Patient Safety Scope Practice Violations Landlord Guide
⚕️ Patient Safety & Scope-of-Practice Violations
California landlord guide: RN/NP/PA violations, reporting obligations, premises liability, and enforcement strategies
Patient Safety Risks for California Landlords
Landlords and medical facility operators who lease space to med-spas, IV therapy clinics, aesthetic injectors, or other healthcare providers face unique patient safety and liability exposures. When tenants operate outside their scope of practice—RNs performing procedures that require physician oversight, NPs exceeding their standardized procedures, or unlicensed persons posing as medical professionals—patients are at risk and landlords face premises liability.
California law imposes a duty on property owners to maintain safe premises and, in some circumstances, to prevent third parties (tenants) from causing foreseeable harm to others (patients). Understanding scope-of-practice rules, recognizing red flags, and knowing when to intervene are critical to protecting your facility and avoiding liability.
Why Patient Safety Matters for Landlords
- Premises liability (Civ. Code § 1714): Landlords owe a duty of reasonable care to persons injured on their property. If you have actual knowledge of a tenant’s unsafe practices and fail to act, you may be liable for patient injuries.
- Negligent selection/retention: If you knew or should have known tenant was unqualified, unlicensed, or dangerous, you may be liable for negligently renting to them or failing to evict after discovering violations.
- Vicarious liability (limited): Generally landlords are not vicariously liable for tenant malpractice unless landlord exercises control over tenant’s clinical operations (which triggers CPOM issues).
- Regulatory exposure: Medical Board investigations of tenant violations often expand to include landlord—especially if Board suspects landlord facilitated or profited from unlicensed practice.
Common Patient Safety Issues in Medical Co-Working
| Safety Issue | Landlord Liability Risk | Prevention Strategy |
|---|---|---|
| RN performing procedures beyond scope | High—if landlord knew RN lacked physician supervision and did nothing, liable for patient injuries | Require proof of physician supervision agreements; inspect for compliance; terminate if violations found |
| Unsanitary conditions / infection risk | Moderate—landlord liable if failure to maintain premises (e.g., mold, vermin, unsanitary common areas) contributes to infections | Regular facility inspections; require tenant to maintain infection control; OSHA compliance audits |
| Lack of emergency equipment / protocols | Low—generally tenant’s responsibility, but landlord may be liable if emergency access blocked or facility lacks required exits | Verify tenant has AED, oxygen, emergency medications; ensure clear egress paths; test fire alarms |
| Controlled substance diversion | Moderate—DEA may investigate facility; landlord liable if aware of illegal drug activity and did not report or evict | Require tenants with DEA licenses to provide copies; report suspicious activity (e.g., high volume of opioid prescriptions) |
| Unlicensed practitioners | High—landlord may face “aiding and abetting” claims if knew tenant was unlicensed and continued to rent space | Verify all tenant licenses via state boards; surprise inspections to confirm personnel match licensed individuals |
The “Knowledge” Standard for Landlord Liability
Landlords are generally not liable for tenant malpractice unless they have actual knowledge of unsafe conditions and fail to act reasonably to prevent harm. Key concepts:
Actual Knowledge: You must have real awareness of the problem—not just constructive knowledge (“should have known”). Sources of actual knowledge:
- Direct observation during inspections
- Written notice from regulatory agencies (Medical Board, OSHA)
- Complaints from patients, employees, or other tenants
- Admission by tenant (e.g., “We don’t have a supervising physician right now”)
Reasonable Action: Once you have knowledge, you must take reasonable steps to prevent harm:
- Demand tenant cure violations immediately
- Prohibit tenant from operating until compliance achieved
- Evict tenant if violations not cured
- In extreme cases (imminent patient harm), notify regulators or emergency services
Scope-of-Practice Rules for RN, NP, and PA in California
Registered Nurse (RN) Scope of Practice
Authorized Activities (B&P §§ 2725-2727):
- Patient assessment and observation
- Administering medications prescribed by physician
- Wound care and dressing changes
- IV insertion and infusion monitoring (with proper training)
- Patient education and discharge planning
Medical Functions Requiring Physician Supervision (CCR § 1379):
RNs may perform the following only under written standardized procedures created and supervised by a physician:
- Botox injections, dermal fillers, sclerotherapy
