Archive of Previous IPAC Investigations (investigations older than 12 months)

This page contains reports on premises where an infection prevention and control lapse was identified through the assessment of a complaint or referral, or through communicable disease surveillance. It does not include reports of premises which were investigated following a complaint or referral where no infection prevention and control lapse was ultimately identified.

These reports are not exhaustive and do not guarantee that those premises listed and not listed are free of infection prevention and control lapses. Identification of lapses is based on assessment and investigation of a premises at a point-in-time, and these assessments and investigations are triggered when potential infection prevention and control lapses are brought to the attention of the local medical officer of health.

Reports are posted on the website of the board of health in which the premises is located. Reports are posted on a premises-by-premises basis, i.e., will correspond with one site only. Should you have questions about any posted lapse, please contact the Control of Infectious Diseases/Infection Control Program at 416-338-8400.

Initial Report

Premise/facility under investigation (name and address)  Dr. Katherine Chu

200-1371 Neilson Road.

Toronto, ON.  M1B 4Z8

Type of premise/facility: (E.g. clinic, personal services setting) Obstetrics and Gynecology office
Date Board of Health became aware of  IPAC lapse
Date of Initial Report posting  August 25, 2021
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  1. No quality assurance reprocessing logs for the “sterilizer”
  2. No reprocessing quality assurance with Biological Indicators or a minimum of Class 4 Chemical Indicator strips
  3. The “sterilizer” was not challenged using a Process Challenge Device
  4. No dedicated reprocessing area; all reprocessing actions were performed in a patient exam room used for patient exams
  5. The “sterilizer” is kept in a patient recovery room
  6. Sterilized packages were not labelled as per best practices
  7. Speculums were reprocessed unpackaged and thereafter being stored without packaging in drawers
  8. No regular maintenance on the “sterilizer”; no manufacturer’s instructions for use (MIFU) noted on site
  9. No training on reprocessing and IPAC recorded for staff
  10. No IPAC or occupational health Policies and Procedures (P&P’s) available
  11. No documentation/log of COVID-19 screening including taking and recording of body temperature
  12. Multi-use ultra-sound gel tubes are being used
  13. Vitamins for patients stored in open shelving in hallways
  14. No emergency eye-wash station noted in the clinic (This is a Ministry of Labour requirement)
  15. Un-used equipment and furniture stored in the clinic
  16. Patient exam table has cracked upholstery,
  17. Biohazardous waste freezer is not labelled,
  18. No handwashing signs posted at sinks
  19. No Safety Data Sheets available onsite for products being used at the clinic
  20. Unpackaged Single-Use speculums noted in drawer
  21. Bleach and water mixture of unknown strength used for presoaking used instruments.
  22. Incorrect use of face mask which was not covering the nose
  23. Improper storage of sterile instruments, and
  24. Inadequate pre-cleaning and cleaning of multi-use instrument

