          IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Carol Markowitz,                          :
                   Petitioner             :
                                          :
             v.                           : No. 1743 C.D. 2015
                                          : Submitted: February 5, 2016
Bureau of Professional                    :
and Occupational Affairs,                 :
State Board of Pharmacy,                  :
                   Respondent             :

BEFORE:      HONORABLE MARY HANNAH LEAVITT, President Judge
             HONORABLE ANNE E. COVEY, Judge
             HONORABLE ROCHELLE S. FRIEDMAN, Senior Judge

OPINION NOT REPORTED

MEMORANDUM OPINION
BY PRESIDENT JUDGE LEAVITT                                  FILED: August 25, 2016

             Carol Markowitz petitions for review of an adjudication of the State
Board of Pharmacy (Pharmacy Board) denying her request for a reinstatement of
her pharmacy license. Markowitz contends that the Pharmacy Board erred because
she presented reports from her treating physician and psychiatrist that she is stable,
physically and mentally, and ready to resume her profession as a pharmacist.
Markowitz argues that the Pharmacy Board simply disregarded this evidence and
relied, instead, upon a report undertaken by providers appointed by the Pharmacy
Board who did not testify at the hearing. After review, we conclude that we are
constrained to affirm.
             In 1987, the Pharmacy Board issued Markowitz a pharmacy license.
In 2009, the Bureau of Professional and Occupational Affairs (Bureau) initiated an
enforcement action against Markowitz after she attempted suicide. The parties
settled by a consent decree that (1) suspended her license for three years and (2)
stayed the suspension in favor of probation. The probation required her to undergo
a mental health evaluation, drug treatment and random drug testing and, finally, to
abstain from alcohol.       The probation included monitoring by the Professional
Health Monitoring Program.1
              Approximately two months into her probationary period, Markowitz
tested positive for Oxazepam, a Schedule IV controlled substance2 and Ethyl
Glucuronide, an alcohol marker.             Based on the test results, the Program
recommended that Markowitz enter an in-patient residential treatment center for
chemical dependency, which she did in October 2009. Markowitz left the center
without completing the program and, thereafter, did not report for drug testing as
required by the consent decree.
              On February 16, 2010, the Bureau instituted an administrative
proceeding to enforce the consent decree. Its petition alleged that Markowitz had
violated the consent decree and requested the Pharmacy Board to vacate the stay of
her license suspension. Markowitz, through her legal counsel, waived her right to




1
  According to the Department of State’s website, professionals with a physical or mental
disorder, including substance abuse, may undergo monitoring so that they can practice their
profession safely. There are two “Professional Health Monitoring Programs”: a voluntary
recovery program and the disciplinary monitoring program for licensed professionals that have
been the subject of an enforcement action by their professional licensing board.
http://www.dos.pa.gov/ProfessionalLicensing/OtherServices/ProfessionaHealthMonitoringProgr
ams/Pages/default.aspx (last visited August 19, 2016). It is not clear by what authority these
programs were established or receive funding.
2
  Title 28 of the Pennsylvania Code, Section 25.72, lists the schedules of “all controlled
substances.” “Oxazepam” is listed as a Schedule IV controlled substance. 28 Pa. Code
§25.72(e)(1)(xiv).


                                              2
a hearing.3 The Pharmacy Board ordered her license suspended for three years,
retroactive to February 16, 2010.
               The Pharmacy Board’s order set forth the terms of reinstatement after
completion of the suspension. It stated:

               [Markowitz] may petition for reinstatement after three years.
               [Markowitz] must submit to the [Pharmacy] Board satisfactory
               evidence that [she] is able to practice pharmacy with reasonable
               skill and safety and has completed at least three years of
               rehabilitation      and    continuous      sustained   recovery.
               Documentation of such recovery shall include, but is not
               limited to, the following:
                      (a) An evaluation and assessment from a
                      treatment provider approved by the Professional
                      Health Monitoring Program indicating that
                      [Markowitz] is fit to safely practice as a
                      pharmacist;
                      (b) Periodic and random drug and alcohol
                      screening indicating the lack of illicit substances,
                      the last screen to be completed no more than thirty
                      (30) days prior to the petition for reinstatement;
                      (c) A current Criminal History Record
                      Information (a/k/a “Criminal Record Check”) from
                      a governmental agency from all states where
                      [Markowitz] has resided since the suspension,
                      compiled no more than three months prior to the
                      petition for reinstatement; and



