Previous Infection Prevention & Control (IPAC) Investigations

See the Current IPAC Investigations

 

Below are listed Infection Prevention and Control (IPAC) investigations that are older than 12 months.

Initial Report Details
Premise/facility under investigation (name and address) Dental X

170 Rimrock Rd.

Unit # D/2

Toronto ON M3J3A6
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of IPAC lapse April 13, 2022
Date of Initial Report posting May 5, 2022
Date of Initial Report update(s) (if applicable) May 5, 2022
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  1. Inappropriate packaging of items to be sterilized.
  2. Inadequate labelling of sterilization packages.
  3. Inadequate storage of reprocessed instruments.
  4. Inappropriate space for reprocessing.
  5. Inconsistent record keeping of the sterilizer’s physical parameters.
  6. Incomplete quality assurance of the sterilization process.
  7. Sterilization was not maintained until the point of use.
  8. No plumbed eyewash station on site.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Dental Hygienist of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. All items to be sterilized are packaged appropriately in an unlocked and open position without overlapping.
  2. Sterilization packages are to be labelled with:
    1. Date of sterilization
    2. Load number
    3. Reprocessing personnel’s initials
  3. Multi-use sterilized brushes to be stored appropriately.
  4. There must be a designated enclosed area for reprocessing.
  5. Maintain logs of the sterilizer’s physical parameters for every cycle.
  6. Process challenge device (PCD) and Internal Chemical Indicators (CI) must be consistently used.
  7. All sterilized equipment must be stored in their sterile packages until the time of use.
    1. Install eyewash station that meets Ministry of Labour (MOL) requirement.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) April 20, 2022 – Letter of Recommendation with directions was sent to the operator.
Initial Report Comments Details
Any additional comments
Final Report Details
Date of Final Report posting: July 13, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) N/A
Brief description of corrective measures taken The 3-month IPAC re-inspection was conducted.

All IPAC infractions that were previously noted by TPH on initial visit, were observed to be in compliance.
Date all corrective measures were confirmed to have been completed July 13, 2022
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416 338-8400

Initial Report Details
Premise/facility under investigation (name and address) Dr. Leonard Jerome

737 Mount Pleasant Road

Toronto ON M4S2N4
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of IPAC lapse July 22, 2022
Date of Initial Report posting August 10 2022
Date of Initial Report update(s) (if applicable) August 10 2022
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  1. Inadequate labelling of sterilization packages.
  2. Inconsistent record keeping of the sterilizer’s physical parameters.
  3. Incomplete quality assurance of the sterilization process.
  4. Sterilization was not maintained until the point of use.
  5. Dental Unit Water Lines (DUWLs) were not maintained in a sanitary manner
  6. Single use devices were reprocessed.
  7. No policies or procedures on site.
  8. No staff education reported
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Royal College of Dental Surgeons of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. Sterilization packages are to be labelled with:
    1. Date of sterilization
    2. Load number
    3. Reprocessing personnel’s initials
  2. Reprocessing physical parameters must be maintained in a log for every cycle.
  3. The sterilizer must be challenged every day it is in use with a process challenge device (PCD) containing a test Biological Indicator. It must be incubated with and compared to a control BI each time.
  4. All sterilized equipment must be stored in their sterile packages until the point and time of use
  5. DUWLs must be cleaned and disinfected on a regular basis.
  6. All single use devices are to be disposed of after use, at point of care.
  7. Policies & Procedures are to be developed as per Public Health Ontario’s (PHO) Best Practices for the following:
    1. General infection prevention & control,
    2. Management of blood and body fluid spills/exposures,
    3. Prevention of blood-borne pathogens, including a policy for hepatitis B vaccination, a serology record of documented immunity to hepatitis B, and post-exposure to blood borne pathogens,
    4. Healthy workplace policy, which includes a clear expectation that staff do not come to work when ill,
    5. Immunization for staff, as recommended by National Advisory Committee on Immunization (NACI).
  8. All Policies and Procedures are to be updated & reviewed by all staff annually. A record of this is to be maintained on site with date and staff signatures.
  9. Staff are to complete the PHO IPAC Core Competencies course annually. A record of completion dates are to be maintained on site.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 2, 2022 – Verbal Order served.

