Performance audit and sunset review, Board of Chiropractic Examiners

              Debra K. Davenport
Auditor General
Performance Audit and Sunset Review
Board of Chiropractic
Examiners
Performance Audit Division
June • 2010
REPORT NO. 10-06
A REPORT
TO THE
ARIZONA LEGISLATURE
The is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting services
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Audit Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
Melanie M. Chesney, Director
Dot Reinhard, Manager and Contact Person
Emily Chipman, Team Leader
Sebrina Beckstrom
Representative Judy Burges, Chair Senator Thayer Verschoor, Vice Chair
Representative Tom Boone Senator John Huppenthal
Representative Cloves Campbell, Jr. Senator Richard Miranda
Representative Rich Crandall Senator Rebecca Rios
Representative Kyrsten Sinema Senator Bob Burns (ex efficio)
Representative Kirk Adams (ex efficio)
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
MELANIE M. CHESNEY
DEPUTY AUDITOR GENERAL
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
June 30, 2010
Members of the Arizona Legislature
The Honorable Janice K. Brewer, Governor
Patrice Pritzl, Executive Director
Board of Chiropractic Examiners
Transmitted herewith is a report of the Auditor General, a Performance Audit and Sunset
Review of the Board of Chiropractic Examiners. This report is in response to a November
3, 2009, resolution of the Joint Legislative Audit Committee. The performance audit was
conducted as part of the sunset review process prescribed in Arizona Revised Statutes
§41-2951 et seq. I am also transmitting within this report a copy of the Report Highlights for
this audit to provide a quick summary for your convenience.
As outlined in its response, the Board of Chiropractic Examiners (Board) agrees with most
of the findings and plans to implement or implement in a different manner all of the
recommendations. We have attached a brief reply to the Board’s response to address
some statements in the response.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on July 1, 2010.
Sincerely,
Debbie Davenport
Auditor General
Attachment
cc: Members, Board of Chiropractic Examiners
Established in 1921, the Board is
responsible for regulating chiropractors in
the State. The Board does this by issuing
licenses, including
certifications in
acupuncture and
physiotherapy. The
Board also receives
and investigates
complaints. When
necessary, the
Board disciplines
licensees who
violate statutes.
Opening complaints—Chiropractic
statutes indicate there are two key
provisions for opening complaints:
whether the complaint involves a licensee,
and whether there is a potential statute
violation.
To help open new complaint
investigations, the Board adopted a
complaint-opening policy in February
2010. The policy provides that complaints
will be opened only:
 When they fall within the Board’s
jurisdiction;
 When there is sufficient information; and
 After review by the Board when the
Executive Director cannot determine
whether it is appropriate to open a
complaint.
The guidance is a step in the right
direction, but it should be more specific.
For example, the policy does not establish
that, according to statute, a complaint can
be opened only if it involves the actions of
a licensed chiropractor. The policy should
provide staff with greater direction on
actions to take if a complaint does not
2010
June • Report No. 10 - 06
Board of Chiropractic
Examiners
Our Conclusion
The Board of Chiropractic
Examiners (Board) should
improve four key aspects
of its complaint-handling
process. (1) It should
ensure that board and staff
decisions about whether to
open a complaint are
consistent with statutory
authority by enhancing its
complaint-opening policy
to provide additional
guidance. (2) It should,
where possible, limit its
subpoenas to records
directly related to the
nature of the complaints it
is investigating. (3) It
should not review a
licensee’s complaint or
disciplinary history until
after the complaint is
adjudicated to avoid
prejudicing its review. (4) It
should consider
establishing disciplinary
guidelines to help ensure
that its disciplinary actions
are consistent. Finally, the
Board should seek a
statutory change clarifying
how it can use advisory
letters.
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
Key complaint-handling processes need
improvement
involve a licensed chiropractor, such as
what information staff should gather so the
Board can seek injunctive relief and how
staff should distinguish that the complaint
involves a nonjurisdictional issue.
Investigating complaints—When
investigating complaints, the Board
generally subpoenas all of a patient’s
records and medical information, without
regard to the nature of the allegations in
the complaint. However, statute provides
that the Board should subpoena only
information that is relevant to the
investigation. In 3 of the 42 complaints we
reviewed, the Board subpoenaed more
records or information than necessary.
One of these involved the chiropractor
billing a patient $11 more than the co-pay.
In that matter, the Board subpoenaed all
the patient’s records, including health
history, treatment plans, and x-rays.
Requesting irrelevant information causes
the chiropractor extra time to assemble
and copy the records, and the board staff
to review the records. It also may cause a
perception that the Board is searching for
statute or rule violations in addition to
those identified in a complaint.
Where possible, the Board should limit its
subpoena to the minimum amount and
type of information needed to address the
complaint allegations. Some Arizona
health regulatory boards limit the amount
and type of records requested in
subpoenas. For example, Podiatry Board
staff indicated that complete medical
records are not always necessary, and
they are sometimes able to limit records
requests to records associated with a
particular event or situation.
Board of Chiropractic
Examiners
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
June 2010 • Report No. 10 - 06
page 2
A copy of the full report is available at:
www.azauditor.gov
Contact person:
Dot Reinhard (602) 553-0333
Adjudicating complaints—The Board generally
handles the adjudication process properly, but it
should change two procedures.
First, the Board should stop considering the
licensee’s complaint and disciplinary history prior to
deliberations about the allegations in the complaint.
Because the complaint and disciplinary history are
not relevant to whether the allegations of a new
complaint are or may be true, this information may
prejudice assessments of new complaints.
Second, the Board and its staff should not allow
complainants to withdraw complaints alleging
statute violations. Doing so prevents the Board from
fulfilling its mission to protect the public. Auditors
identified three cases where the Board and its staff
have inconsistently permitted complainants to
withdraw complaints. In two cases, complainants
were allowed to withdraw complaints even though
the complaints alleged potential violations and
board staff had conducted investigative work. For
example, in one complaint, board staff allowed the
complainant to withdraw a complaint involving billing
and record-keeping concerns even though its
investigation identified statute violations. The staff
presented information about the complaint at a
board meeting, and the Board voted to table the
complaint for 6 months. Despite the Board's vote,
when the complainant decided to withdraw the
complaint, a staff member sent a letter to the
licensee stating that the complaint was being
withdrawn. In contrast, another complainant was not
permitted to withdraw a complaint because it
alleged statutory violations.
Applying discipline—We identified one complaint
where the Board appeared to issue inconsistent
discipline to a licensed chiropractor. Specifically, a
licensee received a $250 civil penalty for failing to
obey an order to attend a board meeting, while four
other licensees who also ignored a board order to
attend a board meeting during the same time period
did not receive a civil penalty. The Board could help
ensure greater consistency in discipline by
developing disciplinary guidelines.
The Board should also seek a statutory change to
clarify how it can use advisory letters. Some Arizona
health regulatory boards can issue an advisory letter
when they have not found a statutory violation but
have a concern based on the circumstances.
Statute implies that the Board can issue an advisory
letter only if it finds a statutory violation of insufficient
seriousness to merit discipline.
Other concerns unfounded—During the audit,
members of the public contacted us, raising
concerns about conflicts of interest and the Board’s
documentation standards. However, we found board
members appear to appropriately recuse
themselves when they have a conflict of interest. In
addition, the Board’s form for assessing licensees’
recordkeeping is based on rules, policy, and clinical
competencies outlined by the nationally recognized
Council on Chiropractic Education (Council). Statute
allows the Board to hold licensees accountable to
recognized standards, and the Council’s
competencies appear to be the type of recognized
standard contemplated by statute.
Office of the Auditor General
TABLE OF CONTENTS
page i
continued
1
7
8
9
11
14
16
19
19
21
23
a-i
Introduction & Background
Finding 1: Board should improve key complaint-handling
processes
Complaint-opening policy should be enhanced
Board should limit subpoenas to records directly related to complaint
allegations
Board should change two important aspects of adjudication process
Board could enhance disciplinary process
Recommendations
Other Pertinent Information
Board’s financial status
Board efforts to address financial problems
Sunset Factors
Appendix A: Methodology
Agency Response
Auditor General Reply to Agency Response
State of Arizona
TABLE OF CONTENTS
concluded
Tables:
1 Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2004 through 2010
(Unaudited)
2 Statutory Guidance for Opening Complaints
3 Number of Initial and Renewal Chiropractic Licenses
Fiscal Years 2004 through 2009
(Unaudited)
4 File Review Results by Selection Method
Fiscal Years 2006 through 2009
Figures:
1 Example of Sanction Guidelines
page ii
5
8
21
a-ii
15
The Office of the Auditor General has conducted a performance audit and sunset
review of the Board of Chiropractic Examiners (Board) pursuant to a November 3,
2009, resolution of the Joint Legislative Audit Committee. This audit was conducted
as part of the sunset review process prescribed in Arizona Revised Statutes (A.R.S.)
§41-2951 et seq.
