Infection Prevention & Control (IPAC) Investigations

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.

Birchmount Dental Group (Initial & Final Report)

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

Scarborough Health Network Hospital - Centenary Site

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

Warden Woods Medical Centre (Initial & Final Report)

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: 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. Ensure there is one-way flow from clean to dirty in the reprocessing room. Dispose of open multi-dose vials according to MIFU. Make available appropriate personal protective equipment (PPE). Create Infection Prevention and Control (IPAC) policies/procedures based on current provincial best practices. 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

Fine Skin Care (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Fine Skin Care 28 Finch Ave West, Unit # 109 Toronto, ON M2N2G7
Type of premise/facility: (E.g. clinic, personal services setting)	Personal Services Setting
Date Board of Health became aware of IPAC lapse	December 3, 2019
Date of Initial Report posting	December 20, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	Plasma pen and hyaluronic pen observed on premises. Both devices are not currently authorized by Health Canada for use. Seven unpackaged micro-needling cartridges observed, not immediately discarded after opening/use into an approved sharps container. One loose open acupuncture-type needle observed, not immediately discarded after opening/use into an approved sharps container. Single–use plastic tips for HydraFacial procedure observed submerged in disinfectant, not discarded after use on one client as required. No approved sharps container observed on premises.

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?	No
If yes, was the issue referred to the regulatory college?	No
Were any corrective measures recommended and/or implemented?	Verbal Order under Section 13 of the HPPA was issued to the owner of the premises to immediately remove plasma pen and hyaluronic pen and all the supplies required to provide procedures using these devices from premises until further notice. All single-use items were discarded during inspection as required. Operator to obtain an approved sharps container and dispose of single-use sharps immediately after use.
Please provide further details/steps	Not applicable
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	December 3, 2019: Verbal Order issued.

Initial Report Comments

Any Additional Comments (Do not include any personal information or personal health information)	Operator was verbally ordered to remove the plasma pen from premises during complaint investigation in February 2019.

Final Report

Date of Final Report posting:	December 20, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	December 3, 2019: Verbal Order issued.
Brief description of corrective measures taken	Not applicable
Date all corrective measures were confirmed to have been completed	On December 9, 2019 the Premises was re-inspected and found to be in compliance with the current requirements under Ontario Regulation 136/18.

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

Metro Radiology Limited (also known as Bluewater Imaging) (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Metro Radiology Limited (also known as Bluewater Imaging) 950 Lawrence Ave W, Suite #203 Toronto, Ontario M6A 3B5
Type of premise/facility: (E.g. clinic, personal services setting)	Medical Diagnostic
Date Board of Health became aware of IPAC lapse	October 4, 2019
Date of Initial Report posting	December 4, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Referral from regulatory college
Summary Description of the IPAC Lapse	inadequate reprocessing of multi-use medical instruments/devices sterility not maintained until point of use inadequate storage of dirty and clean items inadequate reprocessing room flow

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?	Complaint was referred to Toronto Public Health (TPH) by the Regulatory College.
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	TPH Infection Prevention and Control (IPAC) Audit conducted on October 9, 2019. Reprocessing recommendations provided including ensuring manufacturer instructions for use (MIFU) are followed on all medical instruments/devices, all items are maintained sterile until point of use, dirty and cleaned items are stored in labelled containers, and the reprocessing room is designated and ensures a dirty to clean workflow. Only perform biopsies using a pre-packaged sterile, single use medical instrument/device.
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)	Biopsies requiring a multi-use medical instrument/device are currently not being used.

Final Report

Date of Final Report posting:	December 20, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	Not applicable
Brief description of corrective measures taken	IPAC recommendations provided on November 22, 2019 have been satisfied. Biopsies requiring a multi-use medical instrument/device are currently not being performed.
Date all corrective measures were confirmed to have been completed	December 12, 2019

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

Humber 27 Dental at 106 Humber College Blvd (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Humber 27 Dental 106 Humber College Blvd, Suite 206 Toronto, ON, M9V 4E4
Type of premise/facility: (E.g. clinic, personal services setting)	Dental clinic
Date Board of Health became aware of IPAC lapse	October 25, 2019
Date of Initial Report posting	November 11, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	inadequate quality assurance for the sterilizer and ultrasonic cleaner inadequate management of single-use devices sterilization not maintained until point-of-use

