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

This website 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 Danielle Steinman at 416-338-8400.

Initial Report

Premise/facility under investigation (name and address) The Toronto Cosmetic Clinic
5400 Yonge St
Toronto ON
Type of premise/facility: (E.g. clinic, personal services setting) Outpatient Clinic
Date Board of Health became aware of  IPAC lapse May 15, 2018
Date of Initial Report posting  May 18, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Reportable Disease Investigation
Summary Description of the IPAC Lapse
  • Inadequate reprocessing and management of re-usable critical and semi-critical devices.
  • Inadequate monitoring of sterilizers and 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? Yes
Please provide further details/steps The premises was ordered to hold services pending testing of the sterilizer for quality assurance, document results, and repackage and reprocess all critical and semi-critical instruments prior to resuming medical procedures at clinic.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order served May 15, 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

 

Initial Report

Premise/facility under investigation (name and address) Arshia Hair Salon and Spa
6062A Yonge Street
Toronto, M2M 3W6
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting
Date Board of Health became aware of  IPAC lapse May 7, 2018
Date of Initial Report posting  May 17, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse On May 8th, 2018, the following inadequate IPAC practices were observed:

  • Two pre-filled syringes with unknown substance stored in the refrigerator (no client present).
  • Open multi-use vials were not marked with the date when the vial was first opened (no client present).
  • Syringes purchased in bulk.
  • Injectable products and topical agents not to be Health Canada approved (no drug identification number available on labels).
  • Unsealed and unlabelled lip balm tubes stored in a glass container.
  • No client records maintained for clients who received the service available at the premises.

 

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
  1. Stop providing cosmetic injection services at the Premises and at any other locations in the City of Toronto, until the owner/operator is able to demonstrate to the satisfaction of Toronto Public Health (TPH) that all topical agents, including lip balm and injectable substances used to provide the services have received all necessary Health Canada approvals, and until advised by TPH that services may resume.
  2. Do not pre-fill syringes for later use.
  3. Purchase individually packaged syringes.
  4. Mark multidose vials with the date it was first used and ensure that it is discarded at the appropriate time.
  5. Use only Health Canada approved injectable substances and topical agents.
  6. Stop using, selling and/or providing clients with homemade lip balm.
  7. Keep accurate client records for all clients who receive these services on site at the premises for 1 year and maintain client records for 5 years..
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Service closed on May 8, 2018. Verbal Order issued on May 8, 2018.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Health Canada notified regarding injectable products, topical agents and home-made lip balm.

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) QS Nails and Spa
75 Rylander Boulevard, Unit 3-1A
Toronto, M1B 5M5
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting
Date Board of Health became aware of  IPAC lapse March 6, 2018
Date of Initial Report posting  March 15, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Not Applicable

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? Not Applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Used blades must be discarded immediately after each client into the sharps container
  • Immediately discard expired disinfectant
  • Provide containers on-site to facilitate effective disinfection
  • Multi-use instruments such as nail clippers, cuticle cutters, metal foot paddles, and tweezers, must be disinfected with an intermediate level disinfectant, after cleaning with soap and water, with a small brush
  • All used single-use items such as nail files, buffer blocks and toe separators must be discarded after each client
  • Store and cover clean and disinfected instruments
  • Store clean linens in a sanitary manner
  • Disinfect and clean workstation surfaces and drawers regularly
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)  Verbal order was issued to the owner on March 6, 2018.

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: March 15, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Not Applicable
Brief description of corrective measures taken
  • Used blades discarded into the sharps container
  • Expired disinfectant discarded
  • Intermediate disinfectant and the containers to facilitate effective disinfection are available on site
  • Multi-use instruments such as nail clippers, cuticle cutters, metal foot paddles, and tweezers, are disinfected with an intermediate level disinfectant after cleaning with soap and water, with a small brush
  • Cleaned and disinfected instruments are stored and covered
  • All used single-use items such as nail files, buffer blocks and toe separators discarded after each client
  • Clean linens are stored in a sanitary manner
  • Workstation surfaces and drawers cleaned and disinfected
Date all corrective measures were confirmed to have been completed A re-inspection was conducted on January 29, 2018.