3
  The consent decree set forth the procedure for its enforcement. It provided that the Bureau
would present a petition to the Pharmacy Board’s Probable Cause Screening Committee. Upon a
finding of probable cause, the Committee would issue a preliminary order vacating the stay of
suspension; terminating Markowitz’s probation; and activating the suspension of her license.
Upon notice of the preliminary order, Markowitz would have 20 days to request a formal
hearing. If she declined to do so, “the Board shall issue a final order affirming the suspension of
[her] license.” Consent Decree at 17.


                                                3
                      (d) A signed verification that [Markowitz] has not
                      practiced pharmacy since the suspension.
              Prior to reinstatement, [Markowitz] must prove at a formal
              hearing before the [Pharmacy] Board or its designee that [she]
              is capable of practicing pharmacy with reasonable skill and
              safety.

Pharmacy Board Order of May 7, 2010; Reproduced Record at 140 (R.R. __).4
              In 2013, Markowitz contacted the Department of State’s Professional
Health Monitoring Program for assistance in pursuing a license reinstatement. At
that time, she underwent a psychiatric evaluation by Joseph M. Garbely, D.O., and
William J. Heran, Ph.D., who issued a joint report on September 17, 2013. R.R.
134-137.
              On August 28, 2014, Markowitz applied for a reinstatement of her
license. In support, she attached a clean criminal background check and a number
of random drug testing results. She submitted a lab test done on July 30, 2014, by
Parkway Clinical Laboratories, which was negative, and nine tests done from May
13, 2013, through August 5, 2013, by Firstlab. Six of the Firstlab tests were
positive for amphetamines. Markowitz’s application stated that the random drug
tests showed she was not taking any substance for which she did not have a valid
prescription. Finally, her application included two mental health evaluations. The

4
 The consent decree also explained that if the Pharmacy Board suspended her license she would
be subject to the following requirements when requesting reinstatement:
      [A]fter at least three (3) years of active suspension and any additional imposed
      discipline, [Markowitz] may petition the [Pharmacy] Board for reinstatement
      based upon an affirmative showing that [she] has at least thirty-six (36) months of
      sustained documented recovery, [she] has undergone an evaluation by a treatment
      provider approved by [the Program] and is fit to safely practice the profession,
      and [she] has abided by and obeyed all laws….
Consent Decree at 17.


                                               4
first was from Eric W. Fine, M.D. and the second was from Kevin M. Fosnocht,
M.D.    Both opined that she was physically and mentally able to work as a
pharmacist.
              The Pharmacy Board’s counsel advised Markowitz that she was
obligated to present a fitness assessment from a provider that had been approved
by the Professional Health Monitoring Program. The providers who evaluated
Markowitz were not on that list. The Pharmacy Board’s counsel suggested that
Markowitz contact the Program for the name of an approved provider.               In
response, Markowitz submitted the joint report by Drs. Heran and Garbely
completed on September 17, 2013, with a letter explaining that she did not include
it with her application because it contained numerous misstatements. She also
submitted a medical evaluation done by her psychiatrist, Stanford Bazilian, M.D.,
who treats her for ADHD.
              Seven members of the Pharmacy Board appeared to hear Markowitz’s
request for reinstatement. The Pharmacy Board’s counsel conducted the hearing
on March 17, 2015. All of Markowitz’s documents in the Pharmacy Board’s
record were marked as Exhibit B-1. The Bureau lodged a hearsay objection to
those reports in Exhibit B-1 that were authored by Drs. Fine, Fosnocht, and
Bazilian. It also noted that none of the three were present to testify and none were
Program-approved. The Pharmacy Board overruled the objection, explaining that
it would determine the weight to give the reports of Drs. Fine, Fosnocht and
Bazilian. Markowitz objected to the admission of the joint report of Drs. Garbely
and Heran because it contained statements that were not factually true.          The
Pharmacy Board admitted the report of Drs. Garbely and Heran into evidence,
again noting that it would decide the weight to be assigned the expert report.