August 5, 2022 – Letter of Recommendation with directions sent to owner.
Initial Report Comments Details
Any additional comments
Interim Reports Details
Date of Interim Report posting: August 8, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
  1. All sterilized packages appropriately labelled.
  2. Logbook maintained with all physical parameters.
  3. A process challenge device and a control BI used every day the sterilizer is in use.
  4. Sterilized equipment is stored in sterile packages until the time of use.
  5. DUWL’s cleaned and disinfected regularly.
  6. Single use devices disposed after each use.
Date all corrective measures were
confirmed to have been completed		 August 8 2022
Interim Report Comments Details
Any additional comments
Final Report Details
Date of Final Report posting: March 23, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken Corrective measures implemented.

IPAC Infractions identified from initial TPH audit, now observed to be in compliance.
Date all corrective measures were confirmed to have been completed March 23 2023
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416-338-8400

Initial Report Details
Premise/facility under investigation (name and address) Med-Health Laboratories

2050 Weston Road. Unit 109

Toronto, Ontario

M9N 1X4
Type of premise/facility: (e.g. clinic, personal services setting) Medical Laboratory & Phlebotomy Services
Date Board of Health became aware of IPAC lapse July 29, 2022
Date of Initial Report posting August 10, 2022
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Reprocessing and re-use of items that are deemed to be single use devices.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Medical Radiation and Imaging Technologists of Ontario (CMRITO)
Were any corrective measures recommended and/or implemented? Verbal order served on August 4, 2022

Letter of IPAC recommendations sent on August 17, 2022

Clinic to use disposable single use blood collection devices and tourniquets

Deliver service(s) using acceptable infection prevention and control (IPAC) practices as detailed above as corrective action required.

The following recommendations were provided by TPH at the time of the audit and provided in a letter of recommendation:

1) Clinic to use disposable Single Use Device tourniquets and blood collection devices,

2) Soap container must not be topped up, and

3) Alcohol Based Hand Rub (ABHR) must be available at point of care
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 4, 2022
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Final Report Details
Date of Final Report posting: November 17 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Corrective measures implemented.

IPAC Infractions identified from initial TPH audit, now observed to be in compliance.
Date all corrective measures were confirmed to have been completed November 10, 2022
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416 338-8400

Initial Report Details
Premise/facility under investigation (name and address) Metro Central Ultrasound & Echocardiography

27 Queen St East Toronto, ON. M5C 2M6
Type of premise/facility: (E.g. clinic, personal services setting) Ultrasound Clinic
Date Board of Health became aware of IPAC lapse June 17, 2022
Date of Initial Report posting July 11, 2022
Date of Initial Report update(s) (if applicable) July 11, 2022
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse Notified by Ministry of Health’s Independent Healthcare Facility Branch (IHF) that transvaginal ultrasound transducers (probes) were not cleaned and disinfected as per Public Health Ontario’s Best Practices for Reprocessing.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes: College of Physicians and Surgeons of Ontario (CPSO) and College of Medical Radiation and Imaging Technologists of Ontario (CMRITO)
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order on June 22, 2022

Letter of recommendation sent to owner June 24, 2022
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order made under authority of Section 13(7) of the HPPA on June 22, 2022:

  1. Stop providing any and all services and/or procedures that require multi-use medical devices that require reprocessing by either High Level Disinfectant (HLD) or sterilization, immediately until Toronto Public Health has authorized you to resume providing these services. This includes, but is not limited to, procedures such as Trans-vaginal Ultrasounds and sonohysterogram.
  2. Use only pre-packaged, sterile, single use devices in the services described in section 1 at Metro Central Ultrasound immediately, until Toronto Public Health has authorized you to resume providing service(s).
  3. Deliver service(s) using acceptable infection prevention and control practices as detailed above as corrective action required.

