PREMISES INSPECTION COMMITTEE REPORT Dr.

Wee-Lim Sim Medical Practice Level 2 Ottawa, Ontario Following a review of the inspection-assessment report and submissions from Dr. WeeLim Sim Medical Practice, the Premises Inspection Committee affirms the decision of the outcome of the inspection to be a FAIL. At this time neither you nor any other physician is permitted to perform any OHP procedures at Dr. Wee-Lim Sim Medical Practice. The Fail outcome will remain so unless and until the Premises receives a Pass or Pass with Conditions, and conditions have been addressed. You may continue patient consultations for OHP procedures at the Premises. This decision does not affect your non-OHP practice. The Committee directed that your premises would be assessed as a level 2 OHP. Therefore, you are not permitted to perform any therapeutic abortions as you do not use the minimum expected standard of a Paracervical block for these procedures. In addition, your premises does not meet the level 2 requirements as outlined in the inspectionassessment report. Once all outstanding conditions identified in the inspection-assessments report have been corrected and brought to a level 2 standard, including providing receipts for all purchased items, the premises will be reinspected to see whether the premises can receive a Pass or Pass with Conditions rating. The Committee confirms that insertions/removals of IUDs are procedures that do not fall under the jurisdiction of OHP. The reasons for the fail result are as follows:

QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605

1. As per Out-of-Hospital Premises 3.3. OHP Responsibilities, the OHP must provide a policy and procedure (P&P) manual. The premises is recommended to provide policies and procedures for the following areas: 6.1. Administrative c ) Scope and limitations of practice to include age of patients seen on the premises. 6.2 Job Descriptions a) Job Descriptions that define scope and limitations of functions and responsibilities for patient care including the role of the physician assistant. 6.3 Procedures: i) Combustible and Volatile Materials ii) Delegation of Controlled Acts iii) Infection Control - sterilization of instruments including use of internal, external and biological indicators - cleaning of the procedure room between patients and terminal cleaning - cleaning protocols for housekeeping staff iv) Medication handling and inventory v) Medical Directives vi) Patient Booking Systems vii) Response to Latex Allergies viii) Safety precautions regarding electrical, mechanical, fire and internal disaster ix) Garbage Disposal 2. As per Out-of-Hospital Premises Standards, 4.1. General Physical Standards, it is recommended that the premises a) comply with all fire code regulations including having a fire extinguisher and a fire plan in place. It is also recommended to provide evidence that the premises conforms to local fire codes. b) have an emergency power supply that can provide for safely completing the procedure and recovering the patient. c) have a stretcher, wheelchair or other adequate method of emergency transport.

3. As per Out-of-Hospital Premises Standards, 4.2 Procedure Room/Operating Room Physical Standards, it is recommended for the premises to:
QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605

a) ensure that floors and walls are uncluttered so that they can be cleaned. b) have accessibility for the disabled. c) ensure space to allow the physician to move around the OR/procedure table with access to both sides of the patient without contamination. d) provide suction equipment and back-up suction equipment. e) provide oxygen saturation equipment. f) ensure that there is no loose wiring in the reception area ceiling. g) provide a second supply of oxygen (normally a spare cylinder)with a pressure gauge, regulator and wrench available (note currently no oxygen is on the premises). h) provided biotechnician reports that the suction aspirator and sterilizer have been maintained and inspected regularly for functionality. Equipment operating manuals, maintenance contracts and a log for maintenance of all medical devices must be provided. 4. As per Out-of-Hospital Premises Standards 4.4.1 General Medication Standards, it is recommended to have a general medication inventory record. 5. As per Out-of-Hospital Premises Standards 4.4.2 Controlled Substances Standards, it is recommended that: a) controlled substances be counted by two qualified staff (RN, RPN with medications, Physician) b) controlled substances are locked in a designated cabinet. 6. As per Out-of-Hospital Premises Standards 4.4.3.1. Equipment for Monitoring and Resuscitation, it is recommended to have the following equipment: a) Cardiopulmonary resuscitation equipment with current ACLS/PALS-compatible defibrillator b) ECG monitor c) Intubation tray with a variety of appropriately sized blades, endotracheal tubes, and oral airways (#3 oral) airway is on premises d) Laryngeal mask airways e) Means of giving manual positive pressure ventilation (e.g., manual self-inflating resuscitation device) f) Means to verify end-tidal CO2 g) Oxygen source h) Pulse oximeter i) Suction with rigid suction catheter j) Torso backboard
QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605

