As from September 6, 2017, the following is imposed as a term, condition and
limitation on the certificate of registration held by Dr. Nicholas Samuel
Ciurria, in accordance with an undertaking and consent given by Dr. Ciurria to
the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. NICHOLAS SAMUEL CIURRIA
("Dr. Ciurria")
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. Ciurria, certificate of registration number 29153, am a member of
the College.
(3) I, Dr. Ciurria, acknowledge that the College received information from
the NMS and initiated an investigation bearing File Number 7215560 (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. Ciurria, undertake to abide by the provisions of this Undertaking
effective upon the date I sign it (the "Effective Date").
(5) I, Dr. Ciurria, shall keep a Log of all prescriptions for Narcotic Drugs,
Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other
Targeted Substances and All other Monitored Drugs, 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 appointment;
(ii) the name of the patient;
(iii) the name of the medication prescribed, dose, direction, number of
tablets to be dispensed and frequency;
(iv) the clinical indication;
(v) whether the prescription is for a new medication and/or different
dose or frequency than currently prescribed to the patient (Y/N);
(vi) Dr. Ciurria'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).
(6) I, Dr. Ciurria, 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.
(7) Clinical Supervision
(a) I, Dr. Ciurria, 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. Ciurria, 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")
(c) I, Dr. Ciurria, undertake to engage in Phase 1 of Clinical
Supervision for a minimum of four (4) weeks on the terms set out
below.
(d) During Phase 1, I, Dr. Ciurria, undertake to meet with my Clinical
Supervisor(s) at least once every week to discuss the Clinical
Supervisor(s)'s review of:
i. 20 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 since the Clinical Supervisor(s)'s prior review
there are not 20 patients listed in the Prescribing Log to
whom I have prescribed Narcotic Drugs, Narcotic Preparations,
Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs , then the charts of
all patients listed in the Prescribing Log since the Clinical
Supervisor(s)'s prior review; and
ii. At least 10 charts of patients to whom I have initiated a new
prescription for:
1. Narcotic Drugs, or
2. Narcotic Preparations; or
3. Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs where the
patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation,
or if since the Clinical Supervisor(s)'s prior review there
are not 10 patients listed in the Prescribing Log to whom I
have initiated a new prescription for Narcotic Drugs,
Narcotic Preparations or Controlled Drugs, Benzodiazepines
and Other Targeted Substances and All other Monitored Drugs
where the patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation, then the charts of all patients listed
in the Prescribing Log since the Clinical Supervisor(s)'s
prior review.
(e) I, Dr. Ciurria, 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) has reviewed and discussed
with me.
(f) I, Dr. Ciurria, acknowledge that during Phase 1, the Clinical
Supervisor(s) will provide a report to the College at least once
every two (2) weeks.
(g) I, Dr. Ciurria, acknowledge that after a minimum of four (4) weeks
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")
(h) Upon the recommendation of the Clinical Supervisor(s) and approval
by the College, I, Dr. Ciurria, undertake to engage in Phase 2 of
Clinical Supervision for a minimum of two (2) months on the terms
set out below.
(i) During Phase 2, I, Dr. Ciurria, undertake to meet with my Clinical
Supervisor(s) at least once every two (2) weeks 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 since the Clinical Supervisor(s)'s prior review
there are not 15 patients listed in the Prescribing Log to
whom I have prescribed Narcotic Drugs, Narcotic Preparations,
Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs, then the charts of
all patients listed in the Prescribing Log since the Clinical
Supervisor(s)'s prior review; and
ii. At least 10 charts of patients to whom I have initiated a new
prescription for:
1. Narcotic Drugs, or
2. Narcotic Preparations; or
3. Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs where the
patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation,
or if since the Clinical Supervisor(s)'s prior review there
are not 10 patients listed in the Prescribing Log to whom I
have initiated a new prescription for Narcotic Drugs,
Narcotic Preparations or Controlled Drugs, Benzodiazepines
and Other Targeted Substances and All other Monitored Drugs
where the patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation, then the charts of all patients listed
in the Prescribing Log since the Clinical Supervisor(s)'s
prior review.
(j) I, Dr. Ciurria, 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) has reviewed and discussed
with me.
(k) I, Dr. Ciurria, acknowledge that during Phase 2, the Clinical
Supervisor(s) will provide a report to the College at least once
every two (2) weeks.
(l) I, Dr. Ciurria, acknowledge that after a minimum of two (2) months
of Phase 2, 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 3 of Clinical Supervision ("Phase 3")
(m) Upon the recommendation of the Clinical Supervisor(s) and approval
by the College, I, Dr. Ciurria, undertake to engage in Phase 3 of
Clinical Supervision for a minimum of six (6) months on the terms
set out below.
