(1 of 2)
As from July 2, 2019, the following is imposed as terms, conditions and
limitations on the certificate of registration held by Dr. Michael Richard
Woolfrey in accordance with an undertaking and consent given by Dr. Woolfrey to
the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. MICHAEL RICHARD WOOLFREY
("Dr. Woolfrey")
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;
"OHIP" means the Ontario Health Insurance Plan;
"Public Register" means the College's register that is available to the
public.
(2) I, Dr. Woolfrey, certificate of registration number 63967, am a member of
the College.
(3) I, Dr. Woolfrey, acknowledge that the College referred allegations of
professional misconduct to the Discipline Committee in a Notice of
Hearing dated May 29, 2019.
(4) I, Dr. Woolfrey, acknowledge that, after the College receives an original
copy of this Undertaking as signed by me, the College will withdraw the
Notice of Hearing.
B. UNDERTAKING
(5) I, Dr. Woolfrey, undertake to abide by the provisions of this
Undertaking, effective upon the date I sign it (the "Effective Date").
(6) Practice Restrictions
(a) I, Dr. Woolfrey, undertake that I shall see a maximum of forty-five
(45) patients per day and a maximum of one hundred and fifty (150)
patients per week, excluding patients seen while I am on-call.
(b) I, Dr. Woolfrey, undertake that I shall be on call no more than ten
(10) days every three (3) months and no more than thirty-seven (37)
days every year.
(c) I, Dr. Woolfrey, undertake that I shall not perform injections to
treat chronic pain. For greater clarity, I understand that I may
perform injections to treat new acute indications, and may perform
aspirations for inflammatory/arthritic conditions of joints, bursa,
cysts, ligaments, or tendons, aspirations to rule out
infection/inflammatory conditions of joints, bursa, cysts,
abscesses, ligaments, or tendons, and injections for anesthetic
purposes for procedures.
(d) I, Dr. Woolfrey, undertake that I shall not provide counseling for
chronic pain nor bill OHIP for counseling for chronic pain.
(7) Clinical Supervision
(a) I, Dr. Woolfrey, undertake to practise under the guidance of a
clinical supervisor or clinical supervisors acceptable to the
College (the "Clinical Supervisor" or "Clinical Supervisors"), for
twelve (12) months ("Clinical Supervision").
(b) I, Dr. Woolfrey, undertake that during the period of Clinical
Supervision I shall keep a log of all joint injections performed,
including the date, patient identifier and type of injection, to
facilitate review by my Clinical Supervisor.
(c) I, Dr. Woolfrey, acknowledge that I have reviewed the Clinical
Supervisor's undertaking, attached hereto as Appendix "A", and
understand what is required of the Clinical Supervisor. The
Clinical Supervisor will, at minimum:
(i) Facilitate the education program set out in the
Individualized Education Plan ("IEP"), attached hereto as
Appendix "B";
(ii) Review the materials provided by the College and have an
initial meeting to discuss practice improvement
recommendations;
(iii) Meet with me at my Practice Location, or another location
approved by the College, once every month for three (3)
months and once every quarter for nine (9) months thereafter;
(iv) Review at least fifteen (15) of my patient charts at every
meeting, including the charts of every patient who has
received arthroscopy and a selection of those patients who
have received injections;
(v) Discuss any concerns arising from the chart reviews;
(vi) Make recommendations to me for practice improvements and
ongoing professional development and inquire into my
compliance with the recommendations;
(vii) Perform any other duties, such as reviewing other documents
or conducting interviews with staff or colleagues, that the
Clinical Supervisor deems necessary to my Clinical
Supervision; and
(viii)Submit written reports to the College at least once every
month for three (3) months and once every quarter for nine
(9) months thereafter, or more frequently if the Clinical
Supervisor has concerns about my standard of practice.
(d) I, Dr. Woolfrey, acknowledge that the charts reviewed shall be
selected by the Clinical Supervisor based on the criteria set out
above, the educational needs identified in the IEP attached hereto
as Appendix "B", as well as the areas of concern identified in the
reports of the medical inspector dated June 2, 2018, July 2, 2018
and September 25, 2018, and concerns that may arise during the
period of Clinical Supervision.
