Hearing transcript

00:50 Ling Yuan, Committee Chair

… [those who] are vaccinated are not required to wear a mask. However, you are welcome to wear a mask if you are more comfortable doing so. Mr. Egan, will you please read the emergency evacuation procedure.

01:02 Mykl Egan, Board staff

In the case of a fire or other emergency [alarm]… please exit the room using one of the doors on the side of the room. [If you exit on the right,] turn right, follow the corridor… take [the exit] at the end of the hall back to the way [you] came in. [If you exit] the building, proceed straight ahead through the parking lot to the very end of the lot. [ASR unclear — evacuation routing partially garbled.]

01:25 Ling Yuan, Committee Chair

Good morning. My name is Ling Yuan. I’ll be [chairing] this meeting. [We are the] special conference committee of the Board of Pharmacy. We will [review the] allegations contained in the notice of informal conference. If we find that there are violations of the laws and regulations [governing] the conduct of the practice, an order may be entered by the board… We may also refer the matter to the board for a formal hearing. The committee members here today will now participate in the informal [conference]. If we decide that there is no violation, [the matter is closed]. Will board members and staff please identify themselves, starting to my right.

02:18 Ellen Shinaberry, Board staff

Good morning, I’m Ellen Shinaberry, Deputy Executive Director for the Board.

02:29 Mykl Egan, Board staff

Good morning, Mykl Egan, Discipline [Case] Manager.

02:32 Rebecca Ribley, Board staff

Rebecca Ribley, [Adjudication] Specialist with the Administrative Proceedings Division.

02:38 Ling Yuan, Committee Chair

Please identify yourselves.

03:36 Ling Yuan, Committee Chair

[Did you receive the notice of the] informal conference? … We see that an additional packet was provided with additional evidence to be considered. Is there any other evidence, other than this, that you would like us to consider?

04:13 Ellen Shinaberry, Board staff — process

We’ll be reviewing the allegations and [will] go one by one. In the back [of] the notice of informal conference there is an allegation summary worksheet. Just to facilitate and organize the way the conference goes — if you’re okay with that, we’re going to proceed with that allegation summary. Allegation number one, item A: do you acknowledge or do you refuse this allegation?

05:19 Ling Yuan, Committee Chair

Are there any documents provided in the folder, or any statements or comments you would like to add to this allegation?

07:48 Committee Member

This is a [large] checklist form that you provided to the committee. Where is this kept [afterward]?

08:31 Committee Member

So you’re acknowledging that — I think I read earlier in the packet — that your facility documented the administration of the [sedative] [on] cage cards.

08:53 Committee Member

Okay. So we have a [set] of notes — documentation of… some medication, appearing on pages starting on page twenty-three of the evidence; this is this notebook. And throughout it, it has a day, type of animal, the weight of the animal, and [it] looks like how much medication was administered — like looking at the top page, [amounts] like ninety, or nine cc’s, etcetera. So which medication is this documenting?

09:45 Committee Member

So when you say you were documenting the sedatives on cage cards — [you were] taking notes so you could have it all together — but [page 23] is not what you’re talking about? It’s not [kept] together with that?

10:39 Committee Member

… Okay. What was the type of [sedative] that was used for the [sedation] in 2022 and 2023?

11:13 Committee Member

Because I saw that you did provide some invoices for the purchase of that [medication], and I noticed that for all of the invoices dated in 2023 — which is the subject of today’s allegations — they were only for tablets, the 10-milligram tablets. So I’m wondering: was there a period of time when you only relied on tablets for the sedative?

11:42 Committee Member

And when did you start using [the liquid]? I can’t remember the exact date — give me a guess. How long, a year? Two years that you’ve been using that?

12:15 Committee Member

So looking at page 91, which is the supervising veterinarian’s protocol for companion-animal euthanasia from January 25th, 2020 — it looks like the veterinarian said, for the sedative for cats, it should be a concentration [of] ten milligrams per milliliter, and then the dosage of point two five milligrams per pound. So, since it says concentration of ten milligrams per milliliter, that would be a liquid as opposed to tablets — am I understanding that right?

13:36 Committee Member

I just don’t see any allowance here, or direction, for tablets. I guess — what would the dosage be for tablets, or the concentration, since this concentration is described as milligrams per milliliter?

