Infection Prevention And Control (IPAC) Investigations

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

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Not applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) Audit conducted by Toronto Public Health (TPH) on December 20, 2018.

Clinic management to test sterilizer for quality assurance, document results, and repackage and correctly reprocess all critical and semi-critical instruments prior to resuming procedures requiring re-usable sterile instruments at the clinic.

Items to be addressed include:

  • Dispose of open expired multi-dose vials according to Manufacturer’s Instructions for Use (MIFU).
  • Make available appropriate PPE personal protective equipment (PPE).
  • Ensure that patient devices (i.e. glucometers) are used according to MIFUs.
  • Ensure chemicals (ultrasound gels and ABHR) are not topped up.
  • Create Infection Prevention and Control (IPAC) policies/procedures based on current provincial best practices.
  • Educate all staff on updated IPAC policies/procedures and reprocessing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) December 20, 2018 – Health Protection and Promotion Act (HPPA) Verbal Order was served.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

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) SKT Jewellers & Textiles Ltd.
2062 Lawrence Ave., E
Toronto, Ontario
M1H 3H3
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of IPAC lapse December 9, 2018
Date of Initial Report posting
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • unsanitary storage of an ear piercing device
  • re-use of single-use disposable adapters

 

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? December 10, 2018 – Stop providing ear piercing services and closure.

December 13, 2018 – Re-inspection conducted, service closed and posted.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) December 10, 2018 – Health Protection and Promotion Act (HPPA) Section 13 Verbal Order was served.

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:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 December 20, 2018 – Health Protection and Promotion Act (HPPA) Section 13 Verbal Order was served.
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed		 December 20, 2018 – The operator discontinued ear piercing services.

Interim Report Comments

Any additional comments (Do not include any personal information or personal health information) December 20, 2018 – Operator informed  Toronto Public Health (TPH) that ear piercing service closed permanently.

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 416-338-2639

Initial Report

Premise/facility under investigation (name and address) Sherway Medical Clinic
190 Sherway Drive, Suite 417
Toronto, Ontario
M9C 5N2
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of IPAC lapse October 12, 2018
Date of Initial Report posting  December 10, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical instruments
  • 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? Yes
Please provide further details/steps
  • Stop providing services that require re-usable semi-critical and critical instruments until the sterilizer quality assurance can be verified and demonstrated to Toronto Public Health (TPH), such that TPH can approve resuming of sterilizer use.
  • Once sterilizer quality assurance is verified to TPH, instruments are to be reprocessed according to best practices prior to resuming services that require re-usable semi-critical and critical instruments.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • October 23, 2018 – Health Promotion and Protection Act (HPPA) Verbal Order was served.
  • November 14, 2018 – Letter to medical director with additional recommendations was sent.

 

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: December 10, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 No additional orders or directives served.
Brief description of corrective measures taken November 16, 2018 – Clinic has addressed and complied with Infection Prevention and Control (IPAC) requirements set out by TPH.
Date all corrective measures were
confirmed to have been completed		 November 16, 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 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) Midtown Med Spa
567 Mount Pleasant Road
Toronto, M4S 2M5
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse September 19, 2018
Date of Initial Report posting  November 28, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Referral from other Medical Officer of Health
Summary Description of the IPAC Lapse
  • storing open syringes of dermal fillers
  • storing open packages of sterile items and expired items
  • unsanitary storage of sterile prepackaged items
  • use of items with no Health Canada approval

 

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. Operator required to:

  • Discard immediately all open packages of dermal fillers and only use product according to manufacturer instructions.
  • Discard immediately used sterile packages for Intravenous (IV) injections, and other items.
  • Discard immediately all expired medications (e.g. lidocaine, xylocaine and epi-pens), and items such as Baxa Rapid-Fill Connectors.
  • Store insulin syringes and all sterile items in a sanitary and organized manner to prevent cross-contamination.
  • Ensure to properly label open multi-use vials.
  • Only use Health Canada approved products.
Please provide further details/steps
  • Items were corrected during inspection.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) September 19, 2018 – Verbal Order was issued.

October 19, 2018 – Written Order was served.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) All items in the Verbal Order were corrected immediately.

Written Order served requesting access to additional information to complete the investigation.