(e) I, Dr. Woolfrey, undertake to cooperate fully with the Clinical
Supervision of my practice, conducted under the term of this
Undertaking and Appendix "A" to this Undertaking, and to abide by
the recommendations of my Clinical Supervisor, including but not
limited to, any recommended practice improvements and ongoing
professional development.
(f) I, Dr. Woolfrey, undertake to ensure that Appendix "A" to this
Undertaking is signed and delivered to the College within thirty
(30) days of the Effective Date.
(g) I, Dr. Woolfrey, undertake that if a person who has given an
undertaking in Appendix "A" to this Undertaking is unable or
unwilling to continue to fulfill its provisions, I shall, within
twenty (20) days of receiving notice of same, obtain an executed
undertaking in the same form from a similarly qualified person who
is acceptable to the College and ensure that it is delivered to the
College within that time.
(h) I, Dr. Woolfrey, undertake that if I am unable to obtain a Clinical
Supervisor on the provisions set out under sections (6)(f) and/or
(g) above, I will cease practising medicine until such time as I
have obtained a Clinical Supervisor acceptable to the College.
(i) I, Dr. Woolfrey, acknowledge that if I am required to cease
practise as a result of section (6)(h) above this will
constitute a term, condition or limitation on my certificate
of registration and that term, condition or limitation will
be included on the public register.
(8) Professional Education
(a) I, Dr. Woolfrey, undertake to successfully complete all aspects of
the detailed IEP, attached hereto as Appendix "B", including all of
the following professional education (the "Professional
Education"):
(i) University of Toronto Faculty of Medicine program in Medical
Record-Keeping: http://www.cpd.utoronto.ca/recordkeeping/;
(ii) CMPA e-learning modules: Documentation: Charting Medical
Records and Documentation II: Principles of Medical Record
Keeping;
(iii) PROBE: Ethics & Boundaries Program, by receiving a passing
evaluation or grade, without any condition or qualification,
and
(iv) a written summary of approximately 2-4 pages or 2000 words of
the following resources:
1. CPSO Policy "Medical Records":
https://www.cpso.on.ca/Policies-Publications/Policy/Medical-Records;
2. Clinical Practice Guideline: Indications for
Arthroscopy in Patients with Osteoarthritis; and
(v) any additional professional education recommended by my
Clinical Supervisor.
(b) I, Dr. Woolfrey, 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 where relevant, 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. Woolfrey, undertake to complete this requirement by December
31, 2019 or, if no satisfactory program is available by that time,
by the first possible opportunity thereafter.
(d) I, Dr. Woolfrey, acknowledge that a report or reports may be
provided to the College regarding my progress and compliance with
the Professional Education.
(9) Reassessment of Practice
(a) I, Dr. Woolfrey, undertake that, approximately six (6) months after
the completion of the Clinical Supervision set out in section (6)
above and Appendix "A" to this Undertaking, I will submit to a
reassessment of my practice ("the Reassessment") by an assessor or
assessors selected by the College (the "Assessor" or "Assessors").
I acknowledge that the Reassessment may include a chart review,
direct observation of my care, interviews with colleagues and
co-workers, feedback from patients and any other tools deemed
necessary by the College.
(b) I, Dr. Woolfrey, undertake to co-operate fully with the
Reassessment, conducted under the term of this Undertaking.
(c) I, Dr. Woolfrey, acknowledge that my Clinical Supervisor may
receive and review the findings of the Assessor, and may discuss
with the Assessor any issues or concerns arising from the
Reassessment.
(d) I, Dr. Woolfrey, acknowledge that the results of the Reassessment
will be provided to me and reported to the College and the
Reassessment may form the basis of further action by the College.
(10) Monitoring
(a) I, Dr. Woolfrey, undertake to inform the College of each and every
location that 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. Woolfrey, 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) I, Dr. Woolfrey, give my irrevocable consent to the College to make
appropriate enquiries of OHIP and/or any person who or institution
that may have relevant information, in order for the College to
monitor my compliance with the provisions of this Undertaking.
(d) I, Dr. Woolfrey, acknowledge that I have executed the OHIP consent
form attached hereto as Appendix "C".
C. ACKNOWLEDGEMENT
(11) I, Dr. Woolfrey, acknowledge that all appendices attached to or referred
to in this Undertaking form part of this Undertaking.
