Report 2007-117 Summary - March 2008

State Board of Chiropractic Examiners:

Board Members Violated State Laws and Procedural Requirements, and Its Enforcement, Licensing, and Continuing Education Programs Need Improvement

HIGHLIGHTS

Our review of the State Board of Chiropractic Examiners' (chiropractic board) enforcement, licensing, and continuing education programs and the role and actions of the chiropractic board members revealed the following:

  • Board members' lack of understanding about state laws related to their responsibilities as board members, including the Bagley-Keene Open Meeting Act, resulted in some violations of state law and other inappropriate actions.
  • The chiropractic board did not ensure that its designated employees, including board members, complied with the reporting requirements of the Political Reform Act of 1974.
  • Board members inappropriately delegated responsibility to approve or deny licenses to chiropractic board staff.
  • The chiropractic board has not developed comprehensive procedures, such as the length of time it should take to process complaints and, as a result, staff do not always process complaints promptly.
  • The board's weak management of its enforcement program may have contributed to inconsistent treatment of complaints as well as unreasonable delays in processing.
  • The chiropractic board does not ensure that staff process priority complaints promptly. Of 11 priority complaints we reviewed staff took from one to three years to process nine of them.
  • Although the chiropractic board's regulations require that it establish chiropractic quality review panels, it has never complied with its regulation.
  • The chiropractic board has insufficient control over its licensing and continuing education programs.

RESULTS IN BRIEF

The State Board of Chiropractic Examiners (chiropractic board) was created in December 1922 through the Chiropractic Initiative Act of California (initiative act). The initiative act prescribes the terms of issuing licenses to chiropractors, specifies the penalties to impose against licensees who violate those terms, and declares the powers and duties of the chiropractic board. In general, the board is a policy-making and administrative review body with the primary responsibility of protecting California consumers against fraudulent, negligent, or incompetent chiropractic practices.

A lack of understanding among members of the chiropractic board (board members) about state laws related to their responsibilities—including the Bagley-Keene Open Meeting Act (Bagley-Keene), the state law that prescribes open-meeting requirements for all state boards and commissions—resulted in some violations of state law and other inappropriate actions. Problems were also caused by the board's inadequate policies and procedures, such as the lack of documentation to support decisions made in each of the three board programs we reviewed: enforcement, licensing, and continuing education.

In one glaringly inappropriate instance, board members did not provide required written notice to the former executive officer, fired her during a closed-session meeting, and then failed to disclose the action when reconvening the public meeting. Board members remedied these significant errors at a subsequent meeting.

The Political Reform Act of 1974 (political reform act) requires state officials and employees with decision-making authority to disclose certain financial interests by filing statements of economic interests annually and on assuming or leaving a designated position. The chiropractic board did not ensure that designated employees complied with these reporting requirements. Among the 12 board members serving in 2005, 2006, and 2007, and the four employees whose statements of economic interests we reviewed, eight did not correctly complete statements of economic interests, nine filed statements late, and two did not file statements. Finally, the chiropractic board did not require all board employees making decisions on enforcement cases to file statements of economic interests.

The chiropractic board has taken actions, such as adopting an administrative manual in October 2007 and including an agenda item at many board meetings for its legal counsel to provide training or answer questions board members might have related to Bagley-Keene. We believe the new administrative manual and continued ongoing training could assist board members to further improve in executing their board responsibilities.

Board members also inappropriately delegated the responsibility to approve or deny licenses to chiropractic board staff (staff). Because staff rather than board members made final decisions on approving licenses and board members did not review staff-determined denials when applicants did not formally appeal those denials, the chiropractic board did not comply with the initiative act. According to our legal counsel, provisions of the initiative act clearly establish voter intent that the power to issue and deny licenses must be exercised by board members, and the act has no provisions that allow the chiropractic board to delegate this task to its staff. Our legal counsel has advised us that board members could easily remedy this noncompliance by ratifying all licenses approved or denied by staff, thus making board members responsible for those approvals and denials.

Additionally, the chiropractic board has not developed comprehensive procedures. For example, staff have no guidelines on the length of time they should take to process complaints; thus, staff do not always process complaints promptly. Our review of 25 complaints that the chiropractic board's database indicated were closed in fiscal year 2006–07 revealed that the chiropractic board sometimes took excessive amounts of time to resolve complaints and allowed unexplained and unreasonable delays between phases of the complaint review process. Further, the board's weak management of its enforcement program may have contributed to inconsistent treatment of complaints as well as unreasonable delays in processing them. Chiropractic board management (management) did not adequately supervise enforcement staff and their decisions on cases. We found instances when staff processed similar types of complaints differently. Further, staff took unreasonable amounts of time to refer complaint cases, including priority cases—those alleging sexual misconduct, gross negligence or incompetence, the use of drugs or alcohol when performing the duties of chiropractic, and insurance fraud—to the Office of the Attorney General for potential disciplinary actions against the licensees.

