[Federal Register: December 23, 2008 (Volume 73, Number 247)]
[Notices]
[Page 78827-78837]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr23de08-114]
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DEPARTMENT OF JUSTICE
Drug Enforcement Administration
[Docket Nos. 06-19 & 06-20]
Nirmal Saran, M.D.; Nisha Saran, D.O.; Affirmance of Suspension
Orders
On September 19, 2005, I, the Deputy Administrator of the Drug
Enforcement Administration, issued an Order to Show Cause and Immediate
Suspension of Registration to both Nirmal Saran, M.D., and Nisha Saran,
D.O. (Respondents), of Arlington, Texas. The Orders immediately
suspended each Respondent's DEA Certificate of Registration as a
practitioner, on the grounds that each had issued numerous controlled-
substance prescriptions over
[[Page 78828]]
the internet without a legitimate medical purpose and had acted outside
of the course of professional practice, because they did so without
establishing a bona fide doctor-patient relationship with the persons
they prescribed to, in violation of 21 CFR 1306.04(a). Nirmal Saran
OTSC at 6; Nisha Saran OTSC at 6-7.
More specifically, the Show Cause Orders alleged that each
Respondent had participated in a scheme run by Mr. Johar Saran, the
owner of Carrington Healthcare System/Infiniti Services Group (CHS/
ISG), and the son of Respondent Nirmal Saran and brother of Respondent
Nisha Saran. See Nirmal Saran OTSC at 5; Nisha Saran OTSC at 5. The
Orders alleged that as part of the scheme, CHS/ISG operated several
pharmacies and created sham corporations in order to obtain the DEA
registrations necessary for the pharmacies to order controlled
substances, and that the drugs were eventually delivered to CHS/ISG,
where its employees downloaded prescriptions from several internet
sites, filled them, and shipped them to customers. See Nirmal Saran
OTSC at 5; Nisha Saran OTSC at 5. The Orders further alleged that CHS/
ISG was shipping 3,000 to 4,000 drug orders a day. See Nirmal Saran
OTSC at 5; Nisha Saran OTSC at 5.
With respect to Nirmal Saran, the Show Cause Order alleged that his
``primary practice area is ophthalmology.'' Nirmal Saran OTSC at 6. The
Show Cause Order further alleged that between May 1 and June 17, 2005,
he had prescribed thirty-seven different controlled substances to
persons in at least forty-four States, and that between May 18 and June
8, 2005, he issued 1,248 controlled substance (cs) prescriptions and
had issued as many as 217 prescriptions in a day to persons in thirty-
four States. Id. at 7. The Order further alleged that sixty-four
percent of the prescriptions he issued through the scheme were for
schedule III drugs containing hydrocodone. Id. at 6.
With respect to Nisha Saran, the Show Cause Order alleged that
between May 27 and June 3, 2005, she had issued 303 cs prescriptions to
persons in at least forty States, and that she had issued as many as
101 cs prescriptions to persons in twenty-six States in a single day.
Nisha Saran OTSC at 6. Relatedly, the Show Cause Order alleged that
fifty-nine percent of the prescriptions she wrote were for schedule III
drugs containing hydrocodone. Id.
Both Show Cause Orders further alleged that each Respondent's cs
prescriptions were not issued ``for a legitimate medical purpose in the
usual course of professional practice,'' and violated 21 CFR
1306.04(a). Id. at 7; see also Nirmal Saran OTSC at 7. I further found
that the allegations supported the conclusion that each Respondent's
``continued registration during the pendency of [the] proceedings would
constitute an imminent danger to the public health and safety.'' Nisha
Saran OTSC at 7; Nirmal Saran OTSC at 7.
On October 20, 2005, counsel for each Respondent requested a
hearing on the allegations of the respective Show Cause Orders. ALJ
Exs. 3 & 4. The matters were placed on the docket of Administrative Law
Judge (ALJ) Gail Randall, who consolidated the cases and conducted pre-
hearing procedures.
On March 28-30, 2006, a hearing was held in Forth Worth, Texas.
During the hearing, both the Government and Respondents put on
testimony and entered documentary evidence into the record. Following
the hearing, the parties submitted briefs containing their proposed
findings, conclusion of law, and argument.
On November 22, 2006, while the decision of the ALJ was still
pending, the Government moved to terminate both proceedings on the
ground that each Respondent's registration had expired on February 28,
2006, and neither Respondent had submitted a renewal application. ALJ
Exs. 13a & 13b. Thereafter, Respondents' counsel filed oppositions to
both termination motions. ALJ Exs. 14a & 14b.
In support of her opposition, Nisha Saran submitted an affidavit
establishing that in February 2006, and before the expiration of her
registration, she had attempted to renew her registration
electronically at the Agency's Web site, but was unable to do so. ALJ
Ex. 14A (attached as RX 1). In her affidavit, Nisha Saran further
stated that ``I have at no time abandoned my desire to obtain DEA
registration during the pendency of this case.'' Id.
In support of his opposition, Nirmal Saran submitted an affidavit
in which he stated that in February 2006, and before the expiration of
his registration, he had asked his daughter to renew his registration
at the Agency's Web site, but she was unable to do so. ALJ Ex. 14B
(attached as RX 1). In his affidavit, Nirmal Saran also stated that ``I
have at no time abandoned my desire to obtain DEA Registration during
the pendency of this case.'' Id.
Thereafter, the Government moved to withdraw both termination
motions noting my then-recent decision in William R. Lockridge, 71 FR
77791 (2006), which held, in a case arising under similar
circumstances, that the proceeding was not moot. In its withdrawal
motions, the Government acknowledged that each Respondent had indicated
that he/she ``intend[ed] to continue the practice of medicine and
intend[ed] to obtain a DEA registration in order to do so.'' ALJ Exs.
15A at 3; 15B at 3. The Government also acknowledged the unequivocal
statements of each Respondent that he/she had not abandoned his/her
desire to obtain a DEA Registration. ALJ Exs. 15A at 3; 15B at 3.
The ALJ granted the Government's motion and further ordered that
the parties brief various issues including whether ``the record as a
whole establishes by a preponderance of the evidence that the DEA
properly immediately suspended'' each Respondent's registration,
because his/her ``handling of controlled substances creates an imminent
danger to the public health or safety.'' ALJ Exs. 16A at 2-3; 16B at 2-
3. The ALJ also ordered the parties to address what factual findings
were relevant and what legal standard should be applied in determining
the validity of the suspension order. ALJ Exs. 16A at 3; 16B at 3.
On March 7, 2007, after the parties submitted their briefs, the ALJ
submitted a Query to the Deputy Administrator. ALJ Ex. 22. In the
Query, the ALJ asked whether in light of the expiration of each
Respondent's registration she should make findings of fact, whether she
should simply forward the record to me for a final order, or whether
the Government should forward the investigative file to me with the
materials contained therein at the time the immediate suspension orders
were issued. ALJ Ex. at 8.
On April 22, 2007, I answered the ALJ's Query. In my ruling, I
noted that both the Government and the Respondents agreed that the case
was not moot because even though the Respondents' registrations had
expired, each Respondent maintained that they had not ``abandoned their
desire to obtain DEA registrations during the pendency of this case.''
ALJ Ex. 23, at 2. I also explained that DEA's rules do not prohibit a
former holder of a registration from reapplying immediately for a new
registration and that ``neither Respondent ha[d] notified the Agency
that [he/she] intended to permanently cease professional practice.''
Id.
In light of these circumstances, I ``conclude[d] that principles of
judicial economy are best served by making findings of fact and
conclusions of law based on the record established in this
[[Page 78829]]
proceeding rather than subjecting the parties to the potential re-
litigation of the same issues in a future proceeding.'' Id. I further
directed that ``[t]he ALJ's findings of fact and conclusion of law
should be made based on the factors set forth in * * * 21 U.S.C.
824(a),'' as this section ``applies to all suspensions regardless of
whether a suspension is imposed before, or after, a hearing.'' Id. I
further noted that ``my additional findings that Respondents posed `an
imminent danger to public health or safety' [was] not reviewable in the
proceeding before'' the ALJ. Id. at 2-3 (quoting 21 U.S.C. 824(d)).
Thereafter, the ALJ issued her recommended decisions in each case.
With respect to Respondent Nirmal Saran, the ALJ concluded that between
May 18 and June 8, 2005, he had issued over 1,000 prescriptions for
controlled substances to treat pain, and that these ``prescriptions
were issued outside the scope of professional practice, and were not
issued for legitimate medical purposes'' in violation of DEA
regulations. In re Nirmal Saran, ALJ Dec. at 32. In support of her
conclusion, the ALJ noted that Respondent practices as an
ophthalmologist, that he was licensed to practice medicine only in
Texas and yet issued prescriptions to patients in other States, and
that he failed to comply with basic standards of the medical profession
for establishing a doctor-patient relationship. Id. at 31-32.
