Petition for Writ of Certiorari — Sandra Brown, Petitioner v. New Hampshire Board of Veterinary Medicine

APPENDIX

i

APPENDIX

TABLE OF CONTENTS

Appendix A Order on Reconsideration in the State

of New Hampshire Supreme Court

(November 27, 2018) . . . . . . . . . . . App. 1

Appendix B Opinion in the Supreme Court of New

Hampshire

(November 1, 2018). . . . . . . . . . . . App. 3

Appendix C Order Denying Motion to Dismiss

Based on Lack of Subject Matter

Jurisdiction in the State of New

Hampshire Supreme Court

(February 9, 2018) . . . . . . . . . . . App. 15

Appendix D Statutes

RSA 318:8 . . . . . . . . . . . . . . . App. 17

RSA 318:8-a . . . . . . . . . . . . . . App. 17

RSA 318:9-a . . . . . . . . . . . . . . App. 18

RSA 318-B:18. . . . . . . . . . . . . App. 18

RSA 318-B:23. . . . . . . . . . . . . App. 18

RSA 318-B:25. . . . . . . . . . . . . App. 19

RSA 318-B:26. . . . . . . . . . . . . App. 19

RSA 332-B:1-a . . . . . . . . . . . . App. 30

RSA 332-B:3, IV . . . . . . . . . . App. 30

RSA 332-B:14. . . . . . . . . . . . . App. 30

Appendix E New Hampshire Board of Veterinary

Medicine Report of Clinic Inspection

(September 9, 2016) . . . . . . . . . . App. 34

Appendix F New Hampshire Board of Veterinary

Medicine Report of Clinic Inspection

(December 22, 2016) . . . . . . . . . . App. 39

ii

Appendix G New Hampshire Board of Pharmacy

Inspection

(February 24, 2014) . . . . . . . . . . App. 43

Appendix H New Hampshire Board of Pharmacy

Inspection

(August 13, 2014) . . . . . . . . . . . . App. 51

Appendix I New Hampshire Board of Pharmacy

Inspection

(October 18, 2016) . . . . . . . . . . . . App. 57

App. 1

APPENDIX A

THE STATE OF NEW HAMPSHIRE

SUPREME COURT

Case No. 2017-0729

[Filed November 27, 2018]

__________________________

Appeal of

)

Sandra Brown, DVM

)

__________________________ )

In Case No. 2017-0729, Appeal of Sandra

Brown, DVM, the court on November 27, 2018,

issued the following order:

Supreme Court Rule 22(2) provides that a party

filing a motion for rehearing or reconsideration shall

state with particularity the points of law or fact that

she claims the court has overlooked or

misapprehended.

We have reviewed the claims made in the

petitioner’s motion for reconsideration and conclude

that no points of law or fact were overlooked or

misapprehended in our decision. Accordingly, upon

reconsideration, we affirm our November 1, 2018

decision and deny the relief requested in the motion.

Relief requested in motion for

reconsideration denied.

App. 2

Lynn, C.J., and Hicks, Bassett, Hantz Marconi, and

Donovan, JJ., concurred.

Eileen Fox,

Clerk

Distribution:

New Hampshire Board of Veterinary Medicine, 2-7/13

Michael Chen, Esq.

R. James Steiner, Esq.

Thomas R. Broderick, Esq.

Allison R. Cook, Supreme Court

File

App. 3

APPENDIX B

NOTICE: This opinion is subject to motions for

rehearing under Rule 22 as well as formal revision

before publication in the New Hampshire Reports.

Readers are requested to notify the Reporter, Supreme

Court of New Hampshire, One Charles Doe Drive,

Concord, New Hampshire 03301, of any editorial errors

in order that corrections may be made before the

opinion goes to press. Errors may be reported by E-mail

at the following address: reporter@courts.state.nh.us.

Opinions are available on the Internet by 9:00 a.m. on

the morning of their release. The direct address of the

court’s home page is: http://www.courts.state.nh.us/

supreme.

THE SUPREME COURT OF NEW HAMPSHIRE

Board of Veterinary Medicine

No. 2017-0729

[Filed November 1, 2018]

____________________________

APPEAL OF

)

SANDRA BROWN, DVM

)

____________________________ )

(New Hampshire Board of Veterinary Medicine)

Argued: October 11, 2018

Opinion Issued: November 1, 2018

App. 4

Steiner Law Office, PLLC, of Concord (R. James

Steiner and Michael A. Chen on the brief, and Mr.

Steiner orally), for the petitioner.

Gordon J. MacDonald, attorney general (Thomas

Broderick, assistant attorney general, on the brief and

orally), for the respondent.

HICKS, J. The petitioner, Sandra Brown, DVM,

appeals an October 2017 decision by the respondent,

the New Hampshire Board of Veterinary Medicine

(Board), suspending her license to practice veterinary

medicine for six months and further prohibiting her,

following the six-month suspension and until December

31, 2021, from dispensing, possessing, or administering

controlled substances (other than euthanasia solution)

in her practice. On appeal, she argues that the Board

lacked subject matter jurisdiction to discipline her for

violating the Controlled Drug Act, see RSA ch. 318-B

(2017 & Supp. 2017), because the Board is not one of

the agencies statutorily authorized to enforce that act.

She also asserts that the Board lacked jurisdiction to

subject her practice to post-hearing inspections.

Although the petitioner makes other appellate

arguments, we decline to address them substantively.

Those arguments are not properly before us because, to

the extent that the petitioner raised them before the

Board, she did so, for the first time, in an untimely

motion for reconsideration, which is insufficient to

preserve them for our review. See RSA 541:3, :4 (2007);

cf. In the Matter of Sweatt & Sweatt, 170 N.H. 414, 424

(2017) (concluding that, “because the respondent did

not raise [his appellate] arguments in the trial court or

App. 5

in a timely motion for reconsideration, they are not

preserved for our review”). We affirm.

The Board found, or the certified record supports,

the following facts. In May and June of 2013, the Board

received complaints from two of the petitioner’s former

employees alleging, among other things, that she

improperly managed medication and equipment. After

investigating the complaints, the Board commenced an

adjudicatory proceeding. See RSA 332-B:15 (2017).

Based upon the evidence at the hearing, the Board

determined that the petitioner had committed

professional misconduct within the meaning of RSA

332-B:14, II(d) (2017) because she had “engaged in a

pattern of conduct inconsistent with the basic skills

and knowledge required to practice veterinary

medicine.” The Board decided that, despite the

instances of misconduct, it would not suspend or revoke

the petitioner’s license, but would, instead “impos[e] a

series of remedial measures designed to improve [her]

overall medical knowledge and competence.” As a

result, the Board ordered that the petitioner’s “practice

[would] be subject to [B]oard inspections, which [might]

be announced or unannounced, for a period of four . . .

years” from the Board’s September 2015 decision. Such

inspections would include examining the petitioner’s

records as well as reviewing her “hospital[,] surgical[,]

. . . medical[,] . . . [and] management practices.”

Documents in the certified record suggest that the

petitioner may have signed a settlement agreement

with the Board in which she agreed to the inspections.

See RSA 332-B:14, IV, :16, V (2017) (authorizing the

Board to dispose of allegations by entering into a

settlement agreement or consent order).

App. 6

The Board inspected the petitioner’s practice in

May, September, and December 2016. The Board of

Pharmacy, on behalf of the Board, inspected her

practice in October 2016. See RSA 318:9-a (2015). As a

result of the findings from those inspections, the Board

commenced another adjudicatory proceeding against

the petitioner. See RSA 332-B:15. Following a hearing,

the Board found that she had committed professional

misconduct within the meaning of RSA 332-B:14, II

(2017).

Specifically, the Board found that the petitioner had

continually and willfully prescribed and used expired

medications, even after having been notified not to do

so. See RSA 332-B:14, II(d). The Board determined that

doing so was “dangerous as expired medications can

develop increased potency, decreased potency, or

become toxic.” The Board found that the petitioner’s

conduct was willful, observing that she had “[gone] so

far as to make a waiver to justify the use of expired

medication.” See id.

Additionally, the Board found that the petitioner

“consistently showed a nonchalant attitude towards the

multiple investigations and hearings” and that she

failed to “take remedial corrective measure[s] in a

timely fashion” after prior investigations had brought

problems to her attention. See RSA 332-B:14, II(g).

The Board further found that the petitioner failed

“to keep” her “veterinary premises and equipment in a

safe, clean, and sanitary condition.” RSA 332-B:14,

II(l). According to the Board, the petitioner’s “mobile

[veterinary] unit was . . . disorganized, contained

expired medications, and there were no actions being

App. 7

taken to maintain an appropriate temperature to store

the medication properly.”