(12) I, Dr. Woolfrey, 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.
(13) I, Dr. Woolfrey, 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.
(14) I, Dr. Woolfrey, 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").
(15) I, Dr. Woolfrey, 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.
(16) I, Dr. Woolfrey, acknowledge that this Undertaking constitutes terms,
conditions, and limitations on my certificate of registration for the
purposes of section 23 of the Code.
(17) Public Register
(a) I, Dr. Woolfrey, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Woolfrey, acknowledge that, in addition to this Undertaking
being posted in accordance with section (17)(a) above, the
following summary shall be posted on the Public Register during the
time period that this Undertaking remains in effect:
Dr. Woolfrey was referred to the Discipline Committee on
allegations of professional misconduct. In exchange for Dr.
Woolfrey's agreement to the restrictions set out below, the
College withdrew the Notice of Hearing.
Dr. Woolfrey shall see a maximum of 45 patients per day and a
maximum of 150 patients per week, excluding patients seen
while he is on-call.
Dr. Woolfrey shall be on call no more than 10 days every
three months and no more than 37 days every year.
Dr. Woolfrey shall not perform injections to treat chronic
pain, but may perform injections for certain other
indications as specified in the Undertaking.
Dr. Woolfrey shall not provide counseling for chronic pain
and shall not bill OHIP for counseling for chronic pain.
Dr. Woolfrey will practise under the guidance of a Clinical
Supervisor acceptable to the College for 12 months.
Dr. Woolfrey will engage in professional education in medical
record-keeping, certain clinical guidelines, and ethics.
Dr. Woolfrey's practice will be reassessed by an assessor
selected by the College approximately 6 months after the end
of the period of Clinical Supervision.
D. CONSENT
(18) I, Dr. Woolfrey, 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
and to all Clinical Supervisors, and/or Assessors:
(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.
(19) I, Dr. Woolfrey, 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.
(20) I, Dr. Woolfrey, give my irrevocable consent to any persons who
facilitate my completion of the Professional Education, and to all
Clinical Supervisors, Chiefs of Staff and Assessors, to disclose to the
College, and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant to the provisions of the Clinical
Supervisor's undertaking set out at Appendix "A" to this
Undertaking;
(c) any information relevant to the Reassessment;
(d) any information relevant for the purposes of monitoring my
compliance with this Undertaking; and/or
(e) any information which comes to their attention in the course of
providing the Professional Education and which they reasonably
believes indicates a potential risk of harm to my patients.
(2 of 2)
As from July 5, 2017, the following is imposed as a term, condition and
limitation on the certificate of registration held by Dr. Michael Richard
Woolfrey, in accordance with an undertaking and consent given by Dr. Woolfrey
to the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. MICHAEL RICHARD WOOLFREY
("Dr. Woolfrey")
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.
"Controlled Drugs" means from Part G of the Food and Drug Regulations
under the Food and Drugs Act, S.C., 1985, c. F-27, as amended.
"Benzodiazepines and Other Targeted Substances" means from the
Benzodiazepines and Other Targeted Substances Regulations made under the
Controlled Drugs and Substances Act., S.C., 1996, c. 19, as amended
(A summary of the above-named drugs [from Appendix I to the Compendium of
Pharmaceuticals and Specialties] is attached hereto as Schedule "A"; and
the current regulatory lists are attached hereto as Schedule "B")
"All other Monitored Drugs" means as defined under the Narcotics Safety
and Awareness Act, 2010, S.O. 2010, c. 22, as amended, as noted in
Schedule "C".
"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;
"OHIP" means the Ontario Health Insurance Plan;
"Public Register" means the College's register that is available to the
public.
(2) I, Dr. Woolfrey, certificate of registration number 63967, am a member of
the College.
(3) I, Dr. Woolfrey, acknowledge that the College received information from
the NMS and initiated an investigation bearing File Number 7215641 (the
"Investigation") into whether I failed to maintain the standard of
practice of the profession and/or am incompetent in my prescribing of
controlled substances, including narcotics.
B. UNDERTAKING
(4) I, Dr. Woolfrey, undertake to abide by the provisions of this Undertaking
effective immediately upon the signing of this Undertaking.
