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.

Initial Report

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

200-1371 Neilson Road.

Toronto, ON.  M1B 4Z8
Type of premise/facility: (E.g. clinic, personal services setting) Obstetrics and Gynecology office
Date Board of Health became aware of  IPAC lapse
Date of Initial Report posting  August 25, 2021
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  1. No quality assurance reprocessing logs for the “sterilizer”
  2. No reprocessing quality assurance with Biological Indicators or a minimum of Class 4 Chemical Indicator strips
  3. The “sterilizer” was not challenged using a Process Challenge Device
  4. No dedicated reprocessing area; all reprocessing actions were performed in a patient exam room used for patient exams
  5. The “sterilizer” is kept in a patient recovery room
  6. Sterilized packages were not labelled as per best practices
  7. Speculums were reprocessed unpackaged and thereafter being stored without packaging in drawers
  8. No regular maintenance on the “sterilizer”; no manufacturer’s instructions for use (MIFU) noted on site
  9. No training on reprocessing and IPAC recorded for staff
  10. No IPAC or occupational health Policies and Procedures (P&P’s) available
  11. No documentation/log of COVID-19 screening including taking and recording of body temperature
  12. Multi-use ultra-sound gel tubes are being used
  13. Vitamins for patients stored in open shelving in hallways
  14. No emergency eye-wash station noted in the clinic (This is a Ministry of Labour requirement)
  15. Un-used equipment and furniture stored in the clinic
  16. Patient exam table has cracked upholstery,
  17. Biohazardous waste freezer is not labelled,
  18. No handwashing signs posted at sinks
  19. No Safety Data Sheets available onsite for products being used at the clinic
  20. Unpackaged Single-Use speculums noted in drawer
  21. Bleach and water mixture of unknown strength used for presoaking used instruments.
  22. Incorrect use of face mask which was not covering the nose
  23. Improper storage of sterile instruments, and
  24. Inadequate pre-cleaning and cleaning of multi-use instrument

IPAC Lapse Investigation

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

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

Initial Report Comments

Any Additional Comments
  • Patient notification conducted.
  • Policy and procedures to be developed.

Interim Report

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

Interim Report Comments

Any additional comments

Final Report

Date of Final Report posting: April 4, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed March 31, 2022

Final Report Comments

Any additional comments
  • Patient notification completed
  • Policy and procedures developed and reviewed

If you have any further questions, please contact:

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

Initial Report

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

170 Rimrock Rd.

Unit # D/2

Toronto ON M3J3A6
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse April 13, 2022
Date of Initial Report posting May 5,  2022
Date of Initial Report update(s) (if applicable) May 5, 2022
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  1. Inappropriate packaging of items to be sterilized.
  2. Inadequate labelling of sterilization packages.
  3. Inadequate storage of reprocessed instruments.
  4. Inappropriate space for reprocessing.
  5. Inconsistent record keeping of the sterilizer’s physical parameters.
  6. Incomplete quality assurance of the sterilization process.
  7. Sterilization was not maintained until the point of use.
  8. No plumbed eyewash station on site.

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Dental Hygienist of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. All items to be sterilized are packaged appropriately in an unlocked and open position without overlapping.
  2. Sterilization packages are to be labelled with:
    1. Date of sterilization
    2. Load number
    3. Reprocessing personnel’s initials
  3. Multi-use sterilized brushes to be stored appropriately.
  4. There must be a designated enclosed area for reprocessing.
  5. Maintain logs of the sterilizer’s physical parameters for every cycle.
  6. Process challenge device (PCD) and Internal Chemical Indicators (CI) must be consistently used.
  7. All sterilized equipment must be stored in their sterile packages until the time of use.
  8. Install eyewash station that meets Ministry of Labour (MOL) requirement.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) April 20, 2022 – Letter of Recommendation with directions was sent to the operator.

Initial Report Comments

Any additional comments

Final Report

Date of Final Report posting: July 13, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) N/a
Brief description of corrective measures taken The 3-month IPAC re-inspection was conducted.

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

Final Report Comments

Any additional comments

If you Have any Further Questions, Please Contact:

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

 

Initial Report

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

902 Bathurst Street,

Toronto, Ontario, M5R 3G3
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse May 6, 2022
Date of Initial Report posting May 17,  2022
Date of Initial Report update(s) (if applicable) May 17,  2022
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  1. Inappropriate packaging of items to be sterilized.
  2. Incomplete quality assurance of the sterilization process.
  3. Improper reprocessing of devices with lumen.
  4. Inappropriate labelling of hazardous products.
  5. Lack of alcohol-based hand rub (ABHR) dispensers available in the reprocessing area.
  6. Inconsistent use of sharps containers.
  7. Inappropriate use of single use cleaning brushes.
  8. Improper storage of medications.
  9. Improper dispensing of multiuse products.

