I sustain the determination of the Inspector General (I.G.) to exclude Petitioner, Dionisio Lazaro, M.D., from participating in Medicare and State health care programs, including State Medicaid programs, for a period of 20 years.

I. BACKGROUND

A. Background facts

On March 31, 1998, the I.G. notified Petitioner that he was being excluded from participating in Medicare and State health care programs. The I.G. advised Petitioner that she was authorized to exclude him because Petitioner had been convicted of a criminal offense related to the delivery of an item or service under the Medicaid program of the State of California (Medi-Cal). The I.G. told Petitioner that she had determined the length of the exclusion (20 years) by taking into consideration certain aggravating factors that the I.G. had found to be present in Petitioner's case.

Petitioner timely requested a hearing and the case was assigned to me for a hearing and a decision. I conferred with the parties and the parties agreed that the case could be heard based on the parties' written submissions and a hearing to be conducted over the telephone. I held a telephone hearing on March 2, 1999.⁽¹⁾ Petitioner testified on his behalf at that hearing. At the hearing, I admitted into evidence exhibits from the I.G. consisting of I.G. Ex. 1 - 15. I admitted into evidence exhibits from Petitioner consisting of P. Ex. 1 - 15. Subsequent to the hearing, Petitioner offered an additional exhibit, P. Ex. 16. The I.G. has not objected to my receiving P. Ex. 16 into evidence. Therefore, I receive P. Ex. 16 into evidence.

B. Governing law

The I.G. excluded Petitioner pursuant to section 1128(a)(1) of the Social Security Act (Act). This section mandates the exclusion of any individual or entity who is convicted of a criminal offense related to the delivery of an item or service under Medicare or a State Medicaid program. The minimum statutory exclusion period for an exclusion that is imposed under section 1128(a)(1) is five years. Act, section 1128(c)(3)(B). However, where the I.G. has authority to exclude an individual or entity under section 1128(a)(1), the I.G. may exclude that individual or entity for a period that is longer than five years where circumstances warrant a longer exclusion.

The Secretary of the United States Department of Health and Human Services has published regulations which establish criteria which may be considered in determining the length of an exclusion which is imposed pursuant to section 1128 of the Act. 42 C.F.R. Part 1001. The specific criteria to be considered in determining whether an exclusion of more than five years is warranted for an individual or entity who is excluded pursuant to section 1128(a)(1) of the Act are stated at 42 C.F.R. � 1001.102. These criteria are described as aggravating and mitigating factors. 42 C.F.R. � 1001.102(b), (c). The aggravating and mitigating factors that are set forth at 42 C.F.R. � 1001.102(b) and (c) comprise the exclusive factors that may be considered in determining the length of an exclusion to be imposed under section 1128. Evidence which does not relate to an aggravating factor or to a mitigating factor is irrelevant to determining the length of an exclusion.

The Part 1001 regulations were republished with amendments and revisions effective September 2, 1998 and October 2, 1998. The I.G. sent her notice of exclusion to Petitioner on March 31, 1998, a date which is prior to the effective dates of the amended and revised Part 1001 regulations. Consequently, the regulations which govern Petitioner's case are the Part 1001 regulations that were in effect as of March 31, 1998. All references that I make in this decision to regulations are to those regulations that were in effect on March 31, 1998.

An administrative hearing that is conducted pursuant to section 1128 of the Act and to regulations contained in 42 C.F.R. Parts 1001 and 1005 is a de novo hearing. Act, section 205(b); Howard Schreibstein, D.P.M., DAB CR517 (1998). Where the length of an exclusion is at issue, the administrative law judge (ALJ) must decide independently from any determination that has been made by the I.G. whether the exclusion is unreasonable in light of evidence that is relevant to the factors pertaining to the length of exclusions that are set forth at 42 C.F.R. Part 1001.

The Part 1001 regulations, including 42 C.F.R. � 1001.102, do not prescribe the weight that must be given to evidence which relates to an aggravating factor or to a mitigating factor. They merely describe what evidence is relevant. Ultimately, the weight that is assigned to any evidence which is relevant to the issue of the length of an exclusion depends on what that evidence shows about the trustworthiness of an excluded individual to provide care or to claim reimbursement from federally funded health care programs.