                                         5
                 The joint report of Drs. Garbely and Heran detailed Markowitz’s
psychiatric history and substance abuse history, including “Cannibus [sic] Abuse
(In remission)[;] Amphetamine Dependence[;] Attention Deficit Hyperactivity
Disorder, by history [ADHD.]” R.R. 137. The report stated that Markowitz
denied active alcohol use but admitted to use of marijuana for nausea and vomiting
in 1995 when she was being treated with chemotherapy and radiation for breast
cancer. R.R. 135. The report stated that Dr. Bazilian, her psychiatrist, reported
that he had prescribed 20 mg of Adderall per day for her ADHD. By contrast,
Markowitz reported to Drs. Garbely and Heran that Dr. Bazilian had prescribed
120 mg of Adderall per day.                 The joint report summarized Markowitz as
“oppositional” and in a victim stance. It recommended that Markowitz cease
taking all mind altering substances for an extended period of time before being
considered for a license reinstatement.5                  The joint report concluded that
Markowitz’s “poor attitude towards monitoring may make her likelihood to be free
of addictive substances very slim.” R.R. 137.
                 Markowitz saw Dr. Fine, a psychiatrist, on two occasions for the
purpose of evaluating her readiness to return to her pharmacy practice. His report
noted that Markowitz had been prescribed amphetamines for many years to treat
her ADHD, and he did not believe she was addicted to amphetamines. He opined
that there was no psychiatric or physical impediment to her ability to resume her
profession as a pharmacist.
                 Dr. Fosnocht practices internal medicine, and Markowitz is his
patient. He issued a report opining that Markowitz was clinically stable. Her


5
    The report does not specify whether this included the Adderall prescribed by her psychiatrist.


                                                  6
ADHD was managed by her psychiatrist, and she exhibited no symptoms that
would preclude her employment as a pharmacist.
             Dr. Bazilian, Markowitz’s psychiatrist, reported that in spite of past
difficulty, her ADHD is now under control with a daily dose of 30 mg of Adderall,
an amphetamine. He opined that there has been significant improvement with her
depression and that she does not exhibit suicidal tendencies. He opined that there
was no medical or psychological condition that precludes her from being able to
resume her profession.
             Markowitz testified, first, about her 2009 license suspension. After
working for a number of years for different pharmacies, without problem or
incident, she decided to set up her own pharmacy. Her business partner used her
license number to set up secret wholesale accounts to divert drugs. When she
found out, she “kicked him out of the pharmacy.” Notes of Testimony at 32 (N.T.
__). The partner diverted over “98 bottles of 500 tablets of oxycodone and …
Vicodin ES.” N.T. 32. This prompted a criminal investigation. At the same time
the pharmacy began to experience financial difficulties. In the midst of this stress,
Markowitz attempted suicide by ingesting some of the diverted oxycodone tablets.
The overdose caused a serious thrombosis that led to an extended hospitalization,
the loss of her business and her pharmacist license.
             Markowitz challenged the claim in the joint report of Drs. Garbely
and Heran that she abused cannabis. She acknowledged that in 2008, she was
arrested for having a marijuana plant in her house, but it belonged to her husband.
In any case, she was not convicted.
             Markowitz produced documentation on all the pharmacy courses she
has taken to advance her clinical knowledge and remain current on continuing