The ALJ also noted that Respondent had failed to properly safeguard
his controlled substance prescribing authority because he ``allow[ed]
his signature to be scanned into a computer database'' with the result
that ``non-medical personnel were approving the dispensing of
controlled substances in [his] name.'' Id. at 33. Finally, the ALJ
noted that Respondent did not maintain patient records and that there
was ``no indication that [he] interacted with the patient[s] to advise
[them] concerning the risks involved in taking the controlled
substances,'' or that he ``used any of the available control mechanisms
to ensure these individuals were not abusing'' the drugs. Id. Finally,
the ALJ noted that Respondent chose not to testify and thus offered no
assurance that he would comply with Federal law and regulations in the
future. Id. at 34. The ALJ thus concluded that Respondent's
``registration would be adverse to the public interest.'' Id.
With respect to Respondent Nisha Saran, the ALJ concluded that she
too had issued cs prescriptions ``outside the scope of professional
practice'' and without ``legitimate medical purposes.'' In re Nisha
Saran, ALJ Dec. at 30. In support of her conclusion, the ALJ adopted
the conclusion of the Government's expert that Respondent issued
prescriptions in violation of DEA regulations based on his review of
her ``prescriptions, log sheets, [her] type of practice, and the vast
numbers of prescriptions that she wrote during a given period of
time.'' Id. The ALJ also found that ``non-medical personnel were
approving the dispensing of controlled substances in [her] name,'' and
that ``Respondent provided these individuals with the ability to act in
such a manner by allowing her signature to be scanned into a computer
database.'' Id. at 30-31. The ALJ thus concluded that ``[s]uch a
cavalier way of safeguarding her authority to prescribe controlled
substances is certainly outside the public interest.'' Id. at 31.
The ALJ further observed that between May and June 2005, Respondent
had issued ``approximately 220 controlled substance drug orders,'' but
did not ``maintain adequate patient records.'' Id. at 31. More
specifically, the ALJ observed that ``the record contains no charts
documenting the Respondent's diagnosis for which the controlled
substances were prescribed, no treatment plan, and no indication that
the Respondent interacted with the patient to advise the patient
concerning the risks involved in taking the controlled substances and
the need for the patient to follow her directions concerning the
appropriate quantities to take.'' Id. The ALJ also explained that there
was also ``no evidence that * * * Respondent used any of the available
control mechanisms to ensure these individuals were not abusing the''
drugs she prescribed. Id.
Finally, the ALJ noted that Respondent chose not to testify and
thus had offered no assurance that she would comply with Federal law
and regulations in the future. Id. at 32. The ALJ therefore concluded
that Respondent's registration would be ``adverse to the public
interest.'' Id.
Thereafter, Respondents' counsel filed exceptions to the ALJ's
recommended decisions in each matter and the record was forwarded to me
for final agency action. Having considered the entire record, as well
as the exceptions filed in both matters, I hereby issue this Decision
and these Final Orders. I adopt the ALJ's ultimate conclusion of law in
each matter that the respective Respondent's registration would be
inconsistent with the public interest. I make the following findings of
fact.
Findings
Respondent Nisha Saran formerly held DEA Certificate of
Registration, BS8415956, which authorized her to handle controlled
substances as a practitioner in schedules II through V. GX 1 (Docket
No. 06-19). Respondent's registration expired on February 28, 2006. Id.
Respondent has not submitted an application to renew her
registration.\1\ I further find that Respondent is licensed to practice
medicine only in the State of Texas. ALJ Ex. 5, at 2.
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\1\ According to the Chief of the Registration and Program
Support Section, on February 6, 2006, someone made several attempts
to renew DEA Registration, BS8415956, through the Agency's Web page
but was informed that ``[t]he DEA Registration number you provided
is not eligible for online renewal. Please call the DEA Registration
Call Center if you have any questions.'' ALJ Ex. 15A, Appendix I, at
4. The Chief of the Registration Unit further stated that on
November 27, 2006, an additional attempt was made to renew the
registration which resulted in the same message that online renewal
was not available. Id. at 2.
The Chief of the Registration Unit also testified that on
February 6 and November 27, 2006, attempts were made to renew
Respondent Nirmal Saran's DEA Registration AS7091894; each
of these attempts resulted in the message that online renewal was
not available. Id. at 1-2; see also ALJ Ex. 15B, Appendix I, at 1-2.
According to the Chief of the Registration Unit, if the registrants
had called the Registration Call Center, they would have been sent a
renewal form and ``the notation `Renewal Notice Sent' would have
been documented in DEA records but, no such documentation was in the
computer history for either DEA number.'' Id. at 2-3.
The Chief of the Registration Unit further explained that the
Respondents were prevented from renewing their registration online
because their registrations had been immediately suspended. Id. at
2. I find, however, that the Respondents could have obtained renewal
applications from the Agency and submitted them via mail.
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Respondent Nirmal Saran formerly held DEA Certificate of
Registration, AS7091894, which authorized him to handle controlled
substances as a practitioner in schedules II through V. GX 1 (Docket
No. 06-20). Respondent's registration expired on February 28, 2006. Id.
Respondent has not submitted an application to renew his registration.
Respondent is licensed to practice medicine only in the State of Texas.
ALJ Ex. 6, at 2. Respondent practices as an ophthalmologist. Tr. 216.
Mr. Johar (a.k.a. Joe) Saran is the son of Respondent Nirmal Saran
and the brother of Respondent Nisha Saran. Tr. 210; id. at 116. Johar
Saran owned Carrington Health Care System (which later changed its name
to Infiniti Services Group), a corporate entity located in Arlington,
Texas, which owned approximately eighteen to twenty pharmacies. Id. at
55, 60, 421. Carrington/Infiniti used the pharmacies to fill orders for
controlled substances and non-controlled drugs on behalf of ``numerous
web sites'' at which persons could order drugs, including Rx Great
[[Page 78830]]
Prices and Nations Drug Supply.\2\ Id. at 52.
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\2\ On September 20, 2005, a federal grand jury indicted Joe
Saran, Gil Lozano, Fred Word, as well as the various coporations
controlled by Saran including Carrington, Infiniti, and the
pharmacies, on numerous counts including violations of the
Controlled Substances Act. GX 85 (06-20). On November 14, 2006, Joe
Saran entered into a plea agreement with the United States Attorney
for the North District of Texas in which he pled guilty to, inter
alia, conspiring to distribute controlled substances, in violation
of 21 U.S.C. 846, 841(a)(1) & 841(b)(1)(D). GX 104 (06-20) at 1-2.
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Rx Great Prices was owned by Gil Lozano, id. at 617; Lozano also
co-owned with his wife two limited liability corporations, Global One
Marketing and First Management. Id. at 623. Lozano's niece, Tania
Lozano, was the director of marketing for Global One and Rx Direct. Id.
at 611. Rx Great Prices used Joe Saran's businesses exclusively to fill
its orders. Id. at 624.
Nations Drug Supply (NDS) was a Web site owned and operated by
Johar Saran and Infiniti. Id. at 418. The NDS Web site was developed by
Concussion Interactive and became operational sometime in May 2005. Id.
at 399-400. The Web site was managed by Tara Jones.\3\ Id. at 531 &
535.
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\3\ The record also establishes that Colin McConnell was an
employee of Concussion Interactive, Tr. 112, and Fred Word was
Infiniti's Chief Financial Officer. Id. at 114.
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The Investigation
In June 2004, a DEA Diversion Investigator (DI) with the Fort
Worth, Texas Resident Office, initiated an investigation of Carrington/
Infiniti's activities. Id. at 58-60. As part of the investigation, DEA
Investigators conducted trash runs at Infiniti's headquarters during
which they found numerous documents including prescription labels for
controlled substances dispensed by the Triphasic Pharmacy, a pharmacy
owned by Johar Saran, to out of state persons, which listed Nirmal
Saran as the prescribing physician. Id. at 75; GX 104 at 2 (Plea
Agreement of Johar Saran); see GXs 2, 3, 4, 5, 6, 7, 8, 9, & 10 (No.
06-20). During some of the trash runs, the DIs also recovered several
daily reports which listed hundreds of prescriptions for schedule III
controlled substances containing hydrocodone which were dispensed by
Triphasic; the reports listed Nirmal Saran as the prescriber. See GX 5,
at 28-41 (No. 06-20), GX 11, at 1-161 (No. 06-20).\4\
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\4\ In his exceptions, Respondent notes that while the daily
reports list him as the prescriber, it also listed ``an incorrect
DEA number.'' Nirmal Saran Exceptions at 12. Respondent thus
contends that this ``implies that someone attempted to use
Respondent's name in association with the incorrect DEA number.''
Id. at 12-13.
It is acknowledged that the daily reports do not contain
Respondent's correct DEA number. As found below, however, Respondent
admitted to investigators that he prescribed over the Internet.
Moreover, Respondent did not testify at the hearing and thus did not
deny that he issued the prescriptions dispensed by Triphasic. I
therefore reject the exception and find that he did issue the
prescriptions.
Respondent further contends that because the ``labels were all
found in the trash * * * they were, in fact, trash,'' and thus the
probative value of this evidence is limited to showing that the
Government found his name on pieces of paper ``during a time period
unconnected to the'' allegations of the Show Cause Order. Id. at 11-
12. According to Respondent's argument, the labels are not evidence
of prescriptions at all. I conclude, however, that a pharmacy's
employees would not prepare hundreds, if not thousands, of
prescription labels which included the patient's name and address,
dispensing instructions, and various warnings, unless they were to
be used to dispense the prescriptions. I therefore reject
Respondent's contention.
