          IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Christopher Elder,                      :
                   Petitioner           :
                                        :
              v.                        :      No. 66 C.D. 2018
                                        :      Argued: November 13, 2018
Bureau of Professional and Occupational :
Affairs, State Board of Medicine,       :
                   Respondent           :


BEFORE:        HONORABLE MARY HANNAH LEAVITT, President Judge
               HONORABLE PATRICIA A. McCULLOUGH, Judge
               HONORABLE CHRISTINE FIZZANO CANNON, Judge

OPINION
BY PRESIDENT JUDGE LEAVITT                                  FILED: March 27, 2019

               Christopher Elder petitions for review of the December 21, 2017,
adjudication of the Pennsylvania Bureau of Professional and Occupational Affairs
(Bureau), State Board of Medicine (Board), that denied his application for a license
to practice medicine and surgery. The Board denied Elder’s application because of
his 2010 felony convictions for participating in a conspiracy to distribute controlled
substances. The Board rejected the recommendation of its Hearing Examiner that
Elder be granted a provisional license, subject to completion of a Board-approved
remediation program and followed by a three-year period of probation. For the
reasons that follow, we vacate the Board’s adjudication and remand for further
proceedings.

                                 Procedural Posture

               On October 14, 2014, Elder submitted an application to the Board for a
license to practice medicine and surgery in Pennsylvania. The Board provisionally
denied Elder’s application by letter of April 2, 2015. The Board’s decision stated
several grounds.     First, Section 9124(c)(1) of the Criminal History Record
Information Act (CHRIA) authorized the Board to deny a license to an applicant
who has been convicted of a felony. 18 Pa. C.S. §9124(c)(1). Second, Sections
22(b), (c) and 41 of the Medical Practice Act of 1985 authorized the Board to deny
a license to an applicant who lacks good moral character and who cannot
demonstrate the requisite training and experience. Act of December 20, 1985, P.L.
457, as amended, 63 P.S. §§422.22(b), (c), 422.41. Third, Elder’s convictions,
although under the laws of another jurisdiction, would constitute felonies under The
Controlled Substance, Drug, Device and Cosmetic Act, Act of April 14, 1972, P.L.
233, as amended, 35 P.S. §§ 780-101 – 780-144, that bar the issuance of a medical
license for ten years.
             Elder appealed the Board’s provisional denial, and on December 9,
2015, the Board’s Hearing Examiner conducted a formal administrative hearing on
Elder’s appeal. Elder was represented by legal counsel and testified on his own
behalf.
                                Factual Background

             Elder obtained his medical degree from the Medical College of
Pennsylvania and Hahnemann University School of Medicine in 1999.                  He
completed his internship in internal medicine at the Medical College of Pennsylvania
and Hahnemann University School of Medicine in 2000. Elder then completed his
residency at the Baylor College of Medicine in 2003. In 2005, Elder completed and
received a full board certification in physical medicine and rehabilitation at the Mayo
Clinic in Rochester, Minnesota.
             On August 15, 2003, Elder was licensed to practice medicine and
surgery in Texas. Elder began working part-time for the South Texas Wellness

                                          2
Center in Houston, Texas as a locum tenens in August 2004, while studying for his
board examination. Elder left that part-time job in January 2005.
             During his tenure at the South Texas Wellness Center, Elder prescribed
medication for patients, including Schedule III, IV, and V controlled substances. On
February 5, 2008, the United States filed a 24-count criminal indictment against
Elder and four co-defendants in the matter of United States v. Mary Lynn Rostie,
Cynthia S. Martin, Troy R. Solomon, Christopher L. Elder, and Delmon L. Johnson,1
in the United States District Court for the Western District of Missouri. The
indictment alleged that Elder wrote 544 prescriptions for Schedule III, IV, and V
controlled substances, which were not used for a legitimate medical purpose and
prescribed outside the usual course of professional practice. Reproduced Record at
AA376 (R.R. __).
             On June 30, 2010, a jury found Elder guilty of one felony count of
Conspiracy to Possess and Distribute Controlled Substances, 21 U.S.C. §§841, 846,
and eight felony counts of Aiding and Abetting Distribution of Controlled
Substances, 21 U.S.C. §841, 18 U.S.C. §2.2 The sentencing judge stated that he
viewed Elder’s role in the conspiracy differently than the government. More
specifically, the judge stated:

             Clearly Dr. Elder was found guilty by this jury of complicity in
             this conspiracy. I’m not sure that I agree with the government’s
             proposition that he was the linchpin here. My guess is that from
             the evidence, that if Dr. Elder hadn’t done it, they would have
             found someone else to do it.
             My interpretation of Dr. Elder’s participation in this conspiracy
             was of gross negligence, not anything more than that. He ha[d]

1
  United States v. Cynthia S. Martin, Troy R. Solomon, Christopher L. Elder, and Delmon L.
Johnson, Case No. 08-00026-01/02/03/04-CR-W-FJG.
2
  United States v. Christopher Elder, Case No. 08-00026-04-CR-W-FJG.
                                            3
               a responsibility that he didn’t fulfill. The reason why he didn’t
               fulfill it, I’m not sure. I don’t see it for financial gain necessarily
               because I don’t see that to be the issue here. So I see it being
               most likely gross negligence.