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	Toronto Public Health (TPH) Infection Prevention and Control (IPAC) Audit conducted on November 7, 2019. Reprocessing and IPAC recommendations provided to ensure quality assurance of sterilizers and the ultrasonic cleaner is maintained, ensure adequate management of single-use items, and to ensure items are maintained sterile until point of use.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	November 7, 2019 – Health Protection and Promotion Act (HPPA) Verbal Closure Order 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:	November 21, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	Not applicable
Brief description of corrective measures taken	Conducted re-inspection on November 13, 2019. TPH verified compliance with IPAC recommendations provided on November 7, 2019 audit.
Date all corrective measures were confirmed to have been completed	November 13th, 2019

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

Aphrodite Aesthetic Clinic (AAC) (Initial Report)

Initial Report

Premise/facility under investigation (name and address)	Aphrodite Aesthetic Clinic ( AAC) 3311 Bayview Ave, Unit # 101 Toronto, ON M2K 1G4
Type of premise/facility: (E.g. clinic, personal services setting)	Personal Services Setting
Date Board of Health became aware of IPAC lapse	August 13, 2019
Date of Initial Report posting	September 19, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	Unpackaged non-sterile surgical instruments (forceps, scissors, and a haemostat), and two comedone extractors with sharps points were observed with an inadequate method of sterilization at the premises and inappropriately stored. Two unpackaged non-sterile dermarollers were observed at the premises. Re-usable instruments such as eyelash extension tweezers, scissors and microblading hand pieces were not adequately reprocessed between clients. Unpackaged, single-use blades were not discarded into an approved sharps container immediately after use. An approved sharps container was not available on-site.

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?	On August 14, 2019 a Verbal Order under Section 13 of the Health Protection and Promotion Act was given to the owner of the premises to stop providing services that require the use of injections and sharps. All open items were discarded.
Please provide further details/steps	On August 17, 2019 the Premises was re-inspected. Charges were laid under Ontario Regulation 136/18 for failing to keep clients records and not having a sharps container on-site while providing invasive services.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	August 14, 2019 Verbal Order and on August 27, 2019 Written Order served.

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

Toronto Beauty Clinic (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Toronto Beauty Clinic 551 Wilson Heights Blvd Toronto, ON
Type of premise/facility: (E.g. clinic, personal services setting)	Personal Services Setting
Date Board of Health became aware of IPAC lapse	July 10, 2019
Date of Initial Report posting	September 4, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	partially used open syringes with unlicensed (Health Canada) cosmetic dermal fillers stored in the refrigerator expired vial of dysport tubes used for platelet rich plasma (PRP) service found without a manufacture name (unknown if Health Canada approved)

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?	On July 10, 2019, an inspection was conducted, Verbal Order under Section 13 of Health Protection and Promotion Act (HPPA) given to the owner to: Discard expired vial and unlicensed products. Discard and only to use cosmetic products licenced by Health Canada. Stop using PRP tubes until proven that they are licenced by Health Canada.
Please provide further details/steps	Not applicable
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	July 10, 2019, Verbal Order issued.

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:	September 4, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	On July 17, 2019 observed: a box with sterile needles and cannula that were purchased on-line with no lot number, unknown if Health Canada approved 9.5 per cent lidocaine observed with no drug identification number decanting prescription medication from a larger container into smaller containers
Brief description of corrective measures taken	On July 17, 2019, Verbal Order under Section 13 of HPPA given to the owner to: Only use items that are confirmed to be Health Canada approved. Discard and only use medications with a drug identification number. Stop decanting prescription medication and keep product in the original package.
Date all corrective measures were confirmed to have been completed	July 26, 2019 — Visited premises and confirmed items removed from premises.

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

Stars Beauty Salon (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Stars Beauty Salon 6055 Steeles Ave E C-129 Toronto, ON M1X 0A7
Type of premise/facility: (E.g. clinic, personal services setting)	Personal Services Setting
Date Board of Health became aware of IPAC lapse	July 4, 2019
Date of Initial Report posting	August 13, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	Re-use of styptic Alum Crystal

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?	No
If yes, was the issue referred to the regulatory college?	No
Were any corrective measures recommended and/or implemented?	July 5, 2019 inspection conducted. Verbal Order under Section 13 of the Health Protection and Promotion Act (HPPA) given to the owner to stop using Alum Crystal and discard it immediately. Maintain accidental exposure records as required.
Please provide further details/steps	July 10, 2019 re-inspection conducted. Charges laid under Ontario Regulation 136/18, paragraph-4 of subsection 14 (1) for failing to maintain accidental exposure records.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	July 5, 2019. Verbal Order under Section 13 of the HPPA.

