Mark McDougal of the Portland law firm Kafoury & McDougal interviewed advanced registered nurse practitioner Kelly Bell, owner of the Payette Clinic, in July 2011. McDougal allowed The Columbian to review Bell’s sworn deposition for this story. The law firm has multiple lawsuits, including wrongful death, pending against Bell and other staff at the Payette Clinic.
Bell, through her attorney Don Grant of Vancouver, declined to participate or comment for this story, due to pending litigation.
TIMELINE OF EVENTS
• April 2005: Kelly Bell and Scott Pecora receive a business license from the state of Washington and open the Payette Clinic in the VanMall neighborhood.
• December 2008: Rachel Daggett, an Oregon high school senior, dies from an oxycodone overdose. She bought the pill from a Payette patient.
• March 2009: The Drug Enforcement Administration raids the Payette Clinic as part of an investigation sparked by complaints.
• March 2009: Kelly Bell, Scott Pecora and Penny Steers surrender their privileges to prescribe controlled substances and other narcotics to the DEA.
• December 2009: The Washington Nursing Quality Care Assurance Commission suspends Kelly Bell’s privileges to prescribe Schedule II drugs for 24 months.
• January 2010: Kelly Bell and Scott Pecora receive a business license in the Payette Clinic’s new name, Walnut Grove Medical & Mental Health.
• August 2010: The Walnut Grove Medical & Mental Health clinic moves to 300 W. 39th St., in the Lincoln neighborhood.
• January 2011: The Washington State Department of Health opens an investigation into Kelly Bell, Scott Pecora and Penny Steers. The investigation remains open.
The three nurse practitioners linked to a teenager’s overdose death and investigated for overprescribing narcotic medications could have their prescription pads back in hand.
The advanced registered nurse practitioners who operated Vancouver’s Payette Clinic -- Kelly Bell, Scott Pecora and Penny Steers -- are eligible to reapply for the ability to prescribe narcotics and other controlled substances to patients.
That’s despite nearly 60 complaint cases filed against them with the state Department of Health, despite allegations of excessive prescribing and despite the death of a high school senior who overdosed on oxycodone prescribed to a Payette patient.
It’s despite a Drug Enforcement Administration investigation that ultimately shut down the clinic’s prescribing operations in March 2009.
It’s despite Washington State Department of Health sanctions against Bell for unprofessional conduct. The state stripped her of her privileges to prescribe Schedule II drugs -- such as oxycodone, morphine and methadone -- for two years. That suspension period ended last month.
And it’s despite an ongoing state Health Department investigation into Bell, Pecora and Steers. Health officials launched the probe in January 2011 and have no time line for its completion.
The state of Washington issued Bell a registered nursing license in October 1981, and for two decades, Bell worked as a nurse in various hospitals.
In December 2000, Bell completed her master’s degree with an emphasis in family practice at Washington State University Vancouver. The following summer, the state of Washington issued Bell an advanced registered nurse practitioner license, which also gave Bell the authority to prescribe controlled substances in the state.
In 2001, the Drug Enforcement Administration granted her the ability to prescribe narcotic medications. At the time, Bell was working at the Clark County Jail and prescribing “very little” opioids, Bell said in her deposition.
In 2004, the jail revoked Bell’s security clearance, causing her to be terminated from her job. She then went to work at Fisher’s Landing Urgent & Family Care before being fired a year later. In April 2005, Bell and Pecora received a business license from the state of Washington and opened the Payette Clinic in the VanMall neighborhood.
The duo operated the Payette Clinic as a medical and mental health clinic. Nurse practitioners are independent providers and don’t need to work under the authority of a physician. At its height, the clinic had 2,500 patients. Of those, according to Bell, 700 to 900 were pain patients.
Trina Munson was one of those pain patients. The Vancouver woman first started seeing Bell at the Fisher’s Landing clinic and followed Bell to the Payette Clinic.
Munson was a patient of Bell’s for about two years. In that time, Munson said she was never given an X-ray or MRI, never had lab work or a physical exam performed and had only two urinalyses.
What Munson did get was prescriptions from Bell for daily doses of more than 1,800 milligrams of controlled substances.
As word of the liberal prescribing practices at the Payette Clinic spread, the clinic’s client base grew.
Munson recalled arriving at the Payette Clinic for appointments to find people waiting in the parking lot for Bell to open the doors. New patients knew they could hand over $400 cash and, with no previous medical records, walk out of the clinic with a prescription for narcotics, Munson said.
In her July deposition, Bell said she did not have a policy about obtaining a patient’s prior medical records before treating them at the Payette Clinic.
In fact, Bell never had any written procedures for staff to follow when working with pain patients, according to her deposition.
The clinic did not have guidelines regarding the amount of opiates to be prescribed to patients nor did it have guidelines for identifying addiction in patients, Bell said.
Bell considered pain contracts a teaching tool and would sometimes use them if she believed a patient would be on pain medication for a long time. The nurse practitioners used their discretion on whether to monitor patient usage with urinalyses and pill counts, Bell said.
Bell also admitted in her deposition to altering prescription directions in order to get insurance coverage. Munson said her office visits were billed to her insurance as obstetrician appointments.