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

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Not applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Toronto Public Health (TPH) Infection Prevention and Control (IPAC) Audit conducted on November 2, 2018 and November 5, 2018. Required actions:

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

November 29, 2018 – Letter to medical director with additional recommendations

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

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) Dr. Christopher Aldridge
Family Practice and Pain Management Clinic
688 Coxwell Ave, Unit 202
Toronto, ON M4C 3B7
Type of premise/facility: (E.g. clinic, personal services setting) Family Medicine and OHP Interventional Pain Management Clinic
Date Board of Health became aware of  IPAC lapse September 10, 2018
Date of Initial Report posting  September 17, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  • infection Prevention and Control lapse in Interventional Pain Management Procedures (PMP) involving injections
  • failure to provide dedicated medication preparation area and dedicated (separate) hand hygiene sink
  • improper management of syringes containing medication
  • inadequate use of personal protective equipment
  • inadequate sterile technique for IPM procedures
  • inadequate hand hygiene specific for sterile 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? Referred to Toronto Public Health (TPH) by the Regulatory College.
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Recommendations from Site visit on September 10, 2018:

  • Stop providing procedures involving injections until TPH allows to resume.
  • Provide a separate and dedicated medication preparation area.
  • Provide a separate and dedicated hand hygiene sink.
  • Dispose all expired medications. (Note: corrected at time of visit.)
  • Only load and prepare syringes with medication for use immediately prior to use. (e.g., to not pre-load syringes).
  • Use Safety-Engineered Needles (SENs) where possible.
  • Make available and use appropriate Personal Protective Equipment (PPE), specific to the procedures.
  • Make available and use hand hygiene products with Drug Identification Number (DIN) or Natural Product Number (NPN) specific to the procedures.
  • Ensure that all cleaning and disinfecting products for use have a DIN.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • July 31, 2018 – Health Promotion and Protection Act (HPPA) Verbal Closure Order was served
  • August 2, 2018 – Supplemental Infection Prevention and Control (IPAC) Form provided with Observations and Recommendations

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information)  Not applicable

Final Report

Date of Final Report posting: November 14, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 See initial posting
Brief description of corrective measures taken All items corrected at time of re-inspection September 17, 2018.
Date all corrective measures were
confirmed to have been completed		 September 17, 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 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) Marvin D. Obar, Dental Surgeon
2563 Eglinton Ave. West
Toronto, ON  M6M 1T3
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse July 31, 2018
Date of Initial Report posting  August 10, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of instruments
  • inadequate quality assurance
  • sterilization not maintained until point of use
  • inadequate routine practices and personal protective equipment use

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Infection Prevention and Control (IPAC) Audit conducted on July 31, 2018 and August 1, 2018.
  • Health Promotion and Protection Act (HPPA) Verbal Closure Order served on July 31, 2018.
  • Reprocessing and IPAC recommendations provided to ensure dentist can reprocess and maintain instruments as sterile until point of use, and adhere to appropriate routine practices and occupational health and safety requirements, including having up-to-date policies and procedures and training.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • July 31, 2018 – HPPA Verbal Closure Order was served.
  • August 2, 2018 – Supplemental IPAC Form provided with Observations and Recommendations

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

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) Dong Ming Hong Trading Inc.
357 Broadview Ave.
Toronto ON, M4M2H1
Type of premise/facility: (E.g. clinic, personal services setting) Clinic (Traditional Chinese Medicine, including acupuncture)
Date Board of Health became aware of IPAC lapse June 7, 2018
Date of Initial Report posting  July 3, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  • inadequate sharps management
  • inadequate environmental cleaning and surface disinfectant products

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Complaint was referred to Toronto Public Health (TPH) by the Regulatory College.
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Recommendations provided at time of visit.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) June 12, 2018 – Verbal direction was issued.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information)  Not applicable

Final Report

Date of Final Report posting: August 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 Previously identified Infection Prevention and Control (IPAC) infractions were noted to be rectified at the time of the re-inspection (June 15, 2018).
Date all corrective measures were
confirmed to have been completed		 June 15, 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 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) Isma Dent Dental Office
2 Thorncliffe Park Drive, Unit # 26
Toronto, Ontario
M4H 1H2
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse April 23, 2018
Date of Initial Report posting  June 20, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • maintaining items as sterile until point of use
  • inadequate quality assurance and policies related to reprocessing and infection control

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) audit conducted on May 1, 2018.