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:	August 13, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	July 5, 2019. Verbal Order under Section 13 of the HPPA.
Brief description of corrective measures taken	See below
Date all corrective measures were confirmed to have been completed	Re-inspection conducted on July 10, 2019, and premises passed inspection.

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

Toronto Head and Neck Clinic (Initial Report)

Initial Report

Premise/facility under investigation (name and address)	Toronto Head and Neck Clinic 101-491 Eglinton Ave W Toronto, ON M5N 1A7
Type of premise/facility: (E.g. clinic, personal services setting)	Clinic
Date Board of Health became aware of IPAC lapse	November 21, 2018
Date of Initial Report posting	June 27, 2019
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 critical and semi-critical instruments inadequate reprocessing of nasopharyngeal scopes inadequate quality assurance and documentation for reprocessing inappropriate workflow in reprocessing area inconsistent disposal of expired medication

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?	No
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	Stop providing services requiring multi-use instruments and scopes until permitted by TPH to resume. Reprocess all scopes and semi-critical and critical instruments as per manufacturer’s instructions including reprocessing quality assurance. Provide adequate flow of instruments in reprocessing area from dirty to clean to sterile. Ensure occupational health and safety standards are met including available personal protective equipment and an eyewash station. Discard expired medication.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	Verbal Order served on November 23, 2018 Letter of Recommendations – December 19, 2018

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	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

Terminal Barber #2 (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Terminal Barber #2 150 Dundas Street West, Unit 105 Toronto, ON M5G 1C6
Type of premise/facility: (E.g. clinic, personal services setting)	Personal Services Setting
Date Board of Health became aware of IPAC lapse	February 14, 2019
Date of Initial Report posting	February 26, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	Re-use of styptic pencil on clients

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college?	No
If yes, was the issue referred to the regulatory college?	No
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	February 15, 2019 — Inspection conducted and operator advised not to use styptic pencil and item was removed.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	February 15, 2019

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 26, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	Not applicable
Brief description of corrective measures taken	Re-inspection conducted and premises passed inspection.
Date all corrective measures were confirmed to have been completed	February 19, 2019

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

New Family Medicine Network (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	New Family Medicine Network 1110 Sheppard Avenue, Unit 501 Toronto, ON, M2K 2W2
Type of premise/facility: (E.g. clinic, personal services setting)	Medical Clinic
Date Board of Health became aware of IPAC lapse	December 18, 2018
Date of Initial Report posting	January 10, 2019
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Complaint
Summary Description of the IPAC Lapse	inadequate reprocessing of critical and semi-critical instruments, quality assurance and documentation. improper management of multi-dose vials and single-patient devices insufficient personal protective equipment (PPE)

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?	Not applicable
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 December 20, 2018. Clinic management to test sterilizer for quality assurance, document results, and repackage and correctly reprocess all critical and semi-critical instruments prior to resuming procedures requiring re-usable sterile instruments at the clinic. Items to be addressed include: Dispose of open expired multi-dose vials according to Manufacturer’s Instructions for Use (MIFU). Make available appropriate PPE personal protective equipment (PPE). Ensure that patient devices (i.e. glucometers) are used according to MIFUs. Ensure chemicals (ultrasound gels and ABHR) are not topped up. Create Infection Prevention and Control (IPAC) policies/procedures based on current provincial best practices. 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)	December 20, 2018 – 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:	July 11, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	December 20, 2018 – HPPA Verbal Order
Brief description of corrective measures taken	As of July 8, 2019, TPH verified compliance with Dec 20, 2018 IPAC recommendations.
Date all corrective measures were confirmed to have been completed	July 8, 2019

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

Rejuuv Medi Spa (Initial & Final Report)