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Regulatory College initiated referral to TPH
Were any corrective measures recommended and/or implemented?  Yes
Please provide further details/steps
  1. Surfaces, furnishings, equipment, and finishes are smooth, non-porous, seamless (where possible), and cleanable (e.g., no unfinished wood or cloth furnishings). Re-upholster the patient exam table in the patient exam room where the upholstery is cracked and open,
  2. Place signage on each fridge/freezer indicating the use: e. “staff fridge,” “medication fridge”, and “biohazardous waste”
  3. Multi-dose ultrasound gel tubes are to be replaced with single use doses of ultrasound gel
  4. Post handwashing signs at each sink,
  5. Single-use items are to be stored in its original packaging or stored in a closed/covered storage space such as a closed cupboard or drawer
  6. Medications/vitamins are to be stored in a closed cupboard in a space that is not easily accessible to patients and visitors
  7. Develop a policy and procedure for handling of blood and body fluids. This includes blood specimens obtained through venipuncture (e.g., platelet rich plasma for bone grafts) and biopsy specimens
  8. Develop written policies and procedures to prevent and manage injuries from sharp objects
  9. Develop procedures for cleaning each area of the setting; if cleaning is contracted out, ensure the cleaning contractor has procedures in place for cleaning each area of the setting
  10. Develop written procedure for immediate containment, cleaning, and disinfection of spills of blood and body fluids
  11. Develop a policy to prevent the transmission of blood-borne pathogens (i.e., hepatitis B, hepatitis C and HIV) that includes a staff immunization policy for hepatitis B vaccination and a record of documented immunity to hepatitis B by serology
  12. Develop blood-borne pathogen post-exposure management policy and procedure that incorporates staff worker education and facilitation of timely access to a medical assessment for appropriate post-exposure prophylaxis (PEP), if indicated (e.g., HIV PEP medications)
  13. Develop a policy, which includes a clear expectation that staff do not come into work when ill with symptoms of infection
  14. Staff members are immunized as recommended by the National Advisory Committee on Immunization (NACI). Keep a record for each staff and update annually,
  15. Develop a binder/file for Safety Data Sheets (SDS) for cleaning/disinfecting products being used at the clinic and ensure that the SDS are readily available and up to date
  16. Install eyewash station that meet Ministry of Labour (MOL) requirement
  17. Develop a policy that specifies the requirements for, and frequency of, education and training at regular intervals (e.g., orientation and continuing education), as well as competency assessment for all personnel involved in IPAC practices
  18. Develop a process for recording and reporting of attendance at staff education and training sessions
  19. All employees must complete “Public Health Ontario IPAC Core Competencies” course, and renew it annually. Keep a log of the names and dates
  20. As the clinic will be no longer reprocessing multiuse items, please ensure the following:
    1. Remove the “sterilizer” from this clinic once it has been challenged with BI and CI as directed by TPH and results have been reported
    2. Remove all reprocessing instruments and materials used during reprocessing i.e. sterilization pouches etc., from the clinic
    3. Remove all multi-use instruments from the clinic
    4. Develop written policy stating that clinic is to only use Single-Use Devices(SUDs), and
    5. Ensure appropriate supply of SUDs are available at the clinic
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 19, 2021 Verbal Order issued:

  1. Stop using the sterilizer, Pelton & Crane Validator 8 model AB (“sterilizer”), onsite at 200-1371 Neilson Road, Toronto, Ontario, M1B 4Z8, and,
  2. Stop using instruments that were reprocessed in this “sterilizer”, at this clinic or any other clinic

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information)
  • Patient notification conducted.
  • Policy and procedures to be developed.

Interim Report

Date of Interim Report posting: December 14, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
  • Sterilizer removed from clinic. Clinic will use single-use disposable devices and multi-use devices are reprocessed by a third party company.
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

Interim Report Comments

Any additional comments  (Do not include any personal information or personal health information)

Final Report

Date of Final Report posting: April 4, 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 March 31, 2022

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information)
  • Patient notification completed
  • Policy and procedures developed and reviewed

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8400

Initial Report

Premise/facility under investigation (name and address) Dr. Paul Adam:

600 Sherbourne Street, Suite 411
Toronto, Ontario
M4X 1W4

And

1371 Nielson Road, Suite 311
Toronto, Ontario
M1B 2Z8

Type of premise/facility: (E.g. clinic, personal services setting) Dermatology Clinic
Date Board of Health became aware of  IPAC lapse August 6, 2021
Date of Initial Report posting  August 17, 2021
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  • No reprocessing logs on site for the sterilizer or the ultrasonic cleaner
  • No Biological Indicator (BI) or Chemical indicator (CI) or Process Challenge Device (PCD) used in the sterilizer
  • No dedicated reprocessing area
  • Sterilized packages were not labelled appropriately
  • Re-use and reprocessing of single-use devices (SUDs) such as skin biopsy/punch instruments
  • No IPAC/occupational health policies and procedures on site
  • No training on reprocessing/IPAC provided to staff
  • No COVID-19 screening
  • Opened multi-dose vials not labelled properly
  • Expired medication and products on site
  • Inappropriate storage of sterile medical supplies
  • No eye-wash station
  • Cloth chairs in the examination room and the clinic waiting area

