Former interim chief of compliance questions validity of drug testing done at AU

By Emily Garcia |
Special to the Bell Ringer

John Lott, former interim chief of compliance at Augusta University (AU) and compliance investigator on Dr. Sarah Kavianpour’s case, explained that AU officials created false pretenses to drug test her monthly and are likely to do it again to others.

After Lott brought up issues of validity with Dr. Kavianpour’s drug testing to AU officials, he said he was promptly removed from the investigation and terminated shortly after.

“Every student at the university should be scared. Every resident should be scared. Every employee should be scared,” said Lott.

On June 25, 2018, Dr. Kavianpour submitted a pre-employment drug test to obtain her neurosurgery residency contract at AU.

Lott said the drug test given by AU was botched and in violation of Georgia law.

“They didn’t do split sampling, [and] she had the right to split sampling. It was the law, it was the policy, [and] they botched it. They tested her again and it was negative,” said Lott.

Split sample collection is a method used during urine test administration to confirm or negate a positive result at an outside facility. The purpose of split sample collection is to prevent false positives.

By law, once a retest comes back negative, the former result must be disregarded entirely and cannot be used as a means to discipline an individual.

“This woman is a medical doctor. [If] you’re telling people she failed a drug test that she never failed, this could destroy her career. There are ethical concerns for anybody that continues to say things that are not true. It’s defamatory,” Lott explained.

On July 11, 2018, Dr. Kavianpour was offered an employment contract, which she signed.

A little over a month later, Dr. Kavianpour received a memorandum from Susan Norton, the vice president of human resources (HR) at AU, informing her that “in accordance with Augusta University’s Substance Abuse Policy” she would “be subject to random drug testing beginning now until July 31, 2019.”

The letter stated that she was subject to testing because she performed a duty considered to be “high risk.” It also included that she would need to appear for testing within an hour of being contacted by Debra Arnold, the director of employee relations.

The University System of Georgia’s (USG) policy on drug testing allows for testing subjects to appear up to two business days after notification.

The memorandum was signed solely by Norton, according to Dr. Kavianpour’s complaint.

In a statement Dr. Kavianpour gave for this article, she said AU’s HR department violated USG and AU policies on drug testing by testing her every month instead of using “an anonymous basis through an established methodology of employee population each year,” per AU’s substance abuse policy found on the medical college’s webpage.

Dr. Kavianpour was drug tested at least every month for the next several months with every test coming back negative.

The complaint Dr. Kavianpour later filed in federal district court explained that by December 2018, she grew increasingly concerned about her drug test timing jeopardizing patient safety. Dr. Kavianpour expressed her concerns in a meeting with Dr. Walter Moore, the chair of the department of medicine, in mid-December.

In her statement, Dr. Kavianpour wrote, “They unilaterally created a process where abandoning the hospital’s neurosurgical on-call service would be unsafe and the process was in direct violation of Georgia’s law.”

According to the court document, Dr. Kavianpour offered to be available for voluntary drug testing daily if it could be arranged for a time of day that would not interfere with her patient responsibilities as a neurosurgery resident.

In January 2019, Dr. Kavianpour transitioned to a level of independence where she would be the only neurosurgery resident on-call overnight.

The complaint explained that one resident is assigned to the on-call pager that receives urgent notices about changes in patient status and because “patients’ neurological status can be life-threatening and require immediate response and evaluation to determine the need for emergency surgery, residents with on-call pager duty must respond to pages as soon as possible, but in no event within more than 10 minutes.”

On January 22, the complaint reported that Dr. Kavianpour emailed Arnold, Norton and others, asking “again to discuss the inappropriate timing of calls/testing, the lack of flexibility and justification per [the medical college’s] MCG policy (and state and federal laws).”

Several days later, Arnold responded to Dr. Kavianpour, revising Norton’s initial memorandum to include that Dr. Kavianpour would not be subject to testing on her days off and that HR would notify her program director, Dr. Samuel Macomson, when a test was needed to confirm that she’d be available.

Dr. Kavianpour’s subsequent test day was February 13. According to the complaint, Dr. Macomson was not notified as Arnold’s memorandum said he would be.

On February 13, Dr. Kavianpour was given four hours to report to testing instead of the usual one hour.

However, according to the complaint, Dr. Kavianpour informed Arnold on the same day that she might not be able to report to testing because she was on sole pager duty, and the other neurosurgery residents were in the operating room, unable to cover for her.