Board history and responsibilities
Laws 1921, Ch. 118, established the Board of Chiropractic Examiners, which is
responsible for regulating chiropractors in the State. The primary focus of chiropractic
therapy is the relationship between the functions of the spine and the nervous
system, and the effects of these relationships on health. According to A.R.S. §32-925,
the practice of chiropractic therapy includes physical examinations, the use of
diagnostic x-rays, and adjustment of the spine and joints.
The Board’s mission is: “protecting the health, welfare and safety of the public through
the enforcement of the laws governing the practice of chiropractic.” The Board has
various responsibilities that are designed to help accomplish its mission, including:
 Issuing and renewing licenses to ensure that persons practicing chiropractic
therapy possess required qualifications;
 Conducting investigations and hearings concerning unprofessional conduct or
other statutory violations;
 Disciplining violators; and
 Providing consumer information to the public.
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Licensure and certification requirements
One of the ways the Board regulates the profession is through its licensing and
renewal processes. A.R.S. §§32-921 and 32-922 contain the following requirements
to obtain a license to practice chiropractic:
 Graduate from an approved chiropractic college. The Council on Chiropractic
Education currently accredits 15 doctor of chiropractic programs in 18 locations
in North America;
 Pass all parts of the national exam;
 Pass the Board’s Arizona jurisprudence exam, which tests an applicant’s
knowledge of the Board’s statutes and rules, with a score of 75 percent or
higher; and
 Complete a criminal background check, be a person of good character and
reputation, and be physically and mentally able to practice chiropractic skillfully
and safely.
According to A.R.S. §32-922.01, the Board also allows for licensure by reciprocity to
individuals licensed in other states that have similar licensing requirements and
reciprocal privileges. Arizona has reciprocity with four states: Colorado, Louisiana,
Missouri, and New York. Additionally, A.R.S. §32-922.02 provides the Board authority
to issue licensees specialty certifications in acupuncture and physiotherapy.
According to the Board’s administrative rules, acupuncture is the stimulation of
certain points on or near the surface of the body to control and regulate the flow and
balance of energy in the body. According to the National Board of Chiropractic
Examiners, physiotherapy is the treatment or prevention of injuries and illnesses
utilizing physical agents such as heat, cold, ultrasound, or electrical stimulation.
These certifications, which remain active as long as the chiropractor’s license is
active, require the following:
 Acupuncture—Completion of at least 100 hours of study in acupuncture at an
accredited chiropractic college or post-graduate study with staff of an
accredited chiropractic college, and passage of the National Board of
Chiropractic Examiners exam in acupuncture with a score of 375 or higher.
 Physiotherapy—Completion of at least 120 hours of study in physiotherapy at an
accredited chiropractic college and passage of the National Board of
Chiropractic Examiners exam in physiotherapy with a score of 375 or higher.
State of Arizona
page 2
After an individual is licensed, A.R.S. §32-923
requires that his/her license be renewed
annually. See textbox for the fees associated with
the licensing process. Licensees are also
required by A.R.S. §32-931 to annually complete
12 hours of continuing education to maintain
their licenses. According to board information,
during fiscal year 2009, the Board issued 2,472
licenses (79 initial licenses and 2,393 renewed
licenses).1 The Board also issued 12
acupuncture certificates and 82 physiotherapy
certificates.2 Additionally, in fiscal year 2009, the
Board registered 454 chiropractic assistants and
approved 9 preceptorship training programs
through which a chiropractic student may
practice under the supervision of a licensed
chiropractor.
Complaint investigation and
resolution process
The Board also regulates the profession by investigating and adjudicating
complaints involving potential statutory violations and unprofessional conduct by
licensed chiropractors as authorized by statute. A.R.S. §32-924 specifies 28 actions
that are grounds for disciplinary action, including any conduct or practice that
constitutes a danger to the health, welfare, or safety of the patient or public; billing for
procedures not provided; advertising in a false or misleading manner; and practicing
chiropractic under a false or assumed name. Additionally, Arizona Administrative
Code (A.A.C.) R4-7-902 defines 37 specific actions that constitute unprofessional
conduct, such as knowingly making a false statement to the Board, failing to maintain
adequate patient records (such as examination findings), and failing to properly
supervise chiropractic assistants.
One of the initial steps in the complaint process is an investigation, which the Board’s
staff investigator generally conducts. A complaint investigation includes obtaining the
licensee’s response to the complaint. After some initial investigative steps, the Board
subpoenas the licensee to appear before the Board for questioning. The
complainant(s) also has the opportunity to address the Board. After the Board
determines that adequate information has been obtained to determine if a violation
has been committed, the Board adjudicates the complaint. According to statute, if
Office of the Auditor General
page 3
1 The number of licensees reported for fiscal year 2009 does not include licenses that the Board reinstated. An individual
has to seek reinstatement when he/she does not renew his/her license within the specified time period or if his/her
license was suspended as a result of a board sanction. According to board staff, the Board does not track the number
of licenses it reinstates during each fiscal year.
2 According to the Board, as of June 3, 2010, a total of 2,146 licensed chiropractors have a physiotherapy certificate and
391 have an acupuncture certificate.
Board Fees As of June 2010
1 The initial license cost includes a $274 initial license
application and fingerprint fee, and a $100 issuance fee.
2 If the licensee is late in renewing his/her license, his/her
license is automatically suspended. The licensee can apply
for reinstatement within 2 years of the suspension, but is
subject to additional fees.
3 According to board staff, specialty certifications are not
renewed, but are considered active as long as the associated
license is active. Both certifications include a $100 application
fee and $100 certification fee.
Source: Auditor General staff review of A.R.S. §§32-921, 32-922,
32-922.02, and 32-923, and interview with board staff.
Licensing fees:
Initial license1 $374
License renewal2 $170
Specialty certification fees:
Physiotherapy3 $200
Acupuncture3 $200
the Board determines that the licensee has not violated statute or the violation is not
of sufficient seriousness to merit disciplinary action, the Board may dismiss the
complaint or issue a nondisciplinary advisory letter or order for continuing education.
If the Board determines that a violation has occurred and discipline is warranted,
according to statute, it may use one or more disciplinary options, including issuing a
letter of concern, probation, or suspending or revoking the chiropractor’s license.
According to board data, it received 115 complaints during fiscal year 2009.
Organization and staffing
The Board consists of five governor-appointed members who serve staggered terms
of 5 years each. Three of the members must be licensed chiropractors in good
standing who have resided in the State and practiced chiropractic therapy full-time
for at least 3 years preceding appointment.
The Board is authorized five full-time equivalent positions—an executive director, a
deputy director/investigator, a licensing manager, and two support staff. As of April
19, 2010, all five positions were filled. Staff responsibilities include:
 Collecting application, renewal, and other fees;
 Issuing licenses after board approval;
 Investigating complaints; and
 Providing information to the public.
Budget
The Board’s revenue comes primarily from licensing and examination fees, and its
revenue is deposited in the Board of Chiropractic Examiners Fund (see Table 1, page
5). The Legislature grants the Board authority to spend prescribed amounts of
monies from the Chiropractic Fund through appropriation bills. According to A.R.S.
§32-906, the Board deposits 90 percent of its revenue, except civil penalties, into the
Chiropractic Fund and remits all of its civil penalties and 10 percent of all other
revenues to the State General Fund. As shown in Table 1, the Board’s net revenues
have ranged from approximately $440,000 to $480,000 for fiscal years 2004 through
2009. In fiscal year 2010, the Board received a $148,000 State General Fund
appropriation to help ensure it had sufficient operating revenues. This appropriation
State of Arizona
page 4
represented a return of most of the monies transferred to the State General Fund in
fiscal years 2008 and 2009, as required by Laws 2008, Ch. 53 and Ch. 285.1 See the
Other Pertinent Information section, pages 19 through 22, for additional information
about the Board’s revenues and expenditures.
Office of the Auditor General
page 5
2004 2005 2006 2007 2008 2009 2010
(Actual) (Actual) (Actual) (Actual) (Actual) (Actual) (Estimate)
Revenues:
License fees $426,176 $433,680 $469,210 $468,315 $459,575 $448,080 $454,100
State General Fund
appropriation 1
148,000
Examination fees 55,249 50,015 52,637 39,150 44,540 33,270 47,100
Fines, forfeits, and penalties 8,006 5,825 15,723 10,008 14,320 5,475 9,100
Other 7,152 9,381 9,566 8,395 7,934 5,764
Gross revenues 496,583 498,901 547,136 525,868 526,369 492,589 658,300
Remittances to the State
General Fund 2
(56,459)
(54,799)
(66,752)
(57,751)
(63,464)
(53,350)
(58,300)
Net revenues 440,124 444,102 480,384 468,117 462,905 439,239 600,000
Expenditures and transfers out 3
Personal services and
employee-related
250,871
274,947
301,831
326,155
338,926
321,662
344,500
Professional and outside services 62,489 83,696 84,290 81,407 84,226 42,419 26,000
Travel 6,691 9,912 7,929 12,063 9,811 7,572 5,900
Other operating 69,185 79,567 63,704 74,894 73,283 72,969 73,000
Equipment 69 31,202 3,572 230 1,489 11,589 500
Total expenditures 389,305 479,324 461,326 494,749 507,735 456,211 449,900
Transfers to the State General
Fund 4
104,800
71,600
Operating transfers out 920 3,916 2,437 3,252 4,419 2,467 200
Total expenditures and
transfers out
390,225 483,240 463,763 498,001 616,954 530,278 450,100
Net change in fund balance 49,899 (39,138) 16,621 (29,884) (154,049) (91,039) 149,900
Fund balance, beginning of year 308,614 358,513 319,375 335,996 306,112 152,063 61,024
Fund balance, end of year $358,513 $319,375 $335,996 $306,112 $152,063 $ 61,024 $210,924
1 The Board received a State General Fund appropriation in fiscal year 2010 in accordance with Laws 2009, Ch. 11, §117, to restore most
of the monies transferred from the Board of Chiropractic Examiners Fund to the State General Fund (see footnote 4).