(5) Practice Restriction, Prescribing Log and Copies of Prescriptions
(a) I, Dr. Woolfrey, undertake that I shall not prescribe Narcotic
Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and
Other Targeted Substances and All other Monitored Drugs for chronic
non-cancer pain.
(b) Notwithstanding paragraph (5)(a), I, Dr. Woolfrey, may:
i. prescribe the above-noted medications for acute post-injury,
post-fracture or post-surgical pain; and
ii. write hospital orders for the above-noted medications for
hospital in-patients during the course of their in-patient
stay to be dispensed through the hospital pharmacy only.
(6) I, Dr. Woolfrey, shall keep a log of all prescriptions for Narcotic
Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other
Targeted Substances and All other Monitored Drugs, excluding hospital
orders for these medications made in accordance with paragraph (5)(b)(ii)
of this Undertaking, in the form attached as set out in Schedule "D",
which will include at least the following information (the "Prescribing
Log"):
(i) the date of the patient encounter;
(ii) the name of the patient and chart/file number;
(iii) the name of the medication prescribed, dose, direction,
number of tablets to be dispensed and frequency;
(iv) the clinical indication;
(v) whether Dr. Woolfrey has prescribed this medication and/or
another Narcotic Drug, Narcotic Preparation, Controlled Drug,
Benzodiazepine or Other Targeted Substance to this patient
for a consecutive duration exceeding three (3) months (Y/N);
(vi) Dr. Woolfrey's signature;
(vii) the date of the Clinical Supervisor's review (if applicable,
as set out below); and
(viii)the Clinical Supervisor's signature (if applicable, as set
out below).
(7) I, Dr. Woolfrey, undertake to keep a copy of all prescriptions I write
for Narcotic Drugs, Narcotic Preparations, Controlled Drugs,
Benzodiazepines and Other Targeted Substances and All other Monitored
Drugs, in the corresponding patient chart.
(8) Clinical Supervision
(a) I, Dr. Woolfrey, undertake to practise under the guidance of a
clinical supervisor(s) acceptable to the College (the "Clinical
Supervisor(s)"), for a minimum of nine (9) months on the terms set
out below (the "Clinical Supervision").
(b) I, Dr. Woolfrey, acknowledge that the purpose of the Clinical
Supervision is to ensure that I am in compliance with my Practice
Restriction as set out at paragraph 5 of this Undertaking and that
my prescribing of Narcotic Drugs, Narcotic Preparations, Controlled
Drugs, Benzodiazepines and Other Targeted Substances and All other
Monitored Drugs for acute post-injury, post-fracture or
post-surgical pain is appropriate.
(c) I, Dr. Woolfrey, acknowledge and undertake that each phase of
Clinical Supervision set out below will only be reduced upon
recommendation of the Clinical Supervisor(s) and approval by the
College.
Phase 1 of Clinical Supervision ("Phase 1")
(d) I, Dr. Woolfrey, undertake to engage in Phase 1 of Clinical
Supervision for a minimum of three (3) months on the terms set out
below.
(e) During Phase 1, I, Dr. Woolfrey, undertake to meet with my Clinical
Supervisor(s) at least once every month to discuss the Clinical
Supervisor(s)'s review of:
i. 15 charts for patients to whom I have prescribed Narcotic
Drugs, Narcotic Preparations, Controlled Drugs,
Benzodiazepines and Other Targeted Substances and All other
Monitored Drugs since the Clinical Supervisor(s)'s prior
review, or if there are not 15 patients listed in the
Prescribing Log since the Clinical Supervisor(s)'s prior
review, then the charts of all patients listed in the
Prescribing Log since the Clinical Supervisor's prior review;
and
ii. the chart of every patient to whom I have prescribed a
Narcotic Drug, Narcotic Preparation, Controlled Drug,
Benzodiazepine and/or Other Targeted Substance and/or any
other Monitored Drug for a consecutive duration exceeding
three (3) months.
(f) I, Dr. Woolfrey, acknowledge that during Phase 1, the Clinical
Supervisor(s) must sign and date the Prescribing Log to confirm the
charts that the Clinical Supervisor(s) have reviewed and discussed
with me;
(g) I, Dr. Woolfrey, acknowledge that during Phase 1, the Clinical
Supervisor(s) will provide a report to the College at least once
every month.