- Laser treatments (hair removal, skin resurfacing, tattoo removal)
- Microneedling, chemical peels
- IV vitamin therapy, hydration treatments
- PRP (platelet-rich plasma) procedures
Prohibited Activities (cannot do even with supervision):
- Diagnosing medical conditions
- Prescribing medications (except in very limited certified settings with furnishing authority)
- Performing surgery or invasive procedures beyond scope
- Making independent medical judgments without physician consultation
Nurse Practitioner (NP) Scope of Practice
Authorized Activities (CCR §§ 1399.540-.546):
- Diagnosing and treating patients within their specialty (e.g., family practice, women’s health)
- Ordering diagnostic tests and interpreting results
- Prescribing medications (with furnishing authority and DEA if controlled substances)
- Performing procedures authorized in standardized procedures
Supervision Requirement: NPs must practice under standardized procedures developed in collaboration with a physician. Standardized procedures must specify:
- Patient populations NP may treat
- Conditions and procedures authorized
- Consultation and referral requirements
- Chart review and quality assurance protocols
Aesthetic Procedures: NPs can perform Botox, fillers, and lasers IF authorized in standardized procedures. Many NPs exceed their scope by offering procedures not listed in their standardized procedures or by operating without any standardized procedures.
Physician Assistant (PA) Scope of Practice
Authorized Activities (CCR §§ 1399.530-.540):
- Medical services delegated by supervising physician
- History and physical exams
- Ordering tests; interpreting results under physician guidance
- Prescribing medications (with physician delegation and DEA if controlled substances)
- Assisting in surgery; performing delegated surgical tasks
Supervision Requirement: PAs must have a written delegation of services agreement with a supervising physician specifying:
- Scope of delegated medical services
- Practice setting and locations
- Supervision requirements (on-site, availability, chart review)
- Physician’s responsibility to review and countersign charts
Red Flag: PA performing aesthetic injections in a med-spa setting without a delegation agreement or without supervising physician ever visiting the facility.
Unlicensed Personnel: Estheticians & Medical Assistants
Esthetician Scope (B&P §§ 7316-7320):
- Permitted: Facials, makeup, hair removal (waxing, threading—not laser), superficial skin care
- Prohibited: Any procedure penetrating below epidermis; injections (including Botox); prescription products; lasers (medical devices)
Medical Assistant Scope (B&P §§ 2069-2070):
- Permitted: Administrative tasks; taking vitals; assisting physician during procedures; administering injections under physician’s direct supervision
- Prohibited: Independent clinical judgments; performing procedures without physician present; laser operation
- Tenant advertises “RN injector” with no mention of supervising physician
- Business cards show esthetician or medical assistant performing “cosmetic injections”
- Website lists procedures (Botox, fillers, lasers) but no physician on staff
- Tenant refuses to provide copies of standardized procedures or delegation agreements when requested
- Staff you observe on-site do not match the licensed professionals listed on tenant’s documentation
Recognizing Red Flags & Scope-of-Practice Violations
Red Flag #1: No Physician On-Site or Rarely Visits
Observation: You’ve leased space to a med-spa that advertises Botox, fillers, and laser services. Over 6 months, you’ve never seen a physician enter the suite. RN staff arrive daily and perform treatments.
Legal Issue: For RNs to perform medical procedures, California requires physician supervision, which typically means the physician must be:
- Available for consultation (phone or in-person)
- Conducting periodic on-site visits to observe procedures and review charts
- Providing training and competency verification
If the physician never visits, “supervision” is likely a sham. The RN is effectively practicing medicine without a license.
Your Action: Request copies of the supervising physician’s visit logs, chart review documentation, and standardized procedures. If tenant cannot produce these, demand they cease operations until compliant.
Red Flag #2: High Volume of Patients with No Physician
Observation: Your tenant’s IV therapy lounge has 10-15 patients daily, all receiving IV infusions. You’ve observed only one RN on-site, with no physician ever present.
Legal Issue: High patient volume with minimal physician oversight suggests inadequate supervision. Standardized procedures for IV therapy typically require physician availability during treatment hours and chart review of a percentage of patients (e.g., 10% monthly).
If RN is treating 300 patients/month with physician reviewing 0% of charts, supervision is non-existent.
