Infection Prevention & Control (IPAC) Investigations

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

 

This page includes reports of infection prevention and control (IPAC) investigations in Toronto (e.g., doctors’ offices, dental clinics, hospitals and personal service settings (PSSs) such as tattoo, aesthetic, and body piercing establishments, etc.) where an IPAC lapse has been identified.

An IPAC lapse is when proper IPAC practices were not followed and have resulted in a risk of transmission of infectious diseases to clients, attendees or staff. This can be through a potential exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, contaminated equipment or soiled items.

IPAC Investigation Process

Toronto’s Medical Officer of Health is alerted about IPAC lapses as the result of investigation and surveillance, as well as through public complaints or referral from a provincial regulatory body. If a lapse is identified following an investigation, Toronto Public Health (TPH) will post the investigation summary on this page, as per the Ontario Public Health Standards’ Infection Prevention and Control Disclosure Protocol, 2022, or as current. Investigation summaries are posted by location (i.e., for sites that have multiple locations, reports will correspond with one site only).

Legislative Requirements

IPAC lapse investigations and postings are carried out in accordance with the provincial Health Protection & Promotion Act (HPPA), the Ontario Public Health Standards (OPHS) and the following protocols:

Timelines, Archiving, and Review of archived investigations (12 to 24 months old)

Investigation summaries are moved to the “Previous IPAC Investigations” page 12 months from the investigation completion date.

At 24 months from the investigation end date, they are removed from the website.

To request a copy of a report that is older than 24 months, please visit the Freedom of Information (FOI) request page.

The IPAC lapse investigations look at IPAC issues during a specific point-in-time. Investigation summaries are only posted when TPH identifies an IPAC lapse.  This page doesn’t guarantee the absence of IPAC issues in premises that have or do not have summaries posted.

The summary reports represent what was found at the time of the investigation and TPHs recommendations, based on the provincial requirements.

Initial Report Details
Premise/facility under investigation (name and address) Dr. Esther Park

20 Edna Ave, Toronto
Type of premise/facility: (E.g. clinic, personal services setting) Gynecology Clinic
Date Board of Health became aware of IPAC lapse September 19, 2024
Date of Initial Report posting November 5, 2024
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Patient’s complaint
Summary Description of the IPAC Lapse
  • Inadequate reprocessing
  • No reprocessing quality assurance records on site.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes, CPSO
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes

  • Re-processing steps and use of disinfectants reviewed and corrected.
  • Owner replacing re-usable instruments with single-use devices (SUDs) where possible.
Please provide further details/steps Risk assessment consultation with PHO ongoing
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) October 10, 2024, Dr. Park was directed to review and correct reprocessing procedure.

October 11, 2024, MIFU for disinfectants reviewed with Dr. Park.
Initial Report Comments Details
Any Additional Comments Reprocessing corrected as per MIFU and IPAC Best Practices
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
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
416-338-8400

Initial Report Details
Premise/facility under investigation (name and address) Glam Forever Beaute

1237 Woodbine Avenue, BSMT, Toronto
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Settings
Date Board of Health became aware of IPAC lapse January 5, 2024
Date of Initial Report posting
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Complaint received January 5, 2024
Summary Description of the IPAC Lapse
  • Inadequate reprocessing of reusable nail tools between clients.
  • Re-use of single-use items such as buffers. Re-useable items not maintained in a sanitary manner.
IPAC Lapse Investigation Results
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? HPPA Section 13 Verbal Order on premises owner to:

  • Reprocess all reusable nail tools
  • Properly store clean and disinfected tools
  • Discard all single-use items immediately after use
  • Maintain premises in a sanitary manner
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) January 5, 2024
Initial Report Comments Details
Any Additional Comments On-site re-inspection to be conducted.
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
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
416-338-8400

