Discipline Decisions (May 2024)

• Failed to keep records as required respecting her patients and/or practice with respect to Rx [Number 1], Rx [Number 2], COVaxON #DA-[Number 3], and/or COVaxON #DA-[Number 4] between in or about August 13, 2021 and in or about September 13, 2021;
• Falsified a record relating to her practice and/or a person’s health record with respect to Rx [Number 1], Rx [Number 2], COVaxON #DA-[Number 3], and/or COVaxON #DA-[Number 4] between in or about August 13, 2021 and in or about September 13, 2021;
• Signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement with respect to Rx [Number 1], Rx [Number 2], COVaxON #DA-[Number 3], and/or COVaxON #DA-[Number 4] between in or about August 13, 2021 and in or about September 13, 2021; and/or
• Submitted (or permitted, consented to or approved, expressly or by implication, the submissions) charges for Rx [Number 1] and/or Rx [Number 2] that she knew or ought to have known were false and misleading between in or about August 13, 2021 and in or about September 4, 2021.

In particular, the Panel found that the Registrant

• Failed to maintain a standard of practice of the profession;
• Failed to keep records as required respecting her patients and/or practice;
• Falsified a record relating to her practice and/or a person’s health record;
• Signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement;
• Submitted (or permitted, consented to or approved, expressly or by implication, the submissions) charges that she knew or ought to have known were false and misleading;
• Contravened the Pharmacy Act, 1991, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, the Narcotics Safety and Awareness Act, 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts in particular: Section 20(1) of Ontario Regulation 264/16;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as unprofessional.

The Panel imposed an Order which included as follows:

1. A reprimand;

2. That the Registrar is directed to impose specified terms, conditions or limitations on the Registrant’s Certificate of Registration, and in particular:

a. That the Registrant shall successfully complete, at her own expense and any time before or within 12 months of the date of the Order:

i. The Ontario College of Pharmacists’ “Documenting Patient Care e-Learning Module”;

ii. “Module 4: Clinical Documentation” of Informatics for Pharmacy Students e-Resource, offered through e-Learning for Healthcare Professional Students; and

iii. The “Complete Professional: Navigating Professional Boundaries in Medicine (DR-2 Edition)” course offered through PBI Education.

3. That the Registrar suspend the Registrant’s Certificate of Registration for a period of two (2) months, with one (1) month of the suspension to be remitted on condition that the Registrant complete the remedial training as specified in paragraph 2(a). The suspension shall commence on January 8, 2024, and shall continue until February 7, 2024, inclusive. If the remitted portion of the suspension is required to be served by the Registrant because she fails to complete the remedial requirement specified in paragraph 2(a), that portion of the suspension shall commence on January 9, 2025, and shall continue until February 8, 2025, inclusive. If the time for completing the remedial steps in paragraph 2(a), above, is extended by the Registrar, the date on which the remitted portion of the suspension shall commence, if required, shall be adjusted accordingly.

4. Costs to the College in the amount of $10,000.00.

In its reprimand, the Panel noted that the Registrant, through her actions, failed in her duties as a pharmacist and a Designated Manager. She breached the standards of practice of the profession, as well as pharmacy legislation.

The Panel observed that the components of the Order are intended to provide the Registrant with an opportunity to rehabilitate her conduct in her pharmacy practice. The Panel expressed its hope that she will learn from this experience, and that she will not appear before a panel of the Ontario College of Pharmacists’ Discipline Committee again.

• Misappropriated narcotics, contrary to Section 4(1) of the Controlled Drugs and Substances Act, S.C. 1996, from on or about October 2018, to on or about January 28, 2019; and/or
• Falsified records with respect to the Pharmacy’s narcotics inventory, from on or about October 2018, to on or about January 28, 2019.

In particular, the Panel found that she:

• Failed to maintain a standard of practice of the profession;
• Falsified a record related to her practice;
• Contravened section 4(1) of the Controlled Drugs and Substances Act, S.C. 1996;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as dishonourable and unprofessional.

Following further submissions heard on April 13, 2023 and August 3 and 8, 2023, the Panel imposed an Order, as follows:

1. A reprimand;
2. That the Registrar is directed to revoke the Certificate of Registration issued to the Registrant;
3. Costs to the College in the amount of $28,336.00.

In its reprimand, the Panel noted that the Registrant was a member of the highly regarded pharmacy profession when she was found by this Panel to have committed very serious acts of professional misconduct.

The Panel observed that the Registrant’s failure to participate in the evidentiary and penalty hearings, despite the opportunities provided to ensure that she was aware of these proceedings, indicates that she refuses to recognize her professional obligations to be governed as a registrant of the College, and the Panel had no evidence or information that might indicate that remediation or rehabilitation would be appropriate to protect the public. Her refusal to respect the College’s authority, along with the seriousness of the misconduct at issue, left the Panel with no option other than to order the revocation of her Certificate of Registration.

• On or about December 24, 2020, she was found guilty of two counts of knowingly using a forged narcotic prescription, contrary to section 368(1)(a) of the Criminal Code of Canada;
• She obtained hydromorphone using fraudulent prescriptions on approximately fourteen occasions from on or about December 3, 2018, to on or about July 10, 2019.

In particular, the Panel found that she:

• Has been found guilty of an offence that is relevant to her suitability to practise;
• Contravened sections 4(1) of the Controlled Drugs and Substances Act, S.C. 1996;
• Engaged in conduct that is unbecoming of a member.