2 As required by A.R.S. §32-906, the Board remits all civil penalties and 10 percent of all other revenues to the State General Fund.
3 Administrative adjustments are included in the fiscal year paid.
4 Amounts were transferred to the State General Fund as required by Laws 2008, Ch. 53 and Ch. 285.
Source: Auditor General staff analysis of the Arizona Financial Information System (AFIS) Accounting Event Transaction File for fiscal years 2004
through 2009; AFIS Management Information System Status of General Ledger-Trial Balance screen for fiscal years 2004 through 2009;
and board estimates for fiscal year 2010 as of March 10, 2010.
Table 1: Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2004 through 2010
(Unaudited)
1 As required by Laws 2008, Ch. 53 and Ch. 285, during fiscal years 2008 and 2009, a total of $176,400 was transferred
from the Board of Chiropractic Examiners Fund to the State General Fund as a part of the State’s budget deficit
reduction efforts.
Audit scope and objectives
This performance audit and sunset review focused on assessing whether the Board’s
practices for opening, investigating, and adjudicating complaints are in compliance
with its statutory authority; whether its disciplinary practices are in compliance with its
statutory authority and are consistently applied; and whether the Board can take
steps to improve its processes for opening, investigating, and adjudicating
complaints and providing discipline. Additionally, auditors reviewed the Board’s
financial status. Finally, this report also includes responses to the 12 sunset factors
specified in A.R.S. §41-2954.
We conducted this performance audit in accordance with generally accepted
government auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe that the
evidence obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
The Auditor General and staff express appreciation to the Board of Chiropractic
Examiners and its Executive Director and staff for their cooperation and assistance
throughout the audit.
State of Arizona
page 6
Board should improve key complaint-handling
processes
The Board of Chiropractic Examiners (Board) should improve four key areas of its
complaint-handling processes:
 Opening complaints—The Board should ensure that board and staff decisions
about whether to open a complaint are consistent with statutory authority by
enhancing its complaint-opening policy to provide additional guidance.
 Investigating complaints—The Board should ensure that it limits the amount of
information it subpoenas where possible during the complaint investigation
process. The current process sometimes calls for obtaining a wide range of
information and can create the appearance that the Board is searching for
statute or rule violations that were not brought forward in the initial complaint.
 Adjudicating complaints—The Board should stop its current practice of
considering a licensee’s complaint and disciplinary history before adjudicating
a complaint. Reviewing such information after substantiating the allegations in a
complaint can help ensure the level of discipline is appropriate, but reviewing it
beforehand can affect the objectivity with which a complaint is adjudicated.
 Applying disciplinary measures—The Board should consider establishing
disciplinary guidelines to assist in issuing consistent discipline and should seek
a statutory change to clarify how it can use nondisciplinary advisory letters.
Office of the Auditor General
page 7
FINDING 1
Complaint-opening policy should be enhanced
The Board’s complaint-opening policy should be enhanced. Statutory provisions
suggest two areas to consider when determining whether to open complaints. To
help ensure compliance with statutory direction, the Board should enhance its
guidance related to opening complaints.
Statute provides guidance on what to consider when deciding
whether to open complaint—Based on A.R.S. §§32-924, 32-926, and 32-
928, a decision about opening a complaint should focus on whether the allegation
involves: (1) the actions of a licensed chiropractor, and (2) a potential violation of
law (see Table 2). The Board has statutory authority to open complaints and has
also granted this authority to its Executive Director. Auditors’ review of complaint
files showed that, in some instances, the Executive Director or staff make the
determination of whether to open a complaint, while in other instances, the Board
itself does so.
Board should modify guidance for opening complaints—The Board
adopted a complaint-opening policy in February 2010, and while this policy is a
step in the right direction, a few changes would help ensure that the Board and its
staff have adequate guidance in deciding whether to open a complaint. The
Board’s policy addresses a number of issues, such as stating that complaints will
be opened only if they fall within the Board’s jurisdiction, stating that complaints will
not be opened if there is insufficient information to proceed, and outlining some
State of Arizona
page 8
.
Questions the Board should consider in
deciding whether to open a complaint
Actions the Board has statutory authority to
take
Question 1: Is the complaint about a licensed
chiropractor?
No: The Board does not have authority to
discipline an individual practicing
without a license. However, the Board
does have authority to investigate the
issue and can seek injunctive relief.
Yes: Move on to answering question 2.
Question 2: Does the complaint suggest that
a licensed chiropractor may be in
violation of statutes or rules, or
may be mentally or physically
unable to safely practice?
No: The Board does not have authority to
open a complaint if the complaint does
not suggest a potential violation or safe
practice issue.
Yes: The Board must open and investigate
the complaint.
Source: Auditor General staff analysis of A.R.S. §§32-924, 32-926, and 32-928.
Table 2: Statutory Guidance for Opening Complaints
exception procedures, such as referring the complaint-opening decision to the
Board when the Executive Director is unsure whether it should be opened.
However, to ensure that guidance is adequate, enhancements should be made in
two areas:
 Greater guidance on alternative actions—The policy should provide guidance
on actions to be taken if a complaint does not involve a licensed chiropractor.
For example, the policy should establish what steps to take, such as what
information staff should gather so that the Board can seek injunctive relief if
appropriate, and how staff should distinguish that the complaint and
associated investigation pertains to a nonjurisdictional issue.
 Greater conformity with statute in not considering complainant’s intent—The
policy grants the Executive Director authority to not open complaints based on
the complainant’s intent, such as the intent to intimidate or harass a public
official. This direction is inconsistent with statute, which does not allow the
Board to consider the complainant’s intent.
To ensure its guidance conforms with statutory provisions, the Board should work
with the Attorney General’s Office to revise its policy.
Board should limit subpoenas to records directly related
to complaint allegations
During its investigations, the Board has sometimes subpoenaed unnecessary
information. Steps can be taken to more appropriately limit the amount of information
requested in its subpoenas where possible. However, the Board has appropriately
addressed additional concerns identified during its investigation.
Board sometimes subpoenaed more information than needed—The
Board’s subpoenas are sometimes overly broad in their scope. The Board
explained that it subpoenas full patient records for all complaints in an effort to treat
each case in the same manner. The standardized initial subpoena generally sent
to licensees when complaints are received requests, for a specified patient, “any
and all patient records to include, but not limited to, health histories, treatment
plans, daily notes, examinations, billing documents and x-rays and sign-in sheets.”
However, according to A.R.S. §32-929(B)(1), the Board should subpoena only
records that are relevant to the subject matter of the investigation. Among the 42
complaints reviewed for this audit, auditors identified 3 complaints in which the
Board subpoenaed more records or information than needed to address a
complaint. For example, one complainant reported to the Board that on July 25,
2007, a licensee’s receptionist tried to charge $11 more than the required co-pay
Office of the Auditor General
page 9
and that this was a standard office practice for all patients. The Board subpoenaed
the full patient record, including health histories, treatment plans, and x-rays, but
could perhaps have limited its subpoena to only the patient’s billing records since
the complaint did not cover the treatment received.
Requests for irrelevant information cost the Board, staff, and licensees time and
resources; could lengthen complaint-processing times; and may create the
appearance the Board is searching for additional statute or rule violations. For
example, four individuals who contacted the Office of the Auditor General were
concerned that the Board requests more information than needed to investigate
complaints and inappropriately expands the scope of its investigation by looking
for additional issues other than those identified in complaints.1
According to A.R.S. §32-929(B)(1), licensees have the right to request within 5
days after the service of a subpoena that the Board revoke, limit, or modify a
subpoena. However, the Board’s subpoenas may be misleading in this regard
because they include the following standardized language: “the information
subject to the subpoena is the minimum information necessary for the Board to
fulfill its statutory mandate in protecting the public and regulating its licensees.” It
is not clear that all chiropractors are aware of this right, although one licensee
exercised this right in one of the complaints auditors reviewed. The licensee
requested that the Board limit its request to a certain time period as he had been
seeing the patient for 10 years and it would have caused a hardship to go through
storage to find records that did not have any significance to the case.
Board should take steps to limit requests for evidence where
possible—The Board should modify its complaint-handling policy and practices
to appropriately limit its subpoena requests. Specifically, where possible, the
Board should limit its subpoena to the minimum amount and type of records
needed to address the complaint allegations. For example, the Board may not
need to request billing information if a concern is specific to the standard of care
provided. Conversely, the Board may sometimes need billing records only to
assess whether or not a licensee charged a patient more than the required co-pay.