Also, the Board found that the petitioner’s medical

record-keeping demonstrated “a continued pattern of

not being forthcoming with clients,” in that she failed

to document discussions with clients about adverse

outcomes, including one instance in which her medical

error led to the death of an animal in her care. See RSA

332-B:14, II(n).

Finally, the Board found that the petitioner violated

RSA 318-B:10, II (2017) by filling prescriptions for

schedule IV controlled substances for more than a

seven-day supply on multiple occasions, and that she

violated RSA 318-B:12, I (2017) by “failing to

adequately and accurately keep controlled drug

records.” The Board “felt that [the petitioner] showed

a lack of concern at the seriousness” of the inaccurate

controlled drug records. The Board expressed

“significant concerns regarding [her] ability to properly

prescribe and maintain controlled substances.” The

Board ruled that the violations of RSA 318-B:10, II and

:12, I, constituted “unprofessional conduct” within the

meaning of RSA 332-B:14, II(c). See N.H. Admin. R.,

Vet 501.02 (providing that “[c]onduct which violates the

Principles of Veterinary Medical Ethics of the AVMA as

revised April 2016” constitutes “unprofessional or

dishonorable conduct pursuant to RSA 332-B:14, II(c)”);

see also American Veterinary Medical Association,

Principles of Veterinary Medical Ethics of the AVMA

§ IV (2016) (“A veterinarian shall respect the law,”

which means that he or she “should obey all laws of the

jurisdictions in which [he or she] reside[s] and

App. 8

practice[s] veterinary medicine.”), available at

https://www.avma.org/KB/Policies/Pages/

Principles-of-Veterinary-Medical-Ethics-of-the-AVM

A.aspx.

Because of this conduct, in addition to suspending

the petitioner’s veterinary license for six months, the

Board ordered that, after the suspension and until

December 31, 2021, she would “be limited to practice

veterinary medicine without controlled substances,

with the exception of euthanasia solution,” meaning

that she would “be unable to dispense or administer

controlled substances” and could not keep such

substances (other than euthanasia solution) “on the

clinic grounds or in the mobile unit.” However, the

Board specified that the petitioner would “maintain the

ability to prescribe controlled substances via outside

pharmacies.”

The Board issued its decision on October 3, 2017.

Approximately ten days later, the petitioner filed a

timely motion for rehearing, see RSA 541:3, in which

she admitted that she filled a prescription for a

controlled drug for more than a seven-day supply and

that her controlled drug logbooks contained

inaccuracies. She also admitted to having dispensed

expired medications. She stated that she accepted the

Board’s “limitation on her veterinary license to practice

without controlled substances, with the exception of

euthanasia,” but requested that the restrictions be

modified so as to allow her to use Butorphanol.

Approximately one month after filing her motion for

rehearing, the petitioner requested permission to

prescribe controlled drugs and suggested that the

App. 9

Board “appoint a person it deems fit to oversee [her]

compliance with controlled drugs.” On November 28,

2017, after reviewing the petitioner’s motion and

supplement thereto as well as the objection filed by

hearing counsel, the Board denied the motion,

concluding that its decision on the merits contained no

errors.

On December 21, 2017, the petitioner filed a second

motion for rehearing in which, for the first time, she

argued that the Board: (1) lacked authority “to regulate

the prescription, storage or dispensing of . . . controlled

drugs,” and, therefore, could not have determined that

the petitioner committed misconduct within the

meaning of RSA 332-B:14, II(d) by continually

prescribing expired medications; (2) violated the

petitioner’s state and federal constitutional rights to

due process by arbitrarily creating a standard of care

with respect to the recording of communications with

clients; and (3) improperly determined that she

violated provisions of the Controlled Drug Act because

the Board “is not the administrative or judicial body to

oversee, adjudicate, or enforce” that act and, by so

doing, infringed upon her due process rights.

On December 27, 2017, the petitioner filed a timely

appeal in this court, challenging the Board’s October

merits decision and its November denial of her first

motion for rehearing. The Board denied the petitioner’s

second motion approximately one month later, on

February 8, 2018. The Board “again concluded there

were no . . . errors of fact, errors of reasoning, or

erroneous conclusions” in its October 2017 order on the

merits, and observed that the petitioner’s second

App. 10

motion for rehearing “was filed well outside” the

statutory time frame for such motions. See id.

On appeal, the petitioner argues, among other

things, that the Board lacked subject matter

jurisdiction to discipline her for allegedly violating the

Controlled Drug Act. She asserts that “the authority to

. . . enforce the Controlled Drug Act lies with the Board

of Pharmacy” and that the Board in this case “is not

authorized to . . . sanction a practitioner based on

alleged violations of the Controlled Drug Act.”

Although the petitioner raised this argument for the

first time in her second, untimely motion for rehearing,

we address it because “the issue of subject matter

jurisdiction may be raised at any time in the

proceedings.” Route 12 Books & Video v. Town of Troy,

149 N.H. 569, 575 (2003).

“RSA chapter 541 governs our review of [B]oard

decisions.” Appeal of Huston, 150 N.H. 410, 411 (2013);

see RSA 332-B:16, VII (2017). “[W]e will not set aside

the [B]oard’s order except for errors of law, unless we

are satisfied by a clear preponderance of the evidence,

that it is unjust or unreasonable.” In the Matter of

Bloomfield, 166 N.H. 475, 478 (2014) (quotation

omitted); see RSA 541:13 (2007). “The [B]oard’s

findings of fact are presumed prima facie lawful and

reasonable.” In the Matter of Bloomfield, 166 N.H. at

478 (quotation omitted); see RSA 541:13. “In reviewing

the Board’s findings, our task is not to determine

whether we would have found differently or to reweigh

the evidence, but rather, to determine whether the

findings are supported by competent evidence in the

record.” In the Matter of Bloomfield, 166 N.H. at 478.

App. 11

We review the Board’s rulings on issues of law de novo.

Appeal of Huston, 150 N.H. at 411.

“Administrative agencies are granted only limited

and special subject matter jurisdiction.” Appeal of

Campaign for Ratepayers’ Rights, 162 N.H. 245, 250

(2011) (quotation and ellipsis omitted). “That

jurisdiction is dependent entirely upon the statutes

vesting the agency with power and the agency cannot

confer jurisdiction upon itself.” Id. (quotation and

brackets omitted).

To determine whether the Board had subject matter

jurisdiction to discipline the petitioner for violating the

Controlled Drug Act, we examine RSA chapter 332-B,

the Veterinary Practice Act. See RSA ch. 332-B (2017

& Supp. 2017). We are the final arbiter of the

legislature’s intent as expressed in the words of the

statute considered as a whole. Robinson v. N.H. Real

Estate Comm’n, 157 N.H. 729, 731 (2008). We first

examine the language of the statute, and, where

possible, ascribe the plain and ordinary meanings to

the words used. Id. When a statute’s language is plain

and unambiguous, we need not look beyond it for

further indication of legislative intent, and we refuse to

consider what the legislature might have said or add

language that the legislature did not see fit to

incorporate in the statute. Id. Furthermore, we

interpret statutes in the context of the overall statutory

scheme and not in isolation. Id. By so doing, we are

better able to discern the legislature’s intent and to

interpret statutory language in light of the policy or

purpose sought to be advanced by the statutory

scheme. Id.

App. 12

The stated purpose of the Board “is to promote

public health, safety, and welfare by safeguarding the

people of New Hampshire against incompetent,

unscrupulous, and unauthorized persons and from

unprofessional or illegal practices by persons licensed

to practice veterinary medicine.” RSA 332-B:1-a (2017).

Towards those ends, RSA chapter 332-B authorizes the

Board to: (1) “[e]xamine and determine the

qualifications and fitness of applicants for a license to

practice veterinary medicine in this state”; (2) “[i]ssue,

renew, deny, suspend, revoke licenses and temporary

permits to practice veterinary medicine in the state or

otherwise discipline licensed veterinarians consistent

with the provisions of [RSA] chapter [332-B] and the

rules and regulations adopted thereunder”;

(3) “[e]stablish [licensing] fees”; (4) “[c]onduct

investigations and hearings as provided in RSA

332-B:15 and RSA 332-B:16”; and (5) “[b]ring

proceedings in the courts” to enforce RSA chapter

332-B “or any regulations made pursuant thereto.” RSA

332-B:7, I-IV, VIII (2017).