Following findings of professional misconduct made in a decision dated October 20, 2022, the Panel imposed an Order in a decision dated March 6, 2024, as follows:

1. A reprimand in writing;
2. That the Registrar be directed to revoke the Certificate of Registration issued to Christine Martin;
3. Costs to the College in the amount of $24,336.00.

In its reprimand, the Panel noted that Pharmacy is a highly regarded, self-regulated profession. Practising pharmacy is a privilege granted to those who possess the knowledge, skill and judgment to practice safely and ethically, which the Registrant failed to do.

The Panel acknowledged the circumstances surrounding the Registrant’s misconduct, but still noted that the misconduct was serious, dishonest and intentional, involving fraudulent prescriptions for narcotics that were not prescribed to her.

The Panel observed that the Registrant’s non-attendance and non-participation resulted in a lengthy, costly, contested hearing. Her non-attendance also made it impossible for the Panel to assess her current status, or whether her practice could be rehabilitated or remediated through training, education, or other means.

The Panel wrote that, regardless of difficult personal circumstances, registrants are expected to respect the College as the profession’s regulator, to practice safely, ethically and professionally, and to comply with all applicable laws and standards, which the Registrant failed to do. Her conduct is unacceptable and casts serious doubt on her fitness to practice the profession. As a result, the Panel has ordered that her Certificate of Registration be revoked.

• Failed to maintain the standards of practice of the profession;
• Failed to keep records as required respecting his patients or practice;
• Contravened the Act, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, or the regulations under those Acts, and in particular, ss. 19(k) and 20(1), para. 4 of Ontario Regulation 264/16, made under the Drug and Pharmacies Regulation Act, R.S.O. 1990, c. H-4, as amended;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members of the profession as unprofessional.

Following submissions with respect to the Order to be imposed on October 11, 2023, the Panel imposed an Order in a decision dated February 2, 2024, as follows:

1. A reprimand;

2. That the Registrar is directed to impose specified terms, conditions or limitations on the Registrant’s Certificate of Registration, and in particular:

a. That the Registrant successfully complete, within 12 months of the date of this Order, the College’s Designated Manager (DM) e-Learning Module;

b. That the Registrant successfully complete, within 12 months of the date of this Order, a mentorship, with a mentor approved by the College, regarding the issues raised by the facts and findings of professional misconduct in this case. The mentorship must comply with the following terms:

i. Within six months of the date of this Order, the College shall assign the Registrant a practice mentor and the Registrant shall retain the practice mentor at his own expense;

ii. The Registrant shall meet at least three times with the practice mentor, for the purpose of reviewing the Registrant’s practice with respect to the role and responsibilities of a Designated Manager arising from this matter, including but not limited to: management of inventory, documentation and record-keeping;

iii. The Registrant shall provide the practice mentor with the following documents related to this proceeding:

1. the Agreed Statement of Facts;

2. this Partial Joint Submission on Order; and

3. the Panel’s Decision and Reasons, if and when available;

iv. The Registrant shall develop a learning plan with the mentor to comprehensively address the remediation required;

v. The Registrant shall demonstrate to the mentor that he has successfully achieved all of the goals of the learning plan;

vi. The Registrant shall require the mentor to report the results of the Mentorship Program to the College, in writing and at the Registrant’s own expense, no later than thirteen (13) months from the date of this Order. Such report shall include, but is not limited to:

1. the learning plan; and

2. the mentor’s assessment of the Registrant’s success in meeting the goals of the learning plan.

c. That the Registrant shall be prohibited from acting as a Designated Manager in any pharmacy until the Registrant has completed the practice mentorship outlined in 2(b). This prohibition shall be suspended if the Registrant provides proof, satisfactory to the College, that he has commenced the mentorship program in paragraph 2(b), above, on or by the date of this Order, and shall remain suspended until the College receives the mentor’s report as described in paragraph 2(b)(vi). If the Registrant has not demonstrated to the mentor that he has successfully achieved all of the goals of the learning plan, then the prohibition shall be reinstated and shall continue until the Registrant has successfully completed the mentorship program in paragraph 2(b).

d. That the Registrant’s practice is to be subject to Compliance Audit Reviews (CARs) by the College at any pharmacy in which he has a proprietary interest and/or is the Designated Manager. The following terms shall apply to the CARs:

i. the College will be entitled to conduct any CAR for a period of 12 months following the completion of the mentorship program described in paragraph 2(b), above (“CARs Period”);

ii. if the Registrant ceases to have a proprietary interest in any pharmacy and also ceases be a Designated Manager at any time within the 12 months specified in subparagraph 2(d)(i) above, such that the College is unable to conduct any CARs, then the CARs Period shall be paused and shall resume on the date on which the Registrant again obtains a proprietary interest in a pharmacy and/or commences acting as a Designated Manager, and in such circumstances:

1. the Registrant shall notify the College, in writing, if he no longer holds a proprietary interest in any pharmacy and is no longer a Designated Manager in a pharmacy at any point(s) during any times that the CARs Period remains active; and

2. if the CARs Period is paused at any time(s), the Registrant shall notify the College, in writing, when he again obtains a proprietary interest in a pharmacy and/or commences acting as a Designated manager, at which point the CARs Period shall resume and shall continue until a total period of 12 months has been achieved;

iii. the CARs will be conducted by means of attendances, either virtually or in person, by a representative of the College at any pharmacy in which the Registrant holds a proprietary interest and/or at which the Registrant is acting as a Designated Manager at such times as the College may determine;

iv. the CARs are in addition to any routine inspections conducted by the College pursuant to the Drug and Pharmacies Regulation Act, R.S.O. 1990, c. H.4., s. 148, and are not a substitute for such inspections;

v. the Registrant shall fully cooperate with the College representative during the CARs; and

vi. the Registrant shall pay to the College in respect of such CAR the amount of $1,000.00 per CAR, immediately after each CAR is completed, with the total amount to be paid by the Registrant not to exceed $3,000, regardless of the number of CARs and/or attendances conducted by the College.