Initial Report

Premise/facility under investigation (name and address)	Rejuuv Medi Spa 200 – 5314 Yonge Street Toronto, ON, M2N 5P9
Type of premise/facility: (E.g. clinic, personal services setting)	Out of Hospital Premise and Medi Spa
Date Board of Health became aware of IPAC lapse	November 1, 2018
Date of Initial Report posting	November 28, 2018
Date of Initial Report update(s) (if applicable)	Not applicable
How the IPAC lapse was identified	Referral from regulatory college
Summary Description of the IPAC Lapse	inadequate reprocessing of critical and semi-critical instruments inadequate quality assurance and documentation for reprocessing insufficient counter space to handle volume of reprocessing work improper management of single-use devices (SUDs), multi-dose vials and syringes containing medication

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?	Not applicable
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	Toronto Public Health (TPH) Infection Prevention and Control (IPAC) Audit conducted on November 2, 2018 and November 5, 2018. Required actions: To address reprocessing requirements as part of the Health Protection and Promotion Act (HPPA) Verbal Order on November 2, 2018: Stop providing services requiring the use of reprocessed re-usable semi-critical and critical equipment. Stop reprocessing instruments in the sterilizer until notified by TPH to resume. Test sterilizer for quality assurance (three consecutive Biological Indicator (BI) passes), document results and report back to TPH. Once approved, to resume use of the sterilizer for reprocessing of instruments, repackage and correctly reprocess all critical and semi-critical instruments prior to resuming procedures requiring said instruments at the clinic. Reprocess and disinfect instruments and surfaces as per manufacturer’s instructions and Provincial Best Practices. Properly manage SUDs and multi-dose vials and syringes containing medication, including not pre-loading syringes, and disposal of open and expired multi-dose vials appropriately (corrected at time of visit). Provide adequate Personal Protective Equipment (PPE). Develop and educate staff on IPAC policies/procedures (General IPAC, Occupational Health, and Reprocessing) based on current Provincial Infectious Diseases Advisory Committee (PIDAC) and College of Physicians and Surgeons Ontario (CPSO) best practices. Dispose of waste in an appropriate manner.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	November 2, 2018 – Health Protection and Promotion Act (HPPA) Verbal Order was served. November 29, 2018 – Letter to medical director with additional recommendations

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:	July 10, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	November 2, 2018 – HPPA Verbal Order
Brief description of corrective measures taken	As of June 25, 2019, TPH verified compliance with Nov 2 and 14, 2018 IPAC recommendations.
Date all corrective measures were confirmed to have been completed	June 25, 2019

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

Marvin D. Obar, Dental Surgeon (Initial & Intermediate Report)

Initial Report

Premise/facility under investigation (name and address)	Marvin D. Obar, Dental Surgeon 2563 Eglinton Ave. West Toronto, ON M6M 1T3
Type of premise/facility: (E.g. clinic, personal services setting)	Dental Clinic
Date Board of Health became aware of IPAC lapse	July 31, 2018
Date of Initial Report posting	August 10, 2018
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 instruments inadequate quality assurance sterilization not maintained until point of use inadequate routine practices and personal protective equipment use

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 on July 31, 2018 and August 1, 2018. Health Promotion and Protection Act (HPPA) Verbal Closure Order served on July 31, 2018. Reprocessing and IPAC recommendations provided to ensure dentist can reprocess and maintain instruments as sterile until point of use, and adhere to appropriate routine practices and occupational health and safety requirements, including having up-to-date policies and procedures and training.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	July 31, 2018 – HPPA Verbal Closure Order was served. August 2, 2018 – Supplemental IPAC Form provided with Observations and Recommendations

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:	September 13, 2019
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	H.P.P.A. Section 13 Verbal Order served July 24th, 2019
Brief description of corrective measures taken	Quarantine all reprocessed instruments (including high-speed and slow-speed handpieces) prior to use, until quality assurance (QA) verified. If not able to quarantine instruments prior to QA verification, insert Integrator (Class V chemical indicator (CI)) into each sterilization package prior to sterilization. Class V CI to be checked prior to storing sterile instruments prior to use, and at point of use. Challenge sterilizer daily with a Process Challenge Device (PCD) for each day the sterilizer is in use, with a method appropriate for specified sterilizer. Ensure integrity of sterilized packages have not been compromised, prior to use.
Date all corrective measures were confirmed to have been completed	July 24, 2019

Interim 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