13:57 Committee Member

Right. But at the time of the [euthanasia] evaluations in 2022 and 2023, this was the protocol in place that you were supposed to follow. So it looks like, according to the invoices you provided, your facility only purchased the [acepromazine] tablets from the second half [of] February 2022. How would [the] effects differ [between tablet and liquid]?

15:38 Committee Member

How much longer would you say?

15:48 Committee Member

So would your staff just wait the extra time, instead of using the liquid?

15:55 Committee Member

Did you ever talk with the [supervising veterinarian] about using tablets [instead of the liquid]? … [On the form] there are three places [to initial] on the cage card. Do you keep a soft copy of it, or do the records get scanned at all?

16:54 Committee Member

In your folder, okay. So it’ll just be physical records — it’s not scanned to, let’s say, a folder in a computer?

17:25 Committee Member

[On the form,] the initials — is that the initials of the personnel that administers the drug… and that also does the monitoring?

17:46 Committee Member

Are there any instances where you have someone administering the drug and a different person doing the monitoring of that one?

18:22 Committee Member

How long [do you keep] it?

20:28 Committee Member

In regards to the period of time where you determine [that] more medication will be needed — would [that be around] ten minutes?

20:59 Committee Member

So thirty minutes, okay. … Mind if I ask one more question — and I just want to make sure I’m reading the documents correctly. I have in front of me a [checklist]. You mentioned a euthanasia checklist. Was there discussion on any points to potentially add the weight of the animal to the checklist, mainly because everything is weight-based?

21:35 Committee Member

[A] question about the additional medication — the [dose] that would be added past the one [milliliter] per 10 pounds, and you told me about the process of observing. Since it’s in the supervising veterinary protocol, was that veterinarian made aware of what was happening?

22:40 Committee Member

And then that veterinarian made the determination of how much additional would be [administered]. Okay.

23:37 Committee Member

[And] how often would you say you do that? … On page twenty-three, would these have all been intravenous administrations, or does it vary?

24:19 Committee Member

So looking at the protocol — it says cats: IV injection should be used rarely, and only if the cat is older than six months and calm; and that IP injection should be utilized on most cats and kittens. … Some of these administrations documented starting at page 23 are from cats, and you’re saying that those represent IP administrations, but you didn’t differentiate in these records whether it was IP or IV. Starting with page 23 — I don’t see anything that says IP or IV, so that’s what I was asking.

25:34 Committee Member

It’s looking like the dosages [should be] based on the protocol — different for IV versus IP. Like, for cats, the IV dosage is one milliliter per ten [pounds], but the IP dosage is three milliliters per ten [pounds]. So is that something that your staff was aware of at the time?

28:00 Committee Member

Do you weigh the animal — like, how readily accessible is a way to weigh the animal?

28:07 Committee Member

Okay. Because I was just looking back at this record, and it says, for example — [around page] thirty-three — there’s a cat that, on January ninth, 2023… weighed two pounds, I think is what it says, and then thirty cc’s, or three milliliters, of the sodium pentobarbital were administered. So this cat was two pounds, it was given three milliliters — but the IP dosage, which should be utilized on those cats and kittens, is three milliliters per ten pounds. So it’s like a three-pound cat getting the dose of a ten-pound cat. What do you think is the reason for that?

29:18 Committee Member

And it’s like — the [records show] a six-pound cat also got that same amount; another two-pound cat got that same amount. Is that pretty typical for cats that are that small — to not [need less]?

33:28 Committee Member

[Walk us through the] processes that you have put in place to prevent this from happening again.

34:04 Committee Member

Will you walk me through the process if you were to certify a new staff member — basically [starting them] under the [supervised] euthanasia [program]? How does the selection look, what does the training process look like, what does the certification training look like?

36:56 Committee Member

[For] the process that the new staff member will go through, and the documentation — at any point, do you consider having a checklist also, to document that everything has been met before the staff member begins [euthanasia]?

37:42 Committee Member

During that annual performance review — even for employees who have been [doing euthanasia] for years — is there some place where they can express that they need additional training, [or that] they want a refresher [in this] workshop? Is there some place on that annual performance review that addresses that, and their ability to continue with that process?