RSA 332-B:14 (2017) governs disciplinary

proceedings by the Board. Pursuant to RSA 332-B:14,

II, “[m]isconduct sufficient to support disciplinary

proceedings” includes “[a]ny unprofessional conduct, or

dishonorable conduct unworthy of, and affecting the

practice of, the profession.” RSA 332-B:14, II(c). RSA

332-B:14, III allows the Board to revoke, suspend,

limit, or restrict a veterinarian’s license because of

misconduct. RSA 332-B:14, III(b), (c). Thus, RSA

chapter 332-B allows the Board to discipline a

veterinarian for engaging in “any unprofessional” or

“dishonorable” conduct. RSA 332-B:14, II(c).

App. 13

Consistent with its rule-making authority under

RSA 332-B:7-a (Supp. 2017), the Board has adopted

regulations clarifying that “[c]onduct which violates the

Principles of Veterinary Medical Ethics of the AVMA as

revised April 2016” constitutes “unprofessional or

dishonorable conduct pursuant to RSA 332-B:14, II(c).”

N.H. Admin. R., Vet 501.02. Those principles, in turn,

exhort veterinarians to “obey all laws” of the

jurisdiction in which they “reside and practice

veterinary medicine.” American Veterinary Medical

Association, supra § IV(a).

Although we need not decide the full scope of the

Board’s jurisdiction to discipline a veterinarian for the

violation of “all laws,” we conclude that the Board had

subject matter jurisdiction to discipline the petitioner

for violating the Controlled Drug Act. Even if we

assume without deciding that the Board’s jurisdiction

is limited to disciplining licensed veterinarians for

violating laws bearing a nexus to the Board’s purpose

of promoting “public health, safety, and welfare” by

protecting the public from “incompetent, unscrupulous,

and unauthorized persons and from unprofessional or

illegal practices by” licensed veterinarians, RSA

332-B:1-a, the violations of the Controlled Drug Act at

issue plainly fall within that jurisdiction.

Contrary to the petitioner’s assertions, nothing in

the Controlled Drug Act compels a different conclusion.

Nothing in that act precludes the Board from

disciplining a veterinarian for engaging in

“unprofessional” conduct that includes violating

provisions of the Controlled Drug Act. Indeed, the

Board has the exclusive authority to subject licensed

App. 14

veterinarians to professional discipline. See RSA

332-B:7, :14, :15, VI, :15-a (2017); cf. RSA 332-B:9, :17

(2017).

The petitioner also asserts that the Board lacked

jurisdiction to subject her practice to inspections

pursuant to its September 2015 order and that the

Board, therefore, “relied impermissibly” on those

inspections and on the inspecting veterinarian’s

testimony. However, documents in the certified record

suggest that the petitioner agreed, at the very least

implicitly, to the inspections as part of a settlement

agreement with the Board. Moreover, RSA 332-B:14,

III(b) authorizes the Board to discipline a licensee by

restricting or limiting that individual’s license.

Subjecting an individual’s practice to periodic

inspections is a form of restriction or limitation on that

person’s license to practice veterinary medicine.

For all of the above reasons, we hold that the Board

had subject matter jurisdiction to discipline the

petitioner for violating the Controlled Drug Act and to

subject her practice to post-hearing inspections.

Affirmed.

LYNN, C.J., and BASSETT, HANTZ MARCONI,

and DONOVAN, JJ., concurred.

App. 15

APPENDIX C

THE STATE OF NEW HAMPSHIRE

SUPREME COURT

Case No. 2017-0729

[Filed February 9, 2018]

__________________________

Appeal of

)

Sandra Brown, DVM

)

__________________________ )

In Case No. 2017-0729, Appeal of Sandra

Brown, DVM, the court on February 9, 2018,

issued the following order:

Appeal from a decision of the New Hampshire

Board of Veterinary Medicine is accepted and will be

scheduled for oral argument before the full court.

The motion to dismiss for lack of subject matter

jurisdiction is denied without prejudice to the parties’

ability to address those issues in their respective briefs.

This case appears to be eligible for mediation

pursuant to Rule 12-A. Under Rule 12-A(2), the

agreement of all parties is required for appellate

mediation. If all parties in this case agree to participate

in mediation, Sandra Brown shall submit the

completed Appellate Mediation Agreement form to the

court on or before February 26, 2018. An Appellate

Mediation Agreement form (NHJB-2614-SUP) is being

provided to Sandra Brown with this order. If an

App. 16

Appellate Mediation Agreement form is not filed, an

order will be issued regarding further proceedings.

Dalianis, C.J., and Hicks, Lynn, Bassett, and Hantz

Marconi, JJ., participated.

Eileen Fox,

Clerk

Distribution:

New Hampshire Board of Veterinary Medicine, 2-7/13

R. James Steiner, Esq.

Michelle Heaton, Esq.

File

App. 17

APPENDIX D

RSA 318:8. Board of Pharmacy. Enforcement of

Law

It shall be the duty of the board [of pharmacy],

through officials and employees appointed by it or

under its supervision for that purpose, and of all peace

officers within the state, and of all county attorneys, to

enforce all the provisions of this chapter. When so

requested, the department of health and human

services and its officials and employees shall cooperate

with the board in collecting and analyzing samples of

drugs and medicines sold, or suspected of being sold, in

violation of this chapter. The members of the board, its

inspectors and investigators shall have free access

during business hours to all places where drugs,

medicines, poisons or hypodermic devices are held,

stored, or offered for sale and to all records of sale and

disposition of drugs.

RSA 318:8-a. Board of Pharmacy, Inspection and

Regulation of Certain Users of Prescription

Drugs

All physicians, veterinarians, dentists, advanced

registered nurse practitioners, physician assistants,

and clinics under contract to the department of health

and human services and agricultural, technical, or

industrial users of prescription drugs shall be subject

to inspection and regulation by the board of pharmacy

App. 18

with regard to the storage, labeling, distribution, and

disposal of prescription drugs.

RSA 318:9-a. Board of Pharmacy. Inspectional

Services

The pharmacy board shall provide inspectional

services under this chapter and RSA 318-B:25 to the

board of medicine, the board of veterinary medicine,

the board of podiatry, the board of registration in

optometry, the board of dental examiners, and the

board of nursing.

RSA 318-B:18. Controlled Drug Act. Notice of

Conviction to be Sent to Licensing Board

On the conviction of any person for violation of any

provision of this chapter, a copy of the judgment and

sentence, and of the opinion of the superior court if any

opinion is filed, shall be sent by the clerk of the court to

the board by whom the convicted defendant has been

licensed or registered to practice his profession or to

carry on his business. The board may summarily

suspend, limit or revoke the license or registration of

the convicted defendant to practice his profession or to

carry on his business.

RSA 318-B:23. Controlled Drug Act. Enforcement

and Cooperation

It is hereby made the duty of the department of

health and human services, its officers, agents,

inspectors, and representatives; the pharmacy board,

its officers, agents, inspectors and representatives; and

App. 19

of all peace officers within the state, and of all county

attorneys, to enforce all provisions of this chapter,

except those specifically delegated, and to cooperate

with all agencies charged with the enforcement of the

laws of the United States, of this state, and of all other

states relating to controlled drugs.

RSA 318-B:25. Controlled Drug Act. Authority for

Inspection

All officers, agents, inspectors and representatives

of the department of health and human services who

are charged with the responsibility to enforce this

chapter; all officers, agents, inspectors, and

representatives of the pharmacy board who are charged

with the responsibility to enforce this chapter; all peace

officers within the state; the attorney general and all

county attorneys; and federal, state, county and

municipal law enforcement officers are authorized to

enter during normal business hours upon the premises

used by a practitioner for the purpose of his practice

and to inspect such original records or prescriptions or

both for controlled drugs as defined herein. Every

practitioner, his clerk, agent, or servant shall exhibit to

such person on demand every such original record or

prescription or both so kept on file.

RSA 318-B:26. Controlled Drug Act. Penalties

I. Any person who manufactures, sells, prescribes,

administers, or transports or possesses with intent to

sell, dispense, or compound any controlled drug,

controlled drug analog or any preparation containing a

controlled drug, except as authorized in this chapter; or

App. 20

manufactures, sells, or transports or possesses with

intent to sell, dispense, compound, package or

repackage (1) any substance which he represents to be

a controlled drug, or controlled drug analog, or (2) any

preparation containing a substance which he

represents to be a controlled drug, or controlled drug

analog, shall be sentenced as follows, except as

otherwise provided in this section:

(a) In the case of a violation involving any of the

following, a person shall be sentenced to a maximum

term of imprisonment of not more than 30 years, a fine

of not more than $500,000, or both. If any person

commits such a violation after one or more prior

offenses as defined in RSA 318-B:27, such person may

be sentenced to a maximum term of life imprisonment,

a fine of not more than $500,000, or both:

(1) Five ounces or more of a mixture or substance

containing any of the following, including any

adulterants or dilutants:

(A) Coca leaves, except coca leaves and extracts of

coca leaves from which cocaine, ecgonine, and

derivatives of ecgonine or their salts have been

removed; or

(B) Cocaine other than crack cocaine, its salts,

optical and geometric isomers, and salts of isomers; or

(C) Ecgonine, its derivatives, their salts, isomers,

and salts of isomers.

