⚕️ Medical Director & Supervision Failures – Demand Letters

Legal Framework for Medical Supervision in California

Business & Professions Code – Unlicensed Practice & Delegation

B&P § 2052 – Unlicensed Practice of Medicine: It is a crime and civil violation for any person not licensed as a physician to practice medicine or surgery, or to hold themselves out as able to do so. "Practice of medicine" includes diagnosing, treating, prescribing, and performing procedures requiring medical training.

B&P § 2053 – Aiding & Abetting Unlicensed Practice: Physicians who aid or abet unlicensed practice (e.g., by lending their name/credentials without supervision) face license discipline and criminal penalties.

B&P §§ 2070-2071 – Physician Responsibility for Supervision: Physicians who delegate medical tasks to RNs, NPs, or PAs remain legally responsible for supervising those individuals. Failure to supervise = license discipline.

B&P § 650 – Division of Fees / Kickbacks: Paying or receiving compensation for patient referrals is illegal in California. Med-spa arrangements where physicians receive fees for "lending their name" without actual supervision violate § 650.

Registered Nurse (RN) Supervision Requirements

CCR Title 16, § 1379 – Standardized Procedures for RNs: RNs may perform medical functions (e.g., injections, IV therapy, laser treatments) only under written "standardized procedures" developed by a physician and nurse, approved by the facility, and documented in policies. The physician must provide supervision, training, and periodic evaluation.

B&P §§ 2725-2727 – Scope of RN Practice: RNs may not diagnose, prescribe medications (except under specific furnishing protocols with additional certification), or perform procedures outside standardized procedures.

Nurse Practitioner (NP) Supervision Requirements

CCR Title 16, §§ 1399.540-1399.546 – NP Standardized Procedures & Furnishing: NPs have broader scope than RNs but still require physician collaboration. NPs must operate under "standardized procedures" approved by a physician and facility. NPs with furnishing authority may prescribe medications within their scope, but the standardized procedures must define what conditions they may treat.

Supervision vs. Collaboration: California uses "standardized procedures" rather than "supervision" for NPs, but the physician retains ultimate responsibility. If an NP performs aesthetic procedures (Botox, fillers), the standardized procedures must authorize those specific tasks.

Physician Assistant (PA) Supervision Requirements

CCR Title 16, §§ 1399.530-1399.540 – PA Delegation & Supervision Agreements: PAs work under a written "delegation agreement" with a supervising physician. The agreement must specify:

• Scope of delegated tasks (e.g., aesthetic injections, laser treatments)
• Setting/location of practice
• Supervision requirements (on-site, availability, chart review frequency)
• Physician's responsibility to review and countersign charts

If the supervising physician terminates the agreement, the PA must cease practice until a new supervising physician is secured.

Misuse of Physician Name or Credentials

B&P § 2261 – False Statements Regarding Medical License: Making false statements about holding a medical license or about the status of a license is a misdemeanor.

B&P § 2262 – False Name or Impersonation: Using another person's name or credentials to practice medicine or represent oneself as qualified is a misdemeanor.

B&P § 17500 – False Advertising: Advertising a supervising physician who is no longer affiliated, or misrepresenting the qualifications of practitioners, constitutes false advertising and is actionable by the Attorney General, district attorney, or private parties.

Regulatory Bodies & Enforcement

Common Medical Supervision Violations

Scenario 1: Misrepresentation of Supervising Physician After Termination

Fact Pattern: Your med-spa tenant prominently displays "Dr. Jane Smith, Medical Director" on their website, intake forms, and signage. You discover Dr. Smith terminated her relationship with the tenant six months ago. The tenant's RNs continue performing Botox and filler injections, representing that Dr. Smith supervises their work.

