College of Nurses of Ontario v. Julie Salkeld, 2024 ONCNO 139299

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Michael Hogard, RPN Chairperson

Tyler Hands, RN Member

Sherry Szucsko-Bedard, RN Member

Sandra Larmour Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) JEFFREY FEINER for

) College of Nurses of Ontario

• and - )

JULIE SALKELD ) NO REPRESENTATION for

Registration No. 06289018 ) Julie Salkeld

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: June 17, 2024, via videoconference

DECISION AND REASONS

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on June 17, 2024.

The Allegations

The allegations against Julie Salkeld (the “Member”) as stated in the Notice of Hearing dated February 2, 2024, are as follows:

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, during your employment at Ontario Shores Centre for Mental Health Sciences (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, and in particular, in or around 2011-2017, you submitted false claims under the Facility’s employee group benefit plan (the “Benefit Plan”).

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(8) of Ontario Regulation 799/93, in that, during your employment at the Facility, you misappropriated property from a client or workplace, and in particular, in or around 2011-2017, you submitted false claims under the Benefit Plan.

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(15) of Ontario Regulation 799/93, in that, during your employment at the Facility, you signed, in your professional capacity, a document that you knew or ought to have known contained a false or misleading statement, and in particular, in or around 2011-2017, you submitted false claims under the Benefit Plan.

4. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(28) of Ontario Regulation 799/93, in that, during your employment at the Facility, you submitted an account or charge for services that you knew was false or misleading, and in particular, in or around 2011-2017, you submitted false claims under the Benefit Plan.

5. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, during your employment at the Facility, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, and in particular, in or around 2011-2017, you submitted false claims under the Benefit Plan.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1, #2, #3, #4 and #5 in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admissions were voluntary, informed and unequivocal.

Agreed Statement of Facts

College Counsel and the Member advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited and without exhibits mentioned therein, as follows:

THE MEMBER

1. Julie Salkeld (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) in the General Class on September 1, 2006.

2. The Member was employed at Ontario Shores Centre for Mental Health Sciences (“Ontario Shores” or the “Facility”), located in Whitby, Ontario, from July 4, 2006 until May 18, 2017.

3. The Member’s employment with Ontario Shores was terminated on May 18, 2017. Since June 7, 2013, the Member was not working in an RN role but performed an administrative role at the Facility.

4. The Member is currently working as an RN in a managerial role with Saint Elizabeth Health, where she has worked since 2018.

BENEFIT PLAN

5. The Facility offers its employees a self-insured group insurance policy by which Ontario Shores provides coverage to employees for extended health care, dental and other insurance benefits (the “Benefit Plan”). Sun Life Financial “(Sun Life”) administered the Benefit Plan on behalf of the Facility. The Facility, however, was the plan sponsor for the Benefit Plan, and therefore funded the cost of claims paid out to employees under the plan.

6. To submit a benefit claim at the relevant time, members of the Benefit Plan were required to complete a medical expense claim form provided by Sun Life or accessed through its online portal. To make a claim online, a plan member was required to provide certain information, including information on the plan member, any dependents for whom a claim was made, the nature of the claim, including the service provider and the service date, and the total amount claimed for each service. To complete the claim, the plan member was required to certify that all goods or services being claimed were received and that the information provided in support of the claim was “true and complete”.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

7. Between March 5, 2011 and October 29, 2015, the Member had submitted claims using the online portal totalling $7,620.26 on behalf of herself and her dependants for services that were never provided. This includes amounts claimed for prescription drugs, physiotherapy, and chiropractic services. Of this amount, a total of $3,469.90 was paid to the Member.

8. In 2015, Sun Life selected a claim submitted by the Member for quality review and noted that certain services claimed for were not provided. Sun Life continued its investigation in 2017 by contacting various service providers on the Member’s claims. On March 8, 2017, Sun Life sent heath claims verification letters to the service providers with a chart listing the various medical services that the Member claimed that she or her dependants had received. Five service providers responded that that they did not provide the services as claimed by the Member.

9. Sun Life advised the Facility of the conclusions of its investigation. The Facility informed the Member that this behaviour constituted theft, which resulted in her termination.

10. The Member acknowledges that it was her responsibility to ensure that the claims submitted to the Benefit Plan were accurate and made in respect of the services that she and/or her dependents actually received. The Member acknowledges that she submitted claims that were false and/or improper. The Member expresses her deep remorse and assures the Discipline Committee that she has learned from these events and that she will not engage in any such conduct in the future. The Member accepts responsibility for her actions.

11. On June 14, 2024, the Member made restitution to the Facility, paying back $3,469.90, representing the total amount that was paid to the Member in respect of services that were never provided.

