PREMISES INSPECTION COMMITTEE REPORT Dr. C.

Farazli MD, FRCP (C ) – Level 2 Ottawa, Ontario Following a review of the inspection-assessment report and submissions from Dr. C. Farazli MD, FRCP (C ), 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 the Dr. C. Farazli MD, FRCP (C ) You may continue patient consultations at the Premises for OHP procedures. The Fail outcome will remain so unless and until the Premises receives a Pass or Pass with Conditions, and conditions have been addressed. This decision does not affect your non-OHP practice. The Committee reviewed your response as to how you intend to correct the deficiencies that were identified in your report. It is recommended that you first consult with an architect regarding the proposed re-design of your premises layout to ensure that you have the space to accommodate the necessary equipment and overall layout changes of your premises as you have indicated in your letter. As for the equipment purchased, the Committee will need to receive verification of the purchase order and receipts. The Committee acknowledges that you have registered for the ACLS course at the University of Ottawa. However, until you have received this ACLS training, you will not be permitted to perform procedures without another physician/anesthesiologist who has current ACLS training. In addition, it will be expected that there is also another individual with ACLS to monitor the patient. The Committee expects to receive a copy of your ACLS certification when completed. Furthermore, the Committee confirms that the RN in the procedure room should have the sole responsibility to monitor the patient during the procedure and not be responsible for any additional tasks.

The reasons for the fail result are as follows: 1. Pursuant to the OHP Standards 4.1- General Physical Standards
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

The premises is cramped and cluttered, especially in the procedure room. It would be quite difficult to transfer any of their patients out of the procedure room in the event of an emergency. 2. Pursuant to the OHP Standards- Procedure room 4.2.2 The reprocessing area (dirty area) and the Medivator are located in one corner of the procedure room. The technician uses the sink in the procedure room to clean scopes while the procedure is being performed and the air quality is questionable. According to the Standards, the technicians who work in the reprocessing room must be protected by proper PPE (Personal Protective Equipment). In this case, not only was the technician not wearing a mask herself, but also, the patient was exposed to potential toxic fumes inside the procedure room. 3. Pursuant to the OHP Standards 6.2 Intra-procedure Patient Care The noise from the Medivator is interfering with the ability to hear the audible sounds of the monitoring machine. 4. Pursuant to the OHP Standards 3.3 .6.3g Infection Control The premises is in the practice of reusing single-use items such as snares. Biopsy forceps may be reused but only if they are effectively decontaminated and sterilized using a proper sterilizer. They must follow all Infection Control and Sterilization Standards. Currently, the premises is attempting to sterilize them in the Medivator (however, it cannot be used as a surgical sterilizer). It is imperative that this practice be stopped immediately, because it is posing immediate potential harm to patients’ health using unsterilized instruments and it promotes the transmission of diseases. 5. Pursuant to the OHP Standards 6.2 intra-procedure Patient care The RN in the procedure room is ACLS certified, and there is also a technician present in the room who assists with the procedure. However, the RN is preoccupied with advancing the scope instead of monitoring the patient’s vital signs.

6. Pursuant to the OHP Standards 6.2 Intra-procedure Patient Care There is no intra-operative record noted, which means that the nurse is not recording vital signs during the procedures.
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7. Pursuant to the OHP Standards 6.1.3.2 First and second verifications are combined into one quick check while walking the patient into the procedure room and no proper documentation is noted. The NAC could not find a proper pre-operative check list in the patient's chart as well. 8. Pursuant to the OHP Standards 3.3 .6.3g Infection Control During the procedure the physician used the biopsy forceps to obtain a specimen. However, after she took the biopsy, she dipped the biopsy forceps in formalin to get rid of the specimen and then re-inserted the same forceps into the patient’s esophagus without first rinsing it in water. (Formaldehyde is known to be harmful to human health due to its carcinogenic properties.) This practice must be stopped immediately before causing more harm to the patients. All biopsy forceps must be properly sterilized, otherwise they must be disposable. 9. Pursuant to the OHP Standards 6.3 post–Procedure Patient Care There is a small recovery room – which tightly holds one examination bed and one recliner, within 3 feet of the procedure room. There was no suction machine and no oxygen available inside this room. In addition, there is no record of any postoperative recording being done on the patient’s vital signs. The RN was recovering the patient on the procedure table while the technician was cleaning the scope in this same small room post-operatively. The Medivator must be moved out of the procedure room. The cleaning of scopes should not be carried out inside the procedure room. 10. Pursuant to the OHP Standards 4.4 NAC noted a bottle of an out-dated enzymatic solution was among the other bottles of enzymatic solutions. 11. Pursuant to the OHP Standards 3.3.6.3 g Infection Control Both during and at the end of the procedure, there was gross cross-contamination occurring from the dirty scope. 12. Pursuant to the OHP Standards 3.3.6.3c Combustible and Volatile Materials Not only were five oxygen tanks containing a combustible material being stored in the procedure room about two feet away from the procedure table, but they were being stored without any visible method of securing them. These tanks should be moved to a storage area and secured through the use of a chain or using a crate. 13. Pursuant to the OHP Standards 4.1OHP Physical Standards
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

This premises does not have an Uninterrupted Power source, for use in the case of a power disruption. 14. Pursuant to the OHP Standards 4.1 Emergency Measures There are no fire exit signs and there is no evacuation floor plan visible for the patients. 15. Pursuant to the OHP Standards 3.3.6.3 g Infection Control The Medivator was being used improperly for a high-level disinfection of the scopes and for the sterilization of the instruments. Additional training is required. 16. Pursuant to the OHP Standards 3.3.6.3g Infection Control This premises is re-using all of its suction tips. The NAC was informed that they routinely rinse them out and sterilize them by using the Medivator. Suction tips cannot be sterilized adequately in the Medivator. This is an unsafe practice and it must be stopped immediately because suction tips cannot be thoroughly sterilized by the Medivator. They require gas sterilization or are considered disposable (single use). The current practice has great potential for transmitting disease from one patient to the others. 17. Pursuant to the OHP Standards 4.1Emeergency Measures Although they are located on the 6th floor of their office building, they do not have any suitable emergency transportation equipment to assist the removal of incapacitated patients from the clinic in the event of fire, or another emergency.

18. Pursuant to the OHP Standards 4.4.3 This premises does not have a proper crash cart, instead using a small lockable portable box containing emergency drugs. In addition, there are a number of level 2 emergency drugs missing. 19. Pursuant to the OHP Standards There was no torso board available, and the NAC was advised that they would flip
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

over a hard plastic dinner tray (currently sitting on a shelf holding supplies) to improvise. 20. Pursuant to the OHP Standards 4.2 Equipment The premises does not have a maintenance record for the Automatic External Defibrillator, with the reason being given that this is because it is new. 21. Pursuant to the OHP Standards 4.2 Equipment The premises does not provide any log or other evidence that it conducts any regular maintenance of its medical equipment. 22. Pursuant to the OHP Standards 3.3.6.3
The premises keeps the contaminated garbage from all of its previous cases under the procedure table.

23. Pursuant to the OHP Standards 3.3.6.3g Infection Control The premises conducts no proper cleaning between cases. 24. Pursuant to the OHP Standards 6.2 The physician is not ACLS certified although she is providing IV sedation to the patients. However, the RN who is also present in the room is ACLS certified. The physician did inform us that she has registered for the certification course.

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

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