(2) Lysergic acid diethylamide, or its analog, in a

quantity of 100 milligrams or more including any

adulterants or dilutants, or phencyclidine (PCP), or its

App. 21

analog, in a quantity of 10 grams or more including any

adulterants or dilutants.

(3) Heroin or its analog, crack cocaine, or a fentanyl

class drug in a quantity of 5 grams or more, including

any adulterants or dilutants.

(4) Methamphetamine or its analog, in a quantity of

5 ounces or more, including adulterants or dilutants.

(b) In the case of a violation involving any of the

following, a person may be sentenced to a maximum

term of imprisonment of not more than 20 years, a fine

of not more than $300,000, or both. If any person

commits such a violation after one or more prior

offenses as defined in RSA 318-B:27, such person may

be sentenced to a term of imprisonment of not more

than 40 years, a fine of not more than $500,000, or

both:

(1) A substance or mixture referred to in

subparagraph I(a)(1) of this section, other than crack

cocaine, in a quantity of 1/2 ounce or more, including

any adulterants or dilutants;

(2) A substance classified in schedule I or II other

than those specifically covered in this section, or the

analog of any such substance, in a quantity of one

ounce or more including any adulterants or dilutants;

(3) Lysergic acid diethylamide, or its analog, in a

quantity of less than 100 milligrams including any

adulterants or dilutants, or where the amount is

undetermined, or phencyclidine (PCP) or its analog, in

a quantity of less than 10 grams, including any

App. 22

adulterants or dilutants, or where the amount is

undetermined;

(4) Heroin or its analog, crack cocaine, or a fentanyl

class drug in a quantity of one gram or more, including

any adulterants or dilutants;

(5) Methamphetamine or its analog, in a quantity of

one ounce or more including any adulterants or

dilutants;

(6) Marijuana in a quantity of 5 pounds or more

including any adulterants or dilutants, or hashish in a

quantity of one pound or more including any

adulterants and dilutants;

(7) Flunitrazepam in a quantity of 500 milligrams

or more.

(c) In the case of a violation involving any of the

following, a person may be sentenced to a maximum

term of imprisonment of not more than 7 years, a fine

of not more than $100,000, or both. If any person

commits such a violation after one or more prior

offenses as defined in RSA 318-B:27, such person may

be sentenced to a maximum term of imprisonment of

not more than 15 years, a fine of not more than

$200,000, or both:

(1) A substance or mixture referred to in

subparagraph I(a)(1) of this section, other than crack

cocaine, in a quantity less than 1/2 ounce including any

adulterants or dilutants;

(2) A substance or mixture classified as a narcotic

drug in schedule I or II other than those specifically

App. 23

covered in this section, or the analog of any such

substance, in a quantity of less than one ounce

including any adulterants or dilutants;

(3) Methamphetamine, or its analog in a quantity of

less than one ounce including any adulterants or

dilutants;

(4) Heroin or its analog, crack cocaine, or a fentanyl

class drug in a quantity of less than one gram,

including any adulterants or dilutants;

(5) Marijuana in a quantity of one ounce or more

including any adulterants or dilutants, or hashish in a

quantity of 5 grams or more including any adulterants

or dilutants;

(6) Flunitrazepam in a quantity of less than 500

milligrams;

(7) Any other controlled drug or its analog, other

than those specifically covered in this section, classified

in schedules I, II, III or IV.

(d) In the case of a violation involving any of the

following, a person may be sentenced to a maximum

term of imprisonment of not more than 3 years, a fine

of not more than $25,000, or both. If any person

commits such a violation after one or more prior

offenses as defined in RSA 318-B:27, such person may

be sentenced to a maximum term of imprisonment of

not more than 6 years, a fine of not more than $50,000,

or both:

(1) Marijuana in a quantity of less than one ounce

including any adulterants or dilutants, or hashish in a

App. 24

quantity of less than 5 grams including any

adulterants or dilutants;

(2) Any schedule V substance or its analog.

II. Any person who knowingly or purposely obtains,

purchases, transports, or possesses actually or

constructively, or has under his or her control, any

controlled drug or controlled drug analog, or any

preparation containing a controlled drug or controlled

drug analog, except as authorized in this chapter, shall

be sentenced as follows, except as otherwise provided

in this section:

(a) In the case of a controlled drug or its analog,

classified in schedules I, II, III, or IV, other than those

specifically covered in this section, the person shall be

guilty of a class B felony, except that notwithstanding

the provisions of RSA 651:2, IV(a), a fine of not more

than $25,000 may be imposed. If any person commits

such a violation after one or more prior offenses as

defined in RSA 318-B:27, such person shall be guilty of

a class A felony, except that notwithstanding the

provisions of RSA 651:2, IV(a), a fine of up to $50,000

may be imposed.

(b) In the case of a controlled drug or its analog

classified in schedule V, the person shall be sentenced

to a maximum term of imprisonment of not more than

3 years, a fine of not more than $15,000, or both. If a

person commits any such violation after one or more

prior offenses as defined in RSA 318-B:27, such person

shall be guilty of a class B felony, except that

notwithstanding the provisions of RSA 651:2, IV(a), a

fine of not more than $25,000 may be imposed.

App. 25

(c) In the case of more than 3/4 ounce of marijuana

or more than 5 grams of hashish, including any

adulterants or dilutants, the person shall be guilty of a

misdemeanor. In the case of marijuana-infused

products possessed by persons under the age of 21 or

marijuana-infused products as defined in RSA 318-B:2e, other than a personal-use amount of a regulated

marijuana-infused product as defined in RSA 318-B:2c, I(b), that are possessed by a person 21 years of age or

older, the person shall be guilty of a misdemeanor.

(d) In the case of 3/4 ounce or less of marijuana or 5

grams or less of hashish, including any adulterants or

dilutants, the person shall be guilty of a violation

pursuant to RSA 318-B:2-c. In the case of a person 21

years of age or older who possesses a personal-use

amount of a regulated marijuana-infused product as

defined in RSA 318-B:2-c, I(b), the person shall be

guilty of a violation pursuant to RSA 318-B:2-c.

(e) In the case of a residual amount of a controlled

substance, as defined in RSA 318-B:1, XXIX-a, a person

shall be guilty of a misdemeanor if the person is not

part of a service syringe program under RSA 318-B:43.

III. A person shall be guilty of a misdemeanor who:

(a) Except as provided in RSA 318-B:2-c, controls

any premises or vehicle where he or she knows a

controlled drug or its analog is illegally kept or

deposited;

(b) Aids, assists or abets a person in his presence in

the perpetration of a crime punishable under

paragraph II of this section, knowing that such person

App. 26

is illegally in possession of a controlled drug or its

analog.

(c) Manufactures with the intent to deliver, delivers

or possesses with the intent to deliver any drug

paraphernalia when such paraphernalia is knowingly

manufactured, delivered or possessed for one or more

of the uses set forth in RSA 318-B:2, II.

(d) Places an advertisement in violation of RSA 318B:2, III.

III-a. [Repealed.]

IV. Any person who attempts or conspires to commit

any offense defined in this chapter is punishable by

imprisonment or a fine or both, which may not exceed

the maximum punishment prescribed for the offense,

the commission of which was the object of the attempt

or conspiracy.

V. Any person who violates this chapter by

manufacturing, selling, prescribing, administering,

dispensing, or possessing with intent to sell, dispense,

or compound any controlled drug or its analog, in or on

or within 1,000 feet of the real property comprising a

public or private elementary, secondary, or secondary

vocational-technical school, may be sentenced to a term

of imprisonment or fine, or both, up to twice that

otherwise authorized by this section. Except to the

extent a greater minimum sentence is otherwise

provided by this chapter, a sentence imposed under

this paragraph shall include a mandatory minimum

term of imprisonment of not less than one year.

Neither the whole nor any part of the mandatory

App. 27

minimum sentence imposed under this paragraph shall

be suspended or reduced.