(h) I, Dr. Woolfrey, acknowledge that after a minimum of three (3)
months of Phase 1, if the Clinical Supervisor(s) is satisfied that
I have the necessary knowledge, skills and judgment to practice in
a less highly supervised environment, the Clinical Supervisor(s)
may recommend to the College that supervision be reduced.
Phase 2 of Clinical Supervision ("Phase 2")
(i) Upon the recommendation of the Clinical Supervisor(s) and approval
by the College, I, Dr. Woolfrey, undertake to engage in Phase 2 of
Clinical Supervision for a minimum of six (6) months on the terms
set out below.
(j) During Phase 2, I, Dr. Woolfrey, undertake to meet with my Clinical
Supervisor(s) at least once every three (3) months to discuss the
Clinical Supervisor(s)'s review of:
i. 15 charts for patients to whom I have prescribed Narcotic
Drugs, Narcotic Preparations, Controlled Drugs,
Benzodiazepines and Other Targeted Substances and All other
Monitored Drugs since the Clinical Supervisor(s)'s prior
review, or if there are not 15 patients listed in the
Prescribing Log since the Clinical Supervisor(s)'s prior
review, then the charts of all patients listed in the
Prescribing Log since the Clinical Supervisor's prior review;
and
ii. the chart of every patient to whom I have prescribed a
Narcotic Drug, Narcotic Preparation, Controlled Drug,
Benzodiazepine and/or Other Targeted Substance and/or any
other Monitored Drug for a consecutive duration exceeding
three (3) months.
(k) I, Dr. Woolfrey, acknowledge that during Phase 2, the Clinical
Supervisor(s) must sign and date the Prescribing Log to confirm the
charts that the Clinical Supervisor(s) have reviewed and discussed
with me.
(l) I, Dr. Woolfrey, acknowledge that during Phase 2, the Clinical
Supervisor(s) will provide a report to the College at least once
every three (3) months.
(m) I, Dr. Woolfrey, acknowledge that after a minimum of six (6) months
of Phase 2, if the Clinical Supervisor(s) is satisfied that I have
the necessary knowledge, skills and judgment to practice without
supervision, the Clinical Supervisor(s) may recommend to the
College that the Clinical Supervision cease.
(n) I, Dr. Woolfrey, acknowledge and undertake that the Clinical
Supervision will only cease upon recommendation of the Clinical
Supervisor(s) and approval by the College.
(o) I, Dr. Woolfrey, acknowledge that I have reviewed the Clinical
Supervisor(s)'s undertaking, attached hereto as Schedule "E", and
understand what is required of the Clinical Supervisor(s). In
addition to what is set out above, the Clinical Supervisor(s) will,
at a minimum:
(i) Facilitate the education program set out in the
Individualized Education Plan ("IEP") attached as Schedule
"F";
(ii) Discuss any concerns with me arising from chart reviews and
observations;
(iii) Make recommendations to me for practice improvements and
ongoing professional development and inquire into my
compliance with the recommendations; and
(iv) Perform any other duties, such as reviewing other documents
or conducting interviews with staff or colleagues, that the
Clinical Supervisor(s) deem necessary to my Clinical
Supervision.
(p) I, Dr. Woolfrey, undertake that all meetings with my Clinical
Supervisor(s) will take place at my Practice Location, or another
location approved by the College;
(q) I, Dr. Woolfrey, acknowledge that all charts reviewed shall be
independently selected by the Clinical Supervisor(s) based on the
educational needs identified in the IEP set out at Schedule "F" to
my Undertaking, as well as the areas of concern identified in the
report of the medical inspector dated February 21, 2017, and
concerns that may arise during the period of Clinical Supervision.
(r) I, Dr. Woolfrey, undertake to cooperate fully with the Clinical
Supervision of my practice, conducted under the terms of this
Undertaking and Schedule "E" attached, and to abide by the
reasonable recommendations of my Clinical Supervisor(s), including
but not limited to, any reasonable recommended practice
improvements and ongoing professional development.
(s) I, Dr. Woolfrey, undertake to ensure that Schedule "E" to this
Undertaking, is signed and delivered to the College within thirty
(30) days of the Effective Date.
