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) Dr. Paul Adam:

600 Sherbourne Street, Suite 411
Toronto, Ontario
M4X 1W4

And

1371 Nielson Road, Suite 311
Toronto, Ontario
M1B 2Z8
Type of premise/facility: (E.g. clinic, personal services setting) Dermatology Clinic
Date Board of Health became aware of  IPAC lapse August 6, 2021
Date of Initial Report posting  August 17, 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
  • No reprocessing logs on site for the sterilizer or the ultrasonic cleaner
  • No Biological Indicator (BI) or Chemical indicator (CI) or Process Challenge Device (PCD) used in the sterilizer
  • No dedicated reprocessing area
  • Sterilized packages were not labelled appropriately
  • Re-use and reprocessing of single-use devices (SUDs) such as skin biopsy/punch instruments
  • No IPAC/occupational health policies and procedures on site
  • No training on reprocessing/IPAC provided to staff
  • No COVID-19 screening
  • Opened multi-dose vials not labelled properly
  • Expired medication and products on site
  • Inappropriate storage of sterile medical supplies
  • No eye-wash station
  • Cloth chairs in the examination room and the clinic waiting area

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?
  1. Complete three consecutive Biological Indicator (BI) tests on the sterilizer on site.
  2. Monitor sterilizer appropriately and maintain logs. If sterilizer no longer used, to remove off site.
  3. Obtain manufacturing instructions for sterilizer and ultrasonic cleaner on site.
  4. Only reprocess multi-use instruments.
  5. Discard single-use items immediately after use.
  6. Where possible only use single-use vials and discard all opened vials.
  7. If using multi-dose vials, label appropriately when opened.
  8. Ensure there is a policy/procedure for the following:
    • General IPAC and Routine Practices (including use of Personal Protective Equipment, “PPE”);
    • General Occupational Health and Safety (including management of body fluid spills, staff immunizations, and staff exposure to chemicals/sharps );
    • Sharps Management (including use of Safety Engineered Needles);
    • Reprocessing (including quality assurance for reprocessing, packaging for sterilizing, and/or use of Single Use Devices);
    • Environmental Cleaning (including supplies storage, and management of chemicals); and
    • Initial and ongoing IPAC training for staff.
  1. Consult with Ministry of Labour regarding eyewash station.
  2. Ensure all staff members are trained in infection prevention and control (IPAC) as well as reprocessing procedures.
  3. Discard all expired medications, items, and products (lotions) from the clinic.
  4. Ensure all medications, instruments, and supplies items are stored in a manner to prevent contamination.
  5. Ensure paper towels are mounted at each sink.
  6. Ensure a sharps container is mounted at each point of use.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 10, 2021, Verbal Order issued:

  1. Stop using the sterilizer for reprocessing instruments located at 600 Sherbourne Street East, Unit 411, Toronto, Ontario M4X 1W4; and
  2. Do not use the reprocessed instruments.

Initial Report Comments

Any Additional Comments

Interim Report

Date of Interim Report posting: November 8, 2021
Date any order(s) or directive(s) were issued to the owner/operator
Brief description of corrective measures taken
  • Three separate Biological Indicator (BI) tests in the sterilizer on site conducted and all three passed.
  • Sterilizer no longer used and has been removed from the clinic site.
  • All re-usable instruments have been opened and removed from the clinic site.
  • Only single-use disposable (SUD) medical equipment/devices are being used.
  • All medications, instruments, and supplies items are stored in a manner to prevent contamination.
  • Multi-dose vials are labelled appropriately.
  • An eyewash station has been installed.
Date all corrective measures were confirmed to have been completed August 27, 2021

Interim Report Comments

Any additional comments
  • Patient notification conducted.
  • Clinic in process of completing policy and procedures and educational modules for employees.

Final Report

Date of Final Report posting December 13, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 All items have been corrected.
Brief description of corrective measures taken All items have been corrected which includes:

1) Policy and procedures have been updated.

2) All staff have been trained in infection prevention and control (IPAC) and reprocessing.
Date all corrective measures were confirmed to have been completed December 10, 2021

Final Report Comments

Any additional comments

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) Beecroft Sheppard Medical Clinic

48 Sheppard Ave West

Toronto, ON M2M 1M2
Type of premise/facility: (E.g. clinic, personal services setting) Walk-in medical clinic
Date Board of Health became aware of  IPAC lapse N/A
Date of Initial Report posting  March 18, 2021
Date of Initial Report update(s) (if applicable) March 4, 2021
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • Sterilizer onsite was used without Biological Indicators (BI) or Chemical Indicators (CI).
  • No sterilizer logs maintained.
  • No ultrasonic machine for cleaning instruments prior to sterilization.
  • Two patient exam tables had upholstery held together with tape.
  • All garbage cans onsite were open, without a lid.
  • Non safety-engineered needles in a box on top of the counter at the vaccine fridge.
  • Self-contained single use bags were not observed in the soap containers. All liquid hand soap containers are topped up.
  • No Occupational Health and Safety information/binders.
  • No written policy or procedures about IPAC and health and safety.
  • No eye wash station