3. That the Registrar be directed to suspend the Registrant’s Certificate of Registration for a period of one (1) month, one (1) month of which shall be remitted upon the Registrant successfully completing the remedial training as specified in paragraph 2 (a) and (b). If the remitted portion of the suspension is required to be served by the Registrant because he fails to complete the remedial training, the remainder of the suspension shall commence on the date that is 18 months from the date that this Order becomes final and shall run for one (1) month without interruption.

4. Costs to the College in the amount of $10,000.

The reprimand in this matter was administered on April 22, 2024.

In its reprimand, the Panel noted that through his actions, the Registrant failed to fulfil his responsibilities as a pharmacist and as a Designated Manager. He failed to maintain the standards of practice of the profession, and he failed to keep records as required for purchase invoices.

The Panel indicated that the components of the Order are intended to provide the Registrant with an opportunity to rehabilitate his conduct in his pharmacy practice. The Order is necessary to deter this Registrant and other registrants from engaging in this type of conduct in the future.

The Panel expressed its hope that the Registrant will learn from this experience, and that he will not appear before a panel of the Ontario College of Pharmacists’ Discipline Committee again.

Referral 1

The Panel found that the Registrant, while engaged in the practice of pharmacy as director, shareholder, owner, Designated Manager, and/or dispensing pharmacist at Lifestyle Pharmacy & Candy Bar I.D.A (the “Pharmacy”), committed professional misconduct with respect to the following:

• Contravening a term, condition or limitation imposed on her certificate of registration by order of a panel of the Discipline Committee of the Ontario College of Pharmacists from June 2, 2015, contrary to paragraph 1 of subsection 2(1) of Ontario Regulation 130/17, as amended, with respect to dispensing narcotics to a family member on or about January 5, 2021;
• Providing pharmaceutical care to herself and/or one or more family members on one or more occasions from in or about February 2020 to in or about September 2020;
• Adapting and/or renewing a drug, namely for some or all of certain identified drugs or products between January 2020 and June 2021, without doing the following, which she was required to do:
  • Notifying the patient’s prescriber that she renewed/adapted the patient’s prescription, and/or recording in the patient’s record the date on which the patient’s prescriber was notified;
  • Recording the information on the prescription and/or the patient record required by sections 37 and 38 of Ontario Regulation 202/94, made under the Pharmacy Act, 1991, S.O. c. 36;
• Submitting (or permitting, consenting to or approving, expressly or impliedly, the submission of) an account or charge for medications using an intervention code that she knew or ought to have known was false or misleading on one or more occasions for Vyvanse dispensed to patient [Patient 1] from in or about January 2019 to in or about September 2020 and/or claims for medications dispensed to patient [Patient 2] from in or about November 2015 to in or about June 2021;
• Billing (or permitting, consenting to or approving, expressly or impliedly, the billing) for dispensing fees at weekly intervals for compliance pack medications that were actually dispensed at bi-weekly or monthly intervals including dispensing fees charged for the medications dispensed to one or more of certain identified patients in or about March 2020, and/or certain identified patients from in or about April 2021 to in or about May 2021;
• Creating (or permitting, consenting to or approving, expressly or impliedly, the creation of) false and/or misleading records indicating compliance pack medications were being dispensed at weekly intervals when the medications were actually being dispensed at bi-weekly or monthly intervals, including records for the medications dispensed to one or more of certain identified patients and/or other identified patients from in or about April 2021 to in or about May 2021;
• Creating (or permitting, consenting to or approving, expressly or impliedly, the creation of) false and/or misleading records on one or more occasions by backdating claims and/or dispensing records to a date different than the date on which the records were created on one or more occasions, with respect to the medications that were dispensed to certain identified patients.

In particular, the Panel found that the Registrant:

• Contravened a term, condition or limitation imposed on her certificate of registration;
• Failed to maintain a standard of practice of the profession;
• Falsified a record relating to her practice or a person’s health record;
• Signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement;
• Submitted an account or charge for services or products that she knew or ought to have known was false or misleading;
• Charged a fee or amount that was excessive in relation to the service or product provided;
• Contravened the Act, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, the Narcotics Safety and Awareness Act, 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts, and in particular, sections 36, 37, and/or 38 of Ontario Regulation 202/94, as amended, made under the Pharmacy Act, 1991;
• Failed to comply with an Order of a panel of the Discipline Committee of the College;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as dishonourable and unprofessional.