Respondent also objects to the admission of numerous exhibits on
the ground that they pre-date the events which form the basis of the
Show Cause Order. At the hearing, however, Respondent did not object
to the admission of any of these exhibits on the ground that they
were irrelevant because they involved prescribings which pre-dated
the period alleged in the Show Cause Order. See Tr. 66 (GX 2), 69
(GX 3), 73 (GX 4), 133 (GX 6), 75 (GX 7), 137 (GX 9), 139 (GX 10),
141 (GX 11) (All exhibit numbers are from Case No. 06-20).
Respondent objected only to portions of GXs 5 and 8, and did so on
the limited basis that they contained a few prescriptions written by
other doctors. See Tr. 130-32 (discussing GX 5); id. at 135-36
(discussing GX 8). The prescriptions issued by other doctors were
removed from the exhibits and the exhibits were entered into the
record. See id. at 132-33, 136. I therefore conclude that Respondent
has waived his objection to the admission of these exhibits.
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Thereafter, DEA investigators obtained a court order under 18
U.S.C. 2516, which authorized them to intercept electronic
communications from Infiniti's Internet protocol (IP) address between
April 26 and June 23, 2005.\5\ Tr. 30-32. According to the DI who
served as a minimizer of the intercept, Nisha and Nirmal Saran's names
appeared as approvers of prescriptions in database files that were
downloaded by persons at Infiniti from the Nations Drug Supply Web
site. Id. at 35-36. Moreover, their names also appeared in various e-
mails that were intercepted.\6\ Id. at 35.
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\5\ According to a DI, the court also authorized the
interception of Infiniti's e-mail for an additional thirty days. Tr.
31.
\6\ These include an April 6, 2005 e-mail from Tara Jones, an
employee of Joe Saran and Infiniti, to Colin McConnell, an employee
of Concussion Interactive, the developer of the Nations' Web site.
GX 75 (06-19). In this e-mail, Ms. Jones provided Nisha and Nirmal
Saran's addresses, phone numbers, and medical license numbers. Id.
In concluding the e-mail, Ms. Jones apologized for taking ``so
long,'' and added that ``Nisha was in LA and just got back today.
She said you were both playing phone tag, so if you still need to
talk to her * * * try her cell number now.'' Id.
The record also contains an e-mail (dated 5/27/2005) from
another employee of Concussion Interactive to Ms. Jones forwarding a
username and password so that Nisha Saran could ``login to the
shopping cart admin.'' GX 79 (06-19).
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After intercepting the database files, the DI used Microsoft Excel
to extract the data and put it into spreadsheet form. Id. at 37. The
Government introduced into evidence spreadsheets listing the
prescriptions which were dispensed by pharmacies that were controlled
by Joe Saran and Infiniti between May 27 and June 17, 2005. See GXs 4-
58 (06-19).\7\ The spreadsheets list numerous controlled substance
prescriptions that were issued by each Respondent for persons located
throughout the country.\8\ See generally id. Among the drugs prescribed
by each Respondent were such highly abused controlled substances as
schedule III combination drugs containing hydrocodone, and schedule IV
benzodiazepines such as diazepam and lorazepam.\9\
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\7\ The exhibits are numbered as GXs 14-68 in No. 06-20.
\8\ According to my review of the record, between May 19, 2005
and June 8, 2005, Respondent Nirmal Saran issued the following
amounts of controlled substance prescriptions to persons in these
States: Eighty-six to persons in Florida, eighty-seven to persons in
California, sixty-four to persons in Tennessee, thirty-two to
persons in Ohio, and twenty-nine to persons in North Carolina.
Moreover, between May 27, 2005 and June 3, 2005, Nisha Saran issued
controlled substance prescriptions in the following amounts to
persons in these States: Seventeen to persons in Florida, eleven to
persons in California, ten to persons in North Carolina and four to
persons in Ohio.
\9\ Respondent Nisha Saran contends that ``her name was used
without her permission or knowledge by NDS employees, most likely
Tara Jones.'' Nisha Saran Exceptions at 11; see also id. at 12
(noting that as systems administrator, Jones could log in `` `as one
of the doctors' and insert a doctor's signature and it would appear
that a doctor had approved the prescription'') (quoting Tr. 420,
testimony of J.B.).
While one of Respondent's witnesses testified that Tara Jones
had approved an order using Ms. Saran's signature, Tr. 547, this
witness subsequently testified that she had observed this ``only the
one time,'' id. at 585, which occurred toward the ``end of August,
beginning of September 2005.'' Id. at 568. The spreadsheets
containing the intercepted prescriptions show, however, that
Respondent issued numerous prescriptions months earlier. Moreover,
even if Respondent's name was used on some prescriptions without her
permission, I note that Respondent did not testify and thus did not
deny that she issued the prescriptions. Nor did she explain why her
signature was found in a hard drive of a computer at Infiniti, her
brother's business. Tr. 183-84. Moreover, as explained above, other
evidence links Respondent to the Nations' and Rx Great Prices'
schemes.
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As part of the investigation, a DI went to the Nations Drug Supply
Web site and made two undercover buys. On June 2, 2005, the DI, using
the name Dwight E. Anderson and an address in Forth Worth, Texas,
ordered ninety tablets of hydrocodone/acetaminophen 10/650 mg., for a
price of $ 373.50 plus shipping. GX 89 (06-20). While visiting the Web
site, the DI was able to select the drug he wanted and place it in his
[[Page 78831]]
shopping cart.\10\ Tr. 152. While the Web site used a program that
required that a customer provide information to establish his identity,
the DI testified that by contacting the site's customer service
department he was able to obtain a ``skip code'' which allowed him to
bypass this process. Id. at 155.
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\10\ At the hearing, the Government introduced into evidence a
DVD which showed the various Web pages that the DI visited in
ordering the drugs; the DVD was made using a software program which
records as a video ``anything that happens on the computer screen.''
Tr. 145-46.
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The DI was then required to complete a patient questionnaire. Id.
at 155-56. The questionnaire asked him about his height, weight,
allergies, past medications including whether he had previously taken
the requested medication, and why he was seeking the medication. Id. at
155-56. With respect to the latter question, the DI ``simply put `[m]y
leg hurts.'' ' Id. at 157.
After indicating that he would pay for the drugs by cash on
delivery, id., the Web site displayed an order confirmation page. Id.
at 158; GX 89 (No. 06-20). This page indicated that the DI's order
number was 817, that the order was placed on ``2005-06-02'' at
``15:15:56,'' that it was sold to and would be shipped to ``Dwight E.
Anderson'' with an address of 819 Taylor St. in Forth Worth, that it
was for 90 tablets of hydrocodone 10/650 mg., and that the drugs cost $
373.50, plus $ 22.00 for overnight shipping for a total cost of $
395.50. GX 89.
The following day, the DI received a prescription vial containing
tablets. The label on the vial indicated that the prescription had been
filled by ``Reliance Pharmacuetical [sic], Inc.,'' with an address of
2805 W. Arlansas Lane, Suite 303, Arlington, Texas. GX 91 (No. 06-20).
The label provided instructions for taking the drug, indicated that the
vial contained 90 tablets of ``Hydrocodone (Lorcet)--10/650,'' and that
the prescribing doctor was ``Nirmal Saran''; the label also included
the name ``Dwight E. Anderson,'' the prescription number of
``817:10294,'' and the order number of ``817.'' Id.
Notably, the information on the order confirmation page and the
vial label matched the information for order 817 contained in the
spreadsheets that were compiled from the internet files that were
intercepted by the Government. See GX 43 (06-20) at 8-14 (line 21).\11\
Moreover, at no time did the DI speak with Nirmal Saran or any other
physician regarding why he was ordering the drugs. Tr. 182.
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\11\ In his exceptions, Respondent argues that ``the name of
Dwight E. Anderson * * * does not appear on the Government's
spreadsheet evidence, rather, order number 817 is shown as having
been filled for a `Robin Daub,' and not `Dwight E. Anderson.' ''
Nirmal Saran Exceptions at 26 (citing GX 87, at 178-80). Relatedly,
Respondent argues that ``No order no. 953 is reflected on the
Government's spreadsheet of `Nirmal Saran's Original Rx's.' '' Id.
at 27. Respondent further argues that ``[i]f the information on the
spreadsheets was in fact downloaded from the servers and put into an
Excel file as testified to by Government's agents, and not
manipulated as they testified, there should be no discrepancies in
the tables/spreadsheets showing different information on them and
definitely should show the undercover buys.'' Id. Based on the
testimony of one of his witnesses, Respondent further asserts that
``the IP addresses reflected on the Government's exhibit would not
instruct a computer to transfer any data, and that [GX 90] does not
reflect the transmission of an actual customer's order.'' Id.
(citing Tr. 426 & 429). Respondent contends that ``[t]his
information * * * suggests that these purchases were fabricated.''
Id.
Respondent misrepresents what exhibit (GX 90) represents. As the
DI testified, GX 90 does not represent the time that the DI
purchased the drug, but rather, the time ``that that file was
transferred that contained the information of the undercover buy''
to Infiniti. Tr. 164. Consistent with the DI's testimony, the order
confirmation that he printed from the Nations Drug Supply Web site
indicates that the order was place at 15:15:56 (or 3:15:56 p.m.),
see GX 89; by contrast, GX 90 indicated that the file was
transferred to Infiniti at 10:37:52 p.m, Greenwich Mean Time, or
4:37 p.m. Fort Worth Time. See GX 90; Tr. 164.
