed was excessive.
IV. ANALYSIS
Disciplinary measures taken against a professional license may be appealed, and such appeal is to be taken in accordance with the Administrative Procedure Act. Langvardt v. Horton, 254 Neb. 878, 581 N.W.2d 60 (1998). Any person aggrieved by a final decision in a contested case is entitled to judicial review under the Administrative Procedure Act. Neb. Rev. Stat. § 84-917(1) (Cum. Supp. 2012); Langvardt v. Horton, supra. In such cases, the review in the district court is conducted without a jury de novo on the record of the agency. Section 84-917(5)(a); Langvardt v. Horton, supra.
An aggrieved party may obtain review of any judgment or final order entered by the district court under the Administrative Procedure Act, and Neb. Rev. Stat. § 84-918 (Reissue 2008) provides the standard of review for the appellate court. Langvardt v. Horton, supra. An appellate court reviews the district court's decision for errors appearing on the record. § 84-918(3); Langvardt v. Horton, supra. An appellate court, in reviewing a judgment of the district court for errors appearing on the record, will not substitute its factual findings for those of the district court where competent evidence supports those findings. Langvardt v. Horton, supra. The appellate court's inquiry is whether the district court's decision conforms to the law, is supported by competent evidence, and is neither arbitrary, capricious, nor unreasonable. Id.
1. DUE PROCESS REGARDING INVESTIGATION
Fasse first assigns various errors related to the investigation process of DHHS. He asserts that the UHC complaint was not sufficient to warrant an investigation, that DHHS did not comply with statutes and regulations regarding the investigation, and that the 2-year gap between the UHC complaint and DHHS' investigation and report prejudiced him. We find no merit to these assertions.
Neb. Rev. Stat. § 38-1,138(1) (Reissue 2008) provides that any person may make a complaint and request investigation of an alleged violation of the Uniform Credentialing Act or the rules and regulations issued under such act. Section 38-1,138(2) provides that DHHS shall review all complaints and determine whether to conduct an investigation. Neb. Rev. Stat. § 38-1,139 (Reissue 2008) provides that upon the request of DHHS, the Attorney General shall institute in the name of the State the proper disciplinary proceedings.
The record in this case indicates that UHC filed a complaint with DHHS. That complaint alleged excessive radiation and injectable exposure, substandard care, and excessive costs. The complaint also included a summary of Fasse's treatment of the three patients between December 2004 and November 2005, including the number of sinus and chest x rays, injections, and office visits charged.
The record indicates that based upon the complaint filed by UHC, DHHS conducted an investigation. DHHS assigned Lemke to conduct the investigation, and she prepared a report. The investigation included Lemke's contacting of Fasse and asking him to "provide a written response to the allegations, [which was] included" in the report. Lemke also contacted the "Special Investigations Administrator" with a different insurance company, contacted Medicaid, interviewed Fasse, and sought an expert review of Fasse's patient records concerning the patients.
In the context of administrative agency or tribunal actions, the Nebraska Supreme Court has recognized that a review of procedural due process includes an inquiry into the jurisdiction of the agency, whether there was reasonable notice and an opportunity for fair hearing, and whether the finding was supported by the evidence. In re Appeal of Levos, 214 Neb. 507, 335 N.W.2d 262 (1983).
The record in this case demonstrates that UHC filed a complaint that included allegations of excessive radiation and substandard care and included details concerning the number of x rays ordered and other treatment provided to the three patients in question. Pursuant to statutory authority, DHHS conducted an investigation. As part of that investigation, DHHS notified Fasse, allowed him to file both a written response and responses through an interview, and ultimately afforded him a disciplinary hearing. At the hearing, he was represented by counsel, was afforded an opportunity to cross-examine the State's witness, and was afforded an opportunity to testify and adduce additional evidence. Although there was a period of time between the UHC complaint and the DHHS investigative report, Fasse adduced no testimony or evidence at the disciplinary hearing to indicate that he suffered any prejudice or that his ability to defend himself against the disciplinary allegations was in any way impeded as a result of this delay.
The district court found that Fasse had not raised issues at the administrative level concerning the sufficiency of the UHC complaint to warrant an investigation, that he had not raised any objection to the sufficiency of the complaint during the disciplinary hearing, and that he had not asserted at the administrative level or to the district court any particular prejudice concerning the delay between the filing of the complaint and the investigation.
The district court also found that the complaint filed by UHC complied with Nebraska statutes and regulations and was sufficient to warrant an investigation, that Fasse received sufficient notice and opportunity to be heard, and that his claimed violations of due process were without merit. Upon our review, we find no error on the record concerning these conclusions by the district court. Fasse's assertions of error regarding alleged due process violations related to the DHHS investigation are without merit.
2. DUE PROCESS REGARDING SUPPLEMENTING RECORD
Fasse next assigns errors to the hearing officer's grant of the State's request to supplement the record after the hearing but denial of his request to supplement the record. We find no error on the record.
During the administrative discipline hearing, Lemke testified about and identified the medical records that she had received from Fasse and provided to Luckey. She testified that she provided Luckey with the medical records, as well as "anything that was forwarded by [UHC], and then also [Fasse's] response letter." Fasse then had the opportunity to cross-examine Lemke about the materials provided to Luckey, and Fasse's counsel did so cross-examine Lemke.
After the conclusion of the hearing, but prior to the CMO's judgment, the State filed a motion to supplement the record. In the motion, the State indicated that Lemke had testified at the hearing that "she sent two letters with documents to" Luckey. The State indicated that Fasse's counsel had expressed an interest in seeing those letters and that copies had been forwarded to Fasse's counsel. The State then requested that the two letters be admitted and added to the record. The hearing officer granted the request.