Referral 2

The Panel found that the Registrant, while engaged in the practice of pharmacy as director, shareholder, owner, Designated Manager, and/or dispensing pharmacist at Lifestyle Pharmacy & Candy Bar I.D.A (the “Pharmacy”), committed professional misconduct with respect to the following:

• Failing (or permitting, consenting to or approving, expressly or impliedly, the failure) to keep records as required with respect to the one or more of certain identified drugs or products or services:
  • from in or about May 2020 to in or about October 2020;
  • from in or about March 2018 to in or about April 2019;
  • from in or about September 2018 to in or about December 2019;
• Creating (or permitting, consenting to or approving, expressly or impliedly, the creation of) false and/or misleading records by using another registrant’s name and/or registration number as prescriber in the course of adapting and/or renewing prescriptions and/or completing related documentation for one or more of certain identified prescription numbers from in or about May 2020 to in or about October 2020;
• Creating (or permitting, consenting to or approving, expressly or impliedly, the creation of) false and/or misleading records by backdating documentation on authorizing prescriptions and/or other related documentation with respect to one or more of certain identified prescription numbers from in or about September 2018 to in or about October 2020;
• Submitting (or permitting, consenting to or approving, expressly or impliedly, the submission of) accounts or charges for services to the Ontario Drug Benefit Program that she knew or reasonably ought to have known were false or misleading for some or all of certain identified MedsCheck reviews and/or Pharmaceutical Opinion Program Claims that were non-compliant with the guidelines of the Ministry of Health and Long Term Care;
• Submitting (or permitting, consenting to or approving, expressly or impliedly, the submission of) accounts or charges for services to the Ontario Drug Benefit Program that she knew or reasonably ought to have known were false or misleading by using another registrant’s name for some or all of certain identified MedsCheck review claims;
• Providing and/or billing (or providing and permitting, consenting to or approving, expressly or impliedly, the billing) for MedsChecks services specific to diabetes without having the required knowledge and/or training as required by the guidelines of the Ministry of Health and Long Term Care, on one or more occasions, from in or about April 2019 to December 2019.

In particular, the Panel found that the Registrant:

• Failed to maintain a standard of practice of the profession;
• Used a name other than her name, as set out in the register, in the course of providing services within the scope of practice of the profession;
• Failed to keep records as required respecting her patients or practice;
• Falsified a record relating to her practice or a person’s health record;
• Signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement;
• Submitted an account or charge for services or products that she knew or ought to have known was false or misleading;
• Contravened the Act, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, the Narcotics Safety and Awareness Act, 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts, and in particular:
  • sections 36, 37, and/or 38 of Ontario Regulation 202/94, as amended, made under the Pharmacy Act, 1991, S.O. 1991, c. 36;
  • section 156 of the Drug and Pharmacies Regulation Act, R.S.O. 1990, c. H4;
  • section 20 and 21 of Ontario Regulation 264/16, as amended, made under the Drug and Pharmacies Regulation Act, R.S.O. 1990, c. H4;
  • Section 15(1) of the Ontario Drug Benefit Act, R.S.O. 1990, c. O.10, as amended;
  • Sections 27 and/or 29 of Ontario Regulation 201/96, made under the Ontario Drug Benefit Act, R.S.O. 1990, c. O.10;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as dishonourable and unprofessional.

The Panel imposed an Order, as follows:

1. A reprimand;

2. That the Registrar is directed to impose specified terms, conditions or limitations on the Registrant’s Certificate of Registration, and in particular:

a. That the Registrant successfully complete a course on ethics and professional judgement with Gail Siskind, or another professional ethics/professional judgement consultant as approved by the College in its sole and absolute discretion, to be designed by the consultant, but with the general aim of addressing the professional and ethical issues arising in the Registrant’s case, within twelve (12) months of the date of this Order becomes final. The following terms shall apply to the course:

i. the number of sessions shall be at the discretion of the consultant, but shall be at least three (3) meetings;

ii. the manner of attendance at the session(s) (e.g., in person, via videoconference, etc.) is a matter to be discussed in advance between the Registrant and the consultant, but shall ultimately be at the discretion of the consultant;

iii. the Registrant shall be responsible for the cost of the course;

iv. the Registrant shall provide to the consultant the following documents, in advance of the course, to facilitate the design of the course:

1. copies of the Notices of Hearing;

2. a copy of the Agreed Statement of Facts;

3. a copy of this Joint Submission as to Penalty and Costs; and

4. a copy of the Decision and Reasons of the Discipline Panel, when available;

5. successful completion of the course shall be determined by the consultant, based on the design of the course; and

vi. the Registrant shall direct the consultant to report to the College, no later than thirteen (13) months from the date that this Order becomes final, that the Registrant completed the ethics course to the satisfaction of the consultant;

b. That the Registrant shall be prohibited from acting as a Designated Manager in any pharmacy for a minimum of three (3) years from the date on which the suspension, set out in paragraph 3, below, is lifted, and continuing thereafter until the date on which the College is notified that the Registrant has successfully completed a mentorship program regarding the issues raised by the facts and findings of professional misconduct in this case, including but not limited to the role and responsibilities of Designated Managers and documentation. The mentorship program shall include the following terms:

i. the Registrant shall retain, at her own expense, a mentor acceptable to the College;

ii. the Registrant shall meet at least three (3) times with the practice mentor, at a place to be determined by the practice mentor, for the purpose of reviewing the Registrant’s practice with respect to the issues outlined in paragraph 2(b) above, and identifying areas in the Registrant’s practice with respect to these issues that require remediation.

iii. the Registrant shall provide the mentor with the following documents related to this proceeding, in advance of the mentorship:

1. a copy of the Notices of Hearing;

2. a copy of the Agreed Statement of Facts;

3. a copy of this Joint Submission as to Penalty and Costs; and

4. a copy of the Decision and Reasons of the Discipline Panel, when available;

iv. the Registrant shall develop a learning plan with the mentor to address the remediation required;

v. the Registrant shall demonstrate to the mentor, in a manner directed by and acceptable to the practice mentor, that she has achieved success in meeting the goals established in the learning plan; and

vi. the Registrant shall require the mentor to report the results of the mentorship program to the College, in writing and at the Registrant’s own expense. Such report shall include, but is not limited to:

1. the learning plan; and

2. the mentor’s assessment of the Registrant’s success in meeting the goals of the learning plan;

c. For a period of three (3) years from the date this Order becomes final, the Registrant shall be prohibited from having any proprietary interest in a pharmacy of any kind.

d. For a period of three (3) years commencing on the date on which the suspension, set out in paragraph 3, below, is lifted, the Registrant shall:

i. Notify the College in writing of the name(s), address(es) and telephone number(s) of all employer(s) within seven (7) days of commencing employment in a pharmacy;

ii. Provide her pharmacy employer(s) with a copy of the Discipline Committee Panel’s decision in this matter and its Order; and

iii. Only engage in the practice of pharmacy for an employer who agrees to write to the College within seven (7) days of the Registrant commencing employment, confirming that they have received a copy of the required documents identified in subparagraph 2(d)(ii).