Section 1128 is a remedial statute. Its purpose is not to impose additional punishment on individuals or entities who have been convicted of crimes or who have been subject to administrative sanctions. Its purpose is to provide protection to federally funded health care programs and to these programs' beneficiaries and recipients from untrustworthy individuals and entities. In order to be reasonable, an exclusion that is imposed pursuant to section 1128 must relate reasonably to the overall statutory purpose and must be based on evidence which addresses the trustworthiness or lack of trustworthiness of the excluded individual or entity.

Although an ALJ has a statutory duty to conduct a de novo hearing and to make an independent determination as to reasonableness in a case involving an exclusion imposed pursuant to section 1128 of the Act, the ALJ also has a responsibility to give some deference to the acumen and expertise of the I.G. in determining the length of exclusions. An exclusion should be upheld where it falls within a reasonable range of possible exclusions that the I.G. might have imposed based on the relevant evidence. Where the ALJ finds independently that an exclusion of a particular length is reasonable, the ALJ should uphold the I.G.'s determination if there is not a significant difference between what the ALJ decides to be reasonable and what the I.G. has determined to be reasonable in that case. Schreibstein, supra. An ALJ may modify the length of an exclusion if that which the ALJ decides independently to be reasonable differs significantly from that which the I.G. has determined to be reasonable.

The issues in this case are whether:

1. The I.G. is required to exclude Petitioner pursuant to section 1128(a)(1) of the Act; and

2. A 20-year exclusion is unreasonable assuming that the I.G. has authority to exclude Petitioner.

I make findings of fact and conclusions of law (Findings) to support my decision that an exclusion is required in this case and that a 20-year exclusion is reasonable. I set forth each Finding below as a separate heading. I discuss each Finding in detail.

1. The I.G. is required to exclude Petitioner.

The undisputed facts of this case establish that Petitioner was convicted of a criminal offense related to the delivery of items or services under Medi-Cal, a federally funded State health care program. Section 1128(a)(1) of the Act requires the I.G. to exclude Petitioner.

Petitioner is a physician. On February 21, 1997, Petitioner was charged with two felony counts in the Municipal Court of Long Beach Judicial District, County of Los Angeles, State of California. I.G. Ex. 4. The felony complaint charged Petitioner, at Count 1, with the crime of grand theft. Id. at 1 - 2. At Count 2, the felony complaint charged Petitioner with participating in a conspiracy with a named individual, Dr. Michael Natividad, and other unnamed individuals to defraud the Medi-Cal program. Id. at 2 - 4.

The felony complaint does not state in Count 1 that the grand theft of which Petitioner was accused constituted theft from the Medi-Cal program. However, I find it to be clear, both from the juxtaposition of Counts 1 and 2 of the felony complaint, and the documentation that was filed in support of the felony complaint, that Petitioner was charged with theft from Medi-Cal.

The felony complaint was supported by a Declaration in Support of Arrest Warrant. I.G. Ex. 3. The declaration alleged that, between January 3, 1994 and November 30, 1995, Petitioner conspired with Dr. Natividad and unlawfully took from the State of California the sum of $1,205,030.59. Id. at 1. The declaration alleged that Petitioner was a co-owner and operator of a clinic known as "The Good Shepherd Family Medical Clinic" (Good Shepherd), located at 3801 N. Long Beach Boulevard, Long Beach, California. Id. It alleged further that Petitioner and Dr. Natividad submitted between 20 and 50 false claims daily between January 3, 1994 and November 30, 1995. Id. at 2. In an interview report which accompanied the declaration, Petitioner admitted that the clinic created 25 Medi-Cal patient charts daily. Id. at 8. However, Good Shepherd treated only 1 - 3 Medi-Cal patients per day. Id. On some days the clinic treated no Medi-Cal patients. Id. Petitioner admitted that he knew that he was a willing participant in the scam of fraudulently billing for Medi-Cal patients that were never treated. Id. at 9.

On May 1, 1997, Petitioner pled guilty to Count 1 of the felony complaint. I.G. Ex. 7; I.G. Ex. 8. As part of a plea agreement entered into by Petitioner, Count 2 was dismissed. Ids.