VI. Except as otherwise provided in this paragraph,

a person convicted under RSA 318-B:2, XII as a drug

enterprise leader shall be sentenced to a mandatory

minimum term of not less than 25 years and may be

sentenced to a maximum term of not more than life

imprisonment. The court may also impose a fine not to

exceed $500,000 or 5 times the street value of the

controlled drug or controlled drug analog involved,

whichever is greater. Upon conviction, the court shall

impose the mandatory sentence unless the defendant

has pleaded guilty pursuant to a negotiated agreement

or, in cases resulting in trial, the defendant and the

state have entered into a post-conviction agreement

which provides for a lesser sentence. The negotiated

plea or post-conviction agreement may provide for a

specified term of imprisonment within the range of

ordinary or extended sentences authorized by law, a

specified fine, or other disposition. In that event, the

court at sentencing shall not impose a lesser term of

imprisonment or fine than that expressly provided for

under the terms of the plea or post-conviction

agreement.

VII. Any person who violates RSA 318-B:2, XI may

be sentenced to a maximum term of imprisonment of

not more than 20 years, a fine of not more than

$300,000, or both. If any person commits such a

violation after one or more prior offenses, as defined in

RSA 318-B:27, such person may be sentenced to a term

of imprisonment of not more than 40 years, a fine of not

more than $500,000, or both.

App. 28

VIII. Any person who knowingly or purposely

obtains or purchases (1) any substance which he

represents to be a controlled drug or controlled drug

analog, or (2) any preparation containing a substance

which he represents to be a controlled drug or

controlled drug analog, except as authorized in this

chapter, shall be guilty of a misdemeanor. If any person

commits such a violation after one or more prior

offenses as defined in RSA 318-B:27, such person shall

be guilty of a class B felony.

IX. Any person who manufactures, sells, or

dispenses methamphetamine, lysergic acid,

diethylamide phencyclidine (PCP) or any other

controlled drug classified in schedules I or II, or any

controlled drug analog thereof, in violation of RSA 318B:2, I or I-a, is strictly liable for a death which results

from the injection, inhalation or ingestion of that

substance, and may be sentenced to imprisonment for

life or for such term as the court may order. For

purposes of this section, the person’s act of

manufacturing, dispensing, or selling a substance is

the cause of a death when:

(a) The injection, inhalation or ingestion of the

substance is an antecedent but for which the death

would not have occurred; and

(b) The death was not:

(1) Too remote in its occurrence as to have just

bearing on the person’s liability; or

(2) Too dependent upon conduct of another person

which was unrelated to the injection, inhalation or

ingestion of the substance or its effect, as to have a just

App. 29

bearing on the person’s liability. It shall not be a

defense to a prosecution under this section that the

decedent contributed to his own death by his

purposeful, knowing, reckless or negligent injection,

inhalation or ingestion of the substance or by his

consenting to the administration of the substance by

another. Nothing in this section shall be construed to

preclude or limit any prosecution for homicide. A

conviction arising under this section shall not merge

with a conviction of one as a drug enterprise leader or

for any other offense defined in this chapter.

IX-a. A qualifying patient or designated caregiver as

defined in RSA 126-X:1 who sells cannabis to a person

who is not a qualifying patient or a designated

caregiver shall be guilty of a class B felony and shall be

sentenced to a maximum term of imprisonment of not

more than 7 years, a fine of not more than $300,000, or

both.

X. Any penalty imposed for violation of this chapter

shall be in addition to, and not in lieu of, any civil or

administrative penalty or sanction authorized by law.

XI. Any person who violates any provision of this

chapter for which a penalty is not provided by

paragraphs I through IX shall be guilty of a class B

felony if a natural person, or guilty of a felony if any

other person.

XII. The penalty categories set forth in this section

based upon the weight of the drug involved are

material elements of the offense; however, the

culpability requirement shall not apply to that element

of the offense.

App. 30

XIII. Any person who violates any provision of this

chapter shall be fined a minimum of $350 for a first

offense and $500 for a second or subsequent offense,

except that any person who violates the provisions of

RSA 318-B:26, II(c) or RSA 318-B:26, II(d) shall be

fined $350. This paragraph shall not apply to violations

of RSA 318-B:2-c.

RSA 332-B:1-a.

New Hampshire Veterinary

Practice Act. Purpose

The purpose of the board of veterinary medicine is

to promote public health, safety, and welfare by

safeguarding the people of New Hampshire against

incompetent, unscrupulous, and unauthorized persons

and from unprofessional or illegal practices by persons

licensed to practice veterinary medicine. The right to

practice veterinary medicine is a privilege granted by

legislative authority to persons possessing personal

and professional qualifications specified in this chapter.

RSA 332-B:3, IV. New Hampshire Veterinary

Practice Act. Compensation

The board [of Veterinary Medicine] shall be an

administratively attached agency, under RSA 21-G:10,

to the department of agriculture, markets, and food.

RSA 332-B:14.

New Hampshire Veterinary

Practice Act. Disciplinary Action; Civil Penalty

I. The board may undertake disciplinary proceedings:

(a) Upon its own initiative; or

App. 31

(b) Upon written complaint of any person which

charges that a person licensed by the board has

committed misconduct under paragraph II and which

specifies the grounds therefor.

II. Misconduct sufficient to support disciplinary

proceedings under this section shall include:

(a) The practice of fraud or deceit in procuring or

attempting to procure a license to practice under this

chapter;

(b) Conviction of a felony or any offense involving moral

turpitude;

(c) Any unprofessional conduct, or dishonorable conduct

unworthy of, and affecting the practice of, the

profession;

(d) Unfitness or incompetency to practice the profession

or any particular aspect or specialty thereof as

evidenced by negligent or willful acts performed in a

manner inconsistent with the health or safety of

animals under the care of the licensee, the intentional

injury of an animal or human in a context related to

the profession, or a pattern of conduct inconsistent

with the basic skills and knowledge required to practice

the profession;

(e) Addiction to the use of alcohol or other habitforming drugs to a degree which renders the person

unfit to practice under this chapter;

(f) Mental or physical incompetency to practice under

this chapter;

App. 32

(g) Willful or repeated violation of the provisions of this

chapter;

(h) Suspension or revocation of a license, similar to one

issued under this chapter, in another jurisdiction and

not reinstated;

(i) The use of advertising or solicitation which is false,

misleading, or fraudulent or is otherwise deemed

unprofessional under rules adopted by the board;

(j) Having professional association with or employing

any person practicing veterinary medicine unlawfully;

(k) Fraud or dishonesty in the application or reporting

of any test disease in animals;

(l) Failure to keep the veterinary premises and

equipment in a safe, clean, and sanitary condition;

(m) Failure to report as required by law, or making

false report of any contagious or infectious disease;

(n) Dishonesty or gross negligence in the inspection of

foodstuffs, maintenance of medical records, or the

issuance of health, vaccination, or inspection

certificates; or

(o) [Repealed.]

(p) Unprofessional conduct as defined in rules adopted

by the board.

III. The board may take disciplinary action in any one

or more of the following ways:

(a) By reprimand;

App. 33

(b) By suspension, limitation, or restriction of license;

(c) By revocation of license;

(d) By requiring the person to participate in a program

of continuing education in the area or areas in which

the person has been found deficient; or

(e) By the imposition of civil penalties of up to $2,000

per violation, or in the case of continuing violations, not

more than $200 per day, whichever is greater.

I. The board may informally dispose of any

complaint by stipulation, agreed settlement,

consent order or default. The board may hold

preliminary hearings to facilitate the informal

disposition of complaints which, during the

preliminary hearing, are found to be

unwarranted or unjustified. The board shall

follow the provisions of RSA 541-A:31, V in

conducting such hearings. All such

investigations and preliminary hearings shall be

confidential and exempt from the provisions of

RSA 91-A, provided that the board shall make

public any action taken under RSA332-B:14, III

resulting from a preliminary hearing or

investigation.

App. 34

APPENDIX E

New Hampshire Board of Veterinary Medicine

Report of Clinic Inspection

9 A.M. 9 September 2016

Veterinarian:

Sandra Brown DVM (SB)

MWV Mobile Veterinary Clinic PLLC

1513 NH Route 16

Conway NH 03818

Persons present:

David B Stowe DVM NH Board of Veterinary Medicine

Todd Flanagan APU Investigator

Sandra Brown DVM Owner of MMV Mobile Vet Clinic

This inspection was in accordance with the terms of

the Settlement signed 28 September 2015 which

ordered that SB’s practice be subject to announced or

unannounced inspections for a period of four years.