The chiropractic board's inadequate policies and procedures resulted in insufficient guidance for staff processing complaints. For example, the board has not established adequate procedures to ensure that only designated employees—staff required to file annual statements of economic interests—make final decisions on complaint cases or that management, who are designated employees, review staff decisions. The chiropractic board also has not established adequate procedures instructing staff on when it is appropriate to open an internally generated complaint. Additionally, the board has not established procedures requiring staff to clearly document their actions and decisions.

Further, the chiropractic board has not yet developed procedures to ensure that staff process priority cases promptly. Staff took more than one year to investigate and close five of the 11 priority complaints we reviewed; they took more than two years to process three and more than three years to close another. Also, staff did not consistently assign priority to certain types of complaints, and management did not monitor the status of open complaints on a regular basis.

The chiropractic board's regulations require that it establish chiropractic quality review panels (review panels). Although this has been a regulation since 1993, changes in executive officers and board members over the years resulted in changes in priorities and efforts to implement the review panels, and the board has never complied with its regulation.

The chiropractic board has insufficient control over its licensing and continuing education programs. It has not established timelines for processing some of its applications for licenses, certificates, and referral services. The board also could not always show whether it verified the status of chiropractors' licenses before approving applications and certificates. Additionally, many of the chiropractic board's current practices for administering its continuing education program are not consistent with its regulations and written policies and procedures. For example, it did not always follow regulations requiring board members to approve or deny the applications submitted by providers of continuing education. To further complicate an understanding of the process used, staff did not always retain appropriate documentation to demonstrate compliance with regulations, policies, and procedures.

RECOMMENDATIONS

To comply with Bagley-Keene, the chiropractic board should continue involving legal counsel to provide information and training to board members at each meeting.

To comply with the initiative act, the chiropractic board should modify its current process so that board members make the final decision to approve or deny all licenses. Additionally, board members should ratify all previous license decisions made by staff.

To comply with the political reform act, the chiropractic board should do the following:

  • Establish an effective process for tracking whether all designated employees, including board members, have completed and filed their statements of economic interests on time, thereby identifying potential conflicts of interest.
  • Periodically review its employees' responsibilities to ensure that all individuals who are in decision-making positions are listed as designated employees in its conflict-of-interest code.

To continue improving their knowledge and understanding of state laws and chiropractic board procedures, board members should consistently use their newly adopted administrative manual as guidance for conducting board business.

To adequately control its complaint review process, the chiropractic board should do the following:

  • Develop procedures to ensure that staff process and resolve complaints as promptly as possible by establishing benchmarks and more structured policies and procedures specific to each step in its complaint review process.
  • Establish time frames for staff to open a complaint case, complete an initial review, refer the cases to a contracted investigator or expert if necessary, and close or otherwise resolve the complaint by implementing informal discipline or referring for formal discipline to ensure that all complaint cases move expeditiously through each phase of the complaint review process.

To ensure that its enforcement procedures are complete and to provide adequate guidance to enforcement staff, the chiropractic board should develop procedures instructing staff when to open and how to process complaints generated internally.

To consistently process and resolve consumer complaints regarding the same types of allegations, the chiropractic board should strengthen its existing procedures to provide guidance for staff on how to process and resolve all types of complaints and to ensure appropriate management oversight.

To process all priority complaints promptly, the chiropractic board should establish a process to clearly identify all priority complaints. In addition, management should ensure that it monitors the status of open complaints regularly, especially those given priority status, to ensure that they do not remain unresolved longer than necessary.

To comply with all its regulations, the chiropractic board should carefully consider the intended purpose of the quality review panels and whether implementing them is the best option to fulfill that intent. If the chiropractic board decides that another option would better accomplish the intended purpose of the review panels, it should implement the process for revising its regulations.

To measure the overall efficiency of its licensing program in processing applications and petitions, the chiropractic board should establish time frames for all the types of applications and petitions it processes.

To defend its decisions on approved applications for satellite offices, corporations, and referral services, the chiropractic board should implement a standard of required documentation that includes identifying when and who conducted eligibility verifications.

To ensure that its continuing education program complies with current regulations, the chiropractic board should do the following:

  • Require board members to ratify staff approvals of continuing education providers.
  • Ensure that its process to approve continuing education providers conforms to its regulations.

AGENCY COMMENTS

The chiropractic board agrees with nearly all of our recommendations and states that it has already implemented most of them, and that with the restoration of its funding, the board plans to meet or exceed the recommendations. However, the chiropractic board disagrees with our recommendation that board members must vote to deny the issuance of a license and that it should fill its chiropractic consultant position. Finally, the chiropractic board states that it is committed to improving its governance, enforcement, licensing, and continuing education functions.

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