CNO STANDARDS

Professional Standards

12. CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.

13. CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

14. CNO’s Professional Standards provides, in relation to the leadership standard, that leadership requires self-knowledge (understanding one’s beliefs and values and being aware of how one’s behaviour affects others), respect, trust, integrity, shared vision, learning, participation, good communication techniques and the ability to be a change facilitator. The leadership expectation is not limited to nurses in formal leadership positions and all nurses, regardless of their position, have opportunities for leadership. Nurses demonstrate this standard by actions such as role-modelling professional values, beliefs and attributes.

15. Attached as Exhibits “A”, “B”, and “C” are copies of CNO’s Professional Standards that were in force at the time of the incidents and have since been retired.

Ethics

16. CNO’s Ethics Standard describes ethical values that are important to the nursing profession in Ontario including patient well-being, patient choice, privacy and confidentiality, respect for life, maintaining commitments, truthfulness and fairness.

17. CNO’s Ethics Standard provides, in relation to maintaining commitments, that nurses have a commitment to the nursing profession and being a member of the profession brings with it the respect and trust of the public. To continue to deserve this respect, nurses have a duty to uphold the standards of the profession, conduct themselves in a manner that reflects well on the profession, and to participate in and promote the growth of the profession.

18. CNO’s Ethics Standard also provides, in relation to truthfulness, that truthfulness means speaking and acting without intending to deceive.

19. Attached as Exhibit “D” is a copy of the CNO Ethics Standard that was in force at the time of the incidents and has since been retired.

20. The Member admits and acknowledges that she contravened CNO’s Professional Standards and Ethics Standard.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

21. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 5 to 11 and 12 to 20 above.

22. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing in that she misappropriated property from a workplace, as described in paragraphs 5 to 11 above.

23. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing in that she falsified a record relating to her practice, as described in paragraphs 5 to 11 above.

24. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing in that she signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement, as described in paragraphs 5 to 11 above.

25. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 5 of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 5 to 11 and 12 to 20 above.

College Counsel's Submissions on Liability

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations as set out in paragraphs 21 - 25 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to the allegations in the Notice of Hearing. College Counsel submitted that the Panel has taken the Member’s plea, conducted a verbal plea inquiry, and received a written plea inquiry which confirmed that the plea was voluntary and informed.

Member’s Submissions on Liability

The Member submitted that she agreed with College Counsel.

Decision

The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.

Having considered the evidence, the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs #1, #2, #3, #4 and #5 of the Notice of Hearing. As to allegation #5, the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.

Allegation #1 in the Notice of Hearing is supported by paragraphs 5 - 11 and 12 - 21 in the Agreed Statement of Facts. The Member admitted to submitting false claims through the Ontario Shores Centre for Mental Health Sciences (the “Facility”) employee group benefit plan (the “Benefit Plan”) between 2011 and 2015, using the online portal totalling $7,620.26 on behalf of herself and her dependants for services that were never provided. The Member received $3,469.90 in relation to those false claims for prescription drugs, physiotherapy and chiropractic services. The Member admitted that the claims she submitted were false and/or improper. The College’s Professional Standards documents that the leadership standard applies to all nurses regardless of their position and indicates that integrity is critical in demonstrating this standard. The Member did not demonstrate integrity and breached the Professional Standards when she purposely submitted false claims for her own benefit. The Member also failed to meet the College’s Ethics Standard when she purposely deceived the Facility’s Benefit Plan by submitting false claims.

Allegation #2 in the Notice of Hearing is supported by paragraphs 5 - 11 and 22 in the Agreed Statement of Facts. The Member admitted to misappropriating property from the Facility when she submitted false claims through the Facility’s Benefit Plan and received money for those false claims. In 2017, Sun Life Financial (“Sun Life”), which administered the Benefit Plan on behalf of the Facility, investigated the claims submitted by the Member and reached out to various service providers the Member documented in her claims’ submissions. Five of the service providers informed Sun Life that they did not provide services to the Member as claimed. By submitting false claims and being financially reimbursed for them, the Member misappropriated property from the Facility’s Benefit Plan in the amount of $3,469.90 between 2011 and 2015.

Allegations #3 and #4 in the Notice of Hearing are supported by paragraphs 5 - 11, 23 and 24 in the Agreed Statement of Facts. The Member committed professional misconduct when she falsified records relating to her practice and signed in her professional capacity, documents that she knew or ought to have known contained false or misleading information and submitted those documents to the Facility’s Benefit Plan. The Member submitted claims through an online portal where she would have had to sign in and had to certify that all goods or services being claimed were received and that the information provided in support of the claim was “true and complete”. The Member admitted to submitting false claims and so she knew the forms contained false information before she confirmed they were “true and complete”. The Member had access to the Benefit Plan by virtue of her employment at the Facility as a Registered Nurse (“RN”) and so her actions were related to her practice as a nurse. Accordingly, the facts support the allegations that the Member signed in her professional capacity, documents that she knew contained false information and falsified and submitted records relating to her practice as she signed and submitted the false claim forms in the context of her employment as an RN at the Facility.