 

 

IPAC Lapse Investigation

Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Royal College of Dental Surgeons of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. All items to be sterilized are packaged appropriately with internal chemical indicators and in a way that they are not overlapped.
  2. Process challenge device (PCD) and Internal Chemical Indicators (CI) must be consistently used.
  3. Manufacture instructions are followed for reprocessing of devices with lumen.
  4. Disinfectant products dispensed from the original container should be labeled as per WHMIS requirements.
  5. ABHR must be available in the reprocessing area.
  6. Sharps containers must be mounted in all point of care and reprocessing areas.
  7. Single use cleaning brushes for reprocessing must be discarded after each use.
  8. Store medications according to manufacturer’s direction.
  9. Dispense multiuse products in a manner to avoid contamination.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) May 16, 2022 – Letter of Recommendation with directions was sent to the operator.

 

Initial Report Comments

Details
Any Additional Comments Patient notification for one exposed patient was completed.

 

Interim Report

Results
Date of Interim Report posting: May 26, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Re-inspection was conducted on May 25, 2022. Infractions identified during initial inspection were corrected.
Date all corrective measures were
confirmed to have been completed		 May 25, 2022

 

Interim Report Comments

Results
Any additional comments

 

Final Report

Results
Date of Final Report posting
Date of any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Comments

 

If you have any further questions, please contact:

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

Initial Report

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

27 Queen St East Toronto, ON. M5C 2M6
Type of premise/facility: (E.g. clinic, personal services setting) Ultrasound Clinic
Date Board of Health became aware of  IPAC lapse June 17, 2022
Date of Initial Report posting July 11, 2022
Date of Initial Report update(s) (if applicable) July 11, 2022
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse Notified by Ministry of Health’s Independent Healthcare Facility Branch (IHF) that transvaginal ultrasound transducers (probes) were not cleaned and disinfected as per Public Health Ontario’s Best Practices for Reprocessing.

 

 

IPAC Lapse Investigation

Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes:  College of Physicians and Surgeons of Ontario (CPSO) and College of Medical Radiation and Imaging Technologists of Ontario (CMRITO)
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order on June 22, 2022

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

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

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

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

 

Initial Report Comments

Details
Any Additional Comments Ongoing consultation with Public Health Ontario to assess risk of transmission based on the information from the IHF and the clinic, as well as the observations at the clinic.

 

Interim Report

Results
Date of Interim Report posting: July 13, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 11, 2022
Brief description of corrective measures taken
  1. Add to procedure for Transducer (probe) cleaning & disinfection:
    1. When to use test strips on High Level Disinfectant (HLD), what is a “pass” on the test strip (colour)
    2. When to change HLD fluid
  2. Add to Hepatitis B policy: staff to provide evidence of Hepatitis B immunity by serology

Owner/Operator updated Policy & Procedures
Date all corrective measures were
confirmed to have been completed		 July 11, 2022

 

Interim Report Comments

Results
Any additional comments Toronto Public Health notified the Ministry of Health’s Independent Health Facilities (IHF) Branch that clinic is in compliance of Public Health Ontario’s Best Practices and that the Owner/clinic may resume intracavitary ultrasound services once IHF confirms date appointments and services for intracavitary ultrasound may begin.

 

Second Interim Report

Results
Date of Second Interim Report posting July 18, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed

 

Second Interim Report Comments

Results
Any additional comments Public Health Ontario consultation for risk assessment concluded. No follow up required for patient lookback or notification based on outcome of provincial consultation.

 

Final Report

Results
Date of Final Report posting
Date of any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Comments

 

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416 338-8352

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

737 Mount Pleasant Road

Toronto ON M4S2N4
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse July 22, 2022
Date of Initial Report posting Aug 10 2022
Date of Initial Report update(s) (if applicable) Aug 10 2022
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  1. Inadequate labelling of sterilization packages.
  2. Inconsistent record keeping of the sterilizer’s physical parameters.
  3. Incomplete quality assurance of the sterilization process.
  4. Sterilization was not maintained until the point of use.
  5. Dental Unit Water Lines (DUWLs) were not maintained in a sanitary manner
  6. Single use devices were reprocessed.
  7. No policies or procedures on site.
  8. No staff education reported

 