3. That the Registrar suspend the Registrant’s Certificate of Registration for a period of seven (7) months, with one (1) month of the suspension to be remitted on condition that the Registrant complete the remedial training as specified in paragraph 2(a). The suspension shall commence on the date this Order becomes final and shall run without interruption for six (6) months. If the remitted portion of the suspension is required to be served by the Registrant because she fails to complete the remedial requirement specified in paragraph 2(a), that portion of the suspension shall commence on the date that is thirteen (13) months from the date that this Order becomes final, and shall continue for one (1) month, without interruption. If the time for completing the remedial steps in paragraph 2(a) above is extended by the Registrar, the date on which the remitted portion of the suspension shall commence, if required, shall be adjusted accordingly.

4. Costs to the College in the amount of $10,000.

The reprimand in this matter remains outstanding.

• He engaged in the trafficking of controlled substance with respect to certain identified items;
• He dispensed drugs and/or products for which prescriptions are legislatively required without an authorized prescriber’s authorization as set out for certain identified items;
• From approximately January 2013 to March 2015, he used his position as pharmacist to traffic in narcotics, in particular fentanyl patches;
• He procured an individual to carry out a simulated robbery of the IDA Rideau Pharmacy on October 26, 2014;
• He made a report to the […] Police in respect of a robbery allegedly committed on October 26, 2014, knowing that the report was false.

In particular, the Panel found that he:

• Failed to maintain a standard of practice of the profession;
• Contravened the Act, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991 or the regulations under those Acts with respect to the following incidents:
  • Dispensing drugs and/or products in the absence of a prescription authorized by a prescriber in contravention of s. 40 of Ontario Regulation 58/11 under the Drug and Pharmacies Regulation Act and ss. 155 and 156;
• Contravened, while engaged in the practice of pharmacy, a federal or provincial law or municipal by-law with respect to the distribution, sale or dispensing of any drug or mixture of drugs, and in particular, and in particular, with respect to the following incidents:
  • Trafficking controlled substances in contravention of s. 5 of the Controlled Drugs and Substances Act;
  • Dispensing drugs in the absence of a prescription authorized by a prescriber in contravention of s. 31 of the Narcotic Control Regulations;
  • Selling drugs in the absence of a prescription authorized by a prescriber in contravention of C.01.041 and G.03.002 of the Food and Drug Regulations;
• Knowingly permitted the premises in which the pharmacy was located to be used for unlawful purposes;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional.

The Panel imposed an Order, as follows:

1. The Registrant be reprimanded in writing;
2. The Registrar be (and is hereby) directed to revoke the Certificate of Registration issued to the Registrant; and
3. Costs to the College in the amount of $10,000.

The reprimand in this matter remains outstanding.

• Dispensed narcotic prescriptions to a single patient from two or more different prescribers without exercising appropriate professional diligence, communicating pertinent information to prescribers, and/or making adequate inquiries with the prescribers for one or more of certain identified drugs;
• Dispensed a monitored drug to one or more patient(s) without submitting the required information to the Narcotics Monitoring System as required by s. 8 of the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c.22 and the Notice issued thereunder for one or more of certain identified transactions;
• Failed to adequately document the actions, if any, taken in response to, and/or the reasons for not taking any action in response to, one or more of certain identified Narcotics Monitoring System alerts; and/or
• Permitted and/or assisted a patient to conceal authorizations for Schedule I controlled substances from another prescriber, contrary to s. 4(2) of the Controlled Drugs and Substances Act.

In particular, it is alleged that he:

• Failed to maintain a standard of practice of the profession;
• Failed to keep records as required with respect to his patients or practice;
• Contravened the Pharmacy Act, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, the Narcotics Safety and Awareness Act, 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts, and in particular: s. 8 of the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c.22;
• Permitted, consented to, approved, counselled or assisted, whether expressly or by implication, the commission of an offence against any Act relating to the practice of pharmacy or the sale of drugs;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.

Mr. Kubar entered into an Undertaking, Agreement, and Acknowledgment by which he agreed to:

• permanently resign as a member of the College;

• not have any proprietary interest in a pharmacy; and

• not seek or hold employment in any pharmacy.

The College made a submission to the Discipline Committee, on consent, to adjourn the hearing of this matter sine die. On the basis of the Undertaking, Agreement, and Acknowledgment, the Discipline Committee accepted the submissions of the College and issued an order on March 1, 2024, adjourning this matter sine die.

• Failed to keep records as required respecting her patients and/or practice with respect to one or more of certain identified drugs and/or products from in or about January 2015 to in or about September 2017;
• Falsified a record relating to her practice and/or a person’s health record with respect to one or more of certain identified drugs and/or products from in or about January 2015 to in or about September 2017;
• Signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement with respect to one or more of certain identified drugs and/or products from in or about January 2015 to in or about September 2017; and/or
• Submitted an account or charge for services that she knew or ought to have known was false and misleading with respect to one or more of certain identified drugs and/or products from in or about January 2015 to in or about September 2017.