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented?
  1. Complete three consecutive Biological Indicator (BI) tests on the sterilizer on site.
  2. Monitor sterilizer appropriately and maintain logs. If sterilizer no longer used, to remove off site.
  3. Obtain manufacturing instructions for sterilizer and ultrasonic cleaner on site.
  4. Only reprocess multi-use instruments.
  5. Discard single-use items immediately after use.
  6. Where possible only use single-use vials and discard all opened vials.
  7. If using multi-dose vials, label appropriately when opened.
  8. Ensure there is a policy/procedure for the following:
    • General IPAC and Routine Practices (including use of Personal Protective Equipment, “PPE”);
    • General Occupational Health and Safety (including management of body fluid spills, staff immunizations, and staff exposure to chemicals/sharps );
    • Sharps Management (including use of Safety Engineered Needles);
    • Reprocessing (including quality assurance for reprocessing, packaging for sterilizing, and/or use of Single Use Devices);
    • Environmental Cleaning (including supplies storage, and management of chemicals); and
    • Initial and ongoing IPAC training for staff.
  1. Consult with Ministry of Labour regarding eyewash station.
  2. Ensure all staff members are trained in infection prevention and control (IPAC) as well as reprocessing procedures.
  3. Discard all expired medications, items, and products (lotions) from the clinic.
  4. Ensure all medications, instruments, and supplies items are stored in a manner to prevent contamination.
  5. Ensure paper towels are mounted at each sink.
  6. Ensure a sharps container is mounted at each point of use.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 10, 2021, Verbal Order issued:

  1. Stop using the sterilizer for reprocessing instruments located at 600 Sherbourne Street East, Unit 411, Toronto, Ontario M4X 1W4; and
  2. Do not use the reprocessed instruments.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information)

Interim Report

Date of Interim Report posting: November 8, 2021
Date any order(s) or directive(s) were issued to the owner/operator
Brief description of corrective measures taken
  • Three separate Biological Indicator (BI) tests in the sterilizer on site conducted and all three passed.
  • Sterilizer no longer used and has been removed from the clinic site.
  • All re-usable instruments have been opened and removed from the clinic site.
  • Only single-use disposable (SUD) medical equipment/devices are being used.
  • All medications, instruments, and supplies items are stored in a manner to prevent contamination.
  • Multi-dose vials are labelled appropriately.
  • An eyewash station has been installed.
Date all corrective measures were confirmed to have been completed August 27, 2021

Interim Report Comments

Any additional comments (Do not include any personal information or personal health information)
  • Patient notification conducted.
  • Clinic in process of completing policy and procedures and educational modules for employees.

Final Report

Date of Final Report posting December 13, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
All items have been corrected.
Brief description of corrective measures taken All items have been corrected which includes:

1) Policy and procedures have been updated.

2) All staff have been trained in infection prevention and control (IPAC) and reprocessing.

Date all corrective measures were confirmed to have been completed December 10, 2021

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information)

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Beecroft Sheppard Medical Clinic

48 Sheppard Ave West

Toronto, ON M2M 1M2

Type of premise/facility: (E.g. clinic, personal services setting) Walk-in medical clinic
Date Board of Health became aware of  IPAC lapse N/A
Date of Initial Report posting  March 18, 2021
Date of Initial Report update(s) (if applicable) March 4, 2021
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • Sterilizer onsite was used without Biological Indicators (BI) or Chemical Indicators (CI).
  • No sterilizer logs maintained.
  • No ultrasonic machine for cleaning instruments prior to sterilization.
  • Two patient exam tables had upholstery held together with tape.
  • All garbage cans onsite were open, without a lid.
  • Non safety-engineered needles in a box on top of the counter at the vaccine fridge.
  • Self-contained single use bags were not observed in the soap containers. All liquid hand soap containers are topped up.
  • No Occupational Health and Safety information/binders.
  • No written policy or procedures about IPAC and health and safety.
  • No eye wash station