                                         7
education requirements for her profession. She also presented the testimony of her
husband, a retired licensed professional counselor who works in a drug and alcohol
clinic. He saw no evidence that his wife was addicted. He reported that he had
worked part-time at the pharmacy she owned. He observed her interaction with
customers to be “very professional.” N.T. 24.
               The Bureau’s sole witness was Kali Harding, a case manager with the
Professional Health Licensing Program. She explained that a “Program-approved
provider” is one who is licensed in Pennsylvania; has training and experience with
patients with addictions; and agrees to follow Program guidelines.                      Harding
testified that when Markowitz contacted the Program in 2013, she was directed to
the peer assistance program for pharmacists. That led to the evaluation by Drs.
Garbely and Heran. When Markowitz again contacted the Program in 2014, she
was advised to undergo a five-day inpatient evaluation, but she did not do so.
Until Markowitz testified that the evaluation would cost $6,000,6 Harding was not
aware of its cost.
               The Pharmacy Board held that Markowitz did not meet her burden of
proving that she was fit to practice pharmacy safely and, thus, denied her
reinstatement request. The Pharmacy Board stated it “[was] not convinced by [the]
reports” of Drs. Fine, Bazilian and Fosnocht. Pharmacy Board Adjudication at 9.
Further, Markowitz failed to produce a positive evaluation from a provider that had
been approved by the Professional Health Licensing Program. Drs. Fine, Bazilian
and Fosnocht are not Program-approved providers as are Drs. Garbely and Heran,
who opined that Markowitz was not ready for a reinstatement of her license. The

6
  Markowitz testified that she lacked the funds to pay for this evaluation in addition to the $950
she spent on the joint report.


                                                8
drug screenings done on Markowitz, completed over a four-month period as part of
her evaluation by Drs. Garbely and Heran, showed amphetamine use in the >10000
ng/mL range on four occasions; in the 18291 ng/mL range on one occasion; in the
54121 ng/mL range on one occasion; and negative for drug use on three occasions.
R.R. 73-74. Markowitz tested positive for amphetamine use as recently as July
2013. The Pharmacy Board held that given those test results, Markowitz did not
establish three years of sustained recovery, which was required under the 2010
suspension as a condition for reinstatement.
              Markowitz petitioned for this Court’s review.7 She has raised four
issues. First, she contends that the Pharmacy Board erred in admitting the joint
report of Drs. Heran and Garbely when they did not testify, their qualifications are
unknown and their report stale. Second, she contends that the Pharmacy Board
erred in admitting the joint report over Markowitz’s objections.                  Third, she
contends that she satisfied her evidentiary burden for reinstatement with her
evidence. Fourth, she contends that the Pharmacy Board abused its discretion in
refusing reinstatement for the stated reason that Dr. Fine is not a Program-
approved provider.




7
  Our review determines whether the Pharmacy Board abused its discretion, committed an error
of law, or violated constitutional rights. DePanfilis v. State Board of Pharmacy, 551 A.2d 344,
345 (Pa. Cmwlth. 1988). The Pharmacy Board’s decision must be supported by substantial
evidence. Cassella v. State Board of Medicine, Bureau of Professional and Occupational
Affairs, 547 A.2d 506, 510 n.23 (Pa. Cmwlth. 1988). “Substantial evidence is that relevant
evidence which a reasonable mind might accept as adequate to support a conclusion.” Hercules,
Inc. v. Unemployment Compensation Board of Review, 604 A.2d 1159, 1163 (Pa. Cmwlth.
1992).


                                              9
                Section 5(a)(4) of the Pharmacy Act8 authorizes the Pharmacy Board,
upon probable cause, to compel a pharmacist to submit to an examination by
“physicians or psychologists approved by the [Pharmacy B]oard.” 63 P.S. §390-
5(a)(4).9 It also provides that a pharmacist whose license has been suspended be
given the opportunity to demonstrate that he or she can resume a competent
practice of pharmacy with reasonable skill and safety to patients. Id. Moreover,
Section 5(c) provides that after a license has been suspended for lack of fitness, the
Pharmacy Board may:

                (1) Deny the application for a license.
                (2) Administer a public reprimand.
                (3) Revoke, suspend, limit or otherwise restrict a license as
                determined by the [Pharmacy B]oard.