A plea of guilty is a "conviction" for purposes of section 1128 of the Act. Act, section 1128(i). Therefore, Petitioner was convicted of a criminal offense. The conviction related to the delivery of items or services under Medi-Cal, a State health care program. As a matter of law, a theft from a federally funded health care program based on false or fictitious claims is a crime that is related to the delivery of items or services under that program. Greene v. Sullivan, 731 F. Supp. 835, 838 (E.D. Tenn. 1990). Thus, Petitioner was convicted of a criminal offense relating to the delivery of an item or service under a State health care program. Exclusion for such a conviction is mandatory under section 1128(a)(1) of the Act. The I.G. is required to exclude Petitioner.

2. Aggravating factors exist in this case.

An exclusion that is imposed pursuant to section 1128(a)(1) of the Act must be for a minimum period of at least five years. Act, section 1128(c)(3)(B). The I.G. determined to exclude Petitioner for a period of 20 years based on her finding that there exist four aggravating factors in this case as are described in 42 C.F.R. � 1001.102(b).

The evidence in this case proves the presence of three of the four aggravating factors that the I.G. determined to be present. These are that: the acts resulting in Petitioner's conviction, or similar acts, resulted in a financial loss to a State health care program of more than $1,500; Petitioner was incarcerated as a consequence of his conviction; and, Petitioner has a prior administrative sanction record. The I.G. did not prove the presence of a fourth alleged aggravating factor, that being that Petitioner allegedly perpetrated his crimes over a period of more than one year's duration.

a. The acts resulting in Petitioner's conviction, or similar acts, resulted in a loss to a State health care program of more than $1,500 (42 C.F.R. � 1001.102(b)(1)).

The version of 42 C.F.R. � 1001.102(b)(1) that was in effect on March 31, 1998, provides that it shall be an aggravating factor if the acts resulting in the excluded individual or entity's conviction, or similar acts, resulted in financial loss to Medicare and the State health care programs of $1,500 or more. There is no dispute that the acts resulting in Petitioner's conviction, or similar acts, resulted in a loss to Medi-Cal in excess of $1,500. Petitioner was sentenced to pay restitution in the amount of $1,234,000 as recompense for his theft. I.G. Ex. 7 at 1. Petitioner has admitted that the claims from Medi-Cal that he generated came to approximately $493,000. Tr. at 46 - 47; Petitioner's posthearing brief at 4 - 5.

b. Petitioner was incarcerated as a consequence of his conviction (42 C.F.R. � 1001.102(b)(4)).

The version of 42 C.F.R. � 1001.102(b)(4) that was in effect on March 31, 1998, provides that it shall be an aggravating factor if the sentence that is imposed on an excluded individual for his or her conviction of a crime within the meaning of section 1128(a)(1) of the Act includes incarceration. That factor plainly is present here. Petitioner was sentenced to a term of two years' imprisonment. I.G. Ex. 7 at 1; I. G. Ex. 8 at 11. He was actually incarcerated for a term of 13 months. Tr. at 50.

c. Petitioner has a prior administrative sanction record (42 C.F.R. � 1001.102(b)(5)).

The version of 42 C.F.R. � 1001.102(b)(5) that was in effect on March 31, 1998, provides that it shall be an aggravating factor if the individual or entity who is excluded has a prior criminal, civil or administrative sanction record. In this case Petitioner was sanctioned twice administratively prior to the date of his exclusion. Effective May 1, 1997, the same date that Petitioner entered his guilty plea, Petitioner's license to practice medicine in California was suspended. I.G. Ex. 11. The determination to suspend Petitioner's license derived from Petitioner's indictment and guilty plea. Id. at 1 - 2. On October 6, 1997, Petitioner was suspended from participating in Medi-Cal. I.G. Ex. 12. As is the case with the suspension of Petitioner's license to practice medicine, the suspension of Petitioner from participating in Medi-Cal relates directly to Petitioner's conviction. Id.

The I.G. argues that Petitioner's license suspension and Medi-Cal exclusion are prior administrative sanctions within the meaning of 42 C.F.R. � 1001.102(b)(5) because they predate the exclusion that the I.G. imposed in this case. Petitioner asserts that these administrative actions are not "prior" sanctions because they occurred after the date of, and indeed, derived from, Petitioner's conviction.

The administrative sanctions that were imposed against Petitioner are "prior" sanctions within the meaning of the regulation. I addressed this issue in John M. Thomas, Jr., M.D. and Texoma Orthopedic Associates, DAB CR281 (1993). In both Thomas and in this case, the administrative sanctions were imposed prior to the date of the I.G.'s exclusion determination and, therefore, the existence of these sanctions establishes the presence of an aggravating factor.