R.R. AA341 (Sentencing Hearing Transcript, 5/3/2011, at 56). Elder was sentenced
to a term of imprisonment of 15 months (a significant downward departure from the
U.S. Federal Sentencing Guidelines) followed by two years of supervised release,
and ordered to forfeit $991,114,3 for which he was found jointly and severally liable
with his co-defendants. The United States Court of Appeals for the Eighth Circuit
affirmed Elder’s criminal convictions.4
               The Texas Medical Board did not take action against Elder’s license as
a consequence of his indictment. However, on August 23, 2010, it suspended his
medical license because of his convictions. In 2012, the Texas Medical Board
denied Elder’s petition to terminate the suspension of his medical license. In 2014,
the Texas Medical Board refused to reinstate Elder’s medical license, which expired.
               At the hearing on his request for a Pennsylvania medical license, Elder
testified. He explained that he wants to relocate to Pennsylvania, where he earned
his medical degree, to be closer to his parents who live on the East Coast. Elder also
described his post-conviction activities. He volunteers for the Howard Calvert
Foundation for Hunger, where he helps distribute food to the homeless and serves
as a mentor to under-privileged youth. As a mentor, he helps the students build
mathematical, science, verbal reasoning and verbal comprehension skills. He has
also served as the foundation’s inventory analyst for its food pantry. Additionally,




3
  The government has not begun collection proceedings.
4
  See United States v. Christopher Elder, 682 F.3d 1065 (8th Cir. 2012).
                                                4
Elder volunteers to instruct paramedics and emergency medical service personnel
on the placement of cervical collars and cervical spine stabilization techniques.
             Since he has stopped practicing medicine, Elder has completed 78
credit hours of continuing medical education. Elder testified that he presently earns
a living by working three days a week in the construction business.
             Elder testified that he takes full responsibility for the actions that led to
his criminal convictions. He acknowledged his failure to handle medical records
appropriately. In his closing remarks, Elder stated:

             I’d like to say that I’m really remorseful for several things. One
             is allowing myself to be placed in a predicament to be utilized by
             others. That’s just straight out being naïve. I’m not a criminal.
             I was naïve, got used, got duped … [I went into] a den of wolves
             who [were] taking [my] credentials and literally using them. I
             just didn’t know better. I’m deeply remorseful that I didn’t know
             better, or I just didn’t have the insight to think like that. Doctors
             aren’t trained to think like criminals.
                                               ***
             One of the things I learned is that, I accept responsibility for my
             actions. My responsibility may not have been direct, but
             nevertheless, I am still at the end of the day accountable because
             [my] prescriptions appeared somewhere where they didn’t
             belong.
                                               ***
             I desire a second chance because this thing has tormented me.
             How could I work so hard to get used the way that I did, and I
             got used.
                                               ***
             I absolutely accept responsibility…. Wrong people, a wrong
             time, and it was the wrong issue.

Notes of Testimony, 12/9/2015, at 163-170 (N.T.__); R.R. AA167-AA174.

                                           5
              Celious Barner III, a psychologist in Texas, testified that Elder is well
regarded in his professional community. Barner testified that after Elder’s release
from prison, Elder donated his time and talent to several community-based
organizations. Before Elder lost his medical license, Barner worked with Elder on
an interdisciplinary team providing treatment to indigent patients who would not
otherwise have had access to the level of treatment that Elder could provide. Both
doctors worked on this team until 2008 and have maintained a collegial relationship
and friendship. Barner stated that Elder is “very remorseful.” N.T., 12/9/2015, at
28; R.R. AA32.
              Lionel Lynch, a physician’s assistant in Texas, testified about his
professional relationship with Elder, who served as Lynch’s supervisor at the South
Texas Wellness Center. Lynch testified about Elder’s work with patients who are
indigent or less able to care for themselves. He testified that Elder had a good
reputation.
              Howard Calvert, CEO of the Howard Calvert Foundation for Hunger
of Texas, testified about Elder’s involvement with his non-profit organization, as
well as Elder’s mentorship to at-risk youth in the Houston area. Elder continued
with this volunteer service after his release from prison and after the completion of
his supervised release term.
              Attorney John Osgood, who represented Elder in the federal criminal
prosecution, testified on behalf of Elder. He explained that he has stayed in contact
with Elder since his conviction. Osgood testified that during Elder’s nearly six-
month tenure at the Texas Wellness Center, he saw approximately 10 patients a day
for whom he wrote prescriptions. Some patients did not fill the prescriptions locally
but gave them to Solomon, who faxed them to a pharmacy in Missouri. According