Legal Issues:

• Unlicensed practice (B&P § 2052): RNs performing injections without a supervising physician's standardized procedures = unlicensed practice
• False advertising (B&P § 17500): Advertising Dr. Smith as medical director when she's not = material misrepresentation
• Unauthorized use of physician identity (B&P § 2261): Using Dr. Smith's name/credentials without authorization may violate identity statutes
• Contract breach: If your lease requires "proof of lawful supervision," tenant's misrepresentation is a material breach

Evidence to Collect:

• Screenshots of website/social media showing Dr. Smith as medical director
• Copies of intake forms, consent forms bearing Dr. Smith's name/signature stamp
• Written confirmation from Dr. Smith that she terminated supervision (email, letter, declaration)
• Lease agreement provisions requiring lawful licensing and supervision
• Medical Board license verification showing Dr. Smith not associated with tenant's business entity

Scenario 2: No Standardized Procedures or Delegation Agreements

Fact Pattern: Your tenant operates an IV therapy lounge. RNs are inserting IVs and administering vitamin infusions. You request copies of the required standardized procedures and supervising physician documentation. Tenant provides a one-page form with a physician's signature but no detailed protocols, training requirements, or emergency procedures.

Legal Issues:

• CCR Title 16, § 1379 violation: Standardized procedures must be comprehensive, facility-specific, and include training, competency verification, and emergency protocols. A one-page form is facially inadequate.
• Patient safety risk: RNs performing IV therapy without proper protocols create infection risk, adverse reaction risk, and liability exposure for facility owner
• Premises liability: If patient is harmed, landlord may be liable for knowingly permitting inadequate supervision

Compliance Requirements: Proper standardized procedures must include:

1. Specific tasks authorized (e.g., "insertion of peripheral IV for vitamin C infusion")
2. Required RN training and competency verification (e.g., "completion of IV insertion certification; annual competency review")
3. Physician availability requirements (e.g., "supervising physician available by phone during all treatment hours")
4. Documentation requirements (e.g., "RN must document IV site, infusion rate, patient response")
5. Emergency protocols (e.g., "If patient exhibits allergic reaction, RN will discontinue infusion, administer oxygen, call 911, notify physician")
6. Chart review schedule (e.g., "physician will review 10% of charts monthly")

Scenario 3: Corporate Practice of Medicine Violation

Fact Pattern: Your tenant is a limited liability company owned by a non-physician esthetician. The LLC employs a physician as "medical director," but the esthetician owner makes all business decisions, sets treatment protocols, determines pricing, and hires/fires clinical staff. The physician is paid a flat monthly fee and rarely visits the facility.

Legal Issues:

• CPOM violation (B&P § 2400): Non-physicians cannot own or control medical practices. The arrangement described is a sham—the esthetician exercises de facto control over medical decision-making.
• Lease breach: If your lease requires tenant to "operate in compliance with all laws," CPOM violation is a material breach
• Medical Board enforcement: MBC aggressively prosecutes CPOM violations, particularly in the med-spa context. Recent enforcement actions have resulted in physician license suspensions and practice shutdowns.

Red Flags for CPOM:

• Physician paid flat fee regardless of patient volume (suggests physician has no economic stake/control)
• Non-physician owner makes clinical protocol decisions
• Physician rarely on-site; "rubber stamp" signature on forms
• Physician cannot terminate relationship without owner's consent
• Marketing materials emphasize owner's brand, not physician's role

Scenario 4: Scope-of-Practice Violations

Fact Pattern: Your tenant's RNs are performing microneedling with platelet-rich plasma (PRP), a procedure that involves drawing blood, centrifuging to concentrate platelets, and injecting PRP into the skin. There is no physician on-site, and the "supervising physician" visits once per quarter.

Legal Issues:

• Unlicensed practice: PRP procedures involve venipuncture, blood processing, and injection of a blood product—medical procedures requiring physician oversight. Quarterly visits are insufficient supervision.
• CCR Title 16, § 1379: Even if standardized procedures exist, the level of supervision must be "appropriate to the procedure's risk." PRP carries infection, blood-borne pathogen, and adverse reaction risks—quarterly oversight is facially inadequate.
• OSHA/Cal-OSHA: Blood handling triggers Bloodborne Pathogens Standard (8 CCR § 5193). Facility owner may be liable for tenant's OSHA violations.