Your Action: Demand proof of physician chart review (e.g., signed chart review logs showing dates and number of charts reviewed). If tenant cannot provide, this is a material lease breach.
Red Flag #3: Emergency Equipment Missing or Expired
Observation: During a walk-through, you notice:
- No AED (automated external defibrillator) visible
- No emergency medications (epinephrine, antihistamines) in treatment rooms
- No oxygen tank or ambu bag
- Fire extinguishers expired or missing
Legal Issue: Facilities performing aesthetic injections (Botox, fillers) must have emergency equipment for allergic reactions, anaphylaxis, and cardiovascular events. OSHA and standardized procedures typically require:
- AED (8 CCR § 6101.8 in some settings)
- Emergency medications (epinephrine auto-injectors, antihistamines)
- Oxygen and delivery system
- Emergency protocols posted
Your Action: This is a life-threatening deficiency. Demand immediate correction (within 48 hours) or prohibit patient treatments until equipment is in place.
Red Flag #4: Unlicensed Staff Performing Medical Procedures
Observation: Tenant’s website lists “Jane Doe, Lead Injector” with no credentials (RN, NP, PA, MD). You Google Jane Doe and find she’s an esthetician, not a nurse or physician.
Legal Issue: Estheticians cannot perform injections (Botox, fillers) or operate medical lasers. This is unlicensed practice of medicine (B&P § 2052) and is a crime.
Your Action: Verify licenses of all clinical staff via state board websites (Medical Board, Board of Registered Nursing, Physician Assistant Board, Board of Barbering and Cosmetology). If tenant employs unlicensed persons to perform medical procedures, this is grounds for immediate lease termination and potentially a duty to report to Medical Board.
Red Flag #5: Controlled Substances Without DEA License
Observation: Tenant advertises “weight loss clinic” with prescriptions for phentermine (Schedule IV controlled substance). Tenant’s NP does not have a DEA registration.
Legal Issue: Prescribing controlled substances requires a valid DEA registration (federal) in addition to state prescribing authority. Prescribing without DEA registration is a federal crime (21 U.S.C. § 841) and exposes your facility to DEA investigation and asset forfeiture.
Your Action: Verify tenant’s DEA registration at http://www.deadiversion.usdoj.gov (limited public search). If no DEA registration, prohibit controlled substance prescribing and consider reporting to DEA.
Red Flag #6: “Wholesale” Medical Services to Other Tenants
Observation: One tenant (licensed physician) appears to be providing “medical director services” to multiple other tenants (estheticians, wellness coaches) in your co-working space. The physician charges a flat monthly fee and signs charts but never actually supervises procedures.
Legal Issue: This is likely Corporate Practice of Medicine (CPOM) violation and/or aiding and abetting unlicensed practice (B&P § 2053). It also exposes you (landlord) to claims that you’re facilitating CPOM by providing the space for this arrangement.
Your Action: Prohibit “medical director for hire” arrangements where physician does not actually supervise. Require each medical tenant to have their own bona fide supervision agreement with documented oversight.
- No emergency equipment: Patient could die from anaphylaxis if no epinephrine available—demand correction within 24 hours
- Bloodborne pathogen exposure: Overfilled sharps, blood in trash—immediate OSHA risk; prohibit operations until corrected
- Unlicensed surgery: If tenant performing surgical procedures without proper licensure, shut down immediately and call Medical Board
- Controlled substance diversion: If you suspect illegal drug sales, report to DEA and local police immediately
Reporting Obligations for Landlords
Do Landlords Have a Duty to Report?
California law generally does not require landlords to report tenant scope-of-practice violations to regulatory agencies. However, several doctrines create quasi-duties:
1. Premises Liability Duty to Prevent Harm: If you have actual knowledge of tenant’s dangerous practices and foresee patient harm, you have a tort duty to take reasonable steps to prevent harm (Civ. Code § 1714). This may include reporting to regulators if eviction alone is insufficient to stop ongoing harm (e.g., tenant continues operating during unlawful detainer proceedings).
2. “Aiding and Abetting” Exposure: If you knowingly provide space for unlicensed medical practice and take no action, you could face claims of aiding and abetting (B&P § 2053). Reporting to authorities may be necessary to avoid criminal liability.