The following recommendations were provided by TPH at the time of the audit and provided in a letter of recommendation:

  1. Clinic to use disposable Single Use Device (SUD) instruments only, where required to be sterilized or high level disinfected (eg. Single use, pre-packaged vaginal specula, sterile, single use, pre-packaged clamps, etc.)
  2. Remove all instruments from the clinic requiring reprocessing.
  3. Until further notice from TPH, immediately cease use of the sterilizer Midmark M11 UltraClave and place a sign on the sterilizer that will be provided by TPH.
  4. Once TPH allows services to resume, Transvaginal ultrasound services (TVUS) to be conducted in rooms that contain appropriate hand hygiene set up with a sink with hot and cold running water, liquid soap, and paper towel. No TVUS to be provided in room(s) without adequate hand hygiene set up.
  5. Develop and implement a step-by-step procedure reprocessing transvaginal ultrasound probes (cleaning and disinfection and rinsing and storage). Develop and implement a procedure for HLD and reprocessing maintenance, which includes testing, monitoring, documentation, and maintenance of HLD. Prior to resuming reprocessing with the sterilizer, you must obtain approval from TPH as there are specific requirements for recommissioning and ongoing quality assurance for the sterilizer.
  6. A separate dedicated room must be designated for reprocessing of TVUS probes, complete with a sink with hot and cold running water, liquid soap, paper towel. There must also be a sink dedicated for hand hygiene. There must be ample counter space to enable adequate cleaning and disinfection of the probes and space for supplies/containers and soaking containers. This room is to be for cleaning and disinfecting purposes only; this room may not be shared space for any other purpose. This area must be labelled accordingly with signage (reprocessing sinks and handwashing sink) to ensure that the 2 sinks are used appropriately. Please refer to the Ministry of Labour requirements for occupational health and safety when using chemicals as there are requirements for emergency eyewash station(s).
  7. Use single use, pre-packaged sterile sheaths for TVUS, as per the Manufacturer’s instructions for use for TVUS probes. Do not use latex condoms or gloves as a replacement option.
  8. The use of multi-use ultrasound gel is not recommended as a best practice. However, if using multi-use lubricant gel bottles due to high volume use, the multi-use ultrasound gel container/tube/bottle is to be dated when opened, and not to be used past 30 days after opening.
  9. Policies & Procedures are to be developed as per Public Health Ontario’s (PHO) Best Practices for the following:
    1. General infection prevention & control,
    2.  Management of blood and body fluid spills/exposures,
    3. Prevention of blood-borne pathogens that includes a policy for hepatitis B vaccination and a record of documented immunity to hepatitis B by serology, post-exposure to blood borne pathogens,
    4. Healthy workplace policy, which includes a clear expectation that staff do not come to work when ill,
    5. Immunization for staff, as recommended by National Advisory Committee on Immunization (NACI).
  10. All Policies and Procedures are to be updated & reviewed by staff annually. A record of this is to be kept with date and staff signatures.
  11. Staff are to complete PHO IPAC Core Competencies course annually. A record of staff names and completion dates are to be kept.
Initial Report Comments Details
Any additional comments Ongoing consultation with Public Health Ontario to assess risk of transmission based on the information from the IHF and the clinic, as well as the observations at the clinic.
Interim Report Details
Date of Interim Report posting: July 13, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 11, 2022
Brief description of corrective measures taken
  1. Add to procedure for Transducer (probe) cleaning & disinfection:
    1. When to use test strips on High Level Disinfectant (HLD), what is a “pass” on the test strip (colour)
    2. When to change HLD fluid
  2. Add to Hepatitis B policy: staff to provide evidence of Hepatitis B immunity by serology

Owner/Operator updated Policy & Procedures
Date all corrective measures were
confirmed to have been completed		 July 11, 2022
Interim Report Comments Details
Any additional comments Toronto Public Health notified the Ministry of Health’s Independent Health Facilities (IHF) Branch that clinic is in compliance of Public Health Ontario’s Best Practices and that the Owner/clinic may resume intracavitary ultrasound services once IHF confirms date appointments and services for intracavitary ultrasound may begin.
Second Interim Report Details
Date of Second Interim Report posting July 18, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Second Interim Report Comments Details
Any additional comments Public Health Ontario consultation for risk assessment concluded. No follow up required for patient lookback or notification based on outcome of provincial consultation.
Final Report Details
Date of Final Report posting March 2, 2023
Date of any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Comments All IPAC infractions that were previously noted by TPH on initial visit, were observed to be in compliance.

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416-338-8400