                                           6
to Osgood, Elder barely knew Solomon and did not know what Solomon was doing.
After Elder left the facility, Solomon continued to fax expired prescriptions on which
Elder had written “no refills.” Osgood explained that notwithstanding Elder’s
conviction he was a “minimal participant” in the conspiracy. R.R. AA95. Osgood
noted that Elder was not convicted of unlawful use of communication facility, i.e.,
“the faxes.” R.R. AA98. Osgood testified that Elder understands and has taken full
and complete responsibility for his crimes.
             Several letters were submitted attesting to Elder’s character and
rehabilitation. Barner, Lynch and Calvert submitted letters of support. Kerrick D.
Floyd, President of AfterCare Ambulance Transfer, Inc., Troy L. Marsaw, President
of Complete Management Services, and Robert J. Bacon, M.D. also submitted letters
to the Board attesting to Elder’s moral character and extensive volunteer work.
             After the hearing, Elder filed a brief with proposed findings of fact and
conclusions of law. It included the following proposed findings of fact related to his
criminal convictions:

             38. Dr. Elder’s original federal criminal charge did not result in
             the Texas Medical Board ex parte or emergently suspending Dr.
             Elder’s medical license. This was unusual.
             39. The facts of the criminal case, set forth in Exhibits A5 and
             A6, focus on the facts that Dr. Elder’s prescription pad was stolen
             and utilized to generate prescriptions in the State of Missouri.
             40. Dr. Elder accepted full and complete responsibility for which
             the jury found him guilty, in that Dr. Elder gave a full statement
             to the police at the time of his initial contact.
             41. Dr. Elder worked at a Southern Texas Wellness Center which
             was a chiropractic facility containing a pharmacy in which
             [Elder] saw and treated patients for six months at his first job out
             of medical school.


                                          7
             42. It was discovered by the federal authorities that Dr. Elder’s
             medical care and treatment generated objectively based
             prescriptions.
             43. It is those prescriptions that were photocopied and faxed from
             Houston, Texas by a co-defendant to Kansas City and were
             altered and sold by co-defendant, Troy Solomon.
             44. Dr. Elder had no knowledge of Troy Solomon altering and
             faxing the prescriptions to Missouri and that a pharmacist in the
             State of Missouri, Lynn Rostie, ran the pharmacy in Missouri.
             45. Dr. Elder did not have any relationship with Lynn Rostie,
             Cynthia Martin and was barely acquainted with Troy Solomon.
             46. The criminal complaint did not include any allegation, and
             no evidence was introduced at trial, that Dr. Elder received any
             money from Troy Solomon or the other co-defendant[s] in the
             case.
             47. Due to Dr. Elder’s very minimum involvement in the federal
             criminal matter, the Federal District Court judge uniquely
             sentenced Dr. Elder below the sentencing guidelines after a
             contested jury trial.

Elder’s Administrative Brief at 6-7; R.R. AA454-AA455 (citations omitted).
             The Bureau presented no evidence at the hearing, but it filed a brief.
Therein, the Bureau took the position that the Board erred in one of its stated grounds
for denying Elder’s application, i.e., under authority of The Controlled Substance,
Drug, Device and Cosmetic Act. This was because Elder’s federal convictions did
not constitute felonies under the Pennsylvania statute. The Bureau also took the
position that the Board had legal grounds for a license denial under the Medical
Practice Act of 1985 and CHRIA.            However, the Bureau did not offer a
recommendation on how the Board should exercise its discretion under those
applicable statutes.



                                          8
                     Hearing Examiner’s Findings of Fact

            Related to Elder’s criminal convictions, the Hearing Examiner issued
the following findings:

            11. [Elder] and Co-Defendants Rostie, Martin, Solomon, and
            Johnson were charged with the felony Conspiracy to Possess and
            Distribute Controlled Substances, in violation of 21 U.S.C.
            §841(a)(1), (b)(1)(D), (b)(2), (b)(3) and 21 U.S.C. §846, through
            Count One of the criminal Indictment.
            12. [Elder] and Co-Defendants Rostie, Solomon, and Johnson
            were charged with the felonies Aiding and Abetting Distribution
            of Controlled Substances, in violation of 21 U.S.C. §841(a)(1),
            (b)(1)(D), (b)(2) and 21 U.S.C. §2 through Counts Three (3)
            through Ten (10) of the criminal Indictment.
            13. Counts Three (3) through Six (6) of the criminal Indictment
            cited to [Elder’s] alleged involvement with writing prescriptions
            for Lorcet, Xanax, and Lortab to four (4) patients in October,
            2004 during the period [Elder] worked at the South Texas
            Wellness Center.
            14. Counts Seven (7) through Ten (10) of the criminal Indictment
            cited to [Elder’s] alleged involvement with writing prescriptions
            for Hydrocodone, Alprazolam in September, 2004, to two (2)
            patients during the period [Elder] worked at the South Texas
            Wellness Center. The Counts additionally alleged that [Elder]
            wrote prescriptions for Hydrocodone, Alprazolam, and
            Promethazine with Codeine to two (2) patients in April, 2005,
            during a period when [Elder] no longer worked at the South
            Texas Wellness Center.
            15. [Elder’s] alleged conduct in the Criminal Matter was related
            to his involvement in a multi-state conspiracy to distribute large
            quantities of controlled substances based on prescriptions for
            lists of patients for whom there was no credible evidence of a
            patient-doctor relationship. [Elder’s] alleged involvement in the
            conspiracy consisted of writing original prescriptions for
            controlled substances which were sent to Defendant Rostie at her
            pharmacy in Missouri to be filled before being [returned] to
            [Elder’s] Co-Defendants in Texas for illicit distribution.