(t) I, Dr. Woolfrey, undertake that if a person who has given an
undertaking in Schedule "E" to this Undertaking is unable or
unwilling to continue to fulfill its provisions, I shall, within
thirty (30) days of receiving notice of same, obtain an executed
undertaking in the same form from a similarly qualified person who
is acceptable to the College and ensure that it is delivered to the
College within that time.
(u) I, Dr. Woolfrey, agree that if I am unable to obtain a Clinical
Supervisor on the terms set out in sections (8)(s) and/or (t)
above, I will cease prescribing narcotic drugs, narcotic
preparations, controlled drugs, benzodiazepines and other targeted
substances, and all other monitored drugs until such time as I have
obtained a Clinical Supervisor acceptable to the College.
(v) I, Dr. Woolfrey, agree that if I am required to cease prescribing
narcotic drugs, narcotic preparations, controlled drugs,
benzodiazepines and other targeted substances, and all other
monitored drugs as a result of section (8)(u) above this will
constitute a term, condition or limitation on my certificate of
registration and that term, condition or limitation will be
included on the Public Register.
(9) Professional Education
(a) In the course of this investigation, I, Dr. Woolfrey, voluntarily
enrolled in the University of Toronto Faculty of Medicine program
in Safe Opioid Prescribing (all three webinars and in-person
workshop): www.cepd.utoronto.ca/opioidprescribing;
(b) I, Dr. Woolfrey, undertake to participate in and successfully
complete all elements of the detailed IEP, attached hereto as
Schedule "F", including but not limited to, the following elements
of professional education (the "Professional Education"):
(i) University of Toronto Faculty of Medicine program in Safe
Opioid Prescribing (all three webinars and in-person
workshop): www.cepd.utoronto.ca/opioidprescribing;
(ii) Review and discuss with my Clinical Supervisor(s) the
following resources:
1. CPSO Policy "Prescribing Drugs":
http://www.cpso.on.ca/Policies-Publications/Policy/Prescribing-Drugs;
2. 2017 Canadian Guideline for Opioids for Chronic
Non-Cancer Pain:
http://nationalpaincentre.mcmaster.ca/guidelines.html;
3. CMPA advice regarding preventing the misuse of opioids
https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/preventing-the-misuse-of-opioids;
and
(iii) any additional professional education recommended by my
Clinical Supervisor(s).
(c) I, Dr. Woolfrey, undertake to provide proof to the College of my
successful completion of each element of the Professional Education
specified above, including proof of registration, attendance and
participant assessment reports where available, within one (1)
month of completion of each element. I acknowledge that the College
will determine, in its sole discretion, whether I have successfully
completed each element of the Professional Education.
(d) I, Dr. Woolfrey, acknowledge that a report or reports may be
provided to the College regarding my progress and compliance with
the Professional Education.
(10) Reassessment of Practice
(a) I, Dr. Woolfrey, undertake that, approximately six (6) months
after the Clinical Supervision set out under section 8 of the
Undertaking has ceased, I will submit to a reassessment of my
practice by an assessor or assessors selected by the College (the
"Reassessment").
(b) I, Dr. Woolfrey, acknowledge and agree that the focus of the
Reassessment shall be on ensuring that I am in compliance with my
Practice Restriction as set out at paragraph 5 of this Undertaking
and that my prescribing of Narcotic Drugs, Narcotic Preparations,
Controlled Drugs, Benzodiazepines and Other Targeted Substances and
All other Monitored Drugs for acute post-injury, post-fracture or
post-surgical pain is appropriate.
(c) I, Dr. Woolfrey, acknowledge and agree that the Reassessment may
include a chart review, direct observation of my care, an interview
of me, interviews with colleagues and co-workers, feedback from
patients and any other tools deemed necessary by the College.
(d) I, Dr. Woolfrey, undertake to co-operate fully with the
Reassessment, conducted under the terms of this Undertaking
(e) I, Dr. Woolfrey, acknowledge and agree that my Clinical
Supervisor(s) may receive and review the findings of the
Assessor(s), and may discuss with the Assessor(s) any issues or
concerns arising from the Reassessment.
(f) I, Dr. Woolfrey, acknowledge that the results of the Reassessment
will be provided to me and reported to the College and that the
Reassessment may form the basis of further action by the College.
