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.

Beecroft Sheppard Medical Clinic (Initial & Final Report)

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: Stop using the sterilizer for reprocessing instruments located at 48 Sheppard Ave West office. Open any reprocessed instruments. 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

Focus Medical (Initial & Final Report)

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: Clinic is challenging the sterilizer appropriately. All multi-use items were sterilized properly. There is a separate reprocessing area which has clear workflow from dirty to clean. Staff was trained formally on reprocessing activities. 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

White Willow Dental (Initial & Interim Report)

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

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

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)

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

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