The Thomas case involved facts which are quite similar to the present case in that Petitioner Thomas' license to practice medicine in Texas was revoked and his participation in the Texas Medicaid program was suspended after he had been convicted of a criminal offense related to the Texas Medicaid program but prior to the date of the I.G.'s determination to exclude him. I held there that the term "prior" in the version of 42 C.F.R. � 1001.102(b)(5) that was in effect as of the date of the Petitioner Thomas' exclusion and which is applicable here, plainly referred to administrative sanctions that are imposed prior to the date of an exclusion determination even if those actions emanate from the same conduct or conviction which is the basis for the I.G.'s exclusion determination.

It is entirely logical that administrative sanctions which derive from a conviction and which predate the date of an exclusion determination be considered as an aggravating factor. Sanction determinations such as a suspension of a license to provide health care or an exclusion from a State Medicaid program are remedial determinations, which, like the sanction determination that was made in the present case, are based on findings that a party is no longer trustworthy to provide care. In a case where an exclusion based on lack of trustworthiness is at issue, it is relevant to consider that other administrative bodies have found an excluded party to be untrustworthy based on the same underlying conduct or action that is the basis for the I.G.'s determination.

Petitioner argues that, in fact, he was not sanctioned administratively until April 16, 1999. That is the date when a final order was issued in the disciplinary proceeding involving Petitioner's license to practice medicine in California. Petitioner's reply brief at 3 - 4; see P. Ex. 16. According to Petitioner, he was not in fact "sanctioned" until after the completion of the entire disciplinary process in California. Therefore, according to Petitioner, the suspension of his license that was imposed upon his conviction is only an interim order, and not a sanction.

I disagree with this argument. The preliminary suspension was an administrative "sanction" within the meaning of the version of 42 C.F.R. � 1001.102(b)(5) that was in effect as of the date of Petitioner's exclusion. The fact that a sanction is "preliminary" and not "final" is not a basis for concluding that it is not a "sanction" within the meaning of the regulation. The regulation does not define what is meant by a "sanction." However, the preliminary suspension plainly acted as a remedy to protect the public from what the California licensing authorities deemed to be an untrustworthy physician. I find that this purpose comports with the use of the term "sanction" in the regulation.

d. The I.G. did not establish that the acts that resulted in Petitioner's conviction, or similar acts, were committed over a period of one year or more (see 42 C.F.R. � 1001.102(b)(2)).

The version of 42 C.F.R. � 1001.102(b)(2) that was in effect on March 31, 1998, provides that it shall be an aggravating factor if the acts that resulted in an excluded individual or entity's conviction, or similar acts, were committed over a period of one year or more. The I.G. argues that the evidence in this case establishes that Petitioner engaged in fraud against Medi-Cal for a period of more than one year. Petitioner disputes that assertion.

I find that the weight of the evidence establishes that Petitioner engaged in criminal conduct over a period of less than one year. Consequently, the I.G. failed to establish the presence of this aggravating factor.

The evidence relied on by the I.G. consists of the allegations that are stated in the felony complaint that was filed against Petitioner. Count 1 of the complaint, to which Petitioner pled guilty, alleges that Petitioner engaged in theft against Medi-Cal from on or about January 3, 1994 to on or about November 30, 1995. I.G. Ex. 4 at 1.

Petitioner argues that, in fact, his association with Good Shepherd was an employment relationship that began in February 1995, and ended in November 1995. Petitioner's posthearing brief at 3; Tr. at 39. Petitioner argues that, notwithstanding what may have been said in the complaint and notwithstanding further what he may have pled guilty to, his actual relationship with Good Shepherd spanned a time frame of only ten months. Consequently, according to Petitioner, he could not have perpetrated his theft of Medi-Cal funds over a period of more than a year.

Normally, I would not look beyond the letter of a criminal complaint and an individual's guilty plea to that complaint to make fact findings if the relevant facts are stated in the complaint and acknowledged in the plea. In that circumstance, the plea of guilty is an admission of the relevant facts. This case is an exception to the rule. It is evident from the unique facts of this case that Petitioner was only involved with Good Shepherd for a period of about ten months and, therefore, could not have engaged in theft arising from his relationship with Good Shepherd over a period of more than one year.