                                         9
            16. [Elder] did not derive significant monetary benefit from the
            activities giving rise to his criminal conviction.

Proposed Adjudication and Order, 3/10/2016, at 5-6; R.R. AA417-AA418 (citations
omitted).
            As to the question of Elder’s remorsefulness and rehabilitation, the
Hearing Examiner made the following findings of fact:

            29. [Elder] has been involved with the Howard Calvert
            Foundation for Hunger (the “Foundation”) since being released
            from incarceration, and has been extensively involved in the
            Foundation’s mentorship group.
            30. [Elder] tutors under-privileged youth and serves as a mentor,
            for the purpose of building the students’ mathematical, science,
            verbal reasoning and verbal comprehension skills.
            31. [Elder] has also served as an inventory analyst for the food
            pantry operated by the Foundation, and has been involved in
            serving meals to the homeless in the Houston, Texas area.
            32. [Elder] dedicates his time to instruct paramedics and EMS
            personnel on the proper manner by which to place cervical
            collars on patients.
                                         ***
            36. [Elder] has demonstrated sincere remorse for his actions to
            Dr. Barner.
            40. Mr. Lynch described [Elder] as having an “outstanding”
            reputation for caring for indigent patients who were otherwise
            unable to be treated by a primary care physician.
                                         ***
            45. Following his criminal conviction, [Elder] has undertaken
            efforts to educate himself regarding the proper criteria for
            prescribing controlled substances to patients.




                                       10
                 46. [Elder] has obtained approximately 78 credits of continuing
                 medical education since having stopped practicing medicine in
                 2010.
                 47. [Elder] had not been subject to licensure disciplinary action
                 prior to the suspension of his Texas medical license on August
                 23, 2010.
                 48. [Elder] had not been involved in the criminal justice system
                 prior to his criminal convictions, and he has not been involved in
                 the criminal justice system since having been criminally
                 convicted.

Proposed Adjudication and Order, 3/10/2016, at 9-11 (citations omitted).
                 The Hearing Examiner concluded that Elder’s evidence demonstrated
his present moral fitness to practice medicine. The Hearing Examiner observed that
Elder offered evidence to establish “his ‘limited role, participation, or even
involvement’ in the conspiracy which ultimately resulted in his criminal
convictions.” Id. at 25-26. The Hearing Examiner concluded that “the totality of
the circumstances articulated above sufficiently establish that [Elder] has
rehabilitated himself during the intervening passage of time, and that [Elder] does
not create a substantial risk of harm to the health and safety of his patients or to the
public related to his moral character.” Id. at 28.
                           Hearing Examiner’s Recommendation

                 The Hearing Examiner reviewed the applicable provisions of law.
Section 9124(c)(1) of CHRIA, 18 Pa. C.S. § 9124(c)(1), authorizes a denial of a
license based on the applicant’s felony convictions.5 Section 22(b) of the Medical

5
    Section 9124(c)(1) of CHRIA states:
          (c) State action authorized.—Boards, commissions or departments of the
          Commonwealth authorized to license, certify, register or permit the practice of
          trades, occupations or professions may refuse to grant or renew, or may suspend or
          revoke any license, certificate, registration or permit for the following causes:
                                                 11
Practice Act of 1985, 63 P.S. §422.22(b),6 requires good moral character and
requisite medical training. Finally, Sections 22(c) and 41 of the Medical Practice
Act of 19857 authorize the denial of a license where another state has suspended or