7. As per Out-of-Hospital Premises Standards 4.4.3.2 Drugs for Resuscitation, it is recommended to have the following on the premises: Oxygen Salbutomol Amiodarone IV Antihypertensive IV (at least one of Labetalol, Hydralazine ASA 81mg po Atropine IV Benzodiazepine IV (at least one of: Midazolam, Diazepam, Lorazepam) BETA Blocker IV (at least one of Metoprolol, Propranolol, Esmolol) Calcium IV (chloride or gluconate) Dextrose 50% IV Flumazinil IV IV agent for SVT (at least one of Adnesosine, Esmolol, Verapamil) Morphine IV Naloxone IV Nitroglycerin Spray Sodium Bicarbonate IV

8. As per Out-of-Hospital Premises Standards 6.2: Intra-procedure Patient Care for Sedation, Regional Anesthesia, or General Anesthesia, it is recommended that if the physician is administering sedation or regional anesthesia is also performing the procedure, the patient must be attended by a second individual: l (physician, RN, other RHP) (1) who is not assisting in the procedure and (2) who is trained to monitor patients undergoing sedation or regional anesthesia. The second individual shall hold ACLS certification and the following skills: 1) assessing and maintaining the patients airway 2) monitoring vital signs 3) venipuncture 4) administering medications as required 5) assisting in emergency procedure including the use of a bagvalve-mask device 6) documenting in the Anesthesia/Sedation Record Also, 6.2.3. Patient shall have O2 saturation, pulse, blood pressure and electrocardiography continuously during the duration of anesthetic
QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605

care. Heart rate and blood pressure shall be documented at least every 5 minutes. The audible and visual alarms must not be disabled and the variable pitch pulse tone and the low-threshold alarm for the pulse oximeter must give an audible and visual alarm. It is recommended that the premises use intraprocedure monitoring for procedures using sedation or regional blocks. 9. As per Out-of-Hospital Premises Standards 7.0 Infection Control, it is recommended for the premises to: i) use external indicators and biological indicators (daily) when using the sterilizer. (Currently internal indicators are used and recorded.) ii) provide alcohol based sanitizer in the reception area and in other areas of the clinic to ensure hand hygiene practices are followed iii) review the current housekeeping protocols used at the premises and develop routine cleaning practices iv) provide Material Safety Data Sheets for all chemicals used on the premises v) remove hollow bore needles on the premises and replace with safety engineered devices vi) provide infection control signs at entry and at reception desk, alcohol based hand sanitizer at Reception

10. As per Out-of-Hospital Premises Standards 3.3 OHP Responsibilities: The premises must establish and maintain patient records that are accurate, legible, complete, follow a consistent format and meet legislative requirements. It is recommended that the premises review and improve the process of patient record keeping and documentation. 11. As per Out-of-Hospital Premises Standards 6.1.3. Verification, it is recommended that the premises to develop a Verification Process, to include 6.1.3.2 First Verification and 6.1.3.3 Second Verification with a time-out for all procedures. 12. As per Out-of-Hospital Premises Standards 8.0 Quality Assurance. It is recommended for the premises to develop their quality assurance program. There is a policy and procedure on Quality Assurance, no evidence of a quality assurance program was provided.

QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605

13. As per Out-of-Hospital Standards 5.0 OHP Staff Qualifications. All staff who administer regional anesthesia (which is the expectation for the procedures performed at this OHP) or who monitor or recover such patients, must maintain PALS and must be trained to handle paediatric emergencies if services are provided to children. 14. As per Out-of-Hospital Standards 3.1 OHP Levels. Therapaeutic abortion requires a minimum expectation that a paracervical block will be employed, which is a form of regional anesthesia and would therefore make this premises a level 2.

QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST 80 College Street, Toronto, Ontario M5G 2E2 Tel: (416) 967-2600 Toll Free: (800) 268-7096 Fax: (416) 967-2605