To be sure, GX 87, which lists Nirmal Saran's prescriptions,
indicates that order number 817 was placed by R.D. and not Dwight E.
Anderson. GX 87, at 178. However, the original spreadsheet listing
order number 817, and which was created following the intercept,
clearly shows that the DI ordered hydrocodone as he testified to,
and that the prescription was authorized by Nirmal Saran. See GX 43
(06-20) at 8-14 (line 21). While the person who created GX 87
testified that she had copied information from the original
spreadsheet files to this file, Tr. 333, there appear to be other
errors in this document as well. For example, the evidence shows
that the hydrocodone prescription given order number 817 cost
$373.50, yet GX 87 indicates that the drugs were paid for with a COD
in the amount of $87. GX 87, at 180. Moreover, Dwight Anderson is
nonetheless listed as having purchased another drug which Nirmal
Saran prescribed, Zydone, a branded drug which also contains
hydrocodone, for a total COD amount of $395.50, even though the
product price is listed at $74.70; the entries for this prescription
also indicate that the purchase was prepaid while simultaneously
indicating a COD amount. See GX 87 at 106-08 (line entry 598). Given
these errors, and the derivative nature of the exhibit, I do not
rely on it.
Based on the great weight of the evidence, which includes the
DI's testimony, the DVD showing the DI's visit to the Web site, the
order confirmation, the evidence showing that the drugs were
delivered, and the original spreadsheet of the intercepted
prescriptions, I reject Respondent's contention that the purchase
was fabricated. I further conclude that it is more likely than not
that the purchase occurred and that Nirmal Saran authorized the
prescribing. As for Respondent's contention regarding order no. 953,
no doctor was listed as the prescriber on either the drug vial's
label, GX 94 (06-20), or on the spreadsheet. GX 54 (06-20) at 8-10
(line 21). It is therefore no surprise that the order is not listed
on GX 87.
---------------------------------------------------------------------------
The following day, the DI revisited the Nations Drug Supply Web
site and ordered sixty tablets of alprazolam 2 mg., a schedule IV
benzodiazepine. GX 92 (No. 06-20); Tr. 169. In completing the
questionnaire necessary to order the drug, the DI indicated that the
reason he needed the drug was because he was ``stressed out from
work.'' Tr. 172. The DI also indicated that he was not taking any other
drugs although he had already obtained the hydrocodone that he
purchased the day before. Id. This time, however, the Web page
indicated that the DI would have to fill out a patient history form
which was to be completed by his doctor and faxed in. Id. at 173. The
DI testified, however, that he never sent in the form and yet still was
able to order and obtain the drugs. Id. at 173-74, 176, 178-80; see
also GX 92 (No. 06-20). The label on the drug vial was missing the name
of the prescribing doctor. GX 94 (No. 06-20).
The Government also elicited the testimony of J.P., a Florida
resident, regarding his obtaining of controlled substances through the
Nations Drug Supply Web site. According to his testimony and the
intercepted prescription data, on at least three separate occasions,
J.P. purchased controlled substances through Nations. More
specifically, on May 30, 2005, J.P. purchased ninety tablets of Norco
10 mg., a schedule III drug containing hydrocodone based on a
prescription issued by Respondent Nisha Saran. Tr. 18-19; GX 9 (06-19)
at 1-7 (line 10). On June 2, 2005, J.P. purchased another ninety
tablets of Norco 10 mg., as well as ninety tablets of Adipex-P 37.5 mg.
(phentermine), a schedule IV stimulant; both prescriptions were
authorized by Nirmal Saran. GX 30 (06-19) at 17-24 (lines 37 & 38).
Finally, on June 6, 2005, J.P. purchased two orders of ninety tablets
of Norco 10 mg., as well as two orders of ninety tablets of Valium (10
mg); each of the four prescriptions were approved by Nirmal Saran. GX
51 (06-19) at 17-24 (lines 35, 37, 40, & 42).\12\
---------------------------------------------------------------------------
\12\ I have considered and reject the suggestion that these were
duplicate prescriptions. Cf. Nirmal Saran's Exceptions at 23.
Notably, the two Norco prescriptions had different order numbers (as
did the two Valium prescriptions). See GX 51 (06-19) at 17.
Moreover, the evidence shows that two different pharmacies, with
different addresses, filled the prescriptions. Id. at 19.
---------------------------------------------------------------------------
J.P. testified that he was not required to send his medical records
to Nations to purchase the controlled substances, that he did not speak
with anyone to obtain the drugs, and that he did not know either
Respondent. Tr. 18. J.P. further testified that at the time he
purchased the drugs, he was not under the care of a physician, id. at
17, and that he ``became physically dependent'' on them. Id. at 22.
On September 21, 2005, law enforcement authorities executed a
federal search warrant at the residence
[[Page 78832]]
of Joe Saran. Id. at 208. While the search was proceeding, Nirmal Saran
arrived at his son's residence, identified himself to a DI as Joe
Saran's father, and said that he wanted to talk to the investigators
about what they were doing. Id. at 209-10. The DI contacted another DI,
who advised him that he needed to serve Nirmal Saran with the
Suspension Order and that he was willing to talk to Dr. Saran. Id. at
212.
Following his arrival at the residence, the other DI served Nirmal
Saran with the Order and after explaining why the Agency had issued the
Order, proceeded to interview him. Id. at 215. During the interview,
``Dr. Saran admitted to prescribing controlled substances via the
[i]nternet for his son's company, Nations Drug Supply.'' Id. at 216.
Dr. Saran explained ``that Nations Drug Supply had a Web site, and that
the Web site list[ed] all the names and the information as to why the
person needed the drug, the person's allergies, blood pressure, and
weight.'' Id. at 216-17. Dr. Saran also stated ``that he would read the
questionnaire and he would prescribe that way.'' Id. at 217. Dr. Saran
further stated that back in May or June 2005, his son and another
employee of Nations had approached him, and that his son had given him
a password which allowed him to access the Web site. Id. Dr. Saran also
told the DIs that his internet prescribing mostly involved painkillers.
Id. at 218.
Dr. Saran further admitted that he did not know any of the persons
he prescribed to, and that during the entire period in which he
prescribed over the internet, he telephoned ``approximately 12 to 15
patients.'' Id. at 219. Dr. Saran also said that in reviewing the
questionnaires, ``he took the person's word for it,'' id., and that the
``questionnaire with all the information for the patient was good
enough for him.'' Id. at 217.
Dr. Saran admitted, however, that in his practice as an
ophthalmologist, ``he would initially examine the patient, take their
blood pressure and weight, review their history, and then prescribe the
medication, which [was] totally opposite of'' how he prescribed online.
Id. at 219. He also told the DIs that he did not ``keep any records of
whatever he prescribed.'' Id. at 220. Finally, he acknowledged that he
was licensed only in Texas, but ``but felt that [because] the
prescriptions were issued in Texas, it was okay for him to prescribe''
to persons residing in other States. Id. at 221.
Respondents' Relationship With Rx Great Prices
During the investigation of Infiniti, DEA Investigators also
intercepted several e-mails which link both Respondents to Rx Great
Prices, the Web site owned and operated by Gil Lozano and the
corporations he controlled. Id. at 613. Moreover, on the same day that
the search warrant was executed at Joe Saran's residence, other
investigators executed a search warrant at Lozano's residence in
Florida.\13\ Id. at 604-05.
---------------------------------------------------------------------------
\13\ In their exceptions, both Respondents moved to strike the
testimony of the DI and seek to exclude the documentary evidence
which includes the employment agreements and e-mails linking them to
Gil Lozano and his corporation, First Management, L.L.C. See Nisha
Saran Exceptions at 15, Nirmal Saran Exceptions at 15. At the
hearing, however, Respondents did not object to the admission of the
employment agreements, see Tr. 607-8, or the e-mails which link them
to Lozano. Id. at 614. Respondents have therefore waived any
argument that the employment agreement and e-mails were improperly
admitted into evidence.
The DI also testified regarding an interview he conducted of
Tania Lozano. Respondents objected to a single question on the
ground that the DI's testimony was hearsay; the ALJ overruled the
objection. Id. Moreover, the Supreme Court has held that hearsay
evidence can still constitute substantial evidence under the
Administrative Procedure Act. See Richardson v. Perales, 402 U.S.
389 (1971). Notably, Respondents did not seek to subpoena Ms.
Lozano. See 21 CFR 1316.52(d). I therefore deny Respondents' motions
to strike the DI's testimony.