38:30 Committee Member

The two forms that were incomplete, from pages 119 and 120, that didn’t have the “individual has demonstrated competency” check box — was that intentional on the part of Dr. [Laura Dover Luffman] — to say, no, these people are not competent?

39:29 Committee Member

[The history], I think, [points] pretty heavily, to my mind — would the annual performance review not be a great time to check and see if the person has this certification? Might that become part of the annual process?

42:27 Committee Member

Is it a paper document?

42:37 Committee Member

Do you have an example of what that would look like? Are you keeping all of those [controlled-substance] records together with the [controlled-substance] record, or are you keeping them separately — technically, [the] controlled [substance] is a separate [record]?

45:12 Committee Member

Okay. And then — so I see the record of [the drug] once received — I mean, it’s based on the invoice. Is there documentation on when those are being used and are taken out of the inventory? I’m just trying to process how the inventory works.

45:49 Committee Member

Then — after the bottle gets opened up, does it get short-dated, or does it just get kept until [used up]?

47:52 Committee Member

[The log] still does not include the name of the medication.

48:04 Committee Member

Does the [euthanasia] logbook still not indicate whether it was IV or IP administration?

48:20 Committee Member

I see on the new checklist that it does have a spot for the administration — IP and IV. So it’d be something you’d consider putting in the logbook as well.

49:04 Committee Member

August first, twenty twenty-five: one bottle [and a] half bottle of Fatal Plus, I’m guessing. And it says [it’s] under [the] old DEA number; and then on August 6th, 2025, it has the same thing, but under [a] new DEA number. So — was your old DEA number surrendered, or what’s going on with that?

49:45 Committee Member

I’m just not familiar enough to [understand] — did it expire and you weren’t able to [renew] the same number, or was there a reason to get a whole new number?

50:25 Committee Member

On the day it was expired — but then you got a new number, like, right away. So there was no day that you had an expired number? Okay. But still — nothing was used. Um, do you have [something] in the system to help prevent the [DEA] number from expiring in the future?

51:02 Committee Member

I was just noticing that the new protocol you provided, from January 2nd, 2025, is different than the previous protocols. For example, in the previous protocol from 2020, the primary sedative was [acepromazine], and there was [no] secondary sedative; but now a secondary sedative has been added, and [there are] other changes — like, the IV dosage for cats [increased] by one milliliter. I’m just curious — did you request these changes, and what was the rationale for doing them?

53:48 Committee Member

Do you admit, or do you deny — or would you like to [add] comments?

54:16 Committee Member

Just for my own clarity — which medication is being discussed on this page?

54:57 Committee Member

[This] is the inventory that you’ve got here — it has the Fatal Plus, the full bottles. On the next page — I guess, if someone opened up this book, would they see a continuous inventory of what was used and how much is left in each [bottle]?

55:22 Committee Member

I know on the front cover, like, it said [08-27-25], you [received] lot [number]… twenty-four bottles. But how do [we] know how many bottles [are left]? Is there something — is there a reconciliation, or a [running total]?

56:52 Committee Member

Just looking at the records — in the allegations, it says eighteen hundred animals euthanized in twenty twenty-three. I noticed that some of the records spilled over into January twenty twenty-four — like, for example, on page ninety-eight, some of those records are from January twenty twenty-four instead of all in twenty twenty-three. So [it’s] eighteen hundred animals in [a span of] more than thirteen months. Is that your average? Has it increased, or decreased?

58:53 Committee Member

I’m just wondering — are the numbers holding steady? Or, since [the recovery]…

1:00:54 Ling Yuan, Committee Chair

Uh, we’re not able to take questions from the public. I just saw, like, a hand being raised in the back, so I just wanted to clarify.

1:01:13 Ling Yuan, Committee Chair

I don’t believe we can take questions while we deliberate on the specific case. Since this case [is being decided], if you have very specific comments that you would like [to make] to the board, I [would] suggest that you [direct them] directly to the board, [in writing], and Mr. Egan can probably provide that email address.

1:01:40 Ling Yuan, Committee Chair

My apologies — it’s just the way the informal conference is structured; we do not allow comment from the public. Ms. Richards-Spruill, will you please [move us into closed session]?