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Physicians and Surgeon’s (CPSO) notified.
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Complete three separate Biological Indicator (BI) tests in the sterilizer onsite.
  • Remove the sterilizer from the clinic site.
  • Remove all re-usable instruments from the clinic site.
  • Only Single Use Disposable (SUD) Medical equipment/devices are to be used at this clinic.
  • Surfaces, furnishings, equipment and finishes are smooth, non-porous, seamless (where possible), and cleanable.  Patient exam tables that have taped upholstery are to be re-upholstered.
  • Liquid hand soap containers are labelled and not refilled or topped up.
  • Needles are safety engineered medical sharps (SEMS).
  • Safety Data Sheets (SDS) for cleaning/disinfecting products are readily available and up to date for staff reference.
  • All garbage cans are to have covered lids.
  • An eyewash station is to be within a  10 second walk from where chemical substances will be used/managed
  • All staff are to complete IPAC core competencies course annually
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) March 11, 2021 verbal order:

  1. Stop using the sterilizer for reprocessing instruments located at 48 Sheppard Ave West office.
  2. Open any reprocessed instruments.
  3. Do not use the reprocessed instruments.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: May 4, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Not applicable
Brief description of corrective measures taken Three separate Biological Indicator (BI) tests in the sterilizer onsite was conducted and all three tested negative

Stopped use of the sterilizer, and sterilizer has been removed from the clinic site.

All re-usable instruments have been opened and removed from the clinic site.

Only Single Use Disposable (SUD) Medical equipment/devices are being used.

Patient exam tables have been re-upholstered.

One time use, labelled, disposable liquid hand soap containers are being used.

Needles are safety engineered medical sharps (SEMS).

Safety Data Sheets (SDS) for cleaning/disinfecting products are available and up to date for staff reference.

All garbage cans have covered lids.

An eyewash plumbed station is to be within a 10 second walk from where chemical substances will be used/managed has been put in place.

Date all corrective measures were confirmed to have been completed  April 16, 2021

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) Not applicable

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Focus Medical
1881 Yonge Street, Suite 503
Toronto, Ontario
M4S 3C4
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse November 18, 2020
Date of Initial Report posting  November 26, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of multi-use medical instruments
  • inadequate quality assurance and documentation for reprocessing
  • inappropriate workflow in reprocessing area
  • staff not trained for reprocessing activities
  • no sharps management policy/procedure

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Immediately stop using the sterilizer and all services requiring multi-use instruments until permitted by Toronto Public Health (TPH) to resume.
  • Open reprocessed items and do not reprocess until permitted by TPH.
  • Record reprocessing activities in a  log book Reprocessing area to only be used for reprocessing, designated a reprocessing area and be appropriately organized, meeting the standards of a reprocessing area (e.g. clear flow from dirty to clean).
  • Staff to be trained on reprocessing.
  • Reprocessing policy and procedures to be readily available, and in the reprocessing area.
  • Sharps management policy and procedure to be available and staff to be trained on this policy and procedure.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) A Verbal Order was issued on November 19, 2020 to immediately stop the use of the sterilizer.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: January 5, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Verbal order was issued on November 19, 2020.
Brief description of corrective measures taken As of November 27, 2020, Toronto Public Health (TPH) verified that the clinic has complied with all recommendations. This includes:

  1. Clinic is challenging the sterilizer appropriately.
  2. All multi-use items were sterilized properly.
  3. There is a separate reprocessing area which has clear workflow from dirty to clean.
  4. Staff was trained formally on reprocessing activities.
  5. There is an appropriate sharps management policy and procedure.
Date all corrective measures were
confirmed to have been completed
November 27, 2020

Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) White Willow Dental
1940 Eglinton Ave. East, Suite 102
Toronto  M1L 4R1
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse November 12, 2020
Date of Initial Report posting  November 26, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • use of unsterilized instruments on eight dental patients
  • inadequate quality assurance and documentation for reprocessing