---------------------------------------------------------------------------
During the search of Lozano's residence, the investigators seized
two documents entitled ``EMPLOYMENT AGREEMENT.'' See GX 101 (06-19), GX
101 (06-20). While the header on both documents stated ``Attorney-
Client Draft Document'' and ``Discussion: Not for Execution,'' each
document also stated that ``THIS EMPLOYMENT AGREEMENT * * * is made and
entered into this 20[th] day of January 2005, by and between [each
Respondent] \14\ a physician (`Employee') and First Management, LLC, a
Florida Limited Liability Company (`Employer').'' See GX 101 (06-19) at
1; GX 101 (06-20) at 1. Each agreement gave an effective date (March 1,
2005 on Nisha Saran's agreement; February 1, 2005 on Nirmal Saran's
agreement), indicated that each Respondent's ``Bonus and Additional
Compensation'' was ``To Be Negotiated,'' and was signed by the
respective Respondent.\15\ See id. (06-19) at 1, 8, & id. (06-20) at 1,
8 & 12.
---------------------------------------------------------------------------
\14\ To clarify, on GX 101 (No. 06-19), ``Nisha M. Saran, D.O.''
was listed as ``a physician (`Employee'),'' and party to the
agreement; on GX 101 (No. 06-20), ``Nirmal Saran, M.D'' was listed
as ``a physician (`Employee')'' and party.
\15\ It is acknowledged that neither agreement was signed by
someone on behalf of First Management. See GX 101 (No. 06-19) at 12;
GX 101 (06-20) at 12. Notwithstanding this, for the reasons
explained in the text, I conclude that each Respondent entered into
a contractual arrangement with First Management to issue Internet
prescriptions.
---------------------------------------------------------------------------
Each agreement stated that ``Employer operated an on-line, Internet
pharmacy business,'' that the ``Employer hereby employs Employee, and
Employee accepts such employment, as a physician to render professional
medical services [on] behalf of Employer,'' and that the ``Employee
shall be required to check and receive patient files for review via the
Internet or facsimile multiple times per days at least (5) days per
week, and spend at least two--three hours per day reviewing patient
files and/or supervising nurse practitioners.'' Id. (06-19) at 1 & id.
(06-2) at 1 & 6. Moreover, the agreements stated that the ``Employee
shall have * * * authority, in their [sic] sole discretion to reject
the patient's file for any request for a prescription or to request
further medical information or history of the patient prior to making
any final decision as to the issuing of any prescription to a
patient.'' Id. (06-19) at 6; id. (06-20) at 6.
The record contains several e-mails which further support the
conclusion that both Respondents entered into a contractual arrangement
with Gil Lozano and his corporation to prescribe over the Internet. For
example, on March 21, 2005, Joe Saran sent an e-mail to Gil Lozano with
the subject line ``Malpractice Information''; the e-mail also indicated
that the matter was of ``High'' importance. GX 77 (06-19). In the e-
mail, Joe Saran wrote: ``I do hope that we can get this resolved
quickly as both my father and sister are quite anxious to get started
with you.'' Id. Continuing, Joe Saran explained that ``the insurance
companies have a few questions. If you can please answer these, then I
believe that the underwriters will approve and this will get done
quickly.'' Id. Saran then listed five things that were needed,
including ``the projected number of prescriptions on a daily basis,''
``a copy of the medical questionnaire from your Web site,'' and
``guidelines as to the range of pharmaceuticals being prescribed.'' Id.
The record also includes a series of e-mails which discuss the
payment of malpractice insurance premiums for Nisha Saran. See GX 99
(06-19). On July 6, 2005, Tania Lozano sent an e-mail to Gil Lozano
with the subject line of ``Nisha info.'' Id. at 1. This e-mail related
that Nisha Saran had paid $19,830 for a year of malpractice insurance,
and that the policy was ``[v]alid until December 12, 2005.'' Id. Ms.
Lozano further stated that Nisha Saran ``said if you want to cover just
for the months that she has been working
[[Page 78833]]
for Rxgreatprice, that would be fine.'' Id. The e-mail also stated:
``First order approved on 5/31/2005 at 11:48 p.m.'' Id.
On July 7, 2005, Tania Lozano e-mailed Nisha Saran and asked her:
``Can you please provide me the address of your bank, as well as your
dad's office address so that Gil can process the funds for you[?]'' Id.
at 2. Continuing, the e-mail stated: ``We will pay 50% of $ 19,830 for
the professional liability insurance on a monthly basis for the amount
of $ 826.25 per month. I will get you a precise day of deposit as well
once I get the above info from you.'' Id. at 2.
The record also contains a July 18, 2005 (10:13 a.m.) e-mail from
Tania Lozano to Gil Lozano and another individual at Global One
Marketing, which appears to forward the text of another e-mail sent by
Nisha Saran to Tania Lozano. Id. The e-mail began: ``Tania * * *. Here
is the information that you requested[,]'' and gives routing and
account information for Nirmal Saran's bank.\16\ Id. Continuing, the e-
mail stated: ``My dad's office address is as follows, but please send
any and all correspondence to his home address[,]'' and appeared to
list his office and home addresses. Id. Next, the e-mail stated:
``Thanks for the info this morning, as well!'' Id. The e-mail ended by
stating: ``Talk to you soon,'' and is signed ``Nisha Saran.'' Id.
---------------------------------------------------------------------------
\16\ The e-mail also includes a redacted portion above Nirmal
Saran's account information. GX 99, at 2.
---------------------------------------------------------------------------
Later that day, Tania Lozano sent another e-mail to Gil Lozano, the
subject being ``Question from Nisha.'' The text reads:
Nisha called me to verify that you were covering 100% of the
malpractice insurance from the months of June 05--Dec 05. If so, the
total due to her from June is 1652.50, not 826.25 as stated in the
last invoice. Can we send her another transfer for just 826.25 to
cover the month of June, then on the following invoice, she will
include 1652.50 to cover the month of July. From there on out, she
will get paid once a month for the insurance on the 30th of each
month. Please let me know if this is okay or if you want to handle
this another way. Thanks!
Id. at 3.
A DI subsequently interviewed Tania Lozano. Tr. 615. Among other
things, Ms. Lozano told the DI that in July 2005, Gil Lozano had told
her ``to stop using the other doctors and [to] direct all of the
requested drug orders through Nisha and Nirmal Saran,'' because he
``was paying the other doctors $25 through a management company, and it
was only costing $12 a prescription through Nirmal and Nisha.'' Id. Ms.
Lozano also told the DI that she talked to Nisha Saran ``frequently,
normally two, three or four times a day, at least ten times per week,
and that they developed a close business relationship over the July,
August and September months that they worked together.'' Id. at 616.
The DI further testified that Tania Lozano told him that she would
call Nisha Saran on her cell phone and tell her: ``We're having
problems getting these orders approved.'' Id. Nisha Saran ``would
tell'' Tania: ``You're going to have to wait until I get off work; I'm
working at the hospital. My father approves the orders in the morning;
I approve in the afternoon.'' Id. Ms. Lozano further told the DI that
she had discussed with Nisha Saran ``problems with the pull-down menus
that had instructions'' for taking a drug, and that ``Nisha was very
particular about what instructions were placed on her drug orders.''
Id.\17\
---------------------------------------------------------------------------
\17\ The DI also testified that he had obtained Ms. Lozano's
cell phone records ``for the months that she was involved with Rx
Great Prices,'' and that both Nisha and Nirmal Saran's phone numbers
were contained in them. Tr. 617.
The DI further testified that he had interviewed a third doctor,
who had attended a meeting with Nirmal, Nisha, and Joe Saran, at
which Joe Saran attempted to recruit him to approve orders for his
Web site. Tr. 618. The third doctor related that in a later
discussion, Joe Saran again attempted to recruit him and told him
that he was paying Nisha and Nirmal $12,000 each per month. Id. at
618-19.
Relatedly, the record contains an exchange of e-mails on August
16, 2005, between Gil Lozano and Joe Saran in which the former
sought the latter's help in recruiting ``one or two more medical
doctors for our sites.'' GX 78 (06-19) at 2. Later that day, Joe
Saran wrote to Lozano: ``I do know another doctor who may be
interested. I will talk to him and see what his response may be. Is
the payment rate the same as for my dad and sister? This will be a
question that I will need to answer for him.'' Id. at 1.
---------------------------------------------------------------------------
The Expert Testimony
George J. Van Komen, M.D., testified on behalf of the Government as
an expert on the standards of medical practice and the use of the
Internet to prescribe controlled substances. At the time of the
hearing, Dr. Van Komen, who is board certified in internal medicine and
a Fellow of the American College of Physicians, had served as an
Assistant Professor of Clinical Medicine at the University of Utah
School of Medicine for fifteen years and had practiced medicine for
more than thirty years. Tr. 234; GX 71 (06-20) at 1. From 1995 to 2002,
he served on the Board of Directors of the Federation of State Medical
Boards (FSMB), and was the Federation's President in 2001 to 2002. GX
71 (06-20) at 3. Dr. Van Komen also was a member of the State of Utah's
Physicians Licensing Board from 1989 to 1999, and served as the Board's
Chairman from 1991 to 1999. Id. Dr. Van Komen testified that he had a
particular interest in prescription drug abuse and the proper use of
controlled substances in medical practice. Tr. 234, 236-37.
In his testimony, Dr. Van Komen acknowledged that the American
Medical Association (AMA) is ``not a government organization'' and
therefore does not ``have any authoritative capabilities.'' Id. at 238.