IPAC Lapse Investigation Details
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Royal College of Dental Surgeons of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. Sterilization packages are to be labelled with:
    1. Date of sterilization
    2. Load number
    3. Reprocessing personnel’s initials
  2. Reprocessing physical parameters must be maintained in a log for every cycle.
  3. The sterilizer must be challenged every day it is in use with a process challenge device (PCD) containing a test Biological Indicator. It must be incubated with and compared to a control BI each time.
  4. All sterilized equipment must be stored in their sterile packages until the point and time of use
  5. DUWLs must be cleaned and disinfected on a regular basis.
  6. All single use devices are to be disposed of after use, at point of care.
  7. Policies & Procedures are to be developed as per Public Health Ontario’s (PHO) Best Practices for the following:
    1. General infection prevention & control,
    2. Management of blood and body fluid spills/exposures,
    3. Prevention of blood-borne pathogens, including a policy for hepatitis B vaccination, a serology record of documented immunity to hepatitis B, and post-exposure to blood borne pathogens,
    4. Healthy workplace policy, which includes a clear expectation that staff do not come to work when ill,
    5. Immunization for staff, as recommended by National Advisory Committee on Immunization (NACI).
  8. All Policies and Procedures are to be updated & reviewed by all staff annually. A record of this is to be maintained on site with date and staff signatures.
  9. Staff are to complete the PHO IPAC Core Competencies course annually. A record of completion dates are to be maintained on site.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 2, 2022 – Verbal Order served.

August 5, 2022 – Letter of Recommendation with directions sent to owner.

 

Initial Report Comments Details
Any additional comments

 

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

 

Interim Report Comments Details
Any additional comments

 

Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Final Report Comments Details
Any additional comments

 

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416 338-8352

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

2050 Weston Road. Unit 109

Toronto, Ontario

M9N 1X4
Type of premise/facility: (e.g. clinic, personal services setting) Medical Laboratory & Phlebotomy Services
Date Board of Health became aware of  IPAC lapse July 29, 2022
Date of Initial Report posting August 10, 2022
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Reprocessing and re-use of items that are deemed to be single use devices.

 

IPAC Lapse Investigation Details
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Medical Radiation and Imaging Technologists of Ontario (CMRITO)
Were any corrective measures recommended and/or implemented? Verbal order served on August 4, 2022

Letter of IPAC recommendations sent on August 17, 2022

Clinic to use disposable single use blood collection devices and tourniquets

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

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

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

2) Soap container must not be topped up, and

3) Alcohol Based Hand Rub (ABHR) must be available at point of care
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 4, 2022

 

Initial Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Interim Report Comments Details
Any additional comments

 

Final Report Details
Date of Final Report posting: November 17 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Corrective measures implemented.

IPAC Infractions identified from initial TPH audit, now observed to be in compliance.
Date all corrective measures were confirmed to have been completed November 10, 2022

 

Final Report Comments Details
Any additional comments

 

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Forest Hill Institute for Aesthetic Plastic Surgery

1188B Eglinton Ave. W., Toronto, ON M6C 2E3
Type of premise/facility: (e.g. clinic, personal services setting) Plastic Surgery Clinic
Date Board of Health became aware of  IPAC lapse  August 16, 2022
Date of Initial Report posting August 22, 2022
Date of Initial Report update(s) (if applicable) August 22, 2022
How the IPAC lapse was identified Referral from regulatory college
Summary description of the IPAC lapse
  1. Sterilization was not maintained until the point of use.
  2. Single use devices were reprocessed.
  3. Inadequate labelling of sterilization packages.
  4. No manufacturer instructions for certain items and instruments available onsite.
  5. Staff members not trained on IPAC policies and procedures.

 

IPAC Lapse Investigation Details
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 Surgeons of Ontario (CPSO)
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order made under authority of Section 13(7) of the HPPA on August 18, 2022:

(1) Stop providing any and all services and/or procedures that require multi-use medical devices that require reprocessing by sterilization, immediately until Toronto Public Health has authorized you to resume providing these services.

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

  1. Ensure labelling on reprocessed packaging includes the load number.
  2. Use a PCD with a biological indicator and Type 5 chemical indicator each day the sterilizer is used and with each type of cycle used that day. Document results in a sterilizer/reprocessing log book.
  3. Maintain critical reusable items in sterilized packaging until point of use.
  4. To ensure steam can penetrate the sterilizer packaging and contact all surfaces of instruments, do not double or triple pouch instruments prior to sterilization. Follow MIFUs for both the packaging and the instruments.
  5. Provide MIFUs for brushes that are able to be reprocessed or provide a stock of single use brushes for reprocessing.
  6. Provide a plan to replace the steam sterilizers with a sterilizer that meets the requirements in provincial best practices documents that has printing/logging capabilities. Remove all other sterilizers from the premises. Ensure new sterilizers are placed in the reprocessing room. Ensure new sterilizers are challenged in accordance with CSA and best practices prior to bringing them into use for the clinic.
  7. Ensure the reprocessing area has a one-way work flow. Send a plan on how the reprocessing room is to be set up.
  8. Disconnect the gas line and/or remove the gas sterilizer from the premises. Fully repackage and reprocess any/all instruments that were previously sterilized with the gas sterilizer if not already repackaged and reprocessed via steam sterilization in an approved and appropriately challenged sterilizer.
  9. Remove the laundry machine from the reprocessing room and relocate to another location in the clinic, to be dedicated for this purpose.
  10. Test sonification performance, of the ultrasonic cleaner, at least weekly, preferably each day it is used, using a commercial method or foil test in accordance with the manufacturer’s instructions. Ensure this is maintained in a log.
  11. Do not reuse single-use devices (SUDs) or items. Ensure MIFUs are followed and staff are trained on use, reprocessing and maintenance of instruments.
  12. Provide MIFUs regarding reprocessing or single use of anesthesia masks. Follow MIFUs and recommendations in the best practices documents listed below.
  13. Implement a process for staff to review the updated IPAC and Occupational Health and Safety policies and procedures. A record of this is to be kept with date and staff signature. Update policies and procedures in accordance with PHO and CPSO IPAC documents.
  14. Staff are to complete Public Health Ontario (PHO) IPAC Core Competencies and Reprocessing modules annually. A record of this is to be kept with date and staff signatures.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 18, 2022 – Verbal Order served.