(11) Monitoring
(a) I, Dr. Woolfrey, undertake to inform the College of each and every
location at which I practise or have privileges, including, but not
limited to, hospital(s), clinic(s) and office(s), in any
jurisdiction (collectively my "Practice Location(s)"), within ten
(10) business days of executing this Undertaking. Going forward, I
further undertake to inform the College of any and all new Practice
Locations within ten (10) business days of commencing practice at
that location.
(b) I, Dr. Woolfrey, undertake and agree that I will submit to, and not
interfere with, unannounced inspections of my Practice Location(s)
and patient records by a College representative for the purposes of
monitoring my compliance with the provisions of this Undertaking.
(c) I, Dr. Woolfrey, give my irrevocable consent to the College to make
appropriate enquiries of the Ontario Health Insurance Plan
("OHIP"), the Drug Program Services Branch, the Narcotics
Monitoring System ("NMS") implemented under the Narcotics Safety
and Awareness Act, 2010 and/or any person or institution who may
have relevant information, in order for the College to monitor my
compliance with the provisions of this Undertaking.
(d) I, Dr. Woolfrey, acknowledge that I have executed the OHIP and NMS
consent form(s), attached hereto as Schedule "G" and Schedule "H",
respectively.
C. ACKNOWLEDGEMENT
(12) I, Dr. Woolfrey, acknowledge that all schedules attached to or referred
to in this Undertaking form part of this Undertaking.
(13) I, Dr. Woolfrey, acknowledge 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.
(14) I, Dr. Woolfrey, acknowledge and confirm 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.
(15) I, Dr. Woolfrey, acknowledge that the College will provide this
Undertaking to any Chief of Staff, or a colleague with similar
responsibilities, at any Practice Location ("Chief(s) of Staff").
(16) I, Dr. Woolfrey, 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.
(17) I, Dr. Woolfrey, acknowledge that this entire Undertaking constitutes
terms, conditions, and limitations on my certificate of registration for
the purposes of section 23 of the Code.
(18) Public Register
(a) I, Dr. Woolfrey, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Woolfrey, acknowledge that, in addition to this Undertaking
being posted in accordance with the section above, the following
summary shall be posted on the Public Register during the time
period that this Undertaking remains in effect:
The College received information from the Narcotics Monitoring
System about Dr. Woolfrey's prescribing of controlled substances,
including narcotics.
Based on the information received, the College conducted an
investigation into whether Dr. Woolfrey failed to maintain the
standard of practice of the profession and/or was incompetent in
his prescribing of controlled substances, including narcotics. As
a result of the investigation:
Dr. Woolfrey shall not prescribe Narcotic Drugs, Narcotic
Preparations, Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs for chronic non-cancer
pain.
Notwithstanding this restriction, Dr. Woolfrey may:
prescribe the above-noted medications for acute post-injury,
post fracture or post-surgical pain; and
write hospital orders for the above-noted medications for
hospital in-patients during the course of their in-patient
stay to be dispensed through the hospital pharmacy only.
Dr. Woolfrey's prescribing of narcotic drugs, narcotic
preparations, controlled drugs, benzodiazepines and other
targeted substances, and other monitored drugs will be
supervised by a Clinical Supervisor acceptable to the College
for a minimum of nine (9) months.
Dr. Woolfrey will engage in professional education in the
prescribing of controlled substances, including narcotics.
Following the professional education and period of
supervision, Dr. Woolfrey's prescribing of controlled
substances, including narcotics, will be re-assessed by an
assessor selected by the College.
D. CONSENT
(19) I, Dr. Woolfrey, 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
and to all Clinical Supervisors, and/or Assessors:
(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.
(20) I, Dr. Woolfrey, give my irrevocable consent to the College to provide
all Chief(s) 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.
(21) I, Dr. Woolfrey, give my irrevocable consent to any person who
facilitates my completion of the Professional Education, and to all
Clinical Supervisors, Chiefs of Staff and Assessors, to disclose to the
College, and to one another, any information:
(a) relevant to this Undertaking;
(b) relevant to the provisions of the Clinical Supervisor's undertaking
set out at Schedule "E";
(c) relevant to the Reassessment;
(d) relevant for the purposes of monitoring my compliance with this
Undertaking; and/or
(e) which comes to his or her attention in the course of providing the
Professional Education and which he or she reasonably believes
indicates a potential risk of harm to my patients.