Initial Report Details
Premise/facility under investigation (name and address) Hopewell Medical Clinic and Walk-in (Dr. M. Rofail)
Type of premise/facility: (e.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of IPAC lapse Feb 1, 2024
Date of Initial Report posting Feb 13, 2024
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Complaint
Summary description of the IPAC lapse
  • Incomplete reprocessing quality assurance.
  • Inappropriate packaging of items to be sterilized.
  • Inadequate labelling of sterilization packages.
  • Inconsistent record keeping of the sterilizer’s physical parameters.
  • No plumbed eyewash station on site.
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? College of Physicians and Surgeons of Ontario
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Stop use of the ‘the current sterilizer.’
  • Affix a sign to the current sterilizer to say, “not to be used”, immediately until TPH has authorized you to resume providing service(s).
  • Conduct pre-qualification of sterilizer with 3 consecutive Biological Indicators (BI), using a process challenge device (PCD), and notify TPH of the results prior to resuming use of the sterilizer for reprocessing any instruments.
  • Use Single Use Devices in the interim until reprocessing issues are resolved.
  • Do not use any multi-use instruments that require reprocessing until TPH has informed you, that you may resume use.
  • Conduct a BI daily, in a PCD, for each day the sterilizer is in use.
  • All items to be sterilized are packaged appropriately in an unlocked and open position without overlapping.
  • Sterilization packages are to be labelled with:
    • Date of sterilization
    • Load number
    • Reprocessing personnel’s initials
  • Maintain logs of the sterilizer’s physical parameters and chemical indicators for every cycle and log BI results daily.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal order issued on February 5, 2024
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: April 2, 2024
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Facility in compliance with all TPH recommendations previously provided from Feb 2024 visit.
Date all corrective measures were confirmed to have been completed April 2, 2024
Final Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

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) Stockyards Medical- Family Practice & Walk In Clinic
1980 St Clair Ave W Unit 203, Toronto, ON M6N 4X9
Type of premise/facility: (e.g. clinic, personal services setting) Community Clinic
Date Board of Health became aware of IPAC lapse June 25, 2024
Date of Initial Report posting Aug 15, 2024
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified On July 5, 2024, during IPAC inspection in response to a complaint, TPH staff observed a sterilizer not meeting the best practices associated with reprocessing.
Summary description of the IPAC lapse
  • Blood collection tubes holders were disinfected with ILD and re-used on multiple clients.
  • The on-site sterilizer had been used from April 2023 to March 2024 without physical, mechanical or biological verification and reprocessing records.
  • Reprocessing room had no one-way flow to prevent cross contamination. Unrelated items were stored inside the re-processing room.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? CPSO
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
  • Blood collection tube holders replaced with SUD.
  • Order Sec 13 HPPA was given to the Manager to immediately stop re-processing on site.
  • Set up and follow verification processes for the autoclave, keep re-processing records as required.
  • Create one way process flow in reprocessing room.
  • Remove/relocate items not pertaining to reprocessing.
  • May re-start use of the autoclave only after receiving an approval from TPH
  • The Clinic conducted three consecutive BI on the autoclave as per TPH request. Passed.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order Sec 13 HPPA issued on June 5, 2024
Recommendations Letter sent to the Clinic on July 29, 2024.
Initial Report Comments Details
Any additional comments The Clinic does not do re- processing on site currently.
Interim Report Details
Date of Interim Report posting: Sept 9, 2024
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) Re-inspection conducted on September 6, 2024
Brief description of corrective measures taken Clinic in compliance with requirements:

  • Re-usable items replaced with SUDs
  • The RITTER autoclave removed from the location.
Date all corrective measures were confirmed to have been completed Sept 6, 2024
Interim Report Comments Details
Any additional comments No 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 (Do not include any personal information or personal health information)