Some boards that regulate health professions in Arizona limit the amount and type
of records requested in subpoenas. Based on interviews with four other health
regulatory boards, three (the Arizona Medical Board, Naturopathic Physicians
Board, and Board of Podiatry Examiners) indicated they attempt to limit their
records request. For example, Podiatry Board staff reported that complete medical
records are not always necessary to conduct a complete investigation and
substantially prove or disprove the allegations. Podiatry Board staff request the
minimum information necessary and are sometimes able to limit records requests
to records associated with a particular event or situation. Similarly, the Board
Limiting subpoena
requests could save the
Board, staff, and
licensees time and
resources.
State of Arizona
page 10
1 During the audit, the Office of the Auditor General received several concerns from chiropractors and others related to
the Board’s complaint-handling processes. The Office of the Auditor General is not statutorily responsible for reviewing
and resolving individual complaints about state agencies, but considers concerns raised by the Legislature and
legislative staff, regulated professionals, and others, including the public, when conducting its work. To the extent that
the concerns received fell within the objectives and scope of this audit, these concerns were included in the audit
analysis.
Some Arizona health
regulatory boards limit
subpoena requests.
should limit the amount and type of records requested in its subpoenas where
possible. To help ensure that this change is made, the Board’s Complaints,
Investigations and Hearings policy should be modified to provide guidance to staff
on how to subpoena appropriate information.
Board appropriately addresses additional statute violations
identified during investigation process—According to A.R.S. §32-
924(B), the Board has authority to address any additional concerns identified
during its investigation. Auditors’ review of 42 complaint files found that the Board
regularly incorporates additional allegations found during its investigation.
Board should change two important aspects of
adjudication process
The Board should change two important aspects of its adjudication process. First,
the Board considers a licensee’s complaint and disciplinary history too soon.
Second, the Board and its staff inconsistently allow complainants to withdraw
complaints alleging statute violations. However, the Board appears to handle other
aspects of the adjudication process appropriately, such as recusing themselves in
situations involving conflicts of interest and holding licensees accountable to
professional record-keeping standards.
Board considers past complaint and disciplinary information too
soon—The Board’s review of a complaint may be prejudiced
because it reviews the licensee’s complaint and disciplinary
history prior to deliberations about the allegations in the
complaint. In 13 of 15 complaint files assessed, auditors found
that staff provided the Board with a licensee’s complaint and
disciplinary history before the Board had decided whether the
allegations of the new complaint were substantiated.1 Based
on observations of board meetings, the file review, and a
review of board policy, auditors determined that receiving
and/or discussing this information before deciding whether the
allegations of the new complaint are substantiated is a
standard board practice.
Because the complaint history and disciplinary history are irrelevant to whether the
allegations in the new complaint may be true, such information may prejudice
decisions by negatively affecting a board member’s assessment of the new
complaint. The Board should, however, be allowed to review a licensee’s
complaint and disciplinary history once the complaint has been adjudicated.
Reviewing complaint and disciplinary history information after it has substantiated
Office of the Auditor General
page 11
A licensee’s complaint history includes
information on all complaints that the
Board received against the licensee,
including complaints that the Board
dismissed without any disciplinary action.
A licensee’s disciplinary history includes
information about previous board
disciplinary actions.
1 Auditors stopped reviewing complaint files for this problem at 15 complaints since 13 complaints had the same concern.
The 2 complaints that did not have this concern were opened and adjudicated during the same board meeting, and
therefore staff did not provide board members with an investigative report containing complaint and disciplinary history
information.
the allegations in a new complaint can help ensure that the Board provides
appropriate discipline. For example, if the licensee was previously disciplined for a
similar violation, the Board may decide that a different disciplinary action is needed
to ensure another similar violation does not recur. Therefore, the Board should also
modify its Complaints, Investigations and Hearings policy to direct staff to provide
complaint and disciplinary information only during the disciplinary phase.
Complainant requests to withdraw complaints inconsistently
handled—Auditors identified 3 cases where the Board and its staff have
inconsistently permitted complainants to withdraw complaints. In two cases,
complainants were allowed to withdraw complaints even though the complaints
alleged potential violations and board staff had conducted investigative work. For
example, in one complaint, board staff allowed the complainant to withdraw a
complaint involving billing and record-keeping concerns even though its
investigation identified statute violations. Board staff presented information about
the complaint at a board meeting, and the Board voted to table the complaint for
6 months. Despite the Board’s vote, when the complainant decided to withdraw
the complaint, a staff member sent a letter to the licensee stating that the
complaint was being withdrawn. The staff member’s letter to the licensee cited
concerns about the licensee’s documentation and stated that the licensee needed
to correct issues that were not in compliance with law. The Board was unaware the
complaint had been handled in this way, and the staff member’s action without
involving the Board makes this withdrawal inappropriate; the presence of statutory
violations heightens the inappropriateness. In contrast, in another complaint file
auditors reviewed, a complainant was not permitted to withdraw a complaint
because it suggested a violation related to accessing patient records.
Although there is no law preventing complainants from requesting to withdraw their
complaints, permitting complainants to withdraw complaints that allege violations
impacts the Board’s ability to fulfill its mission to protect the health, welfare, and
safety of the public through adjudicating complaints concerning unprofessional
conduct or other statutory violations. Therefore, the Board should modify its
Complaints, Investigations and Hearings policy to establish that complainants are
not permitted to withdraw complaints alleging statute or rule violations, and direct
staff to send any complaints that have been investigated to the Board for
adjudication.
Other concerns about adjudication process unfounded—Auditors
received two other concerns about the Board’s adjudication processes regarding
whether board members were appropriately recusing themselves when they had
a conflict of interest and whether the Board was holding licensees accountable to
documentation standards not specified in statute or rule. Audit work did not
substantiate either of these concerns. In both cases, the processes appear to be
appropriate. Specifically:
Permitting complainants
to withdraw complaints
alleging violations
impacts the Board’s
ability to protect the
public.
State of Arizona
page 12
 Board appears to appropriately recuse themselves when conflicts of
interest arise—Two individuals raised concerns to auditors that board
members did not appropriately recuse themselves when they had a
conflict of interest. However, auditors reviewed board meeting minutes
from six meetings that occurred during fiscal years 2008 and 2009, and
found that board members recused themselves in three meetings. It
appeared that board members recused themselves appropriately. For
example, in one board meeting, a board member recused herself from
adjudicating two complaints because she was treating the patient
identified in those complaints.
Auditors also reviewed the Board’s handling of multiple anonymous
complaints. During August and September 2006, board staff received
about 1,100 anonymously filed complaints alleging that three licensed
chiropractors who were current or former board members had improperly
disposed of confidential patient records.1 According to the complaint
letters, the records—which included patients’ names, social security
numbers, and treatment information that was allegedly redacted by the
complainant—had been found in or around trash cans outside the
licensees’ offices. Board members were not required to recuse
themselves in handling these complaints because the Executive Director
decided not to open them, mainly because their anonymity meant the
complainant could not be contacted for additional information. The
Executive Director sent a letter to the Arizona Ombudsman explaining her
decision. The Ombudsman indicated that the decision appeared
appropriate based on Board’s protocol for handling anonymous
complaints described in the Executive Director’s letter.
In October 2009, the Board received similar concerns against the same
three licensees. However, this time the complainant was not anonymous
and provided unredacted copies of confidential patient records that
reportedly had been found out in the area behind the licensees’ offices.
Board staff referred the complaints to the Board at its November 2009
meeting to consider whether or not to open them. During the meeting,
each licensee was provided an opportunity to address the concerns,
including how he or she protects confidential information. The Board
voted not to open a complaint against any of the three licensees. The one
licensee who is an active board member recused herself and did not
participate in these votes.
 Board documentation standards are appropriate—Three individuals
reported to auditors that the Board held them accountable to
documentation standards that are unclear or are not specified in board
statute or rule. Statute does not define record-keeping standards, but
A.A.C. R4-7-101(1) defines and R4-7-902(5) requires that licensees
1 According to A.R.S. §32-924(A)(5) and A.A.C. R4-7-902(29), it is a violation to intentionally dispose of confidential
patient information or records without redacting, incinerating, or shredding the information or record.
Office of the Auditor General
page 13
maintain adequate patient records, including information such as
patients’ health history, clinical impression, and examination findings. The
Board has also developed documentation review forms to help board
staff assess whether licensees have met record-keeping standards
established in rule, a board substantive policy statement, and clinical
competencies outlined by the Council on Chiropractic Education.1 A.R.S.
§32-924(A)(15) allows the Board to hold licensees accountable to
recognized standards in the profession and does not require that these
standards be specifically addressed in statute or an associated rule.
According to the Board’s Executive Director, the Board began posting
guidelines for recordkeeping in 2004, and the forms and information
about the forms was made available to the public and licensees on its
Web site in March 2008.