Dr. Van Komen explained, however, that the AMA's policies and
recommendations are ``well received by government organizations'' and
``by state legislatures.'' Id. Relatedly, Dr. Van Komen testified that
``[t]he Federation of State Medical Boards has no authority'' over the
practice of medicine, but that its membership is comprised of members
of state medical boards and that it does provide guidance and policy
statements to assist the nation's state boards on various issues. Id.
at 251.\18\
---------------------------------------------------------------------------
\18\ In light of Dr. Van Komen's testimony that neither the AMA
nor the FSMB have authority to promulgate binding standards of
medical practice, I conclude that it is unnecessary to discuss the
contents of the various policy statements that these organizations
have issued.
---------------------------------------------------------------------------
Dr. Van Komen further testified, however, that there is a standard
of care for prescribing controlled substances that is ``well accepted
and recognized throughout the medical community.'' Id. at 268. As Dr.
Van Komen testified:
[T]he standard of care is that * * * on any new patient who
comes with a problem that may require a controlled substance, that
the physician has personal contact with the patient, that a careful,
detailed history is undertaken, that that careful, detailed history
is utilized in doing a careful physical examination, and then a
carefully outlaid differential diagnosis or etiology of the
patient's symptoms is derived, and then from that, after appropriate
testing and evaluation when further laboratory tests are in, then
the physician may choose to utilize controlled substances in the
treatment of the patient's ailment and disease.
Id. at 268-69.
After explaining what telemedicine is, Dr. Van Komen was asked what
is the standard for ``forming a legitimate doctor-patient
relationship?'' Id. at 271. Dr. Van Komen answered:
[W]e feel that there needs to be documented a face-to-face
history and physical and evaluation of the patient, and then if this
patient chooses to receive further consultative work or be
established with a physician who practices on the Internet, that the
physician first of all and most formally needs to be identified, and
he needs to have a license in the state in which the patient
resides. * * *
And we also feel that that primary care doctor who did the
history and physical needs to stay in touch with the patient, even
[[Page 78834]]
though the patient might be seeking further consultation from
another physician through the Internet.
Id. at 271. Dr. Van Komen's subsequent testimony suggested, however,
that he was discussing the standard of care as set forth in policy
statements of the AMA and FSMB. See id. at 272 (testifying that the
policy statement of the FSMB and AMA ``absolutely'' outline the
standard of care for Internet prescribing).
After he explained that medical doctors and osteopathic physicians
are subject to the same standard of care,\19\ id. at 275, Dr. Van Komen
was asked whether he had ``formed an opinion on whether the
prescriptions issued by Dr. Nisha Saran and Dr. Nirmal Saran were
issued outside the usual course of professional practice?'' Id. at 276.
Dr. Van Komen answered that ``[f]rom the records that I have seen,
there gives me no reason to believe that they meet even closely the
standard of care that would be an acceptable practice of medicine.''
Id. Dr. Van Komen explained that his opinions were based on the
``prescriptions that were written by them, as well as log sheets,
outlining the type of practice that they have, the number of
prescriptions that they wrote during a particular * * * period of time,
and all of those records lead me to believe that they are far out from
the accepted standard of care.'' Id.
---------------------------------------------------------------------------
\19\ He also explained that an ophthalmologist performs eye
surgery and treats diseases of the eye. Tr. 276.
---------------------------------------------------------------------------
Subsequently, Dr. Van Komen added:
[T]here is no documentation of any doctor-patient contact. There
is no indication of any record being kept. There is no formulation
of a working diagnosis for which the medications were prescribed,
and there is no indication that the patient understood the potential
of addiction or danger of the drugs that were prescribed.
Id. at 277.
Next, with respect to Nirmal Saran, Dr. Van Komen testified that
while an ophthalmologist ``may prescribe * * * an occasional pain
medication * * * it's been my understanding that ophthalmologists
rarely prescribe opioid medication, even after some eye surgery that
they perform.'' Id. at 277-78. Finally, Dr. Van Komen stated that he
was ``100 percent sure'' that the prescriptions that he reviewed were
not issued for legitimate medical purposes, and that he was also ``100
percent'' certain that the prescriptions were issued outside of the
usual course of professional practice because ``[t]here [was] no
indication * * * from the records \20\ that I reviewed that there [was]
any attempt to appropriately practice medicine according to even the
minimal standard of care.'' Id. at 278.\21\
---------------------------------------------------------------------------
\20\ While Nirmal Saran admitted to a DI that he did not
maintain any records on the persons he prescribed to, Tr. 220, there
is no evidence as to whether Nisha Saran also failed to maintain
records. The Government, however, had the burden of proving that
Nisha Saran failed to maintain patient records. Because Dr. Van
Komen's opinion testimony with respect to Nisha Saran was based in
part on the alleged absence of documentation to support her
prescribings, his testimony is rejected to this extent.
\21\ Dr. Van Komen also testified that ``if the patient asks for
a drug by name, you can almost for sure understand that that
individual is going to abuse that drug. It's interesting that on the
internet, you allow the patient to pick whatever drug they want
exactly by name and order it.'' Id. at 279-80. He also explained the
importance of monitoring closely those patients to whom he
prescribed hydrocodone. Id. Moreover, Dr. Van Komen testified that
reviewing an online questionnaire was ``absolutely no way'' for a
physician to detect whether a person who was seeking a controlled
substance was a drug abuser, ``because you have no way of knowing
that the person that filled out the questionnaire filled it out
honestly.'' Id. at 285.
---------------------------------------------------------------------------
On cross-examination, however, Dr. Van Komen was asked if he was
``familiar with the way the Texas Medical Board deals with this
particular type of problem?'' Id. at 302. Dr. Van Komen answered: ``Not
specifically. I would assume that they have, as many medical boards,
accepted the model guidelines that have been distributed through the
Federation of State Medical Boards.'' \22\ Id.
---------------------------------------------------------------------------
\22\ Respondent Nisha Saran also elicited testimony from Rony
Dev, D.O., one of her colleagues at a hospital where she practiced.
Dr. Dev acknowledged, however, that it would not be appropriate to
prescribe to a patient without knowing her medical history, what
medications the patient was on, and her vital signs. Tr. 471. While
Dr. Dev testified that in his experience, Nisha Saran would not
prescribe in this manner, id. at 471-72; he subsequently testified
that he had no direct knowledge of her prescribing over the
internet, id. at 503; and had never discussed her internet
prescribing with her. Id. at 520.
---------------------------------------------------------------------------
Pursuant to 5 U.S.C. 556(e), I take official notice of the
following state standards of medical practice as set forth in statutes,
regulations, and administrative notices: \23\ Cal. Bus. & Prof. Code
Sec. Sec. 2052 \24\ (prohibiting unlicensed practice of medicine) &
2242.1(a) (``No person * * * may prescribe * * * dangerous drugs * * *
on the Internet for delivery to any person in this state, without an
appropriate prior examination and medical indication. * * *''). Cal.
Health & Safety Code Sec. 11352(a) (prohibiting furnishing a
controlled substance ``unless upon the written prescription of a
physician * * * licensed to practice in this state''); N.C. Gen. Stat.
Sec. 90-18 (2005) (``prescribing medication by use of the Internet or
a toll-free telephone number, shall be regarded as practicing
medicine'' in the State).\25\
---------------------------------------------------------------------------
\23\ In accordance with the Administrative Procedure Act (APA),
an agency ``may take official notice of facts at any stage in a
proceeding--even in the final decision.'' U.S. Dept. of Justice,
Attorney General's Manual on the Administrative Procedure Act 80
(1947) (Wm. W. Gaunt & Sons, Inc., Reprint 1979). In accordance with
the APA and DEA's regulations, Respondent is ``entitled on timely
request to an opportunity to show to the contrary.'' 5 U.S.C.
556(e); see also 21 CFR 1316.59(e). To allow Respondent the
opportunity to refute the facts of which I take official notice,
Respondent may file a motion for reconsideration within fifteen days
of service of this order which shall commence with the mailing of
the order.
\24\ In Hageseth v. Superior Court, 59 Cal. Rptr.3d 385 (Ct.
App. 2007), the California Court of Appeal upheld the State's
jurisdiction to criminally prosecute an out-of-state physician, who
prescribed a drug to a California resident over the internet, for
the unauthorized practice of medicine.
\25\ The North Carolina Medical Board has also issued a Position
Statement on the steps which a physician must take before
prescribing a drug. See North Carolina Medical Board, Position
Statement: Contact With Patients Before Prescribing (Nov. 1999).
More specifically, the North Carolina Medical Board has stated that:
It is the position of the North Carolina Medical Board that
prescribing drugs to an individual the prescriber has not personally
examined is inappropriate except as noted * * * below. Before
prescribing a drug, a physician should make an informed medical
judgment based on the circumstances of the situation and on his or
her training and experience. Ordinarily, this will require that the
physician personally perform an appropriate history and physical
examination, make a diagnosis, and formulate a therapeutic plan, a
part of which might be a prescription. This process must be
documented appropriately. Id. The exceptions are for ``admission
orders for newly hospitalized patients, prescribing for a patient of
another physician for whom the prescriber is taking call, or
continuing medication on a short-term basis for a new patient prior
to the patient's first appointment.'' Id. The North Carolina Board
has further declared that ``prescribing drugs to individuals the
physician has never met based solely on answers to a set of
questions, as is common in Internet or toll-free telephone
prescribing, is inappropriate and unprofessional.'' Id.