In particular, the Panel found that the Registrant:

• Failed to maintain a standard of practice of the profession;
• Failed to keep records as required respecting her patients and/or practice;
• Falsified a record relating to her practice and/or a person’s health record;
• Signed or issued, in her professional capacity, a document that she knew and/or ought to have known contained a false or misleading statement;
• Submitted an account or charge for services or products that she knew and/or ought to have known was false or misleading;
• Contravened the Pharmacy Act, 1991, the Drug and Pharmacies Regulation Act, the Regulated Health Professions Act, 1991, the Narcotics Safety and Awareness Act, 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts, and in particular:
  • sections 155(1), 156, 163, and 166 of the Drug and Pharmacies Regulation Act, section 20(1) of Ontario Regulation 264/16, and sections 40(1) and 54(1) of Ontario Regulation 58/11;
• Contravened a federal, provincial or territorial law with respect to the distribution, sale or dispensing of any drug or mixture of drugs, with respect to the distribution, purchase, sale, dispensing or prescribing of any drug or product, the administering of any substance, or the piercing of the dermis, whose purpose is to protect or promote the public health, and/or that is otherwise relevant to her suitability to practise, and in particular:
  • sections 155(1), 156, 163, and 166 of the Drug and Pharmacies Regulation Act, section 20(1) of Ontario Regulation 264/16, and sections 40 and 54(1) of Ontario Regulation 58/11
  • sections 5, 6, and 15(1) of the Ontario Drug Benefit Act and section 27 of Ontario Regulation 201/96;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable and unprofessional.

Following a finding of professional misconduct made in a decision dated January 28, 2022, submissions with respect to the Order to be imposed that were heard on September 19 and 20, 2022. The Panel imposed its Order in a decision dated December 14, 2022, as follows:

1. A reprimand;

2. That the Registrar be directed to suspend the Member’s Certificate of Registration for a period of 14 months. The suspension shall commence on the date that this Order becomes final;

3. That the Registrar be directed to impose specified terms, conditions or limitations on the Member’s Certificate of Registration:

a. That the Member successfully complete, at her own expense, a course with Gail E. Siskind Consulting Services, or another professional ethics consultant acceptable to the College, to be designed by the consultant for the purpose of addressing the professional and ethical misconduct issues arising in this case. The following terms shall apply to the ethics course:

i. the number of sessions shall be at the discretion of the consultant but shall be no fewer than 3 sessions;

ii. the manner of attendance at the sessions (for example, in person, virtually, et cetera) shall be discussed in advance by the Member and the consultant, but ultimately shall be at the discretion of the consultant;

iii. the Member shall provide the consultant in advance of the course, a copy of the Panel’s Reasons for Decision dated January 28, 2022, and the Reasons for Decision on Order;

iv. successful completion of the ethics course shall include an essay that is acceptable to the Registrar, addressing the professional misconduct issues arising in this case;

v. the essay shall be at least 1,000 words in length and the Member shall be responsible for the cost of the consultant’s review to assist the Registrar to determine whether the essay is acceptable, up to a maximum of $500; and

vi. the Member shall request a report from the consultant confirming that she has completed the essay and the course to the consultant’s satisfaction, and she shall provide a copy of the consultant’s report to the College no later than 12 months from the date this Order becomes final.

b. The Member shall successfully complete, at her own expense and within 12 months of the date this Order becomes final, the Ontario College of Pharmacists’ online Designated Manager Module; 

 c. For a period of 5 years, commencing on the date this Order becomes final, the Member: 

i. shall be prohibited from having any proprietary interest in a pharmacy of any kind and/or receiving remuneration for her work as a pharmacist other than remuneration on an hourly or weekly basis; 

ii. shall be prohibited from acting as a Designated Manager in any pharmacy; 

iii. shall be required to notify the College in writing of the names, addresses and telephone numbers of all employer(s) within 14 days of commencing employment in a pharmacy; and 

iv. shall provide her pharmacy employer with a copy of the Discipline Committee Panel’s decision in this matter dated January 28, 2022, and the Reasons for Decision on Order and provide proof to the Registrar within 14 days of the Member commencing employment. 

4. That the Member pay a fine of $7,500 to the Minister of Finance within 30 days from the date that this Order becomes final. The Member shall notify the College, and provide information acceptable to the College, that the fine was paid no later than 7 days after the day that the fine is paid.

5. Costs to the College in the amount of $190,000.00

The reprimand in this matter was delivered on March 8, 2024.

In its reprimand, the Panel noted that the Registrant, through her actions, failed in her duties as a pharmacist and as a Designated Manager.

The Panel observed that the Registrant breached the standards of practice of the profession as well as pharmacy legislation. She failed to ensure that the pharmacy was operated in accordance with the relevant standards and legal requirements. She should have known that what she was doing was wrong.

The Panel noted that the components of the Order are intended to provide the Registrant with an opportunity to rehabilitate her conduct in her pharmacy practice. The Order is necessary to deter the Registrant from engaging in this type of conduct in the future, as well as to deter other registrants from engaging in this type of conduct.

The Panel expressed its hope that the Registrant will learn from this experience and will change the way she practises.