Recommendations given at time of inspection, followed-up with Written Order.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) June 8, 2018 – Written Order was served.

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: July 30, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 17, 2018 – Re-inspection
Brief description of corrective measures taken The items in the June 8, 2018 order are now in compliance as of Toronto Public Health’s (TPH) July 17, 2018 re-inspection.
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) Not applicable

Final Report

Date of Final Report posting: October 29, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken IPAC Policy and Procedures completed.
Date all corrective measures were
confirmed to have been completed		 August 10, 2018

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) Sanomed Medical Clinic
1000 Bay Street
Toronto, Ontario
M58 3A8
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse May 16, 2018
Date of Initial Report posting  June 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 On May 17, 2018, Toronto Public Health inspected the Premises and observed inadequate IPAC practices and procedures including:

  1. issues with quality assurance testing and documentation for sterilization
  2. documentation of IPAC policies and procedures
  3. appropriate storage of equipment

 

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
  1. Effective immediately:
    1. Stop using medical instruments (e.g. suture scissors, forceps, and vaginal speculums) that have been reprocessed using the Ritter M9 UltraClave (the Sterilizer) located at the Premises, until such time  you are able to demonstrate to the satisfaction of Toronto Public Health (TPH) that all biological, chemical, physical parameters are met and appropriate documentation is maintained for the Sterilizer.
    2. Stop using the Sterilizer for the reprocessing of medical instruments.
    3. Use only sterile purchased, pre-packaged, single-use devices when providing patient care services (e.g. medical suture kits and Pap tests).
  2. Report back to TPH with results of the quality assurance testing (three consecutive biological indicator (BI) tests and BI control) of the Sterilizer.
  3. Ensure the following is corrected:
    1. Provide 70–90 per cent alcohol-based hand rub (ABHR), masks, and appropriate signage available at reception.
    2. Do not store clean or sterile medical supplies under sinks.
    3. Do not top up the ABHR containers. Discard container once empty.
  4. 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) Infection Prevention and Control (IPAC) Best Practice Documents.
  5. Establish a sharps management program, as per PIDAC IPAC Best Practices requirements.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • May 17, 2018 – Verbal Order was served.
  • May 31, 2018 – Written 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: June 7, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
  • May 17, 2018 – Verbal Order was served
  • May 31, 2018 – Written Order was served
Brief description of corrective measures taken As of May 31, 2018, 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		 May 31, 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 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) Visions Infinity Foundations Health Fair
3600 Kingston Road
Toronto, ON
Type of premise/facility: (E.g. clinic, personal services setting) Health fair
Date Board of Health became aware of  IPAC lapse March 25, 2018
Date of Initial Report posting  June 1, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  • The lancet and fingerstick device may have been re-used on some of the attendees.
  • Sharps container was not used to discard the lancets.
  • Glucometer device was not used in accordance with manufacturer instructions.

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
  • Lancet must be discarded immediately into an approved sharps container after each use.
  • The fingerstick device is either single-use or single-patient use. This item cannot be re-used on multiple patients. If single-use, it must be discarded immediately after use into a sharps container with the lancet attached. If single-patient use, the client must discard the lancet immediately after into an approved sharps container and follow manufacturer instructions on proper cleaning and disinfection procedures.
  • The glucometer device must be used according to the manufacturer instructions, including how the device is to be cleaned and disinfected.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) April 5, 2018 – Verbal Order issued to Registered Health Professional to stop providing blood glucose testing or training others on blood glucose testing

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: June 1, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken
  • Education and training regarding glucometer use and appropriate IPAC practices provided.
  • Inspection and follow-up on order as above was done.
Date all corrective measures were confirmed to have been completed May 30, 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) Crossways Dental Clinic
2340 Dundas St West,
Toronto
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse April 20, 2018
Date of Initial Report posting  May 28, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse Ensuring items appropriately reprocessed before use; quality assurance monitoring of sterilizer; affected one operatory on one day

 

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 Sterile instruments from a processed load must not be used until the results of the BI (biological indicator) test passes. If instruments are not able to be held until BI results are read, ensure that Internal class 5 (at minimum) chemical indicator is used to ensure that the load reached the appropriate sterilizing parameters.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) All unsterilized instruments were reprocessed according to best practices after Infection Prevention and Control (IPAC) audit.