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) Universal Smiles Dental Centre
204 Rouge Hills Dr
Toronto, ON M1C 2Z1
Type of premise/facility: (E.g. clinic, personal services setting) Mobile Dental Hygiene Clinic (bus)
Date Board of Health became aware of IPAC lapse November 23, 2023
Date of Initial Report posting April 3, 2024
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Self -reporting
Summary description of the IPAC lapse
  • No hand hygiene sink available in clinical area (dental hygiene bus),
  • Sterilizer:
    • Not approved by Health Canada
    • Inappropriate cycle use for wrapped instruments
    • Quality assurance logbook did not reflect parameters for sterilization
    • Portable dental unit used was not approved by Health Canada.
    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? College of Dental Hygienists of Ontario
    Were any corrective measures recommended and/or implemented? Operator voluntary stopped operating until appropriate equipment and IPAC processes can be obtained and organized.
    Please provide further details/steps
    • Ensure hand hygiene sink installed in the mobile dental clinic,
    • Ensure use of a Health Canada approved healthcare devices and instruments (including but not limited to sterilizer and dental unit),
    • Ensure Quality assurance logs are appropriately maintained,
    • Complete Provincial IPAC training (eg. reprocessing)
    Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Business no longer in operation. Operator will notify TPH prior to resuming mobile dental hygiene services.
    Initial Report Comments Details
    Any additional comments (Do not include any personal information or personal health information)
    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) Victoria Medical Group
    1252 Lawrence Ave East, suite 201, Toronto ON
    Type of premise/facility: (e.g. clinic, personal services setting) Medical Clinic
    Date Board of Health became aware of IPAC lapse Jan 3, 2024
    Date of Initial Report posting Jan 12, 2024
    Date of Initial Report update(s) (if applicable) N/A
    How the IPAC lapse was identified Other
    Summary description of the IPAC lapse
    • Failure to manage sterile items in a manner to differentiate sterile from non-sterile items
    • Inadequate sterilization process, including quality assurance and 1-way flow of processes
    • Utilization of expired chemicals, sharps, and medication
    • Failure to maintain a dedicated reprocessing room
    • Failure to maintain hand hygiene items at point of use
    • Reprocessing and re-use of single use devices
    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
    Were any corrective measures recommended and/or implemented? Yes
    Please provide further details/steps On Jan 8, 2024, the premise was verbally ordered under the authority of section 13(7) of the Health Protection and Promotion Act, 1990, as below:

    • Stop use of ‘the current sterilizer’ Ritter M7 Speed Clave Sterilizer for reprocessing instruments, and use of any items that have been reprocessed in this current sterilizer, until Toronto Public Health (TPH) has authorized you to resume providing service(s).
    • Stop providing healthcare services that require use of multi-use instruments and/or instruments that are/have been reprocessed using the current sterilizer immediately until TPH has authorized you to resume providing service(s).
    • Remove all instruments from sterilizer packaging and hold instruments to be reprocessed in a dedicated area, until TPH has authorized you to resume reprocessing and reprocess all items according to Provincial Best Practices for Sterilization.
    • Affix a sign to the current sterilizer to say “not to be used”, immediately until TPH has authorized you to resume providing service(s).
    • Perform 3 consecutive biological indicator tests (inside a process challenge device) on the current sterilizer and report results to TPH.
    • Obtain ABHR, liquid soap, and paper towel in order to perform hand hygiene before and after providing care to a patient, and other points according to Provincial Best Practices
    • Review and remove any and all expired chemicals, products, medications, cleaners, sharps, etc., that are outside of their expiry dates
    • Stop re-use and/or reprocessing of any instruments that are labelled and/or intended as Single Use Devices
    • Ensure that the reprocessing room is dedicated to only reprocessing, and has a 1-way flow of device management
    • Stop providing any and all healthcare procedure in the reprocessing room
    • Deliver service(s) using acceptable infection prevention and control practices as detailed above as corrective action required
    Date any order(s) or directive(s) were issued to the owners/operators (if applicable) HPPA Sec 13. Verbal Order Jan 8, 2024
    Initial Report Comments Details
    Any additional comments
    Interim Report Details
    Date of Interim Report posting: March 21, 2024
    Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
    Brief description of corrective measures taken All requirements listed in the Sec 13 HPPA order are in compliance.
    Date all corrective measures were confirmed to have been completed February 2, 2024
    Interim Report Comments Details
    Any additional comments N/A
    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 (Do not include any personal information or personal health information)

    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

    Questions

    To submit an IPAC concern or complaint

    Contact Toronto Public Health at 416-338-7600 or publichealth@toronto.ca.

    You will hear back from the team within one business day.