                (1) Where the applicant has been convicted of a felony.
18 Pa. C.S. §9124(c)(1) (emphasis added). In Abruzzese v. Bureau of Professional and
Occupational Affairs, 185 A.3d 446, 453 (Pa. Cmwlth. 2018), we stated:
                CHRIA is a general law that authorizes, but does not require, an agency to
                suspend a license upon the licensee’s felony conviction. CHRIA does not
                provide any standards for the exercise of the agency’s discretion under
                Section 9124(c)(1) to suspend or revoke a license for a felony conviction.
6
  Section 22(b) of the Medical Practice Act of 1985 states, in pertinent part:
        (b) Qualifications.—The board shall not issue a license or certificate to an applicant
        unless the applicant establishes with evidence, verified by an affidavit or
        affirmation of the applicant, that the applicant is of legal age, is of good moral
        character and is not addicted to the intemperate use of alcohol or the habitual use
        of narcotics or other habit-forming drugs and that the applicant has completed the
        educational requirements prescribed by the board and otherwise satisfies the
        qualifications for the license or certificate contained in or authorized by this act.
63 P.S. §422.22(b) (emphasis added). In Abruzzese, which involved the suspension of an
esthetician’s license, we explained that “[t]he specific, and more relevant statute is the Beauty
Culture Law [Act of May 3, 1933, P.L. 242, as amended, 63 P.S. §§507-527]….” Abruzzese, 185
A.3d at 53. In this case, the specific and more relevant statute is the Medical Practice Act, and the
only statute we consider here.
7
  Section 22(c) of the Medical Practice Act of 1985 states:
        The board may refuse to issue a license or certificate to an applicant based upon a
        ground for such action contained in section 41[, 63 P.S. §422.41].
63 P.S. §422.22(c). Section 41 of the Medical Practice Act of 1985 states, in pertinent part:
        The board shall have authority to impose disciplinary or corrective measures on a
        board-regulated practitioner for any or all of the following reasons:
               (1) Failing to demonstrate the qualifications or standards for a
               license, certification or registration contained in this act or
               regulations of the board.
               (2) Making misleading, deceptive, untrue or fraudulent
               representations in the practice of the profession or practicing fraud
               or deceit, either alone or as a conspirator, in obtaining a license,
               certification or registration or in obtaining admission to a medical
               college.
                                                12
revoked a license. Although The Controlled Substance, Drug, Device and Cosmetic
Act authorizes a revocation for ten years for felony convictions, the Hearing
Examiner concluded that Elder’s federal felony convictions did not constitute
felonies under the Pennsylvania statute. Accordingly, The Controlled Substance,
Drug, Device and Cosmetic Act did not authorize a license denial in Elder’s case.
               The Hearing Examiner explained that Elder’s criminal conduct
demonstrated moral turpitude at the time of its commission. However, the Hearing
Examiner found that Elder presented persuasive evidence of his rehabilitation and
present moral fitness to practice medicine. The Hearing Examiner credited the
testimony of Elder’s character witnesses, giving weight to their statements about his
remorsefulness and rehabilitation.            The Hearing Examiner found that Elder
completed the terms of his punishment and has exhibited only lawful behavior
during the 11 years (now 15) since he left the South Texas Wellness Center.
               The Hearing Examiner acknowledged Elder’s evidence that explained
his personal involvement in the criminal conspiracy as well as the Texas Medical
Board’s refusal to reinstate Elder’s license. Nevertheless, the Hearing Examiner
concluded that the totality of the circumstances established that Elder had

              (3) Being convicted of a felony or being convicted of a misdemeanor
              relating to a health profession or receiving probation without
              verdict, disposition in lieu of trial or an Accelerated Rehabilitative
              Disposition in the disposition of felony charges, in the courts of this
              Commonwealth, a Federal court or a court of any other state,
              territory or country.
              (4) Having a license or other authorization to practice the
              profession revoked or suspended or having other disciplinary action
              taken, or an application for a license or other authorization refused,
              revoked or suspended by a proper licensing authority of another
              state, territory, possession or country, or a branch of the Federal
              Government.
63 P.S. §422.41 (emphasis added).
                                                13
rehabilitated himself since his 2004 criminal conduct. The Hearing Examiner found,
as fact, that Elder does not present a substantial risk of harm to the health and safety
of his patients or the public, and he does not present a substantial risk of committing
new crimes. In short, the Hearing Examiner concluded that Elder demonstrated the
present moral character required for a license to practice medicine.
              The Hearing Examiner recommended that Elder’s application be
granted provisionally, subject to completion of a Board-approved remediation
program to bring his training up to date. He recommended that the provisional
license be followed by three years of probation.

                                 Board’s Adjudication

              With limited exception, the Board adopted the Hearing Examiner’s
Findings of Fact and Conclusions of Law.8 The Board denied Elder’s application
for a license to practice medicine and surgery. The Board agreed that Elder’s
volunteer work was admirable and significant and acknowledged that Elder has not
been involved in any criminal activity since 2004. It also acknowledged that Elder
practiced medicine without incident until his Texas medical license was suspended
in 2010 as a consequence of his conviction. Although the Board adopted the Hearing
Examiner’s findings of fact about Elder’s remorse and rehabilitation, it came to a
different conclusion.
              The Board explained its decision to deny Elder’s license application as
follows:



8
 The Board did not include the Hearing Examiner’s finding that Elder did not gain significant
monetary benefit from the conspiracy. Hearing Examiner Proposed Order and Adjudication,
Findings of Fact, No. 16. The Board also added its own finding that Elder has not practiced
medicine since 2010. Board Adjudication, Findings of Fact, No. 48.
                                             14
            [Elder] devoted a significant portion of the hearing towards
            establishing his limited role, participation, or even involvement
            in the conspiracy which ultimately resulted in his criminal
            convictions. [Elder’s] testimony belies his repeated assertions
            that he is remorseful for his criminal conduct. Comparing
            [Elder’s] testimony minimizing his responsibility with respect to
            his criminal conviction with the trial court’s sense that [Elder]
            had not “come to grips with the severity of [his] conduct in terms
            of the gross negligence that [he] engaged in …” demonstrates
            how little progress [Elder] has made in rehabilitating himself.
            The United States Court of Appeals for the Eight[h] Circuit cited
            to various portions of the record which portray [Elder] as having
            played a significantly greater role in the criminal activity for
            which he was convicted than [Elder] suggested at the hearing.
            The disparity between [Elder’s] interpretation of the facts proven
            in the criminal matter as they specifically pertained to [Elder],
            and the evidence of record pertaining to [Elder’s] specific
            conduct that the Eighth Circuit for the United States Court of
            Appeal recognized further demonstrates [Elder’s] lack of
            remorse. [Elder’s] lack of remorse and failure to take
            responsibility and ownership of his criminal conduct outweigh
            the societal contributions he has made in providing care,
            treatment, and food to indigent patients and in mentoring youth.

Board Adjudication, 12/21/2017, at 22-23 (emphasis added) (citations omitted). The
Board also explained:

            In general, the Board balances the seriousness of the underlying
            basis for the refusal of a license against any credible mitigating
            evidence that the Applicant presents. The Board also includes
            other relevant facts in weighing these factors to determine
            whether it should license an Applicant.
            [Elder] had no criminal record or professional disciplinary record
            prior to the conduct that led to his federal conviction and the
            suspension of his Texas medical license. However, [Elder] was
            involved in a multi-state conspiracy to illegally distribute
            controlled substances. Rather than to take responsibility and
            express remorse for his criminal misconduct during his
            testimony, [Elder] attempted to minimize his role. As previously
            noted, [Elder’s] testimony demonstrates how little progress in his
            rehabilitation he has made since the trial judge noted [Elder] had
                                        15
              not “come to grips with the severity of [his] conduct in terms of
              the gross negligence that [he] engaged in.” A licensee who has
              not recognized and accepted responsibility for his criminal
              conduct presents a greater risk to the public than a licensee who
              has accepted and takes ownership of his criminal conduct.

Id. at 24 (emphasis added).
              The Board also denied Elder’s application because he was no longer
technically qualified. The Board explained that, at the time of the hearing, Elder had
completed 78 continuing medical education credit hours since he stopped practicing
medicine in 2010. However, Pennsylvania requires active physicians to complete
100 hours of continuing medical education every biennial renewal cycle. Further,
Elder had not undertaken a practice assessment and comprehensive physician re-
education program. Because medicine has changed since Elder last practiced in
2010, the Board explained it “would expect a licensee such as [Elder] who has not
engaged in the practice of medicine for several years to present evidence that he had
successfully and recently completed a nationally recognized, Board-approved
clinical skills evaluation and remediation program….” Id. at 25.
                                           Appeal
              On appeal,9 Elder argues that the Board erred and abused its discretion
in denying his application. Specifically, Elder contends that the Board failed to
balance his one-time episode of criminal conduct against his extensive evidence of
present good character, remorse, and rehabilitation. Elder also argues that the Board
denied him due process “when it willfully and deliberately disregard[ed] competent


9
 This Court’s review of a licensing board’s disciplinary sanction determines “whether there has
been a manifest and flagrant abuse of discretion or a purely arbitrary execution of the agency’s
duties or functions.” Goldberger v. State Board of Accountancy, 833 A.2d 815, 817 n.1 (Pa.
Cmwlth. 2003) (quoting Slawek v. State Board of Medical Education and Licensure, 586 A.2d
362, 365 (Pa. 1991)).
                                              16
testimony and relevant evidence warranting probationary licensure with time to
satisfy educational qualifications.” Elder Brief at 27.
                                             I.
                 We first address Elder’s contention that the Board failed to balance the
limited duration of his criminal conduct against his extensive evidence of present
moral character. The Board denied Elder’s application based on Section 22(b) of
the Medical Practice Act of 1985, which, among other things, provides that the
applicant must show he is of good moral character. 63 P.S. §422.22(b).10 The Board
found that Elder’s criminal convictions demonstrated a lack of moral character.
                 The Board, as does any licensing board, exercises considerable
discretion in policing its licensees. Ake v. Bureau of Professional and Occupational
Affairs, State Board of Accountancy, 974 A.2d 514, 519 (Pa. Cmwlth. 2009). The
Board decides the weight to be assigned to mitigating evidence. Abruzzese v. Bureau
of Professional and Occupational Affairs, State Board of Cosmetology, 185 A.3d
446, 453 (Pa. Cmwlth. 2018). However, this Court “is required to correct abuses of
discretion in manner or degree of penalties imposed.” Ake, 974 A.2d at 519 (citation
omitted).
                 Instructive here is our Supreme Court’s decision in Secretary of
Revenue v. John’s Vending Corporation, 309 A.2d 358 (Pa. 1973), which arose
under a different Pennsylvania licensing statute. In John’s Vending, the Cigarette
Tax Board revoked a wholesale cigarette dealer’s license because its 50-percent
shareholder was convicted of selling, possessing, and transporting untaxed and
unstamped liquor, and selling and possessing opium derivatives. The applicable