This inspection was announced and scheduled well

ahead of the date.

Upon arrival, SB was preparing medical records for

inspection and she informed me that a client was due

any minute to pick up a cat. With SB’s permission, I

left her in the reception area and Todd Flanagan and

I went to the treatment area and began an inspection.

The very first items I found in the cabinets in the

treatment area where 4 small containers of outdated

App. 35

Sterile Water for Injection (2/16) (exhibit A1), a gallon

of Lixotinic (11/13) (exhibitA2,4).

In the refrigerator, I found expired chemistry

reagents (10/11, 2/11) (exhibit B3). SB stated she

“doesn’t use that machine anymore”. I did not examine

her chemistry equipment to confirm whether or not she

had equipment or whether it used these reagents. I

found no other reagents in the refrigerator. I also found

clearly marked medications that indicated they were

expired (exhibit B1); but I also found several outdated

drugs that were not marked expired (exhibit B1, C1:

C2,4: C3,B2).

In the pharmacy area, I found outdated drugs (D1,2)

and a drug in a container where the expiration date

was crossed off and another written (D3,4). There was

a whole drawer full of outdated drugs (exhibits E,F).

When asked about this large number of outdated

drugs, her response was that when clients couldn’t

afford drugs, she gave them the outdated drugs.

On the counter in the pharmacy was a prescription

of Tramadol (exhibit F1,2), a Schedule IV controlled

substance. When asked why it was sitting on the

counter, SB said it was leftover from her last

appointment the day before. SB had prescribed the

drug; but left before the client was discharged because

she had a house call. The prescription was left to be

dispensed by the support staff; but the client declined

the prescription, so the bottle sat on the counter,

unsecured, all night.

The controlled substance “safe” is a home-made

wooden box with a hinged door with a pad locked hasp;

App. 36

but the hasp is attached in such a way that it could

easily be removed with a Phillips head screw driver,

the contents of the safe tampered with and the lock

mechanism replaced without detection. I commented on

this during the previous inspection and recommended

that it be fixed.

Inside the safe was a bottle marked Tram (exhibit

F3, G1) which contained several doses of Tramadol

(presumably; but confirmed by SB). There was no

expiration date or lot number on the bottle. There were

also two bottles of Tramadol, a thousand count bottle

that had been opened and an unopened thousand count

bottle. When I asked how often SB did an inventory of

her controlled substances, she answered monthly. No

inventory records were examined. In the safe were two

containers of outdated drugs in a plastic baggie.

Her practice van was parked outside in the shade.

At approximately 10 A.M. the thermometer in the van

read over 80 degrees. Inside the van were numerous

outdated drugs (exhibits H,I,J) in the various bins that

SB uses to transport her inventory and a cardboard box

of outdated drugs sequestered behind some equipment

(exhibit I3). Included in the van were several

containers of compounded (Wedgewood Pharmacy)

phenylbutazone, one bottle marked expired. In NH,

compounded drugs must be sent from the compounding

pharmacy to the client. Compounded drugs cannot be

obtained from a pharmacy and then dispensed by a

practitioner unless the practitioner is a distributor.

In the truck was a large bottle of Dextrose (J2)

which expired 5/14 but had a pierced date of 8/22/16.

During my last visit, I informed SB that because of the

App. 37

nature of Dextrose (a sugar), these containers are

considered single use. Outdated Dextrose should never

be administered.

In reviewing medical records, I found a patient for

whom SB had prescribed Tramadol as a sedative for

grooming (exhibit K-N). The prescription read to

administer 1/4 tablet weekly and she dispensed 10

tablets. Tramadol, a controlled substance, can only be

dispensed for a period of one week and yet she had

dispensed 40 weeks worth of medication. When I asked

her how long it can prescribed for, she correctly

answered one week; but said it would be unreasonable

to make the client return weekly to refill the

prescription. When I asked her why she didn’t write a

prescription, a legitimate and legal alternative, she had

no response.

When reviewing a record for a dental procedure

(exhibits O,P) she had performed, I asked SB where the

presurgical exam was documented. She indicated that

a line on the anesthetic monitoring form where the

patient’s temperature, heart rate, respiratory rate,

mucous membrane color and capillary refill time was

recorded, was her presurgical exam. Physical exams

should be recorded in a “SOAP” format indicating more

than the few parameters she had recorded. The

anesthetic log had 4 lines filled out representing the

monitoring of the patient over a two hour period. The

standard of care is to check vitals every 5 to 10

minutes, which should have resulted in no less than

approximately 12 entries in the log.

App. 38

(Exhibits T, U) were for a cat being spayed. Again the

presurgical exam is not in a SOAP format and is only

a single line entry on the surgical monitoring form.

“Jasper” xxxx (exhibit Q) was a cat that presented for

ear problems and itching. A Depo (injection) was

administered; but, no notation was made to indicate

there was a discussion of the potential side effects of

Depo, of which there are serious potential side effects.

(Exhibits Rand S) The xxxx dogs which presented for

Wellness exams and both were febrile. Dr. Brown’s

explanation was the dogs were excitable and

presumably not sick; however, there was no notation

that this was discussed.

The very large number of outdated drugs and Dr.

Brown’s repeated stance that dispensing out dated

drugs to clients who cannot afford first line care is

disturbing and hasn’t changed since the first clinic

inspection in May. It is my opinion that Dr. Brown

shows no regard for the standards set forth by the

Licensing Board.

App. 39

APPENDIX F

New Hampshire Board of Veterinary Medicine

Report of Clinic Inspection

10 AM 22 December 2016

Registrant:

Dr. Sandra Brown

MWV Mobile Veterinary Clinic

1513 Route 16

Conway NH 03818

Inspectors:

David B Stowe DVM NH Board of Veterinary Medicine

Todd Flanagan, APU Investigator

This was an unannounced inspection. Since Dr.

Brown signed a settlement with the Board in

September 2015, this was the third inspection (the

others being in May 2016 and September 2016).

Following our last inspection, the Board of Pharmacy

had visited the facility in October. The BOP’s

inspection had significantly differed from our last

inspection. The purpose of this inspection was to stay

on schedule and to see if Dr. Brown had corrected

previous deficiencies prior to the scheduled hearing in

January of 2017.

When Todd Flanagan and I arrived, Dr. Brown was

in an appointment. She emerged from the exam room

twenty minutes after our arrival and when we

explained that we were there to perform an

App. 40

unannounced inspection, she insisted we wait until she

contacted her lawyers. At 11 AM after she had not been

able to speak with her attorneys, she agreed to allow

our inspection.

Because Dr. Brown needed to leave immediately on

a farm call, I did a quick inspection of the farm vehicle.

As in previous inspections there were many out dated

drugs, containers whose expiration dates had worn off

and were illegible and several containers of

compounded drugs (Phenylbutazone) from Wingate

Pharmacy, a veterinary compounding pharmacy, all out

of date.

After Dr. Brown left on her farm call, Todd and I

were left with two of her staff members who cooperated

with our inspection. In the prep area we found

numerous outdated drugs and chemistry reagents. In

the pharmacy area, we found a drawer full of outdated

drugs as we had found previously (see photos).

Included in the pharmacy drawer, with the outdated

drugs, was a form titled “Waiver for Dispensing

Expired Medications”.

I asked the support staff for the records from the

preceding ten outpatient appointments and five or six

of her most recent surgery cases.

In the medical record for “Chewy” Flaherty, there is

a prescription for Tramadol that was dispensed. The

prescription reads 1 TID prn po (40), which indicates

the patient was to receive one tablet three times daily

as needed. Tramadol is a controlled substance and can

only be dispensed for a seven day period, which in this

case would be twenty one tablets. Dispensing 40 tablets

App. 41

is a violation which was addressed in another case

during the previous inspection.

“Lucy” Cronin is a geriatric feline patient who was

examined September 29th and returned for dental

surgery October 11th. There is no record of a

presurgical examination, a deficiency we had discussed

at my last visit in September.

“Tobie” Cretien, an Australian Shepard (dob

10/5/2003) was seen September 19th and admitted for

surgery on the 22nd. According to the medical records,

the patient was given 62.5 mg Acepromazine orally at

home two hours prior to arriving at the hospital. At the

hospital, he was administered additional Acepromazine

and Butorphanol and Atropine as a premed. There is

no presurgical examination recorded and no notation

documenting the effect of the orally administered

Acepromazine. The patient arrested within 7 minutes

of being induced with Propofol.

The oral dose of Acepromazine he received was 2.2

mg/kg which is the high end of the dose for his weight;

but the record notes his BCS was 7.5/9, indicating he

was overweight. If he were dosed based on lean body

weight, the Acepromazine dose he received would be

above the high end of the dosage range.