Sample Demand Letters for Supervision Failures

Regulatory Leverage: Reporting vs. Extortion

The Extortion Problem in Medical Demand Letters

California Penal Code § 518 defines extortion as obtaining property or compelling someone to act through threats. When drafting demand letters for medical supervision failures, the line between lawful leverage and unlawful extortion is razor-thin.

Permissible vs. Prohibited Language in Demand Letters

Key Principles for Compliant Demand Letters

1. Factual Statements Are Safe: Describing what violations you've observed and citing statutes is permissible. Example: "Your RNs are performing Botox without a supervising physician, in violation of B&P § 2052."

2. Legal Rights Statements Are Safe: Stating that you have a right or obligation to report is permissible. Example: "As facility operators, we may have a duty to report patient-safety risks to regulators."

3. Conditional Statements Are Risky: "If X, then Y" phrasing can be extortion if it links payment to silence. Safe: "If violations continue, we will report." Unsafe: "If you pay us, we won't report."

4. Focus on Compliance, Not Payment: Frame demands around corrective actions (cease operations, obtain supervision, provide documentation) rather than money. If damages are owed, present them as a separate calculation, not as "hush money."

5. Never Guarantee Silence: Do not promise to refrain from reporting in exchange for payment. Even implied agreements ("We'll resolve this privately if you cooperate financially") can be extortion.

When to Report to Regulatory Agencies

How to Report to California Regulatory Agencies

Medical Board of California (MBC):

• Online complaint: www.mbc.ca.gov → File a Complaint
• Phone: (800) 633-2322
• Provide: Facility address, tenant name, physician name (if misused), description of unlicensed practice, dates, evidence (photos, documents, patient statements if available)
• MBC investigates unlicensed practice, CPOM violations, and physician supervision failures

Board of Registered Nursing (BRN):

• Online complaint: www.rn.ca.gov → Enforcement → File a Complaint
• BRN investigates RN scope violations, standardized procedure failures, and unprofessional conduct

Attorney General's Office (for false advertising):

• File complaint regarding B&P § 17500 violations (false advertising of medical director)
• AG has civil enforcement authority and can seek injunctions, penalties, and restitution

Attorney Services for Medical Supervision Disputes

Medical supervision failures create complex legal issues at the intersection of healthcare licensing, commercial landlord-tenant law, premises liability, and regulatory enforcement. Whether you're a landlord, medical facility operator, or practice owner dealing with a tenant's unlicensed practice or misrepresentation of physicians, these disputes require careful legal navigation to protect your interests without triggering extortion claims.

How I Can Help

I represent California landlords, medical facilities, and practice owners in disputes involving med-spa tenants, aesthetic clinics, IV therapy lounges, and other healthcare co-working arrangements. My practice focuses on compliance enforcement, lease breach litigation, regulatory reporting strategy, and premises liability defense.

Why Legal Representation Matters

Med-spa and aesthetic clinic tenants often have sophisticated legal teams and argue that supervision failures are "technical violations" or that landlords lack standing to enforce healthcare regulations. An attorney levels the playing field by:

• Documenting violations: Gathering evidence of unlicensed practice, misrepresentation, and patient safety risks in admissible formats
• Avoiding extortion traps: Drafting demands that assert legal rights without creating Penal Code § 518 exposure
• Navigating CPOM: Analyzing whether tenant arrangements violate Corporate Practice of Medicine doctrine—a complex area requiring healthcare law expertise
• Coordinating with regulators: Presenting information to Medical Board, BRN, or AG in ways that trigger enforcement while protecting client confidentiality
• Maximizing damages: Pursuing not just unpaid rent, but also indemnity for premises liability exposure, investigation costs, and reputational harm

Common Client Scenarios