3. OSHA Violations: Cal-OSHA requires employers to report serious injuries and fatalities. If you’re aware of OSHA violations (bloodborne pathogen risks) and an employee or patient is injured, your failure to report or correct could trigger OSHA penalties against you as facility owner.
4. Controlled Substance Diversion: Federal law imposes reporting duties on persons with knowledge of controlled substance diversion or illegal drug activity. Failure to report can result in DEA investigation and potential accessory-after-the-fact charges.
When You Should Report (Risk-Based Analysis)
| Scenario | Report? | To Whom? | Why? |
|---|---|---|---|
| RN performing Botox with no physician supervision; no patient injuries yet | Optional (after demand letter) | Medical Board; Board of Registered Nursing | Unlicensed practice; reporting protects you from “aiding” liability if tenant continues |
| Patient injured due to tenant’s scope violation; patient threatens to sue landlord | Yes | Medical Board; your insurer | Demonstrates you took reasonable action upon learning of violations; supports premises liability defense |
| Tenant refuses to correct OSHA violations (sharps, PPE); continues operating | Yes | Cal-OSHA | OSHA can issue citations and shut down tenant; protects you from “controlling employer” liability |
| Esthetician performing surgical procedures (deep laser, fat removal) without license | Yes (urgent) | Medical Board; possibly DA | Extreme patient safety risk; potential criminal activity; landlord must act to avoid facilitation claims |
| Tenant prescribing controlled substances without DEA registration | Yes | DEA; Medical Board | Federal crime; landlord at risk of DEA asset forfeiture if facility used for illegal drug activity |
| Tenant misrepresenting physician credentials (false advertising) but no patient harm | Optional | Medical Board; AG (false advertising) | Business fraud; reporting is discretionary but may support lease termination |
How to Report (Framing to Avoid Extortion Claims)
When reporting tenant violations to regulators, frame your report carefully to avoid extortion or interference claims:
- “We are the landlord for [Tenant Name] and have observed possible scope-of-practice violations. We are reporting out of concern for patient safety and to fulfill our legal obligations as facility operators.”
- “We demanded tenant correct violations. Tenant refused. We are reporting to prevent ongoing patient harm.”
- “We have terminated the lease due to unlicensed practice. We are notifying the Board to ensure tenant does not continue operating at another location.”
- Do NOT say: “We’re reporting because tenant owes us rent”
- Do NOT say: “If tenant pays the settlement, we won’t report”
- Do NOT file reports before giving tenant opportunity to cure (unless imminent patient harm)
Reports must be motivated by patient safety, not financial disputes. Tenant can argue your report was retaliatory or extortionate if it appears tied to lease negotiations.
Reporting Procedures by Agency
Medical Board of California:
- Online complaint: http://www.mbc.ca.gov → File a Complaint
- Phone: (800) 633-2322
- Provide: Facility address, tenant name, description of violations, evidence (photos, documents), your concern for patient safety
- Follow-up: Board will investigate; may subpoena you for documents/testimony
Board of Registered Nursing:
- Online complaint: http://www.rn.ca.gov → Enforcement → File a Complaint
- For RN scope violations, lack of standardized procedures
Cal-OSHA:
- Report serious injury/illness: Within 8 hours (800-963-9424)
- Non-emergency complaints: http://www.dir.ca.gov/dosh/complaint.htm
- Bloodborne pathogen violations, lack of PPE, sharps disposal issues
DEA (Drug Enforcement Administration):
- Report diversion: http://www.deadiversion.usdoj.gov → Report Suspicious Activity
- Phone: Local DEA field office (find via DEA website)
- Controlled substance prescribing without DEA license, suspicious volumes
Sample Demand Letters for Patient Safety Violations
Sample 1: Scope-of-Practice Violation (RN Exceeding Scope)
Date: [Current Date]
To: [Tenant Med-Spa Name]
[Suite Address]
From: [Landlord Name / Property Management]
[Address]
RE: NOTICE OF PATIENT SAFETY VIOLATIONS – DEMAND FOR IMMEDIATE CORRECTIVE ACTION
Dear [Tenant]:
This letter documents serious patient-safety concerns regarding your operations and demands immediate corrective action to bring your practice into compliance with California law.