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Physicians and Surgeon’s (CPSO) notified.
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Complete three separate Biological Indicator (BI) tests in the sterilizer onsite.
  • Remove the sterilizer from the clinic site.
  • Remove all re-usable instruments from the clinic site.
  • Only Single Use Disposable (SUD) Medical equipment/devices are to be used at this clinic.
  • Surfaces, furnishings, equipment and finishes are smooth, non-porous, seamless (where possible), and cleanable.  Patient exam tables that have taped upholstery are to be re-upholstered.
  • Liquid hand soap containers are labelled and not refilled or topped up.
  • Needles are safety engineered medical sharps (SEMS).
  • Safety Data Sheets (SDS) for cleaning/disinfecting products are readily available and up to date for staff reference.
  • All garbage cans are to have covered lids.
  • An eyewash station is to be within a  10 second walk from where chemical substances will be used/managed
  • All staff are to complete IPAC core competencies course annually
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) March 11, 2021 verbal order:

  1. Stop using the sterilizer for reprocessing instruments located at 48 Sheppard Ave West office.
  2. Open any reprocessed instruments.
  3. Do not use the reprocessed instruments.

Initial Report Comments

Any Additional Comments Not applicable

Final Report

Date of Final Report posting: May 4, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken Three separate Biological Indicator (BI) tests in the sterilizer onsite was conducted and all three tested negative

Stopped use of the sterilizer, and sterilizer has been removed from the clinic site.

All re-usable instruments have been opened and removed from the clinic site.

Only Single Use Disposable (SUD) Medical equipment/devices are being used.

Patient exam tables have been re-upholstered.

One time use, labelled, disposable liquid hand soap containers are being used.

Needles are safety engineered medical sharps (SEMS).

Safety Data Sheets (SDS) for cleaning/disinfecting products are available and up to date for staff reference.

All garbage cans have covered lids.

An eyewash plumbed station is to be within a 10 second walk from where chemical substances will be used/managed has been put in place.
Date all corrective measures were confirmed to have been completed  April 16, 2021

 

Final Report Comments

Any additional comments 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) Focus Medical
1881 Yonge Street, Suite 503
Toronto, Ontario
M4S 3C4
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse November 18, 2020
Date of Initial Report posting  November 26, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of multi-use medical instruments
  • inadequate quality assurance and documentation for reprocessing
  • inappropriate workflow in reprocessing area
  • staff not trained for reprocessing activities
  • no sharps management policy/procedure

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Immediately stop using the sterilizer and all services requiring multi-use instruments until permitted by Toronto Public Health (TPH) to resume.
  • Open reprocessed items and do not reprocess until permitted by TPH.
  • Record reprocessing activities in a  log book Reprocessing area to only be used for reprocessing, designated a reprocessing area and be appropriately organized, meeting the standards of a reprocessing area (e.g. clear flow from dirty to clean).
  • Staff to be trained on reprocessing.
  • Reprocessing policy and procedures to be readily available, and in the reprocessing area.
  • Sharps management policy and procedure to be available and staff to be trained on this policy and procedure.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) A Verbal Order was issued on November 19, 2020 to immediately stop the use of the sterilizer.

Initial Report Comments

Any Additional Comments Not applicable

Final Report

Date of Final Report posting: January 5, 2021
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Verbal order was issued on November 19, 2020.
Brief description of corrective measures taken As of November 27, 2020, Toronto Public Health (TPH) verified that the clinic has complied with all recommendations. This includes:

  1. Clinic is challenging the sterilizer appropriately.
  2. All multi-use items were sterilized properly.
  3. There is a separate reprocessing area which has clear workflow from dirty to clean.
  4. Staff was trained formally on reprocessing activities.
  5. There is an appropriate sharps management policy and procedure.
Date all corrective measures were
confirmed to have been completed		 November 27, 2020

Final Report Comments

Any Additional Comments 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) White Willow Dental
1940 Eglinton Ave. East, Suite 102
Toronto  M1L 4R1
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse November 12, 2020
Date of Initial Report posting  November 26, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • use of unsterilized instruments on eight dental patients
  • inadequate quality assurance and documentation for reprocessing

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college?  Yes
Were any corrective measures recommended and/or implemented?
  • remove two unused sterilizers from premises
  • open and reprocess all multi-use items
  • maintain appropriate logs of the sterilizer for each cycle including physical indicators, chemical indicators and biological indicators
  • maintain an appropriate log for the ultrasonic process and keep this documentation separate from the sterilization process log
  • all staff trained and frequently review reprocessing policy and procedures
  • all clinic staff to annually complete the online IPAC core competencies course available on the Public Health Ontario website
  • all clinic staff with reprocessing duties including the dentists to complete online IPAC reprocessing course available on the Public Health Ontario website
Please provide further details/steps
  • notification of eight exposed patients by Toronto Public Health to complete baseline testing for HBV, HCV, and HIV, and get assessed for post-exposure prophylaxis
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • Directions provided during onsite inspection on November 18, 2020.
  • Letter of recommendation emailed November 23, 2020.

Initial Report Comments

Any Additional Comments Not applicable

Interim Report

Date of Interim Report posting: December 21, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken
  