1:01:57 Patricia Richards-Spruill, Board Member

Yes, Madam Chair. I move that the Special Conference Committee of the Board of Pharmacy convene a closed meeting pursuant to Section 2.2-3711(A)(27) of the Code of Virginia, for the purpose of deliberation to reach a decision in the matter of [the Danville Area Humane] Society. Additionally, I move that Mykl Egan, Ileita Redd, and Mary [Ann (sp?)] and Ellen Shinaberry attend [the] closed session, because [their] presence is deemed necessary and will aid the board in its deliberations.

1:02:30 Ling Yuan, Committee Chair

[I’ll] second the motion — and the motion carries. We are now in closed session. At this point, we would like you to gather your belongings and your companions [and wait at] the main entrance. We will call you back as soon as we finish.

~1:44 Ling Yuan, Committee Chair

The decision has been made by the committee to issue an order regarding your permit. Mr. Egan, the [Discipline] Case Manager, will read the findings of fact and conclusions of law regarding this matter. Please note that this information is going to be emailed to you.

~2:01 Mykl Egan, Board staff (reading the order)

Finding of Fact Number 1: On August 27, [1984], the Board issued controlled substances registration number 0220-0001882 [to the] Danville Area Humane Society, in the Commonwealth of Virginia, pursuant to [its] desire to operate as a humane society.

Finding of Fact Number 2: Danville Area Humane Society, Incorporated, violated Virginia Code §§ 54.1-3316(1), (2), (6) and (7) and § 54.1-3423(E) and 18 VAC 110-20-25 [of the] regulations governing the practice of pharmacy, [in that] the facility failed to maintain euthanasia records as required. Specifically, the supervising veterinarian['s] (Dr. Laura Dover Luffman) euthanasia protocol directed the facility to sedate animals with [acepromazine] as part of the [pre-]euthanasia [sedation]; the facility… failed to document the name and strength of the sedative drug administered in the euthanasia [logs], in violation of 18 VAC 110-20-25(B)(6) of the regulations.

~3:10 Mykl Egan, Board staff — disposition of each allegation

[The committee noted] that while [the sedative entries] were not [originally] included, [DAHS] had since created a card attempting to hold the necessary relevant information.

Allegation [B] — as written, with the addition of Ms. Hogan stating to the committee that the documentation did not [contain] the information but the matter was being corrected.

Allegation C — as written, with the addition of Ms. Dean stating to the committee that she believes the [competency check] boxes [were left unchecked] inadvertently; [as of] the last [time] checked, the staff has been retrained and the documentation has been updated.

Allegation D — as written, except: on D5, [regarding] the last inventory, Ms. [Hogan had not] finished the [annual inventory] but stated that the [reminder] for [conducting] inventories is currently on both her and Ms. Hogan’s calendar[s]; and D2, regarding the last [bottle] inventory, is [noted as] corrected.

~4:23 Ling Yuan, Committee Chair

May I have a motion regarding [the] Danville Area Humane Society?

~4:27 Patricia Richards-Spruill, Board Member

Yes, Madam Chair. I move to adopt the findings of fact and conclusions of law as read by Mykl Egan.

~4:35 Ling Yuan, Committee Chair

I second the motion, and the motion carries. May I have a motion as to the sanction in the matter of the Danville Area Humane Society?

~4:42 Patricia Richards-Spruill, Board Member

Yes, Madam Chair. I move to impose a monetary penalty of $500, and within one year of entry of the order, Danville Area Humane Society will be subject to one unannounced inspection of the facility at the cost of the facility.

~5:19 Ling Yuan, Committee Chair

Okay. You have heard [the decision] of the committee. A certified true copy of the order will be sent to you once the order is entered by the Board, which should be within the next two to three weeks. If you decide to appeal the order, the instructions for doing so will be contained in the cover letter as well as the order. As provided by law, this decision shall become a final order thirty (30) days after service of the order, unless you provide the Board with a written request for a formal hearing within the thirty-day timeframe. Upon your request for a formal hearing, the decision of this committee shall be vacated. This concludes today’s informal conference. Mr. Egan will walk out with you and answer any questions you may have.