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college?  Yes
Were any corrective measures recommended and/or implemented?
  • remove two unused sterilizers from premises
  • open and reprocess all multi-use items
  • maintain appropriate logs of the sterilizer for each cycle including physical indicators, chemical indicators and biological indicators
  • maintain an appropriate log for the ultrasonic process and keep this documentation separate from the sterilization process log
  • all staff trained and frequently review reprocessing policy and procedures
  • all clinic staff to annually complete the online IPAC core competencies course available on the Public Health Ontario website
  • all clinic staff with reprocessing duties including the dentists to complete online IPAC reprocessing course available on the Public Health Ontario website
Please provide further details/steps
  • notification of eight exposed patients by Toronto Public Health to complete baseline testing for HBV, HCV, and HIV, and get assessed for post-exposure prophylaxis
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • Directions provided during onsite inspection on November 18, 2020.
  • Letter of recommendation emailed November 23, 2020.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Interim Report

Date of Interim Report posting: December 21, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Not applicable
Brief description of corrective measures taken
  • Two unused sterilizers removed from premises.
  • New log created for the sterilizer.
  • New and separate log created for the autoclave.
  • Designated process challenge device (PCD) used for every load.
  • Written policies and procedures that are an umbrella statement referring to Public Health Ontario (PHO) Best Practices documents.
  • All staff to begin the PHO Core Competency course; to be completed and logged for six-month re-inspection review by Toronto Public Health (TPH).
  • All staff completing reprocessing duties to begin PHO Reprocessing in the community course; to be completed and logged for six-month re-inspection review by TPH.
Date all corrective measures were 
confirmed to have been completed

Interim Report Comments

Any additional comments  (Do not include any personal information or personal health information) PHO courses to be started; completion in six months

 

Final Report

Date of Final Report posting: March 15, 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 PHO courses completed

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information)

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Birchmount Dental Group
2000 Eglinton Avenue E, #3H
Scarborough, ON, M1L2M6
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse February 12, 2020
Date of Initial Report posting  February 24, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical and critical instruments
  • inadequate one-way flow in the reprocessing area
  • inadequate re-qualification of sterilizers
  • inadequate storage of clean and sterilized instruments

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) Audit conducted by Toronto Public Health (TPH) on February 14, 2020.

Items to be addressed include:

  1. Ensure all semi-critical instruments are reprocessed as per manufacturer’s instructions for use (MIFUs), including quality assurance and its documentation.
  2. Perform sterilizer re-qualification for each sterilizer on-site and each cycle used as per MIFU.
  3. Ensure there is one-way flow from dirty to clean in the reprocessing room. This was corrected during inspection.
  4. Ensure hinged instruments are reprocessed in open and unlocked positions.
  5. Ensure clean and sterilized instruments are stored securely in a manner that prevents contamination. This was corrected during inspection.

Stop performing Immediate Use Steam Sterilization (also known as Flash Sterilization).

Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Not applicable

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: February 24, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Not applicable
Brief description of corrective measures taken As of February 20, 2020, TPH verified compliance with February 14, 2020 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed
February 20, 2020

Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Email address Danielle.Steinman@toronto.ca
Phone number 416-338-8400

 

Initial Report

Premise/facility under investigation (name and address) Scarborough Health Network Hospital – Centenary Site
2867 Ellesmere Road
Toronto, Ontario
M1E 4B9
Type of premise/facility: (E.g. clinic, personal services setting) Diagnostic imaging unit in hospital
Date Board of Health became aware of  IPAC lapse November 18, 2019
Date of Initial Report posting  February 14, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
  • noted that intravenous (IV) tubing for catscan (CT) contrast procedure was inappropriately set-up
  • possible that a section of single-use CT contrast tubing was not discarded immediately after use and that there may have been re-use of this section of tubing

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented?
  • Ensure single-use CT contrast tubing is discarded immediately after each use.
Please provide further details/steps
  • On-site visits conducted.
  • Ensure strict monitoring of trainees and new staff to ensure adherence to policies and procedures.
  • Ensure clear assignment of staff, and documentation of procedures.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Not applicable

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Warden Woods Medical Centre
99 Firvalley Court
Scarborough, ON M1L1P2
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse June 10, 2019
Date of Initial Report posting  February 13, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical instruments
  • inadequate management of multi-dose vials

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) Audit conducted by Toronto Public Health (TPH) on July 3, 2019 and July 10, 2019.