Observations During Facility Inspection ([Date]):
- No physician on-site: Your business advertises Botox, dermal fillers, and laser treatments. During our inspection and multiple prior visits over the past 3 months, we have never observed a physician on-site.
- RN performing procedures independently: We observed RN staff administering injections to patients with no physician consultation or oversight visible.
- No emergency equipment: Treatment rooms lacked AED, epinephrine auto-injectors, oxygen, or other emergency medications required for managing allergic reactions or cardiovascular events.
- Inadequate standardized procedures: When we requested copies of your RN standardized procedures (as required by Lease Section [X]), you provided a one-page form that does not meet California Code of Regulations Title 16, § 1379 requirements.
Legal Violations:
- Business & Professions Code § 2052 (Unlicensed Practice): RNs performing medical procedures (Botox, fillers, lasers) without adequate physician supervision constitutes unlicensed practice of medicine.
- CCR Title 16, § 1379 (Standardized Procedures): RNs may perform medical functions only under comprehensive written standardized procedures that include physician supervision, training, competency verification, and emergency protocols. Your one-page form is non-compliant.
- Patient Safety: Lack of emergency equipment creates imminent risk of patient death if anaphylaxis or adverse reaction occurs.
Landlord Liability Exposure: Your violations expose our facility to premises liability under Civil Code § 1714. If patients are injured due to inadequate supervision or lack of emergency equipment, we may be held liable for knowingly permitting unsafe medical practice on our premises.
IMMEDIATE CORRECTIVE ACTIONS REQUIRED (within 72 hours):
- Cease all medical procedures (Botox, fillers, lasers) until compliant physician supervision is in place.
- Obtain compliant standardized procedures drafted by a healthcare compliance attorney or consultant, reviewed and signed by your supervising physician, addressing all CCR § 1379 requirements.
- Install emergency equipment in all treatment rooms: AED, epinephrine auto-injectors (EpiPens), antihistamines (diphenhydramine), oxygen tank with delivery masks, and emergency protocols posted.
- Provide proof of physician supervision: Written schedule showing physician’s on-site visit frequency, chart review logs, and contact information for physician availability during treatment hours.
- Submit written certification that all RN staff have been trained on new standardized procedures and emergency protocols, with competency verification signed by supervising physician.
Consequences of Non-Compliance: If you fail to complete these actions within 72 hours, we will:
- Prohibit patient treatments in your suite until compliance is achieved
- Serve Three-Day Notice to Cure or Quit for material lease breach
- Evaluate our duty to report patient-safety concerns to the Medical Board of California and Board of Registered Nursing
- Pursue indemnity and contribution from you for any premises liability claims arising from your operations
This is an urgent patient-safety matter. Contact me immediately at [phone/email] to confirm corrective actions.
Sincerely,
[Your Name]
[Title]
Enclosures: Inspection photos (dated [Date]); CCR Title 16, § 1379 (Standardized Procedures requirement); Lease Section [X]
Sample 2: Unlicensed Practitioner (Esthetician Performing Medical Procedures)
Date: [Current Date]
To: [Tenant Business Name]
[Suite Address]
From: [Landlord]
[Address]
RE: NOTICE OF UNLICENSED MEDICAL PRACTICE – IMMEDIATE CESSATION REQUIRED
Dear [Tenant]:
We have discovered that your business is engaging in unlicensed practice of medicine in violation of California law. You must immediately cease all medical procedures or face lease termination and regulatory reporting.
Discovery of Unlicensed Practice: Your business website and marketing materials advertise “Jane Doe, Lead Injector” performing Botox and dermal filler treatments. We verified Jane Doe’s credentials via the Board of Barbering and Cosmetology website and confirmed she holds an esthetician license only—she is not a registered nurse, nurse practitioner, physician assistant, or physician.
California law (Business & Professions Code §§ 7316-7320) strictly prohibits estheticians from:
- Performing injections of any kind, including Botox and dermal fillers
- Operating medical lasers
- Performing any procedure that penetrates below the epidermis
Ms. Doe’s performance of Botox injections constitutes unlicensed practice of medicine under B&P § 2052, which is a crime punishable by imprisonment and fines.