10
     See n.6, supra.
                                             17
statute prohibited the licensing of an entity whose 50-percent shareholder is
convicted of a crime involving moral turpitude. The licensee appealed.
             On review, the Pennsylvania Supreme Court examined the applicable
statute, which prohibits the sale of unstamped cigarettes to protect against the loss
of tax revenue. To that end, the statute required the licensee to demonstrate
character, integrity, and honesty.     The Supreme Court found that the “past
derelictions” of the 50-percent shareholder did not adversely affect his present
ability to do the job lawfully. Id. at 361. Indeed, the officer had held a position of
responsibility for a number of years after his conviction without wrongdoing. The
Supreme Court explained that the nature of the offending conduct and its remoteness
in time must be considered where an agency seeks to revoke a professional license
on the basis of a criminal conviction. The Court further explained that “where the
prior convictions do not in anyway reflect upon the [applicant’s] present ability to
properly discharge the responsibilities required by the position, we hold that the
convictions cannot provide a basis for the revocation of a … license.” Id. Elder
contends that John’s Vending requires a reversal of the Board’s refusal to license
him.
             John’s Vending requires the licensing authority to consider the
relationship of a criminal conviction to the licensee’s “present ability to properly
discharge the responsibilities” of the licensed position. Id. In the case at bar, over
ten years have elapsed between Elder’s offending conduct and his application to
practice medicine in Pennsylvania. Although not as long as the 20 years that elapsed
in the case of the licensee in John’s Vending, Elder’s criminal conduct is remote and
was an isolated event.




                                         18
             According to the Eighth Circuit, Elder wrote 544 prescriptions during
his six-month tenure at the South Texas Wellness Center. As Elder’s counsel
pointed out, the government did not present evidence that the prescriptions were not
medically warranted. The Board found that Elder wrote prescriptions to four
patients in October of 2004 and to two patients in September 2004.            Those
prescriptions were then used by the co-defendants, without Elder’s knowledge, after
he left the South Texas Wellness Center.
             In its analysis, the Board focused on the Eighth Circuit opinion and not
its own findings of fact about the nature of Elder’s conduct, i.e., writing six
prescriptions, which the sentencing judge described as gross negligence. Further,
the Eighth Circuit opinion is not current. Elder has since fulfilled the terms of his
sentencing, probation and post-incarceration rehabilitation work.
             The Board was dismissive of Elder’s mitigating evidence, stating that
“[r]ather than to take responsibility and express remorse for his criminal misconduct
during his testimony, [Elder] attempted to minimize his role.” Board Adjudication,
12/21/2017, at 24. Elder responds that he was not minimizing his criminal conduct
but explaining his role in the underlying conspiracy, which the Board misconstrued
as a collateral attack on his conviction. Elder directs the Court to Nguyen v. Bureau
of Professional and Occupational Affairs, State Board of Cosmetology, 53 A.3d 100
(Pa. Cmwlth. 2012).
             Nguyen involved the revocation of a license to practice as a nail
technologist on the basis of a federal felony. This Court set aside the licensing
board’s revocation because it imputed to Nguyen the culpability of another
defendant that related to involuntary servitude. The Board’s prosecuting staff
recognized that Nguyen’s conduct was not as culpable as his co-defendant. Elder


                                         19
argues that Nguyen teaches that an applicant or licensee may, and should, explain
his role in a criminal conviction that involves multiple defendants. We agree. The
Board erred in drawing an adverse inference from Elder’s evidence that compared
his conduct to that of his co-defendants.
               With respect to Elder’s mitigating evidence, the Board stated that
Elder’s “lack of remorse and failure to take responsibility and ownership of his
criminal conduct outweigh the societal contributions he has made in providing care,
treatment, and food to indigent patients and in mentoring youth.”                            Board
Adjudication, 12/21/2017, at 22-23. The record does not support the Board’s
assertion that Elder failed to express remorse or to take responsibility for his criminal
conduct. At the hearing, Elder stated that he was “really” and “deeply” remorseful
and he “absolutely accept[s]” responsibility.” N.T., 12/9/2015, at 163-170; R.R.
AA167-AA174. He presented witnesses to attest to his remorse. The Board did not
explain how this testimony was inadequate or what else Elder could have said.
Elder’s attempt to place his criminal conduct into context and explain his role in the
conspiracy does not demonstrate a lack of remorse or rehabilitation, as the Board
presumed. The Board simply made a subjective determination that was contrary to
that of the Hearing Examiner, who directly observed Elder and his witnesses, and
accepted his evidence on remorse.
               We hold that the Board erred and abused its discretion in reaching the
conclusion that Elder does not have the present moral character required for a
license.11 Elder’s crimes were committed over 14 years ago and were isolated to a