Final Report

Date of Final Report posting: October 24, 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 June 20, 2018, Toronto Public Health (TPH) verified that all recommendations are now in compliance for IPAC best practices.
Date all corrective measures were confirmed to have been completed June 20, 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:

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) Women’s Care Clinic
501-960 Lawrence Ave West
Toronto, ON.  M6A 3B5
Type of premise/facility: (E.g. clinic, personal services setting)  

Clinic
Date Board of Health became aware of  IPAC lapse April 17, 2018
Date of Initial Report posting  May 28, 2018
Date of Initial Report update(s) (if applicable) May 25, 2018
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  • Critical and semi-critical instruments were not reprocessed and stored according to manufacturers’ instructions for use (MIFU) and Infection Prevention and Control (IPAC) Best Practices.
  • Chemicals were not adequately labelled.
  • Patient care barriers were not adequate

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 notified Toronto Public Health (TPH)
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • April 18, 2018 – Toronto Public Health (TPH) Audit resulting in a Verbal Order re: items noted above
  • May 10, 2018 – Follow-up inspection
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • April 18, 2018
  • May 10, 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: May 28, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken
Date all corrective measures were 
confirmed to have been completed		 May 10, 2018

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) All critical items have been corrected

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) The Toronto Cosmetic Clinic
5400 Yonge St
Toronto ON
Type of premise/facility: (E.g. clinic, personal services setting) Plastic Surgery Clinic
Date Board of Health became aware of  IPAC lapse May 11, 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 premise was ordered to test the sterilizer for quality assurance, document results, and repackage and reprocess all critical and semi-critical instruments prior to resuming medical procedures at the clinic.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) May 15, 2018 – Verbal Order was served

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Services on hold until Toronto Public Health permits procedures to resume.

Final Report

Date of Final Report posting: July 25, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 June 8, 2018 – Written order was served
Brief description of corrective measures taken As of July 3, 2018, the facility is now in compliance with all Infection Prevention and Control (IPAC) recommendations from previous Toronto Public Health (TPH) IPAC audits and visits, including maintaining items as sterile until point of use, quality assurance program for sterilizer in place, one-way flow of a dedicated reprocessing room.
Date all corrective measures were confirmed to have been completed July 3, 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 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 Infection Prevention and Control (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) May 8, 2018 – Service closed and Verbal Order was issued.

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.

Final Report

Date of Final Report posting: September 7, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Written order issued to the owner of the premises and a Registered Practical Nurse.
Brief description of corrective measures taken Illegal injectable and topical medication removed from premises.
Date all corrective measures were
confirmed to have been completed		 May 17, 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) 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) March 6, 2018 – Verbal Order was issued to the owner.

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 are discarded into the sharps container.
  • Expired disinfectant is 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 are discarded after each client.
  • Clean linens are stored in a sanitary manner.
  • Workstation surfaces and drawers are cleaned and disinfected.
Date all corrective measures were confirmed to have been completed January 29, 2018 – A re-inspection was conducted.

 

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) March 6, 2018 – Verbal Order was issued to the owner

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 March 7, 2018 – A re-inspection was conducted.

 

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) February 26, 2018 – Verbal Order was issued to close aesthetic services.

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 February 27, 2018 – A re-inspection was conducted and premises passed the 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 were used which may have been inadequately reprocessed.
  • Sterilizer may have not been working optimally.
  • Soaking/Pre-cleaning process and products are inadequate.
  • There is 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:

  • Educate all staff on updated Infection Prevention and Control (IPAC) policies/procedures and reprocessing
  • Provide 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)		 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.

Corrective measures taken:

  • The manufacturer’s instructions for operation and maintenance of sterilizing equipment are being followeda
  • Enzymatic cleaner is available on sitea
  • Pre-cleaning procedure is appropriate
  • Quality Assurance program for autoclave and documentation was updateda
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 aesthetic 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) January 16, 2018 – Verbal Order was issued.

 

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: January 29, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 January 19, 2018 – Written Order was served to the owner.

 
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 12, 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) January 12, 2018 – Premises closed and Verbal Order issued.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Not applicable

Final Report

Date of Final Report posting: September 7, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
  • January 12, 2018 – Verbal Order was given.
  • February 5, 2018 – Written order was served.
Brief description of corrective measures taken January 12, 2018 – Closure of services
Date all corrective measures were
confirmed to have been completed		 February 12, 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