Finally, while North Carolina recently amended the State's
Medical Practice Act, it is a felony offense ``if the person so
practicing without a license is an out-of-state practitioner who has
not been licensed and registered to practice medicine * * * in th[e]
State.'' N.C. Gen. Stat. Sec. 90-18(a); see also id. Sec. 90-
1A(5)(f) (defining ``[t]he practice of medicine'' as including
``[t]he performance of any act, within or without this State,
described in this subdivision by use of any electronic or other
means, including the Internet or telephone'').
---------------------------------------------------------------------------
Relatedly, the administrative rules of the medical boards of Ohio
and Tennessee expressly prohibit--with only limited exceptions--a
physician's prescribing to a person he/she has not personally
physically examined. For example, under the rules of the Tennessee
Board of Medical Examiners:
[[Page 78835]]
* * * it shall be a prima facie violation of T.C.A. Sec. 63-6-
214(b) (1), (4), and (12) for a physician to prescribe or dispense
any drug to any individual, whether in person or by electronic means
or over the Internet or over telephone lines, unless the physician
has first done and appropriately documented, for the person to whom
a prescription is to be issued or drugs dispensed, all of the
following:
1. Performed an appropriate history and physical examination;
and
2. Made a diagnosis based upon the examination and all
diagnostic and laboratory tests consistent with good medical care;
and
3. Formulated a therapeutic plan, and discussed it, along with
the basis for it and the risks and benefits of various treatment
options, a part of which might be the prescription or dispensed
drug, with the patient; and
4. Insured availability of the physician or coverage for the
patient for appropriate follow-up care.
Tenn. Comp. R. & Regs. 0880-2-.14(7). See also id. R. 0880-2.16
(requiring telemedicine license).\26\ See Ohio Admin. R. 4731-11-09
(``Except in institutional settings, on call situations, cross coverage
situations, situations involving new patients, protocol situations, and
situations involving nurses practicing in accordance with standard care
arrangements * * * a physician shall not prescribe, dispense, or
otherwise provide, or cause to be provided, any controlled substance to
a person who the physician has never personally physically examined and
diagnosed.'').\27\
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\26\ I also take official notice of the Medical Board of
California's Decision and Order in Jon Steven Opsahl, M.D., at 3
(Med. Bd. Cal. 2003) (revoking medical license and finding that ``a
physician cannot do a good faith prior examination based on a
history, a review of medical records, responses to a questionnaire
and a telephone consultation with the patient, without a physical
examination of the patient'' and that ``[a] physician cannot
determine whether there is a medical indication for prescription of
a dangerous drug without performing a physical examination''); see
also id. at 17.
In addition, the Medical Board of California has issued numerous
Citation Orders to out-of-state physicians for internet prescribing
to State residents. See, e.g., Citation Order Harry Hoff (June 17,
2003); Citation Order Carlos Gustavo Levy (Nov. 30, 2001). It has
also issued press releases announcing its position on the issuance
of prescriptions by physicians who do not hold a California license.
See Medical Board of California, Record Fines Issued by Medical
Board to Physicians in Internet Prescribing Cases (News Release Feb.
10, 2003) (available at http://www.mbc.ca.gov/NR_2003_02-10_
Internetdrugs.htm). I also take official notice of these materials.
\27\ On September 14, 2003, the Florida Board of Medicine issued
Fla. Admin. R. 64B8-9.014, Standards for Telemedicine Prescribing
Practice. This rule states inter alia that:
Physicians * * * shall not provide treatment recommendations,
including issuing a prescription, via electronic or other means,
unless the following elements have been met: (a) A documented
patient evaluation, including history and physical examination to
establish the diagnosis for which any legend drug is prescribed. (b)
Discussion between the physician * * * and the patient regarding
treatment options and the risks and benefits of treatment. (c)
Maintenance of contemporaneous medical records meeting the
requirements of Rule 64B8-9.003, F.A.C.
Fla. Admin Code R. 64B8-9.014(2); see also Fla. Admin Code R.
64B15-14.008 (adopting similar rule for osteopathic physicians).
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Discussion
Section 304(a) of the Controlled Substance Act (CSA) provides that
``[a] registration * * * to * * * dispense a controlled substance * * *
may be suspended or revoked by the Attorney General upon a finding that
the registrant * * * has committed such acts as would render his
registration under section 823 of this title inconsistent with the
public interest as determined under such section.'' 21 U.S.C.
824(a).\28\ In determining the public interest, the CSA directs that
the following factors be considered:
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\28\ Section 304(d) further provides that ``[t]he Attorney
General may, in his discretion, suspend any registration
simultaneously with the institution of proceedings under this
section, in cases where he finds that there is an imminent danger to
the public health or safety.'' 21 U.S.C. 824(d).
(1) The recommendation of the appropriate State licensing board
or professional disciplinary authority.
(2) The applicant's experience in dispensing * * * controlled
substances.
(3) The applicant's conviction record under Federal or State
laws relating to the manufacture, distribution, or dispensing of
controlled substances.
(4) Compliance with applicable State, Federal, or local laws
relating to controlled substances.
(5) Such other conduct which may threaten the public health and
safety.
Id. Sec. 823(f).
[T]hese factors are * * * considered in the disjunctive.'' Robert
A. Leslie, M.D., 68 FR 15227, 15230 (2003). I ``may rely on any one or
a combination of factors, and may give each factor the weight [I] deem
appropriate in determining whether a registration'' is consistent with
the public interest and whether a registrant has committed acts which
warranted the suspension of his/her registration. Id. Moreover, case
law establishes that I am ``not required to make findings as to all of
the factors.'' Hoxie v. DEA, 419 F.3d 477, 482 (6th Cir. 2005); see
also Morall v. DEA, 412 F.3d 165, 173-74 (D.C. Cir. 2005).
I acknowledge that neither Respondent's state license has been the
subject of disciplinary proceedings and that neither Respondent has
been convicted of an offense under Federal or State laws related to
controlled substances. I nonetheless conclude that the evidence as to
each Respondent's experience in dispensing controlled substances and
compliance with applicable Federal and State laws establish that both
Respondents committed acts which rendered their registrations
inconsistent with the public interest and which justified the
suspension orders.\29\
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\29\ While each Respondent's registration has expired and
neither Respondent has submitted a renewal application, each
Respondent asserts that he/she intends to continue the practice of
medicine and that he/she has not abandoned his/her desire to obtain
a new registration. See ALJ Exs. 14A & 14B. The Government does not
dispute these assertions. For the reasons stated in my answer to the
ALJ's Query, I hold that neither Respondent's case is moot. See ALJ
Ex. 23.
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Factors Two and Four--Respondents' Experience in Dispensing Controlled
Substances and Record of Compliance with Applicable Federal and State
Laws
Under a longstanding DEA regulation, a prescription for a
controlled substance is not ``effective'' unless it is ``issued for a
legitimate medical purpose by an individual practitioner acting in the
usual course of his [or her] professional practice.'' 21 CFR
1306.04(a). This regulation further provides that ``an order purporting
to be a prescription issued not in the usual course of professional
treatment * * * is not a prescription within the meaning and intent of
[21 U.S.C. 829] and * * * the person issuing it, shall be subject to
the penalties provided for violations of the provisions of law relating
to controlled substances.'' Id. As the Supreme Court recently
explained, ``the prescription requirement * * * ensures patients use
controlled substances under the supervision of a doctor so as to
prevent addiction and recreational abuse. As a corollary, [it] also
bars doctors from peddling to patients who crave the drugs for those
prohibited uses.'' Gonzales v. Oregon, 546 U.S. 243, 274 (2006) (citing
Moore, 423 U.S. 122, 135, 143 (1975)).
It is fundamental that a practitioner must establish a bonafide
doctor-patient relationship in order to be acting ``in the usual course
of * * * professional practice'' and to issue a prescription for a
``legitimate medical purpose.'' See United States v. Moore, 423 U.S.
122 (1975). Under numerous state standards of medical practice, before
issuing a treatment recommendation, a physician must, inter alia,
physically examine a patient to establish a bona-fide doctor patient
relationship and properly diagnose his/her patient. See, e.g., Cal.
Bus. & Prof. Code Sec. 2242.1; Cal. Health & Safety Code Sec.
11352(a); Ohio Admin. R. 4731-11-09; Tenn. Comp. R. & Regs. 0880-
2-.14(7); North Carolina Med. Bd., Position Statement: Contact With
Patients Before Prescribing.