Board could enhance disciplinary process
The Board could enhance its disciplinary process. Specifically, the Board should
consider establishing disciplinary guidelines and should seek a statutory change
clarifying its use of advisory letters.
Disciplinary guidelines may help further ensure Board issues
consistent sanctions—Auditors received concerns from eight
individuals that the Board was issuing inappropriate discipline. However,
auditors’ review of 42 complaints identified no inappropriate discipiline and
only 1 complaint where the Board appeared to issue inconsistent discipline to
a licensed chiropractor. Specifically, in June 2008, the Board issued a $250
civil penalty to a licensee who ignored a board order to attend a board
meeting. Auditors reviewed four other complaints from the same time period
where licensees also ignored a board order to attend a board meeting and
found that none received a civil penalty. Although auditors identified only 1
case, the Board’s risk for issuing inconsistent discipline may be heightened
because the Board is operating without disciplinary guidelines. To reduce the
risk, the Board should consider establishing such guidelines.
Guidelines have been developed elsewhere that may serve as a starting point
for the Board. Specifically, the Federation of Chiropractic Licensing Board’s
Web site has reference to guidelines that Washington’s State Department of
Health developed. These guidelines define four key steps to help identify
appropriate sanctions (see textbox). Further, the guidelines outline how to
handle seven significant and/or common types of violations, and provide
advice on the type of discipline to issue based on severity level as well as
mitigating and aggravating factors (see Figure 1, page 15). Similar guidelines
and sanction schedules subsequently adopted into administrative code also
cover how to handle complaints that do not fall within sanction guidelines.
1 The Council is the agency recognized by the U.S. Secretary of Education for accreditation of programs and institutions
offering the doctor of chiropractic degree.
State of Arizona
page 14
Four Key Steps to Help
Identify Appropriate Sanctions
1. Briefly summarize the
conduct that constituted
unprofessional conduct
meriting action.
2. Identify the severity of the
conduct.
3. Describe other factors. This
includes aggravating or
mitigating circumstances and
prior disciplinary history.
4. Identify the recommended
sanction and additional
conditions.
Source: Auditor General staff review of
Washington State Department of
Health.(2007). Disciplinary guidelines
manual.Olympia,WA:Author. Retrieved
April 22, 2010, http://www.doh.wa.gov/
hsqa/professions/documents/
Sanction_Guidelines.pdf
The Board’s forms used
to assess whether
licensees have met
record-keeping
standards are based on
rule, policy, and
professional standards.
Office of the Auditor General
page 15
PRACTICE BELOW STANDARD AND BOUNDARY VIOLATIONS
Severity Tier / Conduct Sanction Range
Minimum
Not subject to stay
Maximum
Duration
A–Practice
below standard
or nonsexual
boundary
violation with
a low risk of
patient harm.
Reprimand or
conditions.
Probation, conditions,
or suspension for 5
years.
0-5 years
B–Practice
below standard
or nonsexual
boundary
violation with
patient harm or
risk of patient
harm.
Probation or
suspension for 2
years.
Suspension for 7
years or revocation.
2-7 years
unless
revocation
least
greatest
C–Practice
below standard
with serious
physical injury
or death of a
patient or a
risk of
significant
physical injury
or death.
Suspension for 5
years.
Indefinite suspension
or permanent
revocation.
Minimum
5 years
Aggravating Circumstances:
- Number of events
- Actual harm
- Severity of harm
- Prior complaints or discipline for similar conduct
Mitigating Circumstances:
- Outcome not a result of care
- Participation in established or
approved remediation or
rehabilitation program and
demonstrated competency
Figure 1: Example of Sanction Guidelines
Source: Washington State Department of Health. (2007). Disciplinary guidelines manual. Olympia, WA: Author.
Retrieved April 22, 2010, from http://www.doh.wa.gov/hsqa/professions/documents/Sanction_Guidelines.pdf
Board should seek statutory change to clarify how advisory letters
can be used—A.R.S. §32-924(E) appears to imply that the Board may issue
a nondisciplinary advisory letter only when it finds that a licensee violated
statute but also determines that that the violation was not of sufficient
seriousness to merit discipline. However, auditors found that the Board also
uses advisory letters in instances when it has not established that a statutory
violation occurred. Specifically, 11 of the 42 complaints auditors reviewed resulted
State of Arizona
page 16
in advisory letters, and in 3 of the 11 advisory letters, the Board did not indicate
that the licensee violated statute. For example, 1 advisory letter reported that a
licensee “may” have violated sexual boundaries.
The Board’s practice of issuing advisory letters when it has not found a statutory
violation, but only has a concern, appears consistent with the authority granted
to some Arizona health regulatory boards. Specifically, the Arizona Medical
Board, Board of Osteopathic Examiners in Medicine and Surgery, Naturopathic
Physicians Medical Board, and Board of Podiatry Examiners statutes permit
them to use advisory letters or letters of concern, and also further clarify how
these letters can be used.1
For example, the Osteopathic Board’s statutes, A.R.S. §32-1800(15), permit it to
use a letter of concern to “notify a physician that while there is insufficient
evidence to support disciplinary action against the physician’s license there is
sufficient evidence for the board to notify the physician of its concern.” If the
Chiropractic Board intends to use advisory letters when it has not found a
statutory violation, but only has a concern, the Board should seek a statutory
change to add a definition clarifying, like other boards, how the Board can use
these letters. Such a change would also help ensure that the Board’s use of
advisory letters is understood among the profession and the public. The Board
can also enhance its advisory letters by ensuring the letters clearly indicate the
statutes violated, and/or the licensee practices that caused the Board concern.
Recommendations:
1.1. To improve its process for opening complaints, the Board should work with
the Attorney General’s Office to revise its complaint-opening policy to: guide
staff on what actions should be taken if a complaint involves an unlicensed
chiropractor, including what information staff should gather so that the Board
can seek injunctive relief if appropriate and how staff should distinguish that
the complaint and associated investigation pertains to a nonjurisdictional
issue; and eliminate the authority to not open complaints based on the
complainant’s intent, such as the intent to intimidate or harass a public
official.
1.2. To improve its investigation process, the Board should limit the amount and
type of records requested in its subpoenas where possible. To help ensure
that this change is made, the Board’s Complaints, Investigations and
Hearings policy should be modified to provide guidance to staff on how to
subpoena appropriate information.
The Board’s use of
advisory letters is
consistent with the
authority granted to
some Arizona health
regulatory boards.
1 The Naturopathic Physicians Medical Board, Board of Osteopathic Examiners in Medicine and Surgery, and Board of
Podiatry Examiners statutes assign the term “letter of concern” to the document that the Arizona Medical Board’s and
the Board of Chiropractic Examiners’ statutes call an advisory letter.
1.3. To improve its adjudication process, the Board should:
a. Review a licensee’s complaint and disciplinary history information only after
it has substantiated the allegations in a new complaint.
b. Modify its Complaints, Investigations and Hearings policy to direct staff to
provide complaint and disciplinary information only during the disciplinary
phase, establish that complainants are not permitted to withdraw
complaints alleging statute or rule violations, and instruct staff to send any
complaints that have been investigated to the Board for adjudication.
1.4. To improve its disciplinary process, the Board should:
a. Consider developing guidelines to help it ensure that it provides consistent
discipline.
b. Request the Legislature to amend its statutes to add a definition clarifying
how it can use advisory letters.
c. Ensure that its advisory letters clearly communicate the statutes violated
and/or licensee practices that caused the Board concern.
Office of the Auditor General
page 17
State of Arizona
page 18
During this audit, auditors collected other pertinent information related to the Board
of Chiropractic Examiners’ (Board) financial status, including an explanation of how
the Board’s financial status has changed since fiscal year 2004 and what actions the
Board has taken to address increasing expenditures.
Board’s financial status
As shown in Table 1 (see Introduction and Background, page 5), the Board’s fund
balance in fiscal year 2010 is projected to be approximately $148,000 less than it was
in fiscal year 2004. The Board’s decreasing fund balance mainly occurred because
of increases in expenditures without any sustained increases in net revenues.
 Board expenditures have increased in three areas—Board expenditures have
increased in three main areas since fiscal year 2004: salaries and employee-related
expenditures, professional and outside services, and other operating
expenditures. Some expenditure increases were required, while others were
optional. Salary and employee-related expenditures have increased gradually,
and are about $94,000, or approximately 37 percent, higher than in fiscal year
2004.1 Mandated increases included statutorily required salary adjustments and
performance pay increases. Other salary increases were not statutorily required
and occurred for other reasons. For example, the Board increased the Executive
Director’s salary at the beginning of fiscal year 2005 by $16,331. At the end of
fiscal year 2004, the Board’s expenditures were almost $50,000 less than net
revenues. Additionally, the Executive Director restructured staff positions at the
end of fiscal year 2005, causing some positions to be reclassified and resulting
in a salary increase of $2,500 each for two of five staff members. In fiscal year
2005, the Board’s expenditures exceeded net revenues, but it had sufficient
monies in its fund balance to cover the salary increase.