The complaint stated that the neurosurgery department’s coverage practice deviated from standards of care by not having a backup policy in place for situations such as a resident needing to leave for drug testing.

Additionally, AU House Staff Policy 10.0 and graduate medical education core requirements mandate, “Each program must have policies and procedures in place that ensure coverage of patient care in the event that a resident may be unable to perform their patient care responsibilities. These policies must be implemented without fear of negative consequences for the resident who is unable to provide the clinical work.”

Dr. Kavianpour reported to testing the next morning but according to the complaint, Arnold and Norton directed the testing center not to test her.

At that point, the complaint said Dr. Kavianpour called Dr. Macomson and he indicated to her that he was unaware Norton and Arnold asked her to test the previous day.

However, during that day and for the next week, Dr. Kavianpour was able to continue with patient care without any restrictions.

On February 21, Norton and Arnold drafted a letter to Chief Medical Officer Dr. Phillip Coule recommending Dr. Kavianpour’s termination due to her failure to appear for testing.

The complaint alleged that no independent investigation of the allegations contained in Arnold’s letter was done.

In Dr. Kavianpour’s statement for this article she wrote that “Norton and Arnold misrepresented this illegal process as being a legal process and misled hospital and university officials to have me removed from my residency position.”

Following Norton and Arnold’s directive, the complaint said Dr. Coule “drafted a letter immediately suspending Plaintiff from all AU and [AU Medical Center] AUMC clinical activities.”

Dr. Kavianpour explained, “Further in breach of my residency contract, policies and practice, Norton and Arnold drafted my termination letter [from her residency program].”

Dr. Kavianpour was given five days to submit an appeal to Dr. Fernando Vale, the neurosurgery chair at the medical college, and 10 days to appeal to HR.

The complaint explained that Dr. Macomson also informed Dr. Kavianpour that the termination decision “did not come from the department” but was “HR-driven and out of his control.”

Dr. Vale said a similar thing to Dr. Kavianpour five days later when she made her appeal and he upheld the decision to terminate her.

According to the complaint, “Dr. Vale claimed he had not been part of the decision and wanted Dr. Kavianpour to return to work as soon as possible but was powerless to overturn an AUMC decision.”

Dr. Vale could not reinstate Dr. Kavianpour in her residency because Dr. Coule revoked Dr. Kavianpour’s clinical privileges, and without clinical privileges Dr. Kavianpour could not participate in the residency program.

On March 4, Dr. Kavianpour submitted her statement of grievance to HR as directed by her termination paperwork.

However, the complaint stated that this directive contradicted her residency employment contract, which required the GME office to handle “procedures for discipline and redress of grievances.”

The next day Dr. Kavianpour emailed Dr. Coule and others asking to meet to discuss the termination.

On March 13 Dr. Kavianpour filed an urgent retaliation claim with Clay Sprouse, the vice president of compliance at AU, asking him to take over the grievance process under AU’s Non-Retaliation Policy and resolve conflicts of interest.

According to the complaint, Sprouse took no action to suspend HR’s hearing and investigate the matter, “let alone take any corrective measures per AU policy.”

The complaint stated that in the following days Dr. Kavianpour sent out emails to HR and Drs. Coule and Moore, seeking clarification on the grievance process, noting HR’s conflict of interest and the lack of due process for the suspension. Dr. Kavianpour wrote that she believed the grievance process violated laws concerning her rights and the safety of patients.

The complaint said Dr. Kavianpour received no response to these emails.

On March 15, Dr. Kavianpour emailed Sprouse prior to her grievance hearing, asking if she should raise issues of retaliation and unlawful HR practices in her grievance statement.

“She did not initially [raise these concerns] because she feared further retaliation from Arnold and Norton,” the complaint explained.

Sprouse responded that he would collect additional information and be in touch, but never did, according to Dr. Kavianpour.

Dr. Kavianpour’s complaint said she also sought mediation to which her department was agreeable before her hearing which Norton denied.

On March 19 at the pre-hearing, Dr. Kavianpour submitted witness lists to the grievance hearing officer and other HR personnel so that they could, per AU policy, arrange witness attendance.

The complaint stated that the grievance hearing officer “did not do so and they admitted to not knowing or caring about [the Accreditation Council for Graduate Medical Education] ACGME and [graduation medical education] GME policies” as required by Dr. Kavianpour’s contract.