Landlord Liability: By leasing space for unlicensed medical practice, we face:
- Premises liability for patient injuries caused by unlicensed practitioner
- Potential “aiding and abetting” liability under B&P § 2053 if we continue to provide space after discovering the violation
- Medical Board investigation and subpoenas
- Property value diminution due to association with illegal activity
IMMEDIATE DEMANDS:
- Cease all injections and medical procedures immediately. Ms. Doe and any other unlicensed staff must not perform Botox, fillers, lasers, or any medical treatments.
- Provide proof of licensure for all clinical staff within 24 hours. We require copies of current RN, NP, PA, or MD licenses from the appropriate California licensing boards.
- Remove false advertising from website, social media, and marketing materials representing that unlicensed persons perform medical procedures.
If You Do Not Comply Within 24 Hours:
- We will serve a Three-Day Notice to Quit (no opportunity to cure—unlicensed practice is a criminal violation that cannot be cured short of ceasing operations)
- We will file a complaint with the Medical Board of California reporting unlicensed practice at our facility
- We will notify the District Attorney’s office of suspected criminal violations (B&P § 2052)
- We will change locks and prohibit access to premises pursuant to our right to abate criminal nuisances
This is a non-negotiable patient-safety and legal compliance issue. Unlicensed practice of medicine exposes patients to serious harm and exposes us to catastrophic liability. We will not tolerate it.
Confirm cessation of medical procedures in writing within 24 hours to the address above.
Sincerely,
[Your Name]
[Title]
Enclosures: Esthetician license verification (Ms. Doe); screenshot of website advertising “Jane Doe, Lead Injector”; B&P §§ 2052, 7316-7320
Attorney Services for Patient Safety & Scope-of-Practice Disputes
Patient safety and scope-of-practice violations require urgent legal action to protect landlords from premises liability, regulatory enforcement, and criminal exposure. These disputes involve complex healthcare licensing law, tort duty analysis, and regulatory reporting strategy—areas where general landlord-tenant attorneys lack expertise.
How I Can Help
I represent California landlords, medical facility owners, and property managers in patient-safety disputes involving med-spa tenants, IV therapy clinics, and aesthetic providers. My practice focuses on rapid intervention, regulatory coordination, and premises liability defense.
- Patient safety audits: I inspect tenant operations, review standardized procedures, verify licenses, and identify scope-of-practice violations and OSHA risks
- Demand letter strategy: I draft demands that document violations, protect you from “aiding” liability, and establish a record for premises liability defense—without creating extortion exposure
- Emergency injunctions: I obtain court orders halting unlicensed practice when tenant refuses to cease operations
- Regulatory reporting guidance: I advise on when and how to report to Medical Board, OSHA, DEA, or law enforcement—and draft reports that protect your interests
- Unlawful detainer (eviction): I prosecute evictions for scope violations, unlicensed practice, and patient safety breaches
- Premises liability defense: I defend landlords in patient injury lawsuits, proving tenant’s independent contractor status and landlord’s reasonable conduct
- Insurance coordination: I work with your GL carrier to ensure tenant’s malpractice insurer provides defense and indemnity for patient claims
Why Specialized Counsel Matters
Patient safety disputes are time-sensitive and require healthcare regulatory expertise:
- Duty analysis: Determining whether you have actual knowledge triggering a duty to act
- Scope-of-practice rules: Understanding RN/NP/PA scope, supervision requirements, and standardized procedure compliance
- Regulatory leverage: Knowing when to threaten reporting (lawful) vs. when it becomes extortion (unlawful)
- Emergency procedures: Acting within hours when patient harm is imminent—obtaining TROs, coordinating with emergency services, shutting down operations
- Premises liability defense strategy: Building a record that demonstrates you took reasonable action upon learning of violations
Submit Your Case for Review
Patient safety violations create liability that extends beyond typical landlord-tenant disputes. If your medical tenant is operating outside their scope, lacking proper supervision, or engaging in unlicensed practice, every day you wait increases your exposure.
Send me your lease agreement, tenant’s license documentation (or lack thereof), and photos or observations of violations. I’ll assess your duty to act, liability exposure, and immediate steps to protect your facility.
Flat-fee patient safety audits ($2,500-$5,000). Urgent injunctions on hourly basis (expedited). Eviction litigation flat-fee or hourly. Premises liability defense typically through your insurance carrier.