Items to be addressed include:

  1. Ensure all semi-critical instruments are reprocessed as per manufacturer’s instructions for use (MIFUs), including quality assurance and its documentation required related to high-level disinfection.
  2. Ensure there is one-way flow from clean to dirty in the reprocessing room.
  3. Dispose of open multi-dose vials according to MIFU.
  4. Make available appropriate personal protective equipment (PPE).
  5. Create Infection Prevention and Control (IPAC) policies/procedures based on current provincial best practices.
  6. Educate all staff on updated IPAC policies/procedures and reprocessing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) July 10, 2019 – Health Protection and Promotion Act (HPPA) Verbal Order was served.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: February 13, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
July 10, 2019 – Health Protection and Promotion Act (HPPA) Verbal Order was served.
Brief description of corrective measures taken As of January 28, 2020, TPH verified compliance with July 10, 2019 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed
January 28, 2020

Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

If you have any further questions, please contact:

Name Danielle R. Steinman
Title Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Email address Danielle.Steinman@toronto.ca
Phone number 416-338-8400

Initial Report

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

Any additional comments  (Do not include any personal information or personal health information)
Date of Interim Report posting: May 5, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Re-inspection was conducted on May 3, 2022. All identified infractions were corrected.
Date all corrective measures were
confirmed to have been completed
Re-inspection was conducted on May 3, 2022. All identified infractions were corrected.

Initial Report Comments

Any additional comments  (Do not include any personal information or personal health information)

Final Report

Date of Final 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

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information)

If you Have any Further Questions, Please Contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
Email cecilia.alterman@toronto.ca
Phone number 416-338-8065

 

Initial Report

Details

Premise/facility under investigation (name and address) Bathurst Walk-In Dental Centre

902 Bathurst Street,

Toronto, Ontario, M5R 3G3

Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse May 6, 2022
Date of Initial Report posting May 17,  2022
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  1. Inappropriate packaging of items to be sterilized.
  2. Incomplete quality assurance of the sterilization process.
  3. Improper reprocessing of devices with lumen.
  4. Inappropriate labelling of hazardous products.
  5. Lack of alcohol-based hand rub (ABHR) dispensers available in the reprocessing area.
  6. Inconsistent use of sharps containers.
  7. Inappropriate use of single use cleaning brushes.
  8. Improper storage of medications.
  9. Improper dispensing of multiuse products.

 

 

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. All items to be sterilized are packaged appropriately with internal chemical indicators and in a way that they are not overlapped.
  2. Process challenge device (PCD) and Internal Chemical Indicators (CI) must be consistently used.
  3. Manufacture instructions are followed for reprocessing of devices with lumen.
  4. Disinfectant products dispensed from the original container should be labeled as per WHMIS requirements.
  5. ABHR must be available in the reprocessing area.
  6. Sharps containers must be mounted in all point of care and reprocessing areas.
  7. Single use cleaning brushes for reprocessing must be discarded after each use.
  8. Store medications according to manufacturer’s direction.
  9. Dispense multiuse products in a manner to avoid contamination.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) May 16, 2022 – Letter of Recommendation with directions was sent to the operator.

 

Initial Report Comments

Details

Any Additional Comments  (Do not include any personal information or personal health information) Patient notification for one exposed patient was completed.

 

Initial Report

Results

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

 

Final Report

Results

Date of Final Report posting
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

 

If you have any further questions, please contact:

Cecilia Alterman
Manager, Control of Infectious Diseases/Infection Control
Cecilia.Alterman@toronto.ca
416-338-8065