As from September 1, 2020, the following are imposed as terms, conditions and
limitations on the certificate of registration held by Dr. Susan Jacqueline
Hulley in accordance with an undertaking and consent given by Dr. Hulley to the
College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. SUSAN HULLEY
("Dr. Hulley")
to
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
(the "College")
A. PREAMBLE
(1) In this Undertaking:
"Code" means the Health Professions Procedural Code, which is Schedule 2
to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as
amended;
"ICR Committee" means the Inquiries, Complaints and Reports Committee of
the College;
"Narcotic Drugs" means from the Narcotic Control Regulations made under
the Controlled Drugs and Substances Act, S.C., 1996, c. 19, as amended;
"Narcotic Preparations" means from the Narcotic Control Regulations made
under the Controlled Drugs and Substances Act, S.C., 1996, c. 19, as
amended;
"NMS" means the Drug Program Services Branch, the Narcotics Monitoring
System implemented under the Narcotics Safety and Awareness Act, 2010,
S.O. 2010, c. 22, as amended; and
"Public Register" means the College's register that is available to the
public.
(2) I, Dr. Hulley, certificate of registration number 65576, am a member of
the College.
(3) I, Dr. Hulley, acknowledge that, on June 15, 2009, after the College
received information relating to my prescribing practices, I entered into
an undertaking with the College whereby I relinquished my prescribing
privileges with respect to Narcotic Drugs and Narcotic Preparations
("2009 Undertaking").
(4) I, Dr. Hulley, acknowledge that in February 2020, I made a request to the
College to be released from the 2009 Undertaking.
(5) I, Dr. Hulley, acknowledge that the College has agreed to release me from
the 2009 Undertaking in exchange for my agreement to and execution of
this undertaking ("2020 Undertaking"), which replaces the 2009
Undertaking.
B. UNDERTAKING
(6) I, Dr. Hulley, undertake to abide by the provisions of this Undertaking,
effective immediately.
(7) Professional Education
(a) I, Dr. Hulley, undertake to participate in and successfully
complete all aspects of the detailed IEP, attached hereto as
Appendix "A", including all of the following professional education
(the "Professional Education"):
(i) Review, reflection, and a written summary of the following
policies and other self-study:
1. 2017 Canadian Guideline for Opioids for Chronic
Non-Cancer Pain, Michael G. DeGroote National Pain
Centre;
2. Prescribing Drugs, College policy;
3. CRISM National Guideline for the Clinical Management of
Opioid Use Disorder;
(ii) The Safer Opioid Prescribing Program, The University of
Toronto; and
(iii) The Buprenorphine-Naloxone Treatment for Opioid Use Disorder
Online Course, Centre for Addiction and Mental Health (CAMH).
(b) I, Dr. Hulley, undertake to provide proof to the College of my
successful completion of the Professional Education, including
proof of registration and attendance and participant assessment
reports, within one (1) month of completing it. I acknowledge that
the College will determine, in its sole discretion, whether I have
successfully completed the Professional Education.
(c) I, Dr. Hulley, undertake to complete this requirement by January
30, 2021, or, if no satisfactory program is available by that time,
by the first possible opportunity thereafter.
(d) I, Dr. Hulley, acknowledge that a report or reports may be provided
to the College regarding my progress and compliance with the
Professional Education.
(e) I, Dr. Hulley, acknowledge that if any of the programs listed above
become unavailable, substitution requests will be reviewed by the
College and the College will determine in its sole discretion
whether substitution is appropriate.
(8) Change of Scope/Re-Entering Practice
(a) I, Dr. Hulley, acknowledge that, although I have been released from
the 2009 Undertaking, I do not prescribe Narcotic Drugs or Narcotic
Preparations, and that it is outside of my scope of practice to do
so.