A review of Plumb’s Veterinary Drug Handbook (8th

Edition) states “Anecdotal dosage recommendations

vary widely, but generally are similar to the labeled

dosage range of 0.55 - 2.2 mg/kg, although some think

that dosages at the higher end of this range are too

high.” In the Contraindications section, it says “”Dogs

with MDRI mutations (many Collies, Australian

App. 42

Shepards, etc.) may develop a more pronounced

sedation that persists longer than normal.” “In

geriatric patients, very low doses have been associated

with prolonged effects of the drug.” Under Adverse

Effects, it states “Cardiovascular collapse (secondary to

bradycardia and hypotension) has been described in all

major species. Dogs may be more sensitive to these

effects than other animals.”

The drug log was photocopied to support the case

mentioned above (Chewy Flaherty); but also because

there is evidence of the Tamadol being taken out of

hospital inventory and moved into the van. The van

was not locked when I inspected it.

During the inspection the temperature of the van

was 48 degrees F. Ivermectin, Oxytetracycline and

Atropine all present in the van, are labeled for storage

between 15 and 30 degrees C (59 and 86 F).

App. 43

APPENDIX G

STATE OF NEW HAMPSHIRE

BOARD OF PHARMACY PRACTITIONER / CLINIC

INSPECTION REPORT

February 24, 2014

[Fold-out Exhibit, see next page]

App. 44

1) Question of suitable drug potency of medicines

stored in mobile unit

a) in summer, Dr. Brown keeps windows open;

travels with A/C on

b) in winter, Dr. Brown keeps mobile unit in a

heated garage

RECOMMENDATION: obtain a thermometer

and MONITOR temperatures within mobile

unit.

2) Dr. Brown states that the tablets for small animal

use are rotated out of the mobile unit into the clinic,

ON A MONTHLY BASIS. These medicines are then

used IN the clinic until expired.

App. 45

MWV Mobile Veterinary Clinic , PLLC

Sandy Brown, DVM

Veterinarian

www.mwvmobilevet.com

Bringing compassionate veterinary care to your home.

MWV Mobile Vet

1513 NH Rt 16

Conway, NH 03818

Phone: (603) 447-8311

Fax: (603) 447-8313

vet@mwvmobilevet.com

App. 46

NOTICE OF INSPECTION

[SEAL] State of New Hampshire

Board of Pharmacy

121 South Pruit Street

Concord, NH 03301-2412

(Office - (603) 271-2350)

(Fax - (603) 271-2858)

Facility: MWV Mt. Washington, Valley Mobile

Veterinary Clinic

Street: 1513 Route 16

City: Conway

Zip: 03818

District 003 Pharmacy [ ] Practitioner [T] Institution

[ ] Home Infusion [ ] LTC Facility

[ ] Other: _____________________

Date: 2/24/14

Time: 11:00 AM

PURPOSE OF INSPECTION

Routine [T] Complaint [ ] Follow-up [ ] Other: ________

This is to acknowledge that New Hampshire Board

of Pharmacy Inspector/Investigator, Robert D.

Elder, R.Ph., has identified him/herself by

presentation of official credentials. Pursuant to the

provisions of RSA 318:8, RSA 318:8-a of the New

Hampshire Pharmacy Act and RSA 318:B:25 of the

New Hampshire Controlled Drug Act, I hereby

grant permission for the aforementioned agent to

inspect any and all of the records relative to the

receipt, distribution and security of legend drugs at

App. 47

this location. This also includes records which are

required pursuant to the provisions of 21 CFR part

1300 to end, of the Federal Controlled Substance

Act. This inspection also addresses any other

standards of practice issues outlined by other health

care regulatory agencies, which these agents are

charged to enforce. By any signature, I hereby

acknowledge the receipt of this Notice of Inspection

and certify that:

1. I am the owner, for the above described location;

2. I have read this Notice of Inspection and

understand its contents and purpose;

3. I have the authority to act in this matter and

have signed this Notice of Inspection pursuant

to my authority;

4. I have been provided with the purpose of this

Notice of Inspection but, fully realize that the

scope of this inspection may encompass ALL of

the records required pursuant to the

aforementioned Acts or Board rules;

5. I have voluntarily consented to this inspection.

Signature: /s/Sandra Brown Date: 2/24/14

(Print): Sandra Brown

Board Agent: /s/Robert D. Elder, R.Ph., C.I. Date:

2/24/14

(Print): Robert D. Elder, R.Ph., C.I. Ph 500 (Rev. 10/96)

Pursuant to RSA 547-A:31,II, failure to allow access to

the aforementioned records, could result in disciplinary

sanctions

App. 48

On February 24, 2014 James Queenan R.Ph. MBA, a

new compliance inspector, accompanied senior

inspector Robert Elder R.Ph. to MVW-Mobile

Veterinary Clinic located at 1513 NH Route 16

Conway, New Hampshire 03818 for an unannounced

routine veterinary inspection. Since I am the new

compliance inspector, Robert Elder took the lead

during the inspection. We were immediately introduced

to Dr. Sandra Brown the Veterinarian and owner of the

clinic. She informed us that she was just back from

vacation and was accommodating during the

inspection.

There are two “locations” for this type of practice.

There is a standard office with a reception desk,

waiting room, exam rooms, med room, procedure room,

and locked control mediation box. The “second” location

is a van that not only transports the practitioner but

also supplies, equipment and medication for home or

farm veterinary treatment.

During the inspection, Robert Elder and I noted the

following concerns:

1.) There is a metal box that has a key and lock that

is used to contain the controlled substances. The

box is portable. The box was found in the clinic

“vehicle” a van. The van is parked outside the

clinic in an outside driveway during office hours

or on sight during veterinary visit at various

locations throughout the state and at Dr.

Brown’s residence after hours in a heated

garage. The garage was not examined or viewed.

Compliance Officer Elder addressed and noted

that the control box needs to be stored in the

App. 49

clinic which is the licensed DEA approved area

when not in use. Important to note: Dr. Brown

will receive emergency calls during non-office

hours. Storage of controls at the office clinic

would require Dr. Brown during an emergency

to leave her residence, go the clinic to pick up

controls, proceed to the client, after treatment

return controls to the clinic and then return to

her residence. Dr Brown lives 15 minutes from

her office.

2.) Non-controls are also stored in the van during

extended periods of time exposed to outside

weather conditions. On February 24, at 11:00

AM the temperature outside the van in Conway

N.H. was 29 degrees Fahrenheit. Dr. Brown does

not use a thermometer to evaluate temperature

within the van. Dr. Brown noted that the drugs

in the van tend to “turn-over” quickly or they are

rotated out of the van on a monthly basis and

returned to the clinic. Important to note: Drugs

stored in extreme temperatures especially

temperature outside the manufacturer

recommended storage range are prone to

premature degradation; decomposition, chemical

alteration and adulteration.

3.) Product exposed under extreme light conditions

can produce deterioration of the package

labeling. Product name, strengths, lot,

expiration, National Drug Code and storage

requirements should always be easily readable

before a manufacturer’s product is used. (see

attached photos)

App. 50

4.) The control substance log is approximately a 4

inch X 6 inch bound ledger that has pages

divided into columns with segregated pages for

specific drug, strength and dosage form. The

columns contained the date; name of client,

town, quantity used and balance remaining. The

ledger did not list the street address of the client

which is a legal requirement.

5.) The van did not possess temperature control

features, such as propane heaters, as are found

in Recreation Vehicles that are converted for

medical use.

App. 51

APPENDIX H

NEW HAMPSHIRE BOARD OF PHARMACY

PRACTITIONER/CLINIC INSPECTION REPORT

August 13, 2014

[Fold-out Exhibit, see next page]

App. 52

NOTICE OF INSPECTION

NEW HAMPSHIRE BOARD OF PHARMACY

67 Regional Drive

Concord, NH 03301

(Office - (603) 271-2350)

(Fax - (603) 271-2858)

Facility: MWV Mobile Vet

Street: 1513 Route 16

City: Madison/Conway

District 11

Zip:

Pharmacy [ ] Practitioner [T] Institution

[ ] Home Infusion [ ] LTC Facility

[ ] Other: _____________________

Date: 8/13/14

Time: 11:00 AM

PURPOSE OF INSPECTION

Routine [ ] Complaint [ ] Follow-up [T] Other: ________

This is to acknowledge that New Hampshire Board

of Pharmacy Inspector/Investigator, Margaret A.