8
    Act of September 27, 1961, P.L. 1700, as amended, 63 P.S. §§390-1 – 390-13.
9
    It states:
        (a) The [Pharmacy B]oard shall have the power to refuse, revoke or suspend the
        license of any pharmacist upon proof satisfactory to it that the pharmacist:
                                                 ***
                (4) Is unfit or unable to practice pharmacy by reason of a physical
                or mental disease or disability. In enforcing this clause, the
                [Pharmacy B]oard shall, upon probable cause, have authority to
                compel a pharmacist to submit to a mental or physical examination
                by physicians or psychologists approved by the [Pharmacy
                B]oard. Failure of a pharmacist to submit to such examination
                when directed by the [Pharmacy B]oard, unless such failure is due
                to circumstances beyond his or her control, shall constitute an
                admission of the allegations against him or her, consequent upon
                which a default and final order may be entered without the taking
                of testimony or presentation of evidence. A pharmacist affected
                under this clause shall at reasonable intervals be afforded an
                opportunity to demonstrate that he or she can resume a competent
                practice of pharmacy with reasonable skill and safety to patients.
63 P.S. §390-5(a)(4) (emphasis added).


                                               10
             (4) Require a licensee to submit to the care, counseling or
             treatment of a physician or a psychologist designated by the
             [Pharmacy B]oard.
             (5) Suspend enforcement of its finding thereof and place a
             licensee on probation with the right to vacate the probationary
             order for noncompliance.
             (6) Restore or reissue, in its discretion, a suspended license to
             practice pharmacy and impose any disciplinary or corrective
             measure which it might originally have imposed.

63 P.S. §390-5(c)(emphasis added).
             Markowitz’s brief focuses upon the joint report of Drs. Heran and
Garbely. She claims it should not have been admitted in light of her objection and
because the authors did not appear in person to testify; accordingly, she was unable
to confront and cross-examine them on the mistakes that appear in their report.
             The Bureau responds that Markowitz did not raise a hearsay objection
at the hearing. She challenged only its accuracy. In any event, the report’s
admissibility is irrelevant because Markowitz did not prove that she is entitled to
reinstatement. The reasons are several: Markowitz did not submit an evaluation
from a Program-approved provider that she was fit to practice pharmacy; the
favorable reports produced by Markowitz were hearsay; and Markowitz did not
submit proof of three years of sustained recovery.
             “Hearsay is defined as an out-of-court statement, either oral or
written, offered in court for the purpose of proving the truth of the matter contained
in the statement.” Bailey v. Unemployment Compensation Board of Review, 597
A.2d 241, 243 n. 3 (Pa. Cmwlth. 1991). “Hearsay evidence, [p]roperly objected to,
is not competent evidence to support a finding[ ],” but “[h]earsay evidence,
[a]dmitted without objection, will be given its natural probative effect and may
support a finding[ ], [i]f it is corroborated by any competent evidence in the
                                         11
record....” Walker v. Unemployment Compensation Board of Review, 367 A.2d
366, 370 (Pa. Cmwlth. 1976). “[A] finding of fact based [s]olely on hearsay will
not stand.” Id.
                 It is clear that the joint report is hearsay and not corroborated by other
evidence of record. We agree with Markowitz that the report of Drs. Heran and
Garbely should not have been considered by the Pharmacy Board. However, that
does not resolve this appeal. Markowitz had the burden of proof in this case, and
she did not present any physician to testify in person. As such, all of the medical
opinions contained in her expert reports also constitute hearsay.
                 The May 7, 2010, order states that in order to qualify for
reinstatement, Markowitz must provide an “evaluation and assessment from a
treatment provider approved by the Professional Health Monitoring Program
indicating that [she] is fit to safely practice as a pharmacist[.]”                   R.R. 140.
Markowitz did not present this evidence. Notably, this requirement is not found in
the statute, which states that “at reasonable intervals” a pharmacist must be
afforded an opportunity to demonstrate that he or she can resume a competent
practice ....”       63 P.S. §390-5(a)(4).         The statute does not require that this
demonstration be made only through the opinion of a Program-approved
provider.10