A review of the two exhibits indicates that they are letters from Lemke to Luckey and that they indicate the materials being forwarded to Luckey for his expert review. The letters are in accordance with Lemke's testimony at the hearing.
Subsequently, Fasse filed a motion requesting that he be allowed to supplement the record "to include live testimony of . . . Luckey." Fasse asserted that based upon the information in the two exhibits submitted by the State after the disciplinary hearing, "it is essential that . . . Luckey present himself for questioning."
There is nothing in the record to suggest that Fasse was ever prevented from questioning Luckey or from calling him as a witness to be examined at the disciplinary hearing, despite Fasse's prior knowledge that Luckey had conducted a review of the files and provided his opinions to DHHS. Indeed, at the conclusion of the disciplinary hearing, the hearing officer specifically asked Fasse's counsel if he had expected Luckey to be present at the hearing and Fasse's counsel answered, "No." The State's counsel specifically represented that she had informed Fasse's counsel that the State did not intend to call Luckey to testify. The hearing officer then noted that Lemke was unable to answer many of the questions Fasse's counsel might have had about Luckey's conclusions and opinions; noted that Luckey himself could have been, but was not, present; and suggested that Fasse could have subpoenaed Luckey. In response, Fasse's counsel indicated that "[t]here are strategic decisions made."
On the record presented, the district court found that Fasse had not demonstrated a violation of due process. We find no error on the record in our review of the district court's order. This assignment of error is without merit.
3. SUFFICIENCY OF EVIDENCE
Fasse next asserts that the evidence adduced at the administrative hearing was insufficient to demonstrate that he had acted in a pattern of negligent conduct or unprofessional conduct. We find no error on the record.
Neb. Rev. Stat. § 38-178 (Cum. Supp. 2012) provides that a credential to practice a profession may be denied, refused renewal, or have other disciplinary measures taken against it on the grounds of, among other things, practice of the profession "in a pattern of . . . negligent conduct" or for "[u]nprofessional conduct." In this context, unprofessional conduct means departing from or failing to conform to the standards of acceptable and prevailing practice of a profession, regardless of whether a person is injured. Neb. Rev. Stat. § 38-179 (Reissue 2008). Section 38-179 specifies that "unprofessional conduct" includes acts "as may be defined in rules and regulations."
The Nebraska Administrative Code provides the regulations "are intended to implement the laws governing the practice of Medicine and Surgery and Osteopathic Medicine and Surgery." 172 Neb. Admin. Code, ch. 88, § 001 (2004). Those regulations define "[u]nprofessional conduct" as including, among other things, "[a]ny conduct or practice outside the normal standard of care in the State of Nebraska which is or might be harmful or dangerous to the health of the patient or the public." 172 Neb. Admin. Code, ch. 88, §§ 002 and 013(21) (2004).
In the present case, the evidence indicated that Fasse treated all three patients for, among other things, sinusitis. All were subjected to multiple sinus x rays and chest x rays and treated with various antibiotics. Luckey reviewed the patient files and opined that Fasse's treatment of each patient fell below the standard of care. The CMO concluded that Fasse's treatment demonstrated a pattern of negligent conduct, a dangerous pattern of practice, and serious neglect and disregard of expected standards of conduct.
On de novo review, the district court disagreed with some of the factual conclusions reached by the CMO, but found that the multiple x rays and the prolonged antibiotic treatment in this case fell below the standard of care and evidenced a pattern of unprofessional and negligent conduct. This decision conforms to the law, is supported by competent evidence, and is neither arbitrary, capricious, nor unreasonable. See Langvardt v. Horton, 254 Neb. 878, 581 N.W.2d 60 (1998). In an appeal under the Administrative Procedure Act, an appellate court will not substitute its factual findings for those of the district court where competent evidence supports the district court's findings. Poor v. State, 266 Neb. 183, 663 N.W.2d 109 (2003). We cannot find error on the record, and Fasse's assertions concerning the sufficiency of the evidence are without merit.
4. ALLEGED EXCESSIVENESS OF DISCIPLINE
Finally, Fasse alleges that the discipline imposed was excessive. We find no error on the record.
Neb. Rev. Stat. § 38-196 (Reissue 2008) provides that "[u]pon the completion of a hearing held regarding discipline of a credential, the director may dismiss the action or impose . . . sanctions," including censure, probation, limitation, civil penalty, suspension, or revocation. Neb. Rev. Stat. § 38-197 (Reissue 2008) provides that if "discipline is imposed . . . the director may, in addition," require "additional professional training"; require "diagnostic examination by . . . other qualified professionals"; or "[l]imit the extent, scope, or type of practice . . . ." Neb. Rev. Stat. § 38-198 (Reissue 2008) authorizes the imposition of a civil penalty of up to $20,000.
The sanctions imposed by the CMO in this case included censure, a practice monitor to review a random sample of Fasse's patient charts for 1 year, additional professional training, and a civil penalty of $5,000. These sanctions were all authorized by statute, and we do not find them to be inappropriate. Fasse's assignment of error concerning the sanctions is without merit.
V. CONCLUSION
We find no merit to Fasse's assertions on appeal. We find no due process violations, find that the evidence adduced was sufficient to support the district court's affirmance of the CMO's order, and find the sanctions imposed were lawful and appropriate. Accordingly, we affirm.
AFFIRMED.