[[Page 78836]]
Furthermore, a physician who engages in the unauthorized practice
of medicine is not a ``practitioner acting in the usual course of * * *
professional practice.'' 21 CFR 1306.04(a). Under the CSA, the ``[t]he
term `practitioner' means a physician * * * licensed, registered, or
otherwise permitted, by the United States or the jurisdiction in which
he practices * * * to * * * dispense * * * a controlled substance in
the course of professional practice.'' 21 U.S.C. 802(21). See also 21
U.S.C. 823(f) (``The Attorney General shall register practitioners * *
* to dispense * * * if the applicant is authorized to dispense * * *
controlled substances under the laws of the State in which he
practices.''). As the Supreme Court has explained: ``In the case of a
physician [the CSA] contemplates that he is authorized by the State to
practice medicine and to dispense drugs in connection with his
professional practice.'' Moore, 423 U.S. at 140-41 (emphasis added). A
controlled-substance prescription issued by a physician who lacks the
license necessary to practice medicine within a State is therefore
unlawful under the CSA. Cf. 21 CFR 1306.03(a)(1) (``A prescription for
a controlled substance may be issued only by an individual practitioner
who is * * * [a]uthorized to prescribe controlled substances by the
jurisdiction in which he is licensed to practice his
profession[.]'').\30\
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\30\ As the California Court of Appeal has noted: the
``proscription of the unlicensed practice of medicine is neither an
obscure nor an unusual state prohibition of which ignorance can
reasonably be claimed, and certainly not by persons * * * who are
licensed health care providers. Nor can such persons reasonably
claim ignorance of the fact that authorization of a prescription
pharmaceutical constitutes the practice of medicine.'' Hageseth v.
Superior Court, 59 Cal. Rptr.3d 385, 403 (Ct. App. 2007).
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The record establishes that each Respondent committed numerous
violations of the CSA and various state laws by issuing prescriptions
which lacked a legitimate medical purpose and which were far outside of
the course of professional practice. With respect to Respondent Nirmal
Saran, the evidence shows that in just the limited period between May
19 and June 8, 2005, he issued through internet sites, eight-seven
controlled substance (cs) prescriptions to persons in California,
eighty-six cs prescriptions to person in Florida, sixty-four cs
prescriptions to persons in Tennessee, thirty-two cs prescriptions to
person in Ohio, and twenty-nine controlled substance prescriptions to
persons in North Carolina. Nirmal Saran was not licensed in any of
these five States, and admitted to investigators that he prescribed
based on the questionnaires submitted by the Web sites' customers, that
he had only telephoned ``approximately 12 to 15 patients'' during the
entire period he prescribed over the internet, and obviously did not
perform physical examinations (as also demonstrated by the DI's
undercover buy) as required by the standards of medical practice of the
States of California, Ohio, Tennessee, and North Carolina, among
others.
Moreover, given the limited number of phone calls he made to
patients, it is also obvious that he violated state rules requiring
that he explain to his ``patients,'' the risks and benefits of
treatment options including the taking of controlled substances. Tenn.
Comp. R. & Regs. 0880-2-.14(7), Fla. Admin. Code R 64B8-9.014(2).
Furthermore, Nirmal Saran admitted that he did not keep any records of
his internet prescribings and thus violated state medical practice
standards for this reason as well. See, e.g. , Fla. Admin. Code R 64B8-
9.014(2); N.C. Med. Bd., Position Statement. I thus find that Nirmal
Saran did not establish a bona fide doctor-patient relationship with
those persons he prescribed to over the internet, that these
prescriptions lacked a legitimate medical purpose, and that he acted
outside of the usual course of professional practice in issuing them.
21 CFR 1306.04(a). See also Tr. 278 (testimony of Gov. Expert). I
further conclude that Nirmal Saran repeatedly violated the CSA in
issuing prescriptions over the internet and thus committed numerous
acts which rendered his registration ``inconsistent with the public
interest,'' 21 U.S.C. 824(a)(4), and which warranted the suspension of
his registration.
The record likewise establishes that Nisha Saran issued numerous
prescriptions in violation of the CSA and various state laws. As found
above, in just the limited period between May 27 and June 3, 2005,
Nisha Saran issued over the internet, seventeen cs prescriptions to
persons in Florida, eleven cs prescriptions to persons in California,
ten cs prescriptions to persons in North Carolina, and four cs
prescriptions to persons in Ohio.\31\ Nisha Saran practiced in the
State of Texas and was not licensed to practice medicine in any of
these other States. For this reason alone, the prescriptions she issued
to these persons were issued outside of the ``usual course of * * *
professional practice'' and violated the CSA. 21 CFR 1306.04(a); Moore,
423 U.S. at 140-41.
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\31\ My identification of the specific number of prescriptions
issued by each Respondent in violation of various state medical
practice standards during a limited time period is not an all
inclusive list of the violations each committed. Each Respondent
also issued prescriptions to persons in numerous other States; the
Agency is not required to identify each and every instance in which
they violated the CSA and state laws to support the conclusion that
they committed acts inconsistent with the public interest.
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With respect to the Nations Drug Supply Web site (which was owned
by her brother, a now convicted drug dealer), J.P. testified that on
May 30, 2005, he purchased ninety tablets of Norco (hydrocodone/apap);
the intercepted data shows that Nisha Saran approved this prescription.
GX 9 (06-19) at 1-7 (line 10). J.P., a Florida resident, further
testified that he never spoke with anyone in making his various
purchases at Nations, that he was not required to send in any medical
records, and that he did not know Nisha Saran (or her father). It is
thus clear that Nisha Saran did not comply with State of Florida's
standards for telemedicine practice, see Fla. Admin. Code R.64B15-
14.0088-9.014, and that she did not establish a bona-fide doctor-
patient relationship with J.P. I therefore conclude that Nisha Saran
lacked ``a legitimate medical purpose'' and acted outside of the usual
course of professional practice in issuing the Norco prescription to
J.P. See 21 CFR 1306.04(a).
Moreover, given the extensive evidence as to the modus operandi
used by the Nations Drug Supply and Rx Great Prices Web sites, both of
which dispensed controlled substances based on prescriptions issued by
physicians who had not personally performed a physical exam on the
person seeking the prescription, I further conclude that Nisha Saran
failed to establish bona-fide doctor patient relationships with persons
to whom she prescribed controlled substances as required by the
standards of medical practice adopted by the States of California,
North Carolina, and Ohio, among others. See, e.g. , Cal. Bus & Prof.
Code Sec. 2242.1(a); Ohio Admin. R. 4731-11-09; N.C. Med. Bd., Contact
With Patients Before Prescribing. I therefore hold that in issuing
these prescriptions, Nisha Saran lacked ``a legitimate medical
purpose'' and acted far outside of the ``usual course of [her]
professional practice'' and therefore violated the CSA. 21 CFR
1306.04(a); see also Tr. 278.
I acknowledge that Nisha Saran offered the testimony of one of her
colleagues regarding the appropriateness of her prescribing practices
in a hospital setting. This evidence is not, however, relevant in
assessing whether her internet prescribing constituted acts
``inconsistent with the public interest.'' 21 U.S.C. 824(a)(4). Because
her internet
[[Page 78837]]
prescribings violated the CSA and numerous state laws, they were acts
that were inconsistent with the public interest,'' \32\ and which
warranted the suspension of her registration.\33\ Id.
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\32\ As both J.P.'s and Dr. Van Komen's testimony shows, the
prescribing of controlled substances over the internet creates a
grave threat to public health and safety. As Dr. Van Komen
explained, reviewing an online questionnaire is ``absolutely no
way'' for a physician to detect whether a person seeking a
controlled substance has a legitimate medical need for the drug or
is a drug abuser. Tr. 285. This Agency has discussed the threat to
public health and safety posed by internet prescribing in numerous
cases. See, e.g. , William R. Lockridge, 71 FR 77791 (2006); Mario
Alberto Diaz, 71 FR70788 (2006); Mario Avello, 70 FR 11695 (2005).
\33\ Neither Respondent has an application pending before the
Agency. I note, however, that even if the Respondents had submitted
applications, I would have denied their applications.
Under agency precedent, where the Government has proved that a
registrant has committed acts inconsistent with the public interest,
a registrant must `` `present[] sufficient mitigating evidence to
assure the Administrator that [it] can be entrusted with the
responsibility carried by such a registration.' '' Samuel S.
Jackson, 72 FR 23848, 23853 (2007) (quoting Leo R. Miller, 53 FR
21931, 21932 (1988)). Moreover, because ``past performance is the
best predictor of future performance,'' ALRA Labs., Inc., v. DEA, 54
F.3d 450, 452 (7th Cir. 1995), this Agency has repeatedly held that
where a registrant has committed acts inconsistent with the public
interest, the registrant must accept responsibility for his/her
actions and demonstrate that he/she will not engage in future
misconduct. See Jackson, 72 FR at 23853; John H. Kennedy, 71 FR
35705, 35709 (2006); Prince George Daniels, 60 FR 62884, 62887
(1995). See also Hoxie v. DEA, 419 F.3d at 483 (``admitting fault''
is ``properly consider[ed]'' by DEA to be an ``important factor[]''
in the public interest determination).
Notably, neither Respondent testified in this proceeding. I
therefore further find that neither Respondent has accepted
responsibility for his/her misconduct.
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Orders
Pursuant to the authority vested in me by 21 U.S.C. 824, as well as
28 CFR 0.100(b) & 0.104, I affirm my order which immediately suspended
the now-expired DEA Certificate of Registration, AS7091894, issued to
Nirmal Saran. Pursuant to the above cited authority, I also affirm my
order which immediately suspended the now-expired DEA Certificate of
Registration, BS8415956, issued to Nisha Saran. These orders are
effective immediately.
Dated: December 12, 2008.
Michele M. Leonhart,
Deputy Administrator.
[FR Doc. E8-30506 Filed 12-22-08; 8:45 am]
BILLING CODE 4410-09-P