On March 22, Rebecca Williams, the assistant vice president of HR, conducted Dr. Kavianpour’s grievance hearing.

According to the complaint, “at the hearing, the hearing officer did not allow Dr. Kavianpour to raise pertinent evidence, perform or re-direct cross examinations, or discuss discrimination or harassment by HR.”

On March 26 the grievance hearing panel recommended Dr. Kavianpour’s termination be upheld based on a “pattern of passive unwillingness.” The complaint said the panel supported their decision with a letter written by an adverse witness, who was not at the hearing for Dr. Kavianpour to cross examine.

Additionally, the complaint noted that the panel falsely alleged that the drug testing was a condition of Dr. Kavianpour’s contract despite her explaining that it was not.

Lott said the grievance panel also shared this misinformation with the provost and president.

In her written statement for this article she stated that the misrepresentations about the nature of her drug testing poisoned the well and tainted administrative hearings.

On April 2, the provost upheld the grievance panel decision.

Two days later, President Keel wrote Dr. Kavianpour a letter reiterating the panel’s decision and stating that she could apply to the Board of Regents (BOR) for discretionary review.

The complaint said neither the president nor the provost conducted any independent investigation to determine the validity of the allegation against Dr. Kavianpour.

On June 26, John Lott, a third-party contractor from a company called CynergisTek, took over the investigation into Dr. Kavianpour’s complaint of discrimination and retaliation as AU’s incoming chief compliance officer.

The complaint said Lott met with several AU officials as part of his investigation.

A month later, Lott emailed Sprouse recommending that their office “make the University President Keel aware that Arnold admitted to violating AU’s Random Drug Testing Policy as applied to Dr. Kavianpour.”

The next day, Sprouse and Lott conducted interviews with Norton and AU Legal Advisors Clark Speese and Greg Bryan. According to the complaint, the interviews helped them determine that AU, AUMC and USG’s Random Drug Testing Policy were not adhered to in Dr. Kavianpour’s case.

Additionally, the complaint said Lott advised Sprouse to remove himself from the investigation because he was allegedly found to be implicated in the issue.

Lott said the next day he was summoned to Sprouse’s office, removed from his position and shortly after, his contract was terminated.

After Lott’s termination, Sprouse took control of the compliance investigation.

Lott explained that Sprouse falsely told Dr. Kavianpour that he left because his contract was finished. Lott’s contract was not due to end until November of that year and Lott was being offered a permanent position prior to his removal.

According to Lott, Sprouse’s withholding of exculpatory evidence took place despite Sprouse validating his finding in Sprouse’s own statement to Wesley Horne, the director of ethics and compliance for USG. This information was found in an email obtained through Open Records by Dr. Kavianpour.

Lott said that despite Sprouse acknowledging Horne that Dr. Kavianpour’s testing process had been misrepresented to her, this information was not communicated to Kavianpour and was not communicated to her ad hoc committee by her program director during her recorded ad hoc hearing.

Lott, who was present at the ad hoc hearing, said he became concerned after witnessing Dr. Macomson make misleading statements regarding the nature of Dr. Kavianpour’s testing to her ad hoc committee, and then being notified that those misleading statements affected the decision not to renew her contract.

After months of submitting complaints of unethical behavior in the office of compliance to both AU and the BOR, on November 20, 2019, Dr. Kavianpour and her father met with Horne and Dr. Juanita Hicks, the vice president of HR for the BOR, to discuss her concerns.

Dr. Kavianpour was not followed up with until she filed her lawsuit.

Dr. Kavianpour is suing for Americans with Disabilities Act, Georgia Whistleblower Protections Act, Title VII and Title IX violations, as well as breach of contract and violations of the Fourth and Fourteenth Amendments. Her case is still open and can be found in the Northern District of Georgia.

Dr. Kavianpour is requesting a trial by jury, reinstatement and compensatory damages.

Lott said that AU officials are continuing to use university and state funds to defend a case without being completely forthcoming and transparent.

He said he believes AU using the Attorney General’s office to defend individuals that misrepresented their authority in order to illegally procure Kavianpour's bodily fluids for their own purposes of non-compliant testing, is waste and abuse of government resources.

“Procuring her bodily fluids by misrepresentation could be seen as a crime, and is at minimum a violation of AU’s policies and USG’s Code of Conduct,” Lott explained.

AU officials did not respond directly when reached out to for comment.

AU Vice President of Communications Christen Engel stated, “As a practice, we do not comment on personnel issues.”

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