11
  The Board noted Elder’s license discipline in Texas and stated it was “reluctant to grant licensure
to physicians” that have not resolved their out-of-state disciplinary issues. Board Adjudication at
24. Texas suspended Elder’s license for his felony convictions and not for the way he practiced
medicine. The Texas Board action is redundant of the Board’s denial of Elder’s application for
                                                20
single episode in his life. He has served his sentence. The Board erred by
categorizing Elder’s evidence as not accepting responsibility when he was simply
explaining his role in the conspiracy. The Board’s conclusion on Elder’s moral
character cannot be reconciled with John’s Vending, 309 A.2d 358, or Nguyen, 53
A.3d 1000. It did not take into account its own findings that Elder’s conduct since
2004 has been not only free of criminal conduct but dedicated to significant
volunteer and public service activities.
                                              II.
              As to Elder’s technical qualifications, the Board found that Elder has
“made little effort to demonstrate his continued competency to practice medicine.”
Board Adjudication, 12/21/2017, at 25. The Board cited the Commonwealth’s
requirement that an active physician must complete 100 hours of continuing medical
education every biennial renewal cycle, and Elder has completed only 78 hours since
his Texas license was suspended in 2010. The Board noted that it would expect “a
licensee such as [Elder] who has not engaged in the practice of medicine for several
years” to have completed a nationally recognized, Board-approved clinical skills
evaluation and remediation program similar to the post-licensure programs in the
Commonwealth. Id.
              In his Proposed Adjudication, the Hearing Examiner recognized that
Elder did not maintain proficiency in medicine after his 2010 license suspension.
However, instead of denying Elder’s application, the Hearing Examiner
recommended that Elder “undergo a clinical skills evaluation and/or remediation
program” to assist the Board in its assessment of Elder’s current competency.
Proposed Adjudication and Order at 28-29. The Hearing Examiner recommended

lack of moral character as demonstrated by his conviction. The Board has an independent duty to
evaluate an applicant under the laws of Pennsylvania.
                                              21
granting Elder’s license application after he completed such a Board-approved
program, subject to a three-year probationary period.
             Neither the Board’s Final Adjudication nor its brief to this Court
address why the Hearing Examiner’s recommendation was not sufficient to allay the
Board’s concerns about Elder’s technical competency. We recognize that the Board
is not required to accept the Hearing Examiner’s findings of fact, conclusions of law,
or recommendations and has the discretion to impose disciplinary sanctions on
applicants. Abruzzese, 185 A.3d at 453. However, the Board needed to identify,
with specificity, the training Elder needs in order to qualify for a medical license in
Pennsylvania.
             In its brief, the Board states that the Board’s “final adjudication sets
forth the path by which Dr. Elder may obtain licensure in the Commonwealth.”
Board Brief at 27. The Board’s brief suggests that Elder, inter alia, “consider
undertaking a practice assessment and comprehensive physician re-education
program that several nationally recognized programs offer or otherwise establish his
current competency before re-applying for licensure.” Id. at 28. However, the
Board’s final adjudication does not provide any specific direction. The Board cited
Elder’s failure to maintain proficiency, but it did not explain whether a physician
without a license can even enroll in these re-education programs. The Board needs
to identify the specific programs that Elder must complete to demonstrate present
proficiency in medical science.
             The Board’s regulations allow it to conduct an interview to assess the
competency of a physician who has been out of practice for more than four years.
49 Pa. Code §16.15(j). The Board should consider doing such an interview of Elder




                                          22
to evaluate, inter alia, what training he needs to meet the proficiency requirements
for a medical license.
             The Board refused to grant Elder a license for the reason that he has not
practiced medicine for several years. It adverted to its “expectation” that Elder
should successfully complete a “nationally recognized” program, but it did not
specify that program. This was error, and thus, its order will be vacated.
                                       Conclusion

             We hold that the Board erred and abused its discretion by using Elder’s
ten-year-old criminal conviction to evaluate his present moral character and by
characterizing his evidence on his role in the criminal conspiracy as showing a lack
of remorse. In finding Elder not qualified to practice medicine, the Board did not
err. However, it failed to explain, in certain terms, what measures Elder must
undertake to become qualified. Accordingly, we vacate the Board’s adjudication
and remand the matter to the Board for further proceedings consistent with this
opinion.

                                   _____________________________________
                                   MARY HANNAH LEAVITT, President Judge




                                         23
           IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Christopher Elder,                      :
                   Petitioner           :
                                        :
              v.                        :   No. 66 C.D. 2018
                                        :
Bureau of Professional and Occupational :
Affairs, State Board of Medicine,       :
                   Respondent           :


                                  ORDER

            AND NOW, this 27th day of March, 2019, the order the Pennsylvania
Bureau of Professional and Occupational Affairs, State Board of Medicine, dated
December 21, 2017, in the above-captioned matter is VACATED, and the matter is
REMANDED to the Board for further proceedings consistent with the Court’s
opinion.
            Jurisdiction relinquished.
                                   _____________________________________
                                   MARY HANNAH LEAVITT, President Judge