Clifford, RPh, has identified him/herself by

presentation of official credentials. Pursuant to the

provisions of RSA 318:8, RSA 318:8-a of the New

Hampshire Pharmacy Act and RSA 318-B:25 of the

New Hampshire Controlled Drug Act, I hereby

grant permission for the aforementioned agent to

inspect any and all of the records relative to the

receipt, distribution and security of legend drugs at

this location. This also included records which are

required pursuant to the provisions of 21 CFR part

1300 to end, of the Federal Controlled Substance

App. 53

Act. This inspection also addresses any other

standards of practice issues outlined by other health

care regulatory agencies, which these agents are

charged to enforce. By my signature, I hereby

acknowledge the receipt of this Notice of Inspection

and certify that:

1. I am the __________, for the above described

location;

2. I have read this Notice of Inspection and

understand its contents and purpose;

3. I have the authority to act in this matter and

have signed this Notice of Inspection pursuant

to my authority;

4. I have been provided with the purpose of this

Notice of Inspection but, fully realize that the

scope of this inspection may encompass ALL of

the records required pursuant to the

aforementioned Acts or Board rules;

5. I have voluntarily consented to this inspection.

Signature: /s/Sandra Brown Date: 8-13-14

(Print): Sandra Brown

Board Agent: /s/Margaret A. Clifford Date: 8/13/14

(Print): Margaret A. Clifford, RPh Ph 500 (Rev. 10/96)

Pursuant to RSA 547-A:31,II, failure to allow access to

the aforementioned records, could result in disciplinary

sanctions

App. 54

Addendum to Inspection Report of MWV Mobile Vet

8-13-14

The Board of Pharmacy conducted a follow-up

inspection of MWV Mobile Vet Clinic, see attached

inspection report. It appears that Dr. Brown has made

some improvements since our first visit in June of

2013. In a letter dated September 19, 2013, Compliance

Investigator Elder reported to you an apparent lack of

cooperation on Dr. Brown’s part in complying with our

inspection. CI Elder also mentioned that Dr. Brown’s

records of receipt and distribution were in disarray and

concerns over outdated medications. Also on the first

visit it was extremely warm in the medication room.

We did not have a thermometer with us on the first

visit. Yesterday I did have a thermometer with me and

the temperature in the room was 76 degrees which is

acceptable.

During my inspection yesterday, I found Dr. Brown to

be cooperative, professional and courteous. In the

medication room I found both a DEA Binder and a

Controlled Substance record book. I was able to readily

retrieve records of receipt and distribution. This was a

marked improvement over our first visit last year when

the records could not be found. In addition to having

her records readily retrievable, Dr. Brown was

prepared for the scheduling change of Tramadol coming

up on August 18. There was a note hanging on the shelf

reminding her and staff about the change that was

effective on the 18th of this month. I discussed with her

Technician Gina, how to add tramadol to the Biennial

Inventory.

App. 55

I did find some out dated medications both in the Van

and in the medication room, however the majority of

the outdated meds were quarantined in a single drawer

within the med room. I did discuss with Dr. Brown the

few meds that I found in the “stock” area, I believe that

there, were only three in the medication room that

were not quarantined and three in the Van. Additional

outdated stock was observed in the treatment area

connected to the OR and in the locked Controlled

Substance boxes. The outdated meds in the Controlled

substance lock boxes were clearly marked as outdated.

Dr. Brown and I discussed the outdated medication,

she confirmed that the drawer I found is her

quarantined area and that the medications there are

not used. Dr. Brown indicated that she would only use

an outdated medication in an emergency situation.

While looking at the medications stored in the Van, I

did notice that Dr. Brown has added a thermometer for

monitoring temperature. Dr. Brown maintains that the

van is garaged in a temperature controlled

environment when parked at her house. We did not

discuss the issue yesterday but I would still be

concerned about the temperatures inside the van when

the vehicle is not parked in the garage. Again, we did

not discuss this yesterday, but a better solution for

keeping the medications in a controlled environment

would be to have a wheeled cart that could be

transported from the clinic to the van when she needed

to go out on a call.

In the van there is a tote that is labeled Dispensing

Vials. Most of the vials in this tote appear to have been

previously used. Dr. Brown and I discussed the fact

App. 56

that vials should not be reused because of cross

contamination and possible allergic reactions to

medications that were previously in the vial. Dr. Brown

stated that when she does re-use vials she washes

them out first.

The only other observation that I would add is that it

appears the medication room may double as a kitchen.

I did not get a chance to discuss this observation with

Dr. Brown. What I observed was a oloset that

contained food and a toaster oven and Microwave on

the counter. This may not be an issue as there were no

d rugs stored in with the food and no food in the drug

storage area.

Margaret A . Clifford

App. 57

APPENDIX I

NEW HAMPSHIRE BOARD OF PHARMACY

PRACTITIONER/CLINIC INSPECTION REPORT

October 18, 2016

[Fold-out Exhibit, see next page]

App. 58

NOTICE OF INSPECTION

[SEAL] State of New Hampshire

Board of Pharmacy

121 South Fruit Street

Concord, NH 03301-2412

(Office - (603) 271-2350)

(Fax - (603) 271-2858)

Facility: MWV Mobile Vet

Street: 1513 N.H. Route 16

City:

Conway

Zip: 03818

District 003 Pharmacy [ ] Practitioner [T] Institution

[ ] Home Infusion [ ] LTC Facility

[ ] Other: _____________________

Date: 10/18/16

Time: 9:00 AM

PURPOSE OF INSPECTION

Routine [T] Complaint [ ] Follow-up [ ] Other: ________

This is to acknowledge that New Hampshire Board

of Pharmacy Inspector/Investigator, Robert D.

Elder, R.Ph., has identified him/herself by

presentation of official credentials. Pursuant to the

provisions of RSA 318:8, RSA 318:8-a of the New

Hampshire Pharmacy Act and RSA 318-B:25 of the

New Hampshire Controlled Drug Act, I hereby

grant permission for the aforementioned agent to

inspect any and all of the records relative to the

receipt, distribution and security of legend drugs at

this location. This also included records which are

required pursuant to the provisions of 21 CFR part

App. 59

1300 to end, of the Federal Controlled Substance

Act. This inspection also addresses any other

standards of practice issues outlined by other health

care regulatory agencies, which these agents are

charged to enforce. By any signature, I hereby

acknowledge the receipt of this Notice of Inspection

and certify that:

1. I am the owner of practice of, for the above

described location;

2. I have read this Notice of Inspection and

understand its contents and purpose;

3. I have the authority to act in this matter and

have signed this Notice of Inspection pursuant

to my authority;

4. I have been provided with the purpose of this

Notice of Inspection but, fully realize that the

scope of this inspection may encompass ALL of

the records required pursuant to the

aforementioned Acts or Board rules;

5. I have voluntarily consented to this inspection.

Signature: /s/Sandra Brown Date: 10-18-16

(Print): Sandra Brown

Board Agent: /s/Robert D. Elder, R.Ph., C.I. Date:

10/18/16

(Print): Robert D. Elder, R.Ph, C.I. Ph 500 (Rev. 10/96)

Pursuant to RSA 547-A:31,II, failure to allow access to

the aforementioned records, could result in disciplinary

sanctions

App. 60

MWV Mobile Veterinary Clinic

1513 NH Rte 16

Conway, NH 03818-1031

Sandy Brown, DVM

xxxxxxxxxxxxxxxxxs

xxxxxxxxxxxxxxxxxx

xxxxxxxxx

603-447-8311

#8341

10/18/2016

Ex.: 1/12/2017

Give _1_ tablets_2-3_ time(s) daily with food as needed

for pain.

May cause drowsiness.

NDC 65162-0627-11 DOB

Tramadol 50mg Tablets #8341

(15 Tab)

Keep out of reach of children and pets. For

veterinary use only.

Caution: Federal law prohibits the transfer of this drug

to any person other than the patient for whom it was

prescribed

App. 61

MWV Mobile Veterinary Clinic

1513 NH Rte 16

Conway, NH 03818-1031

Sandy Brown, DVM

xxxxxxxxxxxxxxxxxs

xxxxxxxxxxxxxxxxxx

xxxxxxxxx

603-447-8311

#6187

10/18/2016

Ex.:

Apply 1 drop twice daily for 4 days. Avoid bright light

while pupil is dilated. Please call if not improving in 23 days, or worse (ie squinting) at any time.

No chare due to expiration date

Atropine Opthalmic Solution 1% 5ml #6187 (1 bottle)

Keep out of reach of children and pets. For

veterinary use only.