Allegation #5 in the Notice of Hearing is supported by paragraphs 5 - 11, 12 - 20 and 25 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in submitting false benefit claims was clearly relevant to the practice of nursing. A nurse is expected to uphold respect, trust and integrity. The Member’s conduct in submitting false claims multiple times over four years was unprofessional, as it demonstrated a serious and persistent disregard for her professional obligations in breaching the Professional Standards and the Ethics Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit through falsifying records and submitting false benefit claims to the Facility’s Benefit Plan. The Member also knew or ought to have known that her behaviour was unacceptable and fell below the standards of a professional.

Penalty

College Counsel and the Member advised that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. Directing the Executive Director to suspend the Member’s certificate of registration for 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.

3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;

ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):

1. Code of Conduct;

iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;

v. The subject of the sessions with the Expert will include:

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. the development of a learning plan in collaboration with the Expert;

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into the Member’s behaviour;

vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;

b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:

i. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;

ii. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

iii. Provide the Member’s employer(s) with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:

1. that they received a copy of the required documents, and

2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

3. All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

College Submissions on Penalty

College Counsel made submissions which included the following:

The aggravating factors in this case were:

• The Member’s conduct demonstrated serious and persistent dishonesty over a period of four years, at the expense of the Facility’s Benefit Plan;

• The value of the false claims the Member made was significant at $7,620.26 for which she received $3,469.90 in return for those false claims; and

• The Member breached the trust of the Facility’s Benefit Plan and the public.

The mitigating factors in this case were:

• The Member accepted full responsibility for her conduct by admitting to all the allegations and entering into an Agreed Statement of Facts and a Joint Submission on Order with the College;

• The Member is remorseful and indicated that she would never again conduct herself in this way;

• The Member has no prior discipline history with the College; and

• The Member made full restitution.

The proposed penalty provides for specific deterrence through:

• The oral reprimand; and

• The 3-month suspension of the Member’s certificate of registration.

The proposed penalty provides for general deterrence through:

• The 3-month suspension of the Member’s certificate of registration.

The suspension will send a clear message to the other members of the profession that this conduct will not be tolerated.

The proposed penalty provides for remediation and rehabilitation through:

• The terms, conditions and limitations imposed upon the Member, including two meetings with a Regulatory Expert and review of the various College publications, which will help prepare the Member to return to an ethical practice that will meet the expectations of practice.

Overall, the public is protected by the 12 months of employer notification, which will ensure the Member’s employer is aware of the misconduct and will provide oversight of the Member and her practice.

College Counsel submitted that the Member’s conduct was serious, and in turn required a serious penalty to demonstrate that the nursing profession can govern itself.

College Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:

CNO v. Bartolome (Discipline Committee, 2023): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member committed an act of professional misconduct when he submitted false claims to the facility’s benefit plan and received $2,000.00 in relation to those false claims. The member paid restitution. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Soosaipillai (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member committed an act of professional misconduct when she submitted false benefit claims over a period of two years and received $2,150.00 in relation to those false claims. The member remained employed within the facility but received a five-day unpaid suspension and entered into a payment agreement with the facility requiring the member to pay back the amount received. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Lee (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member committed an act of professional misconduct when she submitted false claims to the facility’s benefit plan and received $2,315.00 in relation to those false claims. The member received a five-day unpaid suspension and entered into a payment agreement with the facility requiring the member to pay back the amount received. The penalty included an oral reprimand, a 3-month suspension of the member's certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.

Member’s Submissions on Penalty

The Member indicated she agreed with the Joint Submission on Order and made no further submissions.

Penalty Decision

The Panel accepted the Joint Submission on Order and made the order requested.

Reasons for Penalty Decision

There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.

The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.

The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.

The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.

The proposed penalty provides for specific deterrence through the oral reprimand and the 3-month suspension of the Member’s certificate of registration, which will send a clear message to the Member that benefit fraud will not be tolerated.

The proposed penalty provides for general deterrence through the 3-month suspension of the Member’s certificate, which will demonstrate to the profession that employee benefit fraud will not be tolerated.

The proposed penalty provides for rehabilitation and remediation through the two meetings with a Regulatory Expert and the associated review of the standards.

Overall, the 12 months of employer notification and monitoring period will ensure that the public is protected.

The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.

The penalty is in line with the range of what has been ordered in previous similar cases as demonstrated by the cases submitted and referred to by College Counsel.

I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.