In the second area of increase—professional and outside services—
expenditures increased about $20,000 in fiscal year 2005 compared to fiscal
year 2004 and remained elevated through fiscal year 2008. This increase was
1 The Board’s overall employee-related and salary expenditures increased by $94,000. However, the Board’s 2009
employee-related expenditures were not as high as 2008 because of a vacancy that lasted approximately 4 months.
Office of the Auditor General
OTHER PERTINENT
INFORMATION
page 19
The Board’s fund
balance has
decreased.
due to various factors such as changes in the complaint-handling process,
efforts to reduce a complaint backlog, and efforts to seek fee increases.
Specifically, in response to recommendations in the Office of the Auditor
General’s 2001 performance audit (see Report No. 01-12), the Board began
using outside investigators and court reporters. The Board chose to separate its
investigative and adjudicative functions by using contracted investigators on
cases that required more professional expertise or knowledge than the Board’s
investigator has.1 According to the Executive Director, the Board does not track
how often it uses contracted investigators, but reported that costs vary
depending on the size and complexity of files contractors review. Additionally,
the Board increased its use of contracted investigators in fiscal year 2005 to
reduce a backlog of complaints. The Board also received authority to resolve
more cases on its own instead of having to go to the Office of Administrative
Hearings. According to the Executive Director, the Board uses court reporters to
record its hearings should a licensee appeal a board decision. The Board needs
transcripts to handle appealed decisions and uses those created by court
reporters because its recording equipment is unreliable. Finally, the Board spent
about $40,000 during fiscal years 2006 and 2007 on a lobbyist contract in
unsuccessful efforts to obtain statutory fee increases. The Board had sufficient
monies in its fund balance to cover these expenditures for the lobbyist.
In the third area of increase—other operating expenditures—higher
expenditures were related primarily to telecommunication and postage cost
increases. For example, the Board’s external telecommunication costs
increased by about $5,000 when it was required to switch to the State’s
telecommunication network known as AZNet.
Finally, in addition to expenditure increases in three main areas, the Board’s
equipment expenditures notably increased in fiscal years 2005 and 2009.
According to the Executive Director, increases occurred when the Board: (1)
purchased laptops for board members so that they could receive board
materials electronically, (2) replaced a photocopy machine, and (3) replaced a
broken computer and two laptops. Some other Arizona health regulatory boards
also use laptops for board members to save on costs such as photocopying
and shipping board materials and labor involved in making the copies.
 Net revenues have decreased since 2006—As shown in Table 1 (see
Introduction and Background, page 5), after peaking in fiscal year 2006 at
$480,000, net revenues through fiscal year 2009 steadily declined to fiscal year
2004 levels. Net revenues are projected to be significantly higher in fiscal year
2010, mainly because the Board received a one-time State General Fund
appropriation of $148,000 to restore most of the monies transferred from the
Board of Chiropractic Examiners Fund to the State General Fund. The decline in
Increased professional
and outside services
expenditures are due to
various factors,
including changes to
the complaint-handling
process and efforts to
reduce a complaint
backlog.
1 The Board also could have chosen to use board members to investigate complaints, which would have required the
board member to recuse him/herself from the adjudication process. According to the Executive Director, due to the
large number of complaints and limited number of board members, the Board would have trouble maintaining a
quorum if board members were used to investigate complaints.
State of Arizona
page 20
net revenue since fiscal year 2006 is primarily due to decreases in the Board’s
licensing revenue, which represents the Board’s largest revenue source.
As shown in Table 3, the decrease may be due to fluctuations in the number of
initial licenses along with a steady decrease in the number of individuals
renewing their licenses since fiscal year 2006. The Executive Director reported
that various factors could
have influenced licensure
revenue, including the
economy and decreasing
nation-wide chiropractic
school enrollment numbers.
However, the National Board
of Chiropractic Examiners
reported that the number of
individuals taking their
national prelicensure exams
has remained stable since
2004.
As shown in Table 1 (see Introduction and Background, page 5), during fiscal years
2008 and 2009, $176,400 was transferred to the State General Fund as required by
Laws 2008, Ch. 53, and Laws 2008, Ch. 285, to help reduce the State’s budget
deficit. The one-time State General Fund appropriation of $148,000 made in fiscal
year 2010 restored most of the monies transferred from the Board of Chiropractic
Examiners Fund to the State General Fund. Although this will improve the Board’s
ending fund balance, it will remain below fiscal year 2004 levels. As a result of
increased expenditures, decreased revenues, and net legislative transfers of money,
the Board’s fund balance has decreased in 4 of the past 7 years.
Board efforts to address financial problems
The Board has attempted to address its financial problems by seeking fee increases
and by reducing operating expenditures. Specifically:
 Board reduced some expenditures and unsuccessfully sought statutory fee
increases—The Board reported that it took steps to reduce expenditures
between fiscal years 2004 through 2008, such as reducing newsletter
publications, having the Executive Director review completed investigative
reports rather than a consultant, and borrowing the Board of Dental Examiners’
meeting facility and recording equipment rather than paying for expanded
meeting space and purchasing recording equipment. However, according to
the Executive Director, the Board felt that further reducing its expenditures would
impact the Board’s ability to fulfill its responsibilities, so it decided to seek a
The Board took various
steps to reduce
expenditures, including
reducing publications
and borrowing
equipment.
Office of the Auditor General
page 21
2004 2005 2006 2007 2008 2009
Initial licenses
111
137
114
96
110
79
Renewal licenses 2,349 2,460 2,521 2,502 2,463 2,393
Total 2,460 2,597 2,635 2,598 2,573 2,472
Source: Auditor General staff analysis of initial licensing data from board spreadsheets
and renewal data reported by board staff based on receipt logs and deposit
information for fiscal years 2004 through 2009.
Table 3: Number of Initial and Renewal Chiropractic Licenses
Fiscal Years 2004 through 2009
(Unaudited)
statutory fee increase. The Board subsequently sought statutory fee increases
in 2007 and again in 2008 to address its financial problems, but both efforts
failed.
 Board further reduced expenditures after efforts to seek fee increases failed—
As it became apparent that the Board’s efforts to obtain a statutory fee increase
were not likely to succeed, according to the Executive Director, the Board began
looking for additional ways to further reduce expenditures, such as using
volunteer investigators instead of contracted investigators. In addition, Board
expenditures were significantly reduced in fiscal year 2009, in part because the
Board did not pay for Attorney General services and had a staff position that was
temporarily vacant. The Board has made additional cuts in expenditures for
fiscal year 2010. Specifically, for fiscal year 2010, the Board did not enter into an
interagency service agreement with the Attorney General’s Office for a
designated representative. Staff from the Attorney General’s Office still provide
services to the Board as required by law. However, the Board may receive
services from various representatives instead of a designated representative.
The Executive Director reported that the Board also plans to maintain reductions
from prior years. For example, the Board plans to continue to have reduced
supply and postage costs and plans to conservatively use contractors. Although
these reductions have improved the Board’s situation, board staff indicated the
reductions may also negatively impact board operations. Specifically, the
Executive Director reported that, prior to using a designated Assistant Attorney
General representative, complaints that required hearings were delayed for up
to 4 years.
The Board plans to
maintain prior
expenditure reductions
during fiscal year 2010.
State of Arizona
page 22
Office of the Auditor General
page 23
SUNSET FACTORS
In accordance with Arizona Revised Statutes (A.R.S.) §41-2954, the Legislature
should consider the following 12 factors in determining whether the Board of
Chiropractic Examiners (Board) should be continued or terminated.
1. The objective and purpose in establishing the Board.
The Board was established in 1921 to protect the public’s health, safety, and
welfare by licensing and regulating chiropractors. The Board’s statutes also
provide for certification of chiropractors in physiotherapy and acupuncture. In
addition, the Board registers chiropractic assistants and approves
preceptorship training programs through which a chiropractic student may
practice under the supervision of a licensed chiropractor.
The Board’s mission is “protecting the health, welfare and safety of the public
through the enforcement of the laws governing the practice of chiropractic.” To
accomplish this mission, the Board licenses individuals according to licensing
statutes and rules; investigates and adjudicates complaints concerning
unprofessional conduct or other violations of statutes or rules; disciplines
licensees who have violated statutes; monitors licensees for compliance with
board orders; and provides information to licensees and the public through
various avenues, including its Web site and over the phone.
2. The effectiveness with which the Board has met its objective and purpose and
the efficiency with which it has operated.
The Board has met some of its prescribed purposes and objectives, but should
improve in some other areas. For example, the Board approves continuing
education programs and ensures that licensees meet the required amount of
continuing education prior to renewing licenses. In addition:
 Overall licensing time frame met—Auditors reviewed 10 of the 285 initial
license applications received between fiscal years 2007 and 2009 that
resulted in licensure, and found the Board processed these 10 applications
within the required 145 business days. According to A.A.C. R4-7-502, the
Board must conduct an administrative completeness review of a license
application within 25 business days of receipt to verify the application is
State of Arizona
page 24
complete, and a substantive review and disposition of the application within
120 business days, resulting in an overall time frame of 145 days for both
reviews.