• Submitted claims for dispensing fees bi-weekly for compliance pack medications that were dispensed to patients monthly, including transactions for certain identified patients, in or about June 2016-July 2019;
• Falsified records in relation to dispensing compliance pack medications as though dispensed bi-weekly when the medications were dispensed monthly, including transactions for certain identified patients, in or about July 2016-July 2019;
• Failed to submit cancelled claims, to be reversed manually by the Ontario Drug Benefit Program (“ODB”), within a reasonable period of time, including certain identified transactions, in or about November 2018-January 2019;
• Failed to reverse claims for medications intended for the patients, […], […] and/or […], but not dispensed to the patients prior to the Pharmacy being notified the patients had died, in or about November 2018-June 2019;
• Falsified records in relation to the patients, […], […] and/or […] to indicate the medications intended for the patients before they died had been picked up from the Pharmacy despite prior notice to the Pharmacy regarding the deaths, in or about November 2018-June 2019; and/or
• Submitted claims to the ODB that included markups on drug costs in excess of the markups permitted by the ODB, in relation to approximately 700 claims, in or about January 2019-July 2019, contrary to the Ontario Drug Benefit Act and regulations thereunder, including approximately 190 claims taking improper advantage of coordination of benefits with the patients’ other benefit plans.

In particular, the Panel found that he:

• Failed to maintain a standard of practice;
• Falsified a record relating to his practice or a person’s health record;
• Signed or issued, in his professional capacity, a document that he knew or ought to have known contained a false or misleading statement;
• Submitted an account or charge for services or products that he knew or ought to have know was false or misleading;
• Contravened a federal or provincial law or municipal by-law with respect to the distribution, sale or dispensing of any drug or mixture of drugs, and in particular:
  • The Ontario Drug Benefit Act, sections 4, 6 and/or 15, and/or
  • Ontario Regulation 201/96, sections 13, 20.1, 20.2 and/or 27;
• Contravened the Act, the Drug and Pharmacies Regulations Act, the Regulated Health Professions Act, 1991, the Narcotic Safety and Awareness Act 2010, the Drug Interchangeability and Dispensing Fee Act or the Ontario Drug Benefit Act or the regulations under those Acts, and in particular:
  • Sections 4, 6 and/or 15 of the Ontario Drug Benefit Act, R.S.O. 1990, c.O.10, as amended, and/or
  • Sections 13, 20.1, 20.2 and/or 27 of Ontario Regulation 201/96, as amended;
• Engaged in conduct or performed an act relevant to the practice of pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as dishonourable and unprofessional.

Submissions regarding the order to be imposed were heard on March 11, 2024.

The Panel imposed an Order, as follows:

1. A reprimand;
2. Directing the Registrar to revoke the Registrant’s Certificate of Registration;
3. Costs to the College in the amount of $18,000.

The reprimand in the matter remains outstanding.

• Failed to have available the references and resources for compounding that are required by members practising in the pharmacy to meet the standards of practice of the profession and to support the pharmacy services the members provide; and/or
• Failed to have the necessary systems to allow members practicing in the Pharmacy to meet the standards of practice of the profession with respect to compounding;
• Failed to respond to the College’s request for an action plan in relation the Level III Assessment between on or about May 14, 2019 to on or about June 8, 2019; Level IV Assessment between on or about November 12, 2019 to on or about December 20, 2019; and/or Level V Assessment between on or about January 28, 2022 to on or about February 4, 2022; and/or
• Failed to respond to the College’s request for narcotic reconciliation records for the period of on or about February 24, 2021 to October 2021; and/or

• Failed to take all reasonable steps to correct some or all of the deficiencies identified in the Assessment Reports of June 20, 2018; October 23, 2018; May 6, 2019, and/or October 30, 2019 with respect to narcotics, controlled drugs and targeted substances reconciliation practices; and/or compounding; as identified; and/or
• Failed to conduct monthly narcotic reconciliations and/or submit them to the College’s Manager of Conduct Operations; and/or
• Failed to take steps to ensure that patient personal information is protected; and/or
• Failed to implement and follow policies and procedures to ensure all refrigerators that store medication are maintained at a temperature between 2 and 8 degrees Celsius.

In particular, the Panel found that the Michael Marini, the Designated Manager of Dover Apothecary in Port Dover, Ontario (the “Pharmacy”), and the Director of 740894 Ontario Inc., c.o.b. as Dover Apothecary and to which Certificate of Accreditation #30204 for the Pharmacy was issued as well as 740894 Ontario Inc. (the “Corporation”), which is the Certificate Holder:

• Failed to maintain a standard of accreditation;
• Failed to reply within a reasonable time to a written or electronic inquiry or request from the College;
• Failed to carry out or abide by an undertaking given by the pharmacy to the College;
• Engaged in conduct or performing an act relevant to the operation of a pharmacy that, having regard to all the circumstances, would reasonably be regarded by members as unprofessional.

The Panel imposed an Order, as follows:

1. A reprimand;

2. That the Registrar is directed to impose specified terms, conditions or limitations on the Registrant’s Certificate of Registration, and in particular:

a. The Registrant shall successfully complete, at his own expense and within twelve (12) months of the date of the Order, a course with Gail E. Siskind Consulting Services or another suitable ethics consultant as approved by the College in its sole and absolute discretion, to address the issues proprietary misconduct arising from this matter, to be designed by the consultant. The following terms shall apply to the course:

iv. The number of sessions shall be at the discretion of the consultant, but shall be no fewer than three (3);

v. The manner of attendance at the sessions (e.g., in person, via Skype, etc.) is a matter to be discussed in advance between the Member and the consultant, but ultimately shall be at the discretion of the consultant;

vi. The Registrant shall be responsible for the cost of the course;

vii. The Registrant shall provide to the consultant the following documents, in advance of the course, to facilitate the design of the course:

1. A copy of the Notice of Hearing;

2. A copy of the Agreed Statement of Facts;

3. A copy of this Joint Submission as to Penalty and Costs; and

4. Copy of the Decision and Reasons of the Discipline Panel, when available;

viii. Successful completion of the course shall be determined by the consultant, based on the design of the course; and

ix. The Registrant shall direct the consultant to report to the College, no later than twelve (12) months from the date that this Order becomes final, that the Registrant completed the ethics course to the satisfaction of the consultant;

b. That the Registrant successfully complete, at his own expense, the Jurisprudence exam offered by the College within twelve (12) months of the date this Order becomes final;

c. The Registrant shall be prohibited from acting as a Designated Manager in any pharmacy for a minimum of one (1) year from the date of this Order and continuing thereafter until the date on which the College is notified that the Registrant has successfully completed:

a. A mentorship program regarding the proprietary misconduct arising from this matter. The mentorship program shall include the following terms:

i. The Registrant shall retain, at his own expense, a mentor acceptable to the College;

ii. The Registrant shall meet with the mentor at least three (3) times, for the purpose of reviewing the Registrant’s practice with respect to the role and responsibilities of a Designated Manager including the reconciliation of narcotics, controlled drugs and targeted substances; record keeping in relation to those reconciliations; investigating and reporting of any thefts/losses in relation to discrepancies found in reconciliations; privacy and confidentiality of patient information; resources, and policies and procedures in relation to compounding;

iii. The Registrant shall provide the mentor with the following documents related to this proceeding, in advance of the mentorship:

1. A copy of the Notice of Hearing;

2. A copy of the Agreed Statement of Facts;

3. A copy of this Joint Submission as to Penalty and Costs; and

4. Copy of the Decision and Reasons of the Discipline Panel, when available;

iv. The Registrant shall develop a learning plan with the mentor to comprehensively address the remediation required. The learning plan shall include, but is not limited to, successful completion by the Registrant of the College’s Designated Manager e-Learning Module and its associated Certificate of Completion;

v. The Registrant shall demonstrate to the mentor that he has successfully achieved all of the goals of the learning plan; and

vi. The Registrant shall require the mentor to report the results of the Mentorship Program to the College, in writing and at the Registrant’s own expense. Such report shall include, but is not limited to:

1. The Registrant’s Certificate of Completion of the College’s Designated Manager e-Learning Module;

2. The learning plan; and

3. The mentor’s assessment of the Registrant’s success in meeting the goals of the learning plan; and

d. The Registrant’s practice as Designated Manager and/or the operation of any pharmacy in which he has a proprietary interest, be subject to Compliance Audit Reviews (“CARs”) by the College. The following terms apply to the CARs:

a. The College will be entitled to conduct any CAR for a period of two (2) years from the date of this Order (“CARs Period”);

b. If the Registrant ceases to be a Designated Manager and ceases to have a proprietary interest in any pharmacy at any time within the two (2) years specified in subparagraph i above, such that the College is unable to conduct any CARs, then the CARs Period shall be paused and shall resume on the date on which the Registrant commences acting as a Designated Manager and/or obtains a proprietary interest in a pharmacy, and in such circumstances:

i. The Registrant shall notify the College, in writing, if he no longer is acting as a Designated Manager and no longer has a proprietary interest in a pharmacy at any point(s) during any times that the CARs Period remains active; and

ii. If the CARs Period is paused at any time(s), the Registrant shall notify the College, in writing, when he commences acting as a Designated Manager and/or obtains a proprietary interest in a pharmacy, at which point the CARs Period shall resume and shall continue until a total period of two (2) years has been achieved;

c. The CARs will be conducted by means of attendances by a representative of the College at any pharmacy at which the Registrant is acting as Designated Manager and/or at any pharmacy in which he holds a proprietary interest, at such times as the College may determine;

d. During any CAR, the College representative will be entitled to review and examine the Registrant’s practice, or the practice and operation of any pharmacy in which the Registrant holds a proprietary interest, with respect to the responsibilities in relation to narcotic, controlled drugs and targeted substance reconciliations; recordkeeping in relation to those reconciliations; investigations of any discrepancies and the reporting of any losses/thefts in relation to those reconciliations; and compounding resources, policies, and procedures;

e. The CARs are in addition to any routine inspections conducted by the College pursuant to the Drug and Pharmacies Regulation Act, R.S.O. 1990, c. H.4., s. 148, and are not a substitute for such inspections;

f. The Registrant shall fully cooperate with the College representative during the CARs; and

g. The Registrant shall pay to the College in respect of such CAR the amount of $1,000.00 per CAR, immediately after each CAR is completed, with the total amount to be paid by the Registrant not to exceed $3,000, regardless of the number of CARs and/or attendances conducted by the College.

e. That the Registrar suspend the Registrant’s Certificate of Registration for a period of three (3) months, with one (1) month of the suspension to be remitted on condition that the Registrant complete the remedial training as specified in paragraphs 2(a) and 2(b). If the remitted portion of the suspension is required to be served by the Registrant because he fails to complete the remedial requirement specified in paragraphs 2(a) and/or 2(b), that portion of the suspension shall commence on May 20, 2024, and shall continue until June 19, 2024, inclusive. If the time for completing the remedial steps in paragraphs 2(a) and/or 2(b) above is extended by the Registrar, the date on which the remitted portion of the suspension shall commence, if required, shall be adjusted accordingly.

f. Costs to the College in the amount of $10,000.

The reprimand in this matter remains outstanding.