August 22, 2022 – Letter of Recommendation with directions sent to owner.

 

Initial Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting: August 24, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) August 18, 2022
Brief description of corrective measures taken
  1. Items were reprocessed and kept in sterilization packages until point of use.
  2. Single use devices were discarded and pre-packaged single use devices were available onsite.
  3. Observed correct labelling of sterilized packages.
  4. Single use items and instruments were purchased to replace items with no manufacturer instructions. Manufacturer instructions available onsite for these replacement items and instruments.
Date all corrective measures were confirmed to have been completed August 23, 2022

 

Interim Report Comments Details
Any additional comments Toronto Public Health notified the Ministry of Health and Long-Term Care and CPSO that the clinic is in compliance of Public Health Ontario’s Best Practices and that the clinic may resume normal operations as of August 23, 2022.

 

Interim Report Details
Date of Interim Report posting: November 9, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken Policy and procedures have been updated and reviewed by all staff.
Date all corrective measures were
confirmed to have been completed		 October 4, 2022

 

Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information) A re-inspection was conducted on October 4, 2022. No infractions were observed at the time of inspection.

A final inspection will be completed after clinic renovations are complete.

 

Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Final Report Comments Details
Any additional comments

 

If you have any further questions, please contact:

Danielle R. Steinman
Manager, BBD IPAC Team, Control of Infectious Diseases/Infection Control
Danielle.Steinman@toronto.ca
416 338-8352

Initial Report Details
Premise/facility under investigation (name and address) Bloor West Dentistry, 2420 Bloor St West, Toronto
Type of premise/facility: (e.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse  November 3, 2022
Date of Initial Report posting November 23, 2022
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other: Dental Office self-reported
Summary description of the IPAC lapse Report of unsterilized dental handpieces and scaling tips used on a limited number of patients on one day due to one-time error by an office staff member.

 

IPAC Lapse Investigation Details
Did the IPAC lapse involve a member of a regulatory college? RCDSO
If yes, was the issue referred to the regulatory college? RCDSO notified
Were any corrective measures recommended and/or implemented? Yes, the office implemented corrective measures and notified TPH immediately for next steps.
Please provide further details/steps IPAC and Reprocessing audit conducted, including review of how staff are to verify sterilization has been completed.

Type 5 integrators added to each package prior sterilization

Staff re-trained in re-processing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) N/A

 

Initial Report Comments Details
Any additional comments TPH requested a risk assessment by Public Health Ontario to ascertain if patient notification is required.  Report on file.

Patients’ notification letters sent Nov 23, 2022

 

Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Interim Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed

 

Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

 

Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Final Report Comments Details
Any additional comments

 

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Pinnacle Vitality Rehab

367-4438 Sheppard Ave. E., Toronto, ON

M1S 5V9
Type of premise/facility: (e.g. clinic, personal services setting) Physiotherapy and Massage Clinic
Date Board of Health became aware of  IPAC lapse January 3, 2023
Date of Initial Report posting January 18, 2023
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other: complaint
Summary description of the IPAC lapse Report of no plumbed hot and cold running water

 

IPAC Lapse Investigation Details
Did the IPAC lapse involve a member of a regulatory college? CPO/CMTO
If yes, was the issue referred to the regulatory college? CPO/CMTO
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order made under authority of Section 13(7) of the HPPA on January 18, 2022:

(1) The premises is to be closed and no hands-on healthcare services may be provided to any patients/clients by any operator/staff until TPH approves re-opening.

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

No dedicated and plumbed hand wash station with hot and cold running water available onsite.

No policies or procedures onsite.

No staff education reported.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) January 17, 2023 – Verbal Order served.

January 18, 2023 – Letter of Recommendation with directions sent to owner.

 

Initial Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Interim Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed

 

Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

 

Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

 

Final Report Comments Details
Any additional comments

 

If you have any further questions, please contact:

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