There is evidence in the record of this case other than the criminal complaint against Petitioner which establishes that Petitioner was involved with Good Shepherd for a period of less than one year. Petitioner averred that he began his relationship with Good Shepherd in February 1995 in an interview with Petitioner which was made part of the Declaration in Support of Arrest Warrant. I.G. Ex. 3 at 7 - 8. Petitioner made this statement at a time when the I.G. was not contemplating excluding Petitioner and when it was exceedingly unlikely that Petitioner would have known that criminal activity of more than a year's duration would be an aggravating factor in a subsequent exclusion case. See Tr. at 49.

Other evidence corroborates the statements that Petitioner made in his interview. Petitioner was interviewed on another occasion on December 5, 1995 by representatives of the California Attorney General's office. Petitioner averred that he began work at Good Shepherd in February 1995 and worked there continuously until the clinic closed in November 1995. I.G. Ex. 1 at 27 - 28. On August 14, 1996, Petitioner's alleged co-conspirator, Dr. Michael Natividad, was interviewed. He averred that Petitioner began employment at Good Shepherd by March 1995. I.G. Ex. 2 at 7.

The I.G. asserts that, even if Petitioner only worked at Good Shepherd for a period of ten months, he worked at times prior to his involvement with Good Shepherd at other clinics which have been suspected of perpetrating fraud against Medi-Cal. The I.G. asks that I infer that Petitioner engaged in fraudulent conduct at these clinics and, as a consequence, engaged in fraud against Medi-Cal for a period of more than one year. I do not accept this argument. There is insufficient credible evidence of record in this case for me to conclude that Petitioner engaged in fraud against Medi-Cal at any location other than at Good Shepherd from about February 1995 until November 1995.

3. Petitioner did not prove the presence of any mitigating factors.

The version of 42 C.F.R. � 1001.102 that was in effect as of March 31, 1998, provides that, in determining the length of an exclusion, evidence which proves the existence of aggravating factors may be offset by evidence which proves the existence of mitigating factors. 42 C.F.R. � 1001.102(c). The regulation makes it plain that only those factors which are specifically enumerated in the regulation may be considered to be mitigating. Id.

Petitioner did not establish the presence of any mitigating factor. Petitioner asserted the following affirmative arguments in his posthearing brief:

� Petitioner had an unblemished reputation as a practitioner from 1981 until his conviction in 1997. Petitioner's posthearing brief at 1; see P. Ex. 3.

� Petitioner enjoys an excellent reputation in his church and in the medical community. Petitioner's posthearing brief at 1; see P. Ex. 4.

� Petitioner has cooperated fully with the prosecutors who were involved in his case. He has provided the prosecution with information involving his alleged co-conspirator, Dr. Natividad. He is willing to testify against Dr. Natividad should Dr. Natividad be apprehended and brought to trial. Petitioner's posthearing brief at 6 - 7; see Tr. at 51 - 52.

Petitioner's allegedly spotless reputation prior to his conviction and his reputation in his community are not mitigating factors that may be considered under the version of 42 C.F.R. � 1001.102(c) that was in effect as of March 31, 1998. Cooperation with prosecuting authorities may be a mitigating factor but only if the prerequisites of the regulation are met. Under the version of 42 C.F.R. � 1001.102(c)(3) that was in effect as of March 31, 1998, cooperation with prosecuting authorities may be a mitigating factor where:

The [excluded] individual's or entity's cooperation with Federal or State officials resulted in -

(i) Others being convicted or excluded from Medicare or any of the State health care programs, or

(ii) The imposition against anyone of a civil money penalty or assessment under Part 1003 of this chapter.

The evidence offered by Petitioner does not establish the mitigating factor described in 42 C.F.R. � 1001.102(c)(3). Petitioner may have cooperated with prosecuting authorities. However, there is no evidence that his cooperation with those authorities resulted in the conviction or exclusion of any individual or the imposition against any individual of a civil money penalty or assessment.

4. A 20-year exclusion of Petitioner is reasonable.

As I discuss above, at Part I.B., the presence of aggravating or mitigating factors in a case is not in and of itself a basis for saying that an exclusion of a particular length is reasonable. There is no formula which attaches to these factors which predicts what will be reasonable based merely on the presence or absence of factors. What must be weighed de novo and independently by the ALJ in each case where the length of an exclusion is at issue, is the evidence which relates to each established aggravating and mitigating factor. That evidence will show the degree of untrustworthiness of the excluded individual or entity. And, ultimately, the reasonableness of an exclusion may be decided by comparing the length of the exclusion against the degree of untrustworthiness of the excluded individual or entity.