While the Payette Clinic operated in relative obscurity, as far the general public was concerned, Bell, Pecora and Steers were familiar to the Washington State Department of Health.
Since 2005, the state has opened 36 complaint cases into Bell’s conduct, as well as 17 cases into Steers and six cases into Pecora. The complaints came from patients’ family members, the DEA, Washington State Department of Labor & Industries, Washington State Department of Social and Health Services, Medicare and Medicaid, other providers and pharmacists.
Numerous complaints accused Bell of prescribing excessive amounts of narcotics.
Bell said repeatedly, in her deposition and in response to complaints filed with the state, that there is no prescription ceiling for opioids.
In response to one complaint, Bell wrote, “The doses may be considered ‘high’ by clinicians (physicians and pharmacists) who do not specialize in chronic pain management. In this community, it seems perfectly fine to write for handfuls of Vicodin and Norco (acetaminophen and hydrocodone), but not for a reasonable amount of pure opioid.”
She went on to complain about being investigated.
“It is emotionally draining to be examined, questioned and complained against,” she wrote.
One complaint attributed the overdose deaths of three patients to Bell’s prescribing. The state, however, didn’t find evidence that Bell was responsible for any deaths, said Mary Dale, discipline manager for the Washington Nursing Quality Care Assurance Commission.
Pharmacists from numerous local pharmacies questioned the legitimate need for such large quantities of narcotics and voiced concern for Bell’s patients.
“We provide medications for mental health patients, residents of adult foster homes, residents of assisted living facilities and hospice patients throughout Clark County and other areas. We are not seeing prescriptions of this magnitude being written by other prescribers for other patients,” one pharmacist wrote to officials.
“I do not see any attempt for pain management or treating physical dependence,” another wrote. “I strongly believe she is jeopardizing the health care of her patients and/or disregarding her oath of ethical practice.”
Despite all of the complaints, the 2009 action is the only time the nursing commission sanctioned Bell. Neither Steers nor Pecora have been sanctioned by the nursing commission.
None of the providers lost the ability to work as advanced registered nurse practitioners.
Bell and Pecora reopened the Payette Clinic under a new name, Walnut Grove Medical & Mental Health, and continue to serve pain patients but without prescribing narcotic drugs.
The clinic’s website said it offers pain therapies that use injections -- either of one’s own plasma or a saline solution -- into painful sites such as joints, ligaments or tendons. The fluid is supposed to tighten loose joints and heal the area, according to the clinic.
In August 2010, Bell and Pecora relocated the clinic to 300 W. 39th St. in Vancouver’s Lincoln neighborhood.
In March 2009, Bell, Pecora and Steers all voluntarily surrendered their DEA registrations. The voluntary action was in lieu of the DEA taking the practitioners to court to suspend the privileges.
The DEA did not impose a waiting period before Bell, Pecora or Steers could reapply for their prescribing privileges. None of the practitioners currently has narcotic prescription-writing privileges, but it’s unclear if they have reapplied. The DEA does not confirm or deny the existence of open investigations, said Special Agent Jodie Underwood, spokeswoman for the DEA’s Seattle office.
In December 2009, the state nursing commission suspended Bell’s privileges to prescribe Schedule II drugs for 24 months. In order to get her privileges back, the commission ordered Bell to complete approved graduate-level coursework in pain management.
In her July deposition, Bell said she did not have any interest in prescribing Schedule II controlled substances “at this point.” However, she has completed some courses that would meet the requirements set by the state.
As of late January, Bell had not petitioned the nursing commission to have her privileges reinstated, said Dale, the commission’s discipline manager.
Because Pecora and Steers were never sanctioned, nothing is stopping them from reapplying for prescribing privileges from the DEA, the state’s Dale said.
The fallout from the Payette Clinic sent ripples throughout Clark County, but it also sparked action at the state level.
In 2010, Washington lawmakers passed Engrossed Substitute House Bill 2876, calling for new prescribing rules. State Rep. Jim Moeller, D-Vancouver, who has worked as an addiction counselor for more than 25 years, sponsored the bill as a result of the Payette Clinic.
The bill directed the five governing boards and commissions for Washington practitioners to adopt uniform rules concerning the management of chronic pain not caused by cancer. The rules recently went into effect.
The new rules require a patient evaluation and complete history of pain treatment, a written treatment plan and a written agreement for treatment. The rules also require prescribers of long-acting opioids or methadone to have completed at least four hours of specialized training.
One of the bigger changes is the requirement of a pain specialist consultation. Prescribers with a patient who reaches an established threshold (120 milligrams of a morphine equivalent per day) must seek a pain specialist consultation under the new rules.
In addition, the state launched last month a prescription monitoring program for pain medication and other controlled substances. Physicians, pharmacists and law enforcement officers have access the secure database that tracks the prescriptions.
The chilling effect of the Payette Clinic is still evident in Clark County.
Utter the clinic’s name to emergency department physicians, police officers, pharmacists or pain specialists, and expressions become either solemn, critical or defensive.
But, according to Bell, she did nothing improper or inappropriate when it came to caring for her patients and writing prescriptions.
“I believe I did the best I could with the information that I had available to me at the time in the literature with a very complicated group of people,” she said.