(b) I, Dr. Hulley, undertake that, in the event I intend to resume
prescribing Narcotic Drugs or Narcotic Preparations in the future,
I will not do so until after I have obtained the approval of the
College through its change of scope process, including by
completing and submitting for consideration the relevant
application for changing my scope of practice in compliance with
the College's policy on "Ensuring Competence: Changing Scope of
Practice and/or Re-entering Practice", or any College policy
regarding physicians' changing the scope of their practice in
effect at the relevant time. I acknowledge that the College's
change of scope process may require me to successfully complete a
period of clinical supervision and a reassessment.
(9) Monitoring
(a) I, Dr. Hulley, undertake to inform the College of each and every
location at which I practise or have privileges, including, but not
limited to, any hospitals, clinics, offices, and any Independent
Health Facilities with which I am affiliated, in any jurisdiction
(collectively my "Practice Location" or "Practice Locations"),
within five (5) days of executing this Undertaking. Going forward,
I further undertake to inform the College of any and all new
Practice Locations within five (5) days of commencing practice at
that location.
(b) I, Dr. Hulley, undertake that I will submit to, and not interfere
with, unannounced inspections of my Practice Locations and patient
records by a College representative for the purposes of monitoring
my compliance with the provisions of this Undertaking.
C. ACKNOWLEDGEMENT
(10) I, Dr. Hulley, acknowledge that all appendices attached to or referred to
in this Undertaking form part of this Undertaking.
(11) I, Dr. Hulley, acknowledge and undertake that I shall be solely
responsible for payment of all fees, costs, charges, expenses, etc.
arising from the implementation of any of the provisions of this
Undertaking.
(12) I, Dr. Hulley, acknowledge that I have read and understand the provisions
of this Undertaking and that I have obtained independent legal counsel in
reviewing and executing this Undertaking, or have waived my right to do
so.
(13) I, Dr. Hulley, acknowledge that the College will provide this Undertaking
to any Chief of Staff, or a colleague with similar responsibilities, at
any Practice Location ("Chief of Staff" or "Chiefs of Staff").
(14) I, Dr. Hulley, acknowledge that a breach by me of any provision of this
Undertaking may constitute an act of professional misconduct and/or
incompetence, and may result in a referral of specified allegations to
the Discipline Committee of the College.
(15) I, Dr. Hulley, acknowledge that this Undertaking constitutes terms,
conditions, and limitations on my certificate of registration for the
purposes of section 23 of the Code.
(16) Public Register
(a) I, Dr. Hulley, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Hulley, acknowledge that, in addition to this Undertaking
being posted in accordance with section (16)(a) above, the
following summary shall be posted on the Public Register during the
time period that this Undertaking remains in effect:
In 2009, after the College received information relating to
her prescribing, Dr. Hulley undertook to relinquish her
prescribing privileges with respect to Narcotic Drugs and
Narcotic Preparations. In 2020, Dr. Hulley was released from
the 2009 Undertaking, on condition that she engage in
professional education in prescribing.
(c) I, Dr. Hulley, acknowledge that this Undertaking remains in effect
until the College determines its terms are satisfied.
D. CONSENT
(17) I, Dr. Hulley, give my irrevocable consent to the College to provide the
following information to any person who requires this information for the
purposes of facilitating my completion of the Professional Education:
(a) any information the College has that led to the circumstances of my
entering into this Undertaking;
(b) any information arising from any investigation into, or assessment
of, my practice; and
(c) any information arising from the monitoring of my compliance with
this Undertaking.
(18) I, Dr. Hulley, give my irrevocable consent to the College to provide all
Chiefs of Staff with any information the College has that led to the
circumstances of my entering into this Undertaking and/or any information
arising from the monitoring of my compliance with this Undertaking.
(19) I, Dr. Hulley, acknowledge that I have executed the NMS consent form,
attached hereto as Appendix "B".
(20) I, Dr. Hulley, give my irrevocable consent to any persons who facilitate
my completion of the Professional Education, and to all Chiefs of Staff,
to disclose to the College, and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant for the purposes of monitoring my
compliance with this Undertaking;
(c) any information which comes to their attention in the course of
providing the Professional Education and which they reasonably
believe indicates a potential risk of harm to my patients.
Terms and conditions imposed on certificate by: Member