 Adequate licensing examination procedures—According to A.R.S. §32-
922, the Board must conduct a licensing examination at least semiannually,
and the Board offers licensing examinations once a month. Auditors found
that the Board’s licensing-examination content and administrative
procedures were in accordance with statutory mandates. For example, a
review of ten initial licensing files received between fiscal years 2007 and
2009 found that the Board’s licensing process ensures applicants meet
statutory requirements such as obtaining a minimum score of 75 percent
on the jurisprudence exam. In addition, auditors’ review of six license
renewal files received between fiscal years 2007 and 2009 found that the
Board’s renewal procedures were in accordance with statutory mandates
such as sending renewal application notices to licensees at least 30 days
before the applications are due.
However, the Board can more effectively meet its objectives and purpose by
improving the following four key areas of its complaint-handling processes:
 Opening complaints—The Board should enhance its guidance to ensure
complaint-opening decisions are consistent with statute. A decision about
opening a complaint should focus on whether the allegation involves (1) the
actions of a licensed chiropractor, and (2) a potential violation of law. The
Board should work with the Attorney General’s Office to revise its
complaint-opening policy to provide greater guidance on what should be
considered when deciding whether to open complaints (see Finding 1,
pages 7 through 17).
 Investigating complaints—The Board has sometimes subpoenaed
unnecessary information. Steps can be taken to more appropriately limit the
amount of information requested in its subpoenas where possible (see
Finding 1, pages 7 through 17).
 Adjudicating complaints—The Board’s review of a complaint may be
prejudiced because it reviews the licensee’s complaint and disciplinary
history prior to deliberations about the allegations in the complaint. The
Board should review a licensee’s complaint and disciplinary history
information only after it has substantiated the allegations in a new
complaint. In addition, the Board has inconsistently allowed complainants
to withdraw complaints, even though the complaints alleged potential
statute violations. The Board should modify its Complaints, Investigations
and Hearings policy to establish that complainants are not permitted to
withdraw complaints alleging violations, and direct staff to send any
Office of the Auditor General
page 25
complaints that have been investigated to the Board for adjudication (see
Finding 1, pages 7 through 17).
 Disciplining licensees—The Board should consider establishing
disciplinary guidelines to assist in issuing consistent discipline and should
seek a statutory change to clarify how the Board can use nondisciplinary
advisory letters (see Finding 1, pages 7 through 17).
Auditors also found that the Board is not processing complaints in a timely
manner. The Office of the Auditor General has found that Arizona health
regulatory boards should generally process complaints within 180 days.
However, auditors found that for the 235 complaints received during fiscal years
2007 and 2008, only about 21 percent were
processed within 183 days (see textbox). According
to the Board, it has identified some issues impacting
timely resolution, including the time it takes to
investigate complaints as well as establish consent
agreements. In addition, the Board has taken steps
to resolve these issues, such as establishing time
frames for investigations and the various aspects of
consent agreements.
3. The extent to which the Board has operated within
the public interest.
The Board generally operates in the public interest.
For example, the Board has a Web site that provides
information to the public on licensees and board
activities. This includes information regarding
licensing procedures and licensed chiropractors. In
addition, the Board’s Web site provides information
regarding the complaint-handling process and how to file a complaint. Further,
auditors placed four phone calls to the Board between June 17, 2009 and July
1, 2009, requesting public information about licensees’ complaint and
disciplinary history, and found that board staff provided complete and accurate
information.
4. The extent to which rules adopted by the Board are consistent with the legislative
mandate.
General counsel for the Auditor General has reviewed an analysis of the Board’s
rulemaking statutes by the Governor’s Regulatory Review Council staff,
performed at auditors’ request, and believes that the Board has fully established
rules required by statute.
Complaint-Handling Timeliness
Fiscal Years 2007 and 20081
 21% processed within 183 days
 29% processed from 184 to 252 days
 25% processed from 253 to 349 days
 25% processed from 350 to 658 days
1 The timeliness information is for all complaints received
during fiscal years 2007 and 2008. The Office of
Administrative Hearings conducted formal hearings for some
of the complaints, which the Executive Director indicated can
add up to 4 months or longer to the processing time.
Source: Auditor General staff analysis of the Board’s complaint-tracking
system data for 235 complaints received during
fiscal years 2007 and 2008.
State of Arizona
page 26
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to its
actions and their expected impact on the public.
The Board last amended its rules in fiscal year 2007. In the process of revising
its rules, the Board took steps to inform and involve the public and stakeholders.
For example, the Board filed a notice of proposed rulemaking with the Arizona
Secretary of State and provided for a period of public review and comment.
Further, the Board’s Executive Director reported that the Board made proposed
rule-making information available on its Web site. In addition, the audit found
that the Board generally complied with open meeting law. Specifically, during the
May and June 2009 board meetings, the Board followed published meeting
agendas in accordance with A.R.S. §38-431.02(H). Further, the Board
appropriately entered into executive sessions in accordance with A.R.S. §38-
431.03, which permits the Board to hold executive sessions for reasons such as
discussion or consultation for legal advice, or receipt and discussion for
information or testimony specifically required to be maintained as confidential by
state or federal law. In addition, the Board has recordings of board meetings
available to the public within 3 business days of the board meeting. Finally, in
accordance with A.R.S. §38-431.02(A)(1), the Board filed a statement with the
Office of the Secretary of State identifying where it posts meeting notices.
Although the Board did not post the notice and agenda in all places as required
in May 2009, the Board revised the statement in June 2009 to match its posting
locations.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
The Board has sufficient statutory authority to investigate and adjudicate
complaints within its jurisdiction and has various disciplinary options. As
recommended in the Office of the Auditor General’s 2001 performance audit
and sunset review of the Board (see Report No. 01-12), the Board sought and
received authority to conduct investigative hearings, which are called formal
interviews, which has allowed it to take action against licensees without sending
all complaints to formal hearing. However, this audit recommends
improvements that will help ensure that the Board appropriately investigates and
resolves complaints. For example, this audit recommends that the Board limit
the amount and type of records requested in its subpoenas where possible, and
that the Board consider developing guidelines to help ensure it provides
consistent discipline (see Finding 1, pages 7 through 17).
Office of the Auditor General
page 27
7. The extent to which the Attorney General or any other applicable agency of state
government has the authority to prosecute actions under the enabling
legislation.
A.R.S. §41-192 authorizes the Attorney General’s Office to prosecute actions
and represent state agencies, including the Board. The Board determined not to
enter into an intergovernmental agreement for an assigned Attorney General
representative in fiscal year 2010 (see Other Pertinent Information, pages 19
through 22). Staff from the Attorney General’s Office still provide services to the
Board as required by law. However, the Board may receive services from various
representatives instead of a designated representative.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes, which prevent it from fulfilling its statutory mandate.
The Board has sought a number of statutory changes to address deficiencies in
its statutes. Specifically:
 In 2002, changes to A.R.S. §32-924 increased the complaint-handling
options available to the Board. Specifically, these changes allowed the
Board to issue nondisciplinary advisory letters, forward complaints to
formal interview, and issue disciplinary letters of concern . Previous to these
statutory changes, the Board was required to forward any complaint that
merited discipline to formal hearing, and any violation resulted in at least an
order of censure.
 In addition, further changes to A.R.S. §32-924 in 2007 granted the Board
authority to issue both nondisciplinary and disciplinary orders for continuing
education.
These changes have allowed the Board to issue less severe sanctions for less
severe infractions of the Board’s regulatory statutes that are not of sufficient
seriousness to merit discipline. For example, the Board issued a nondisciplinary
advisory letter to a licensee who failed to place the words “chiropractic,”
“chiropractor,” “chiropractic doctor,” or “chiropractic physician” on his
letterhead.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors in the sunset law.
This audit identified one change that is needed to the Board’s statutes.
Specifically, the Board should request the Legislature to amend its statutes to
add a definition clarifying how it can use advisory letters (see Finding 1, pages
7 through 17).
State of Arizona
page 28
10. The extent to which the termination of the Board would significantly harm the
public’s health, safety, or welfare.
Terminating the Board without assigning its responsibilities to another state
agency would harm the public’s health, safety, and welfare because the Board
is responsible for licensing chiropractors, and investigating and adjudicating
complaints against licensed chiropractors. Without state laws establishing
educational and competency standards, the public could be subject to unskilled
chiropractic practices. Further, the Board has addressed chiropractor actions
that harm the public’s health, safety, and welfare by taking action against
licensees who practice below the standard of care or commit other
inappropriate actions such as suggesting or having sexual contact with a patient
in the course of treatment. Currently, all 50 states regulate chiropractors.
11. The extent to which the level of regulation exercised by the Board is appropriate
and whether less or more stringent levels of regulation would be appropriate.
The audit found that the current level of regulation the Board exercises is
generally appropriate.
12. The extent to which the Board has used private contractors in the performance
of its duties and how effective use of private contractors could be accomplished.