(n) During Phase 3, I, Dr. Ciurria, 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 since the Clinical Supervisor(s)'s prior review
there are not 15 patients listed in the Prescribing Log to
whom I have prescribed Narcotic Drugs, Narcotic Preparations,
Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs, then the charts of
all patients listed in the Prescribing Log since the Clinical
Supervisor(s)'s prior review; and
ii. At least 10 charts of patients to whom I have initiated a new
prescription for:
1. Narcotic Drugs, or
2. Narcotic Preparations; or
3. Controlled Drugs, Benzodiazepines and Other Targeted
Substances and All other Monitored Drugs where the
patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation,
or if since the Clinical Supervisor(s)'s prior review there
are not 10 patients listed in the Prescribing Log to whom I
have initiated a new prescription for Narcotic Drugs,
Narcotic Preparations or Controlled Drugs, Benzodiazepines
and Other Targeted Substances and All other Monitored Drugs
where the patient is also prescribed a Narcotic Drug and/or
Narcotic Preparation, then the charts of all patients listed
in the Prescribing Log since the Clinical Supervisor(s)'s
prior review.
(o) I, Dr. Ciurria, acknowledge that during Phase 3, the Clinical
Supervisor(s) must sign and date the Prescribing Log to confirm the
charts that the Clinical Supervisor(s) has reviewed and discussed
with me.
(p) I, Dr. Ciurria, acknowledge that during Phase 3, the Clinical
Supervisor(s) will provide a report to the College at least once
every month.
(q) I, Dr. Ciurria, acknowledge that after a minimum of six (6) months
of Phase 3, 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.
(r) I, Dr. Ciurria, acknowledge and undertake that the Clinical
Supervision will only cease upon recommendation of the Clinical
Supervisor(s) and approval by the College.
(s) I, Dr. Ciurria, 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.
(t) I, Dr. Ciurria, undertake that all meetings with my Clinical
Supervisor(s) will take place at my Practice Location, or another
Location approved by the College;
(u) I, Dr. Ciurria, 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 May 16, 2017, and concerns
that may arise during the period of Clinical Supervision.
(v) I, Dr. Ciurria, 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.
(w) I, Dr. Ciurria, undertake to ensure that Schedule "E" to this
Undertaking, is signed and delivered to the College within fourteen
(14) days of the Effective Date.
(x) I, Dr. Ciurria, 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
fourteen (14) 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.
(y) I, Dr. Ciurria, agree that if I am unable to obtain a Clinical
Supervisor on the terms set out in sections (7)(w) and/or (x)
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.
(z) I, Dr. Ciurria, 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 (7)(y) 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) In the course of this investigation, I, Dr. C., 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. Ciurria, 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;
4.the Centre for Effective Practice Management of Chronic
Non-
Cancer Pain Tool https://thewellhealth.ca/cncp
(iii) Review and discuss with my Clinical Supervisor(s) the CPSO
Policy "Medical Records": http://www.cpso.on.ca/Policies-
Publications/Policy/Medical-Records; and
(iv) any additional professional education recommended by my
Clinical Supervisor(s).
(c) I, Dr. Ciurria, 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. Ciurria, 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. Ciurria, undertake that, approximately six (6) months after
the Clinical Supervision set out under section 7 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. Ciurria, 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.
(c) I, Dr. Ciurria, undertake to co-operate fully with the Reassessment
conducted under the terms of this Undertaking
(d) I, Dr. Ciurria, 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.
(e) I, Dr. Ciurria, 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.
(10) Monitoring
(a) I, Dr. Ciurria, 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. Ciurria, 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. Ciurria, 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. Ciurria, acknowledge that I have executed the OHIP and NMS
consent form(s), attached hereto as Schedule "G" and Schedule "H",
respectively.
C. ACKNOWLEDGEMENT
(11) I, Dr. Ciurria, acknowledge that all schedules attached to or referred to
in this Undertaking form part of this Undertaking.
(12) I, Dr. Ciurria, 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.
(13) I, Dr. Ciurria, 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.
(14) I, Dr. Ciurria, 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").
(15) I, Dr. Ciurria, 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. Ciurria, acknowledge that this entire 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. Ciurria, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Ciurria, 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. Ciurria's prescribing of controlled substances,
including narcotics.
Based on the information received, the College conducted an
investigation into whether Dr. Ciurria 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. Ciurria'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 minimum of nine (9) months.
* Dr. Ciurria will engage in professional education in the
prescribing of controlled substances, including narcotics.
* Following the professional education and period of
supervision, Dr. Ciurria's prescribing of controlled
substances, including narcotics, will be re-assessed by an
assessor selected by the College.
D. CONSENT
(18) I, Dr. Ciurria, 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. Ciurria, 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.
(20) I, Dr. Ciurria, 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.