In this case, there exist three aggravating factors and no mitigating factors. The evidence which relates to these aggravating factors - and in particular, the evidence which relates to the amount of money that Petitioner helped to steal from Medi-Cal - establishes Petitioner to be an extraordinarily untrustworthy individual. That evidence is proof that the 20-year exclusion that the I.G. imposed against Petitioner is reasonable.

Petitioner helped to steal an enormous amount of money from Medi-Cal in a very short period of time. In ten months of concerted fraud, Petitioner assisted in defrauding the program of an amount that falls between approximately a half-million dollars and more than a million dollars. The fact that Petitioner was so successful in stealing so much in so short a period of time is proof that Petitioner engaged in intensive, thoughtful, and well-organized criminal activity. This shows Petitioner to be highly untrustworthy.

The I.G. asserts that Petitioner stole more than $1,200,000 from Medi-Cal. The I.G. obtained this figure from the criminal complaint against Petitioner and from Petitioner's sentence to pay restitution in the amount of $1,234,000. I.G. Ex. 4 at 2, 4; I.G. Ex. 7 at 1; I.G. Ex. 9 at 1. Petitioner contends that his actual fraud was less than the amount that is asserted by the I.G. According to Petitioner, the claims that he personally submitted to Medi-Cal while employed at Good Shepherd totaled $493,309.26. Petitioner's posthearing brief at 4 - 5; P. Ex. 7 at 2. Petitioner argues that the figure in excess of $1.2 million that is asserted by the I.G. actually is an aggregate of the claims submitted by Petitioner and by Dr. Natividad.

While it may be true that Petitioner personally submitted claims to Medi-Cal for $493,309.26 for services that he allegedly provided at Good Shepherd, that amount does not express the totality of Petitioner's crimes. Petitioner's involvement with Good Shepherd facilitated the theft of much more from Medi-Cal than just that for which Petitioner personally made claims. Petitioner was responsible for the day-to-day operations of Good Shepherd and, therefore, was at least indirectly involved in all of the fraud that was perpetrated at Good Shepherd.

By his own admission Petitioner managed Good Shepherd. I.G. Ex. 1 at 28. He supervised all of Good Shepherd's employees. Id. And, although Dr. Natividad may have been instrumental in setting up and organizing Good Shepherd, Petitioner ran Good Shepherd on Dr. Natividad's behalf. Dr. Natividad was only present at Good Shepherd three or four times per month. Id. at 29.

Moreover, in the final analysis, the precise amount of money that Petitioner helped to steal from Medi-Cal is not so important as is the fact that he helped to steal a huge sum of money in a very short period of time. Petitioner is a highly untrustworthy individual whether he stole $493,309.26 as he alleges, or whether he stole over $1.2 million as the I.G. alleges.

Given the extent of Petitioner's crime and the absence of mitigation there is no reason for me to believe that he will become trustworthy to deal with federally funded health care programs at any time in the foreseeable future. A 20-year exclusion is reasonable based on this evidence.

The additional evidence which relates to aggravating factors supports my decision as to the degree of Petitioner's lack of trustworthiness. The facts that Petitioner was sentenced to imprisonment as a consequence of his plea of guilty and that other agencies have imposed administrative sanctions against him is additional proof that he is untrustworthy.

However, I rest my conclusion that a 20-year exclusion is reasonable primarily on the evidence which shows the extent of Petitioner's criminal conduct as is measured by the amount that he stole from, or facilitated stealing from, the Medi-Cal program. The additional aggravating factors of imprisonment and prior administrative sanctions are of only secondary importance to my conclusion that Petitioner is highly untrustworthy. That is because the amount of Petitioner's theft is so great that, in and of itself, it justifies a very lengthy exclusion.

The 20-year exclusion that I find to be reasonable in this case coincides with what the I.G. determined to be reasonable. Certainly, a 20-year exclusion falls within a reasonable range of possible exclusions given Petitioner's degree of untrustworthiness.

1. I cite to the transcript of the hearing as "Tr." (page number).