10
     Section 7 of the Pharmacy Act states as follows:
          (d.3) The board, with the approval of the Commissioner of Professional and
          Occupational Affairs, shall appoint and fix the compensation of a professional
          consultant who is a licensee of the board with education and experience in the
          identification, treatment and rehabilitation of persons with physical or mental
          impairments. Such consultant shall be accountable to the board and shall act as a
          liaison between the board and treatment programs, such as alcohol and drug
          treatment programs licensed by the Department of Health, psychological
(Footnote continued on the next page . . . )
                                                 12
               In her brief, Markowitz argues that the Bureau failed to authenticate
the Heran and Garbely report and did not present competent evidence to challenge
Dr. Fine’s report.       Accordingly, Dr. Fine’s report in support of her license
reinstatement became the “controlling document” in the case. Markowitz Brief at
32. First, the Bureau did not present the Heran and Garbely report; Markowitz
submitted it to the Pharmacy Board. The Bureau had no obligation to authenticate
it. Second, the exclusion of the Heran and Garbely report does not make Fine’s
report dispositive. The Bureau challenged Dr. Fine’s report on hearsay grounds,
not on his qualifications.
               Markowitz agreed to undergo periodic and random drug screenings.
A lab test done by Parkway Clinical Laboratories on July 30, 2014, was negative.
However, there was no evidence that it was a random drug screening; it certainly
was not periodic. The results submitted by Markowitz from Firstlab appear to be
random and periodic; however, they show positive results for amphetamines.
Markowitz contended that the positive amphetamine readings were due to her
prescription for Adderall. That may be so. However, Markowitz had the burden to
present evidence of random and periodic drug screenings, and the drug screenings
she presented showed amphetamine use. It was her burden to show the varying
levels of amphetamine usage documented in her drug tests correlated to the amount
of Adderall she was legally prescribed at the time. She did not do so.


(continued . . . )
        counseling and impaired professional support groups approved by the board and
        which provide services to licensees under this act.
63 P.S. §390-7(d.3) (emphasis added). This provision does not authorize the Pharmacy Board to
establish a list of “approved providers” to govern a pharmacist’s license reinstatement. It is not
clear whether the Pharmacy Board has appointed a “professional consultant.” Id.


                                               13
             The Pharmacy Board’s demand that Markowitz spend $6,000 on an
evaluation does not appear grounded in statute or even fair given her current
financial difficulties. The statute states that the Board may require her examination
by “physicians or psychologists approved by the [Pharmacy B]oard.” 63 P.S.
§390-5(a)(4). It does not say she cannot challenge the results of that examination,
nor does it condition her reinstatement upon the approval of a Program-approved
physician or psychologist.
             We are left with a difficult record. Dr. Bazilian prescribed Adderall,
and this prescription showed up in her drug tests. Markowitz testified that she was
trying to get off the drug in order to get her pharmacy license, an idea Dr. Fine
thought unadvisable.     Markowitz needs to prove that her Adderall use is
appropriate and not an impediment to her ability to work as a pharmacist.
             She has not done so yet and, accordingly, we are constrained to affirm
the order of the Pharmacy Board.

                                   ______________________________________
                                   MARY HANNAH LEAVITT, President Judge




                                         14
         IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Carol Markowitz,                    :
                   Petitioner       :
                                    :
           v.                       : No. 1743 C.D. 2015
                                    :
Bureau of Professional              :
and Occupational Affairs,           :
State Board of Pharmacy,            :
                   Respondent       :

                                ORDER

           AND NOW, this 25th day of August, 2016, the order of the State
Board of Pharmacy, dated August 25, 2015, in the above-captioned matter is
hereby AFFIRMED.

                                ______________________________________
                                MARY HANNAH LEAVITT, President Judge