The Board has relied on private contractors to perform activities beyond its staff
resources or abilities. For example, the Board contracts for information
technology support. Additionally, the Office of the Auditor General’s 2001
performance audit and sunset review of the Board (see Report No. 01-12)
suggested that the Board could better separate its investigative and adjudicative
functions by contracting with chiropractic medical consultants to assist in
complaint investigations that require technical expertise. The Board has
contracted with medical consultants for these types of investigations since the
2001 audit. According to the Board, it stopped using these contracts in fiscal
year 2009 and decided to limit its use of these contracts during fiscal year 2010
because of budget constraints. The current audit did not identify any changes
that were needed related to the Board’s use of private contractors.
Methodology
Auditors used various methods to study the issues addressed in this report. These
methods included interviewing Board of Chiropractic Examiners (Board) members,
management, and staff; reviewing board statutes and rules; reviewing board policies
and procedures; observing three board meetings during fiscal years 2009 and 2010;
and reviewing board meeting minutes for various board meetings that occurred
during fiscal years 2006 through 2009.
In addition, auditors assessed the Board’s internal control structure that supports the
collection and management review of complaint-handling data to determine
completeness and reliability. Auditors’ work on the controls over the Board’s data
included interviewing various staff and management knowledgeable about and
responsible for data input accuracy to assess supervisory controls over data input.
Auditors also assessed data reliability as follows:
Complaint-handling data—Auditors assessed the reliability of complaint-handling
data in the Board’s complaint-tracking system by (1) assessing
completeness and accuracy of complaint-handling data (dates, allegations,
outcomes, and other identifying information) using ACCESS queries, and (2)
reviewing related documentation for a random sample of ten complaints
opened between fiscal years 2007 and 2009 that were chosen using a random
number generator, and ten files randomly selected from file drawers. Auditors
found the Board’s complaint-tracking system data to be generally complete and
accurate for the purposes of determining overall timeliness.
 Licensing data—Auditors did not evaluate the accuracy of the data sources
used to track the number of licenses issued and renewed, and so limited the use
of this information to background purposes. Auditors noted that the Board does
not track the number of licenses reinstated each year. A license must be
reinstated if it is suspended or if the licensee does not renew his/her license on
Office of the Auditor General
page a-i
APPENDIX A
time. However, the Board indicated that a minimal number of licenses are
reinstated each year.
Auditors also used the following methods:
To determine whether the Board’s opening, investigation, adjudication, and
disciplinary practices are in compliance with its statutory authority, and whether
discipline appeared to be consistently applied, auditors reviewed a total of 42
complaints that were opened and/or resolved during fiscal years 2006 through
2009. The 42 complaints reviewed involved 39 licensees, and included 27
complaints selected randomly and 15 selected judgmentally, including some
that were added to ensure that the file review included board-opened
complaints or the most serious sanctions the Board employed. Table 4 illustrates
the results of the file review by each sampling technique.
In addition, auditors selected four other Arizona health
regulatory boards—the Arizona Medical Board,
Naturopathic Physicians Medical Board, Board of
Osteopathic Examiners in Medicine and Surgery, and Board
of Podiatry Examiners—based on their experience handling
complaints, size, auditors’ familiarity with board processes,
and/or because their professionals provided some of the
same services as chiropractors, and interviewed these
boards’ executive directors regarding their complaint-handling
practices. Auditors also reviewed the four boards’
complaint-handling statutes. Additionally, auditors reviewed
the Washington State Department of Health’s Disciplinary
guidelines manual.
To assess the Board’s financial status, auditors obtained and reviewed
information on the Board’s budget process and various expenditures; compiled
and analyzed unaudited information about the Board from the Arizona Financial
Information System (AFIS) for fiscal years 2004 through 2009 and the AFIS
Management Information System Status of General Ledger—Trial Balance
screen for fiscal years 2004 through 2009, and board estimates for fiscal year
2010 as of March 2010; and reviewed agency documentation including a board
document explaining the Board’s financial situation. Auditors also reviewed the
Office of the Auditor General’s 2001 performance audit and sunset review of the
Arizona State Board of Chiropractic Examiners (see Report No. 01-12), and
changes that occurred to the Board’s statutes after 2001 to determine whether
such changes may have impacted the Board’s financial situation. Finally,
auditors requested national information about the profession from the National
Board of Chiropractic Examiners.
State of Arizona
page a-ii
Selection Method
Random
(27 total)
Judgmental
(15 total)
Subpoena too broad 3 0
Board considered prior
complaint and disciplinary
information too soon 6 7
Advisory letters used
inconsistent with statute 3 0
Inconsistent discipline issued 1 0
Table 4: File Review Results by Selection Method
Fiscal Years 2006 through 2009
Source: Auditor General staff analysis of 42 complaint files selected from
fiscal years 2006 through 2009.
To develop information for the Introduction and Background section, auditors
compiled and analyzed unaudited information about the Board from the Arizona
Financial Information System (AFIS) for fiscal years 2004 through 2009 and the
AFIS Management Information System Status of General Ledger—Trial Balance
screen for fiscal years 2004 through 2009, and board estimates for fiscal year
2010 as of March 2010; reviewed information about the Board in the Joint
Legislative Budget Committee appropriations report for fiscal year 2009; and
reviewed the Board’s organizational chart and other agency-provided
documents. Auditors also reviewed the National Board of Chiropractic
Examiners Web site for national exam information and other chiropractic
information; the Council on Chiropractic Education’s Web site for information on
national chiropractic colleges accredited by the Council; and the Master List of
State Government Programs.
To gather information for the Sunset Factors, auditors relied on work conducted
to complete the audit report’s Introduction and Background section, Finding,
and Other Pertinent Information section. Additionally, auditors placed four
anonymous public information request phone calls to board staff and reviewed
the Board’s records-retention schedule filed with the Arizona State Library,
Archives and Public Records. Auditors also reviewed a sample of ten licensing
files for initial licenses issued between fiscal years 2007 and 2009, including
renewal information for six licenses. Additionally, auditors reviewed an analysis
of the Board’s administrative rules performed by the Governor’s Regulatory
Review Council staff and a board notice of proposed rulemaking filed with the
Secretary of State’s Office. Auditors also assessed the Board’s compliance with
open meeting laws, including reviewing its statement of disclosure filed with the
Secretary of State’s Office as of June 19, 2009, and two board meeting notices
and agendas from May and June 2009. Auditors also reviewed board
interagency service agreements with other state agencies such as the Attorney
General’s Office and board contracts such as those for contracted investigators.
Office of the Auditor General
page a-iii
Office of the Auditor General
AGENCY RESPONSE
The following auditor comments are provided to address certain statements the
Board of Chiropractic Examiners made related to Finding 1:
1. The Board refers to a Court of Appeals (Division 2) case, but according to the
Court, this case does not create legal precedent. The Board's response
indicates that the case demonstrates that the intent of the law regarding the
scope of a subpoena is not to narrow the reasonable scope of an investigation.
However, our report does not recommend narrowing the reasonable scope of
an investigation, but rather that the Board limit where possible the amount and
type of records requested in its subpoenas. (See page 3 of the Board's
response.)
2. The Board's response refers to a statement made by an Assistant Attorney
General for the Office of the Auditor General. However, as allowed by A.R.S. §41-
192(E)(5), our Office has its own General Counsel, and does not make use of
an Assistant Attorney General. (See page 3 of the Board's response.)
3. The Board's response suggests that staff are allowed to dispose of complaints
based on the results of investigations. However, only the Board has authority to
conclude on the results of investigations and resolve complaints. Therefore,
regardless of whether staff investigations identify no or minor violations,
according to A.R.S. §32-924(E) and (F), the Board is responsible for determining
what actions to take such as dismissing a complaint, or issuing nondisciplinary
or disciplinary action. (See page 4 of the Board's response.)
Office of the Auditor General
AUDITOR GENERAL REPLY
TO AGENCY RESPONSE
Performance Audit Division reports issued within the last 24 months
Future Performance Audit Division reports
Department of Agriculture—Sunset Factors
09-08 Arizona Department of Liquor
Licenses and Control
09-09 Arizona Department of Juvenile
Corrections—Suicide Prevention
and Violence and Abuse
Reduction Efforts
09-10 Arizona Department of Juvenile
Corrections—Sunset Factors
09-11 Department of Health
Services—Sunset Factors
10-01 Office of Pest Management—
Restructuring
10-02 Department of Public Safety—
Photo Enforcement Program
10-03 Arizona State Lottery
Commission and Arizona State
Lottery
10-04 Department of Agriculture—
Food Safety and Quality
Assurance Inspection Programs
10-05 Arizona Department of Housing
08-03 Arizona’s Universities—Capital
Project Financing
08-04 Arizona’s Universities—
Information Technology Security
08-05 Arizona Biomedical Research
Commission
08-06 Board of Podiatry Examiners
09-01 Department of Health Services,
Division of Licensing Services—
Healthcare and Child Care
Facility Licensing Fees
09-02 Arizona Department of Juvenile
Corrections—Rehabilitation and
Community Re-entry Programs
09-03 Maricopa County Special Health
Care District
09-04 Arizona Sports and Tourism
Authority
09-05 State Compensation Fund
09-06 Gila County Transportation
Excise Tax
09-07 Department of Health Services,
Division of Behavioral Health
Services—Substance Abuse
Treatment Programs