 

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) I Love Nails
2678 Yonge Street
Toronto, M4N 2H7
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting
Date Board of Health became aware of  IPAC lapse March 6, 2018
Date of Initial Report posting  March 15, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Not Applicable

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? Not Applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Disinfect multi-use instruments such as nail clippers, cuticle cutters, metal foot paddles, and tweezers, with an intermediate level disinfectant after cleaning with soap and water, with a small brush
  • Provide on-site intermediate-level disinfectant and the containers to facilitate effective disinfection
  • Discard all used single-use items such as nail files, buffer blocks and toe separators immediately after each client
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal order was issued to the owner on March 6, 2018.

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: March 15, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Not Applicable
Brief description of corrective measures taken
  • Multi-use instruments such as nail clippers, cuticle cutters, metal foot paddles, and tweezers, are disinfected with an intermediate level disinfectant after cleaning with soap and water, with a small brush
  • Intermediate disinfectant and the containers to facilitate effective disinfection are available on-site
  • All used single-use items such as nail files, buffer blocks and toe separators discarded after each client
Date all corrective measures were confirmed to have been completed A re-inspection was conducted on March 7, 2018.

 

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) Ava Beauty Clinic
326 Sheppard Avenue East, Unit 300
Toronto, ON, M2N 3B4
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting
Date Board of Health became aware of  IPAC lapse February 26, 2018
Date of Initial Report posting  March 15, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Not Applicable

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? Not Applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Intermediate and high-level disinfectants must be available on-site at all times.
  • Reusable metal instruments must be cleaned and disinfected after each client.
  • Sharps container must be available on-site at all times.
  • Discard single-use disposable plastic tips for hydro-facials immediately after each client.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal order was issued to close aesthetic services on February 26, 2018.

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: March 15, 2018
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 22, 2018, all recommendations were confirmed to be in compliance with IPAC best practices.

  • Intermediate and high-level disinfectants are available on-site.
  • Re-usable metal instruments are cleaned and disinfected after each client.
  • Sharps container available on-site.
  • Single-use disposable plastic tips for hydro-facials are discarded immediately after each client.
Date all corrective measures were confirmed to have been completed A re-inspection was conducted on February 27, 2018. Premises passed re-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

Initial Report

Premise/facility under investigation (name and address) The Crossways Sexual Health Clinic
2340 Dundas St W.
Toronto, ON
M6P 4A9
Type of premise/facility: (E.g. clinic, personal services setting) Clinic
Date Board of Health became aware of  IPAC lapse January 16, 2018
Date of Initial Report posting  February 7, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Semi-critical items used which may have been inadequately reprocessed

  • Sterilizer may have not been working optimally
  • Soaking/Pre-cleaning process and products are inadequate
  • Inadequate quality assurance testing 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? Not Applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Recommendations included:

  • Education for all staff on updated Infection Prevention and Control (IPAC) policies/procedures and reprocessing
  • In-service from sterilizer company
  • Revise reprocessing steps and modify reprocessing area to Public Health Ontario’s Provincial Infectious Diseases Advisory Committee IPAC Best Practice Documents
  • Review reprocessing quality assurance methods
  • Assess the use of Single Use Devices’ and additional sterilizer
  • Assess need to increase frequency of sterilizer loads
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: March 7, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
n/a

 

Brief description of corrective measures taken As of February 22, 2018, all recommendations were confirmed to be in compliance with IPAC best practices.

Corrective measures taken:

  • The manufacturer’s instructions for operation and maintenance of sterilizing equipment are being followed
  • Enzymatic cleaner is available on site
  • Pre-cleaning procedure is appropriate
  • Quality Assurance program for autoclave and documentation was updated
Date all corrective measures were confirmed to have been completed February 22, 2018

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) No further action

If you have any further questions, please contact:

Name Herveen Sachdeva
Title Associate Medical Officer Of Health, Communicable Disease Control
email address Herveen.sachdeva@toronto.ca
Phone number 416-338-1607

Initial Report

Premise/facility under investigation (name and address) Modelo Cosmetic Clinic
3768 Bathurst St, Unit 200
Toronto, ON, M3H 3M7
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting/Cosmetic Clinic
Date Board of Health became aware of  IPAC lapse January 16, 2018
Date of Initial Report posting  January 19, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse  On January 16, 2018, the following inadequate infection prevention and control (“IPAC”) practices were observed:

  • Single-use items (e.g. needle, syringe and electrode probe) in open packages at the workstation in the absence of a client
  • Improper storage of unused items (e.g. electrode probes)
  • An expired medication vial
  • Appropriate disinfectants not available for disinfection
  • Antiseptics not available for use prior to invasive procedures

 

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
  1. Stop providing aesethetic services at the premises or any other locations in the City of Toronto, until advised by Toronto Public Health that these services can resume.
  2. Discard single-use items immediately into an approved sharps container after each client
  3. Do not use and discard expired medication immediately
  4. Clean and disinfect multi-use aesthetic instruments immediately after each client
  5. Ensure appropriate disinfectants are available for use at the premises at all times
  6. Store unused items (e.g. electrode probes) in a sanitary manner
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order issued on January 16, 2018

 

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 29, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Written order was served to the owner on January 19, 2018.

 

Brief description of corrective measures taken
  • All items (expired medication vial, open packages, electrode probe, used syringe) were discarded
  • Electrode probe holder and other aesthetic items were properly cleaned and disinfected
  • Intermediate and high-level disinfectants are available on site
Date all corrective measures were confirmed to have been completed  A re-inspection was conducted on January 19, 2018.

 

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) LKM Beauty International
2473 Kennedy Road
Toronto, M1T 3H3
Type of premise/facility: (E.g. clinic, personal services setting) Personal Service Setting
Date Board of Health became aware of  IPAC lapse January 12, 2018
Date of Initial Report posting  January 19, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse On January 12th, 2018, the following inadequate IPAC practices were observed:

  • Single-use items (e.g. micropigmentation needles, needle cartridges, used ink rings and ink caps) in open packages on worktable in the absence of a client.
  • Stains on the single-use protective barrier in the absence of a client.
  • Items not fully covered with a single-use protective barrier at the workstation.
  • Stains on linens in the absence of a client.
  • Overall unsanitary condition of the workstation and 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? Yes
Please provide further details/steps
  1. Stop providing micropigmentation services at the premises and any other locations in the City of Toronto, until such time you are advised by Toronto Public Health you can resume these services.
  2. Use individually packaged and sterile needles and cartridges, and open items in front of clients.
  3. Discard all used items (e.g. needles and needle cartridges) immediately after each use into an approved sharps container.
  4. Dispense ink in front of clients and discard ink and ink rings immediately after each client.
  5. Clean and disinfect multi-use items (e.g. ink cap holders) after each client.
  6. When protective barriers are used ensure it is used in accordance with acceptable IPAC practices.
  7. Launder linens after each client and maintain linens in a clean and sanitary manner.
  8. Maintain workstations and premises in a sanitary manner.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)  Premises closed on January 12, 2018. Verbal Order issued on January 12, 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 Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
Email address cecilia.alterman@toronto.ca
Phone number 416-338-8065

 

Initial and Final Report

Premise/facility under investigation (name and address) Hair Joy,
4404 Bathurst St
Toronto, ON M3H 3R7
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse December 11, 2017
Date of Initial Report posting  January 9, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse On December 11, 2017, the premises was inspected in response to a complaint (skin scratch). During the inspection the following inadequate IPAC practices were observed:

  • Electric clippers used for hair styling and other client services were contaminated with hair debris potentially indicating that timely reprocessing was not performed. No clients were receiving services at the time of the inspection.
  • No records maintained for potential blood-borne infection exposures for clients who have received services at the 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? Not Applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Clean and disinfect electric hair clippers after each client by removing excess hair and spraying with a disinfectant such as 70 per cent alcohol or a disinfectant that is Tuberculocidal and has a drug identification number. After reprocessing store the instruments in a sanitary manner.
  • Establish and maintain a record for clients who have had a potential exposure to a blood-borne infection while receiving services at the Premises. Potential exposures can include a cut or surface scratch. Keep this record in a secure location at the Premises. Record the date, the site of the potential exposure, the client’s name, telephone number, address and the name of the person who provided the service. Each entry in the record shall be kept on the Premises for one year and on file for at least 5 years.
  • Ensure that adequate infection prevention and control (IPAC) practices are used before, during and after providing services to clients at the Premises, as set out in the documents that were provided to the owner: Routine Infection Control Practices for Personal Services Settings, Blood-Borne Diseases, Hairdressing and Barbering Infection Prevention and Control, and Blood and Body Fluid Exposures In Personal Services Settings – Response Procedures.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)  A charge laid under City of Toronto By-law on Dec 13, 2017
Written Order served on Dec 28, 2017

 

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) Universal Smile Dental Care Corp.
201-792 Kennedy Road.
Toronto, ON.  M1K 2C8
Type of premise/facility: (E.g. clinic, personal services setting) Dental Hygiene and Dentistry
Date Board of Health became aware of  IPAC lapse August 15, 2017
Date of Initial Report posting  October 6, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Complaint
Summary Description of the IPAC Lapse
  1. Absence of IPAC policies and procedure documents.
  2. Improper storage of clean dental instruments and equipment.
  3. Inadequate quality assurance testing and documentation for reprocessing.
  4. Dental instruments and devices not stored in sealed packages after reprocessing.
  5. Inability to differentiate between sterile instruments and non-sterile instruments.
  6. Expired products (eg. Formo Cresol)
  7. Dental equipment barriers not removed between each patient.
  8. Inappropriate management of biohazardous waste.

 

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 1. Repackage and re-sterilize all re-usable dental instruments using IPAC Best Practices for reprocessing, including quality assurance.

  • Safely discard used single-use devices (SUDs) after each use, and not reprocess.
  • Do not reprocess any SUDs.
  • Discard all expired chemicals and products used in patient care.
  • Clearly label all chemicals and medications with name, expiry date and DIN or appropriate reference number to comply with Sections 37 and 38 of the Occupational Health and Safety Act R.S.O. 1990, CHAPTER O.1.
  • Remove all single-use barriers from dental equipment after each patient use, and then clean surfaces after each patient has left the dental operatory.
  • Dispose of all biohazardous waste in an approved biohazard waste bin.
  • Remove all food or drink from clinical areas and clinical storage areas, including the fridge used to store dental products.

2.Meet with TPH at a mutually agreeable time to discuss IPAC issues arising from the August 15, 2017 IPAC Audit conducted by TPH at the Premises.

3.Demonstrate to the satisfaction of TPH that all individuals working at the Premises are following Public Health Ontario’s (PHOs) Provincial Infectious Diseases Advisory Committee (PIDAC) IPAC Best Practice Documents.

4.Demonstrate and document to the satisfaction of TPH that all persons working at the Premises receive IPAC training upon hire and at least annually thereafter.

Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • August 15, 2017 – IPAC Audit;
  • August 15, 2017 – HPPA Section 13 verbal Order
  • August 18, 2017 – HPPA Section 13 written Order
  • August 25, 2017 – Re-inspection
  • Sept 6, 2017 – Re-inspection and Premise re-opened

 

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:  October 6, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 See initial report (above)
Brief description of corrective measures taken  As of September 6, 2017, TPH verified that all recommendations and items for which the Owner was ordered, are now in compliance for IPAC best practices.
Date all corrective measures were
confirmed to have been completed
September 6, 2017

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) North York Medical Group
704-240 Duncan Mill Road
Toronto, ON M3B 3S6
Type of premise/facility: (E.g. clinic, personal services setting) Doctor’s office
Date Board of Health became aware of  IPAC lapse August 3, 2017
Date of Initial Report posting  September 21, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Notified by the premises directly
Summary Description of the IPAC Lapse Sterilizer malfunction

 

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 Recommendations included:

  • Stop use of any re-usable sterilized instruments until sterilizer is approved for use
  • Obtain replacement sterilizer
  • Conduct quality assurance sterilizer
  • Reprocess all re-usable instruments prior to use, once sterilizer is approved or new sterilizer obtained
  • Review quality assurance program for autoclave and documentation
  • Update IPAC Policies for clinic

Provide training to staff on IPAC Best Practices

Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • August 3, 2017 – TPH verbal & email direction August 9, 2017 – TPH Letter of recommendation

 

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 21, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 See above
Brief description of corrective measures taken
  •  Sterilizer replaced
  • Quality assurance testing completed
  • Re-sterilization of all instruments to ensure sterility completed
  • Reprocessing documentation completed
  • Quality assurance program for autoclave and updated documentation completed
  • IPAC Policies for clinic completed
  • Training to staff on IPAC Best Practices (including reprocessing) completed
Date all corrective measures were
confirmed to have been completed
August 24, 2017

 

 Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) No further action.

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 and Final Report

Premise/facility under investigation (name and address)
Xiana Beauty Centre
4675 Steeles Ave. East, Unit #2C13
Toronto, Ontario
M1V 4S5
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse March 30, 2017
Date of Initial Report posting   May 15, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified  Other
Summary Description of the IPAC Lapse On March 30, 2017, the following inadequate infection prevention and control (“IPAC”) practices were observed:

  • Unpackaged single-use items including several surgical needles with threads attached, and a used needle, re-usable lancet, scissors used in invasive procedures, were deposited together inside a plastic container, containing a clear liquid. The operator advised that the clear liquid was a 70 per cent alcohol disinfectant.
  • Unpackaged suture needles with threads, unpackaged scissors used in invasive procedures and haemostats were stored loosely in plastic bags.
  • No English instructions were observed on packages of suture needles and some injectable products.
  • A preloaded syringe was observed at the workstation. No client was present.
  • Three packages of an injectable solution with an expired best before date, stored inside a work cabinet.
  • Packages of syringes did not have safety-engineered needles

 

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
  1. Immediately stop providing services that require the use of scalpels, suture needles, threads, scissors used in invasive procedures, haemostats, or injectable substances at Xianni Beauty centre located at 4675 Steeles Avenue E, Unit #2C13, Toronto, Ontario, M1V 4S5 and any other locations in the City of Toronto, until such time as they are advised by TPH that they can resume these services.
  2. Ensure that only sterile, individually packaged instruments or sterile individually packaged, single-use items are used to provide services at the premises.
  3. Ensure that all used single-use items, used to provide services at the premises are discarded immediately after each use.
  4. Ensure all reusable items, used to provide services at the premises, are cleaned and then sterilized in an approved autoclave, according to manufacturer instruction.
  5. Ensure the autoclave is spore tested on a bi-weekly basis.
  6. Ensure all items and injectable products used to provide services at the premises have the necessary Health Canada approvals.
  7. Ensure that instructions in English are available on all injectable products used to provide services at the premises.
  8. Ensure that only hollow-bore safety-engineered needles are used to provide services at the premises. Ensure that all hollow-bore non-safety-engineered needles are removed from the premises immediately.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order issued on March 30, 2017.
A charge laid under City of Toronto By-law March 30, 2017.
Written Order served on April 18, 2017.

 

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Issue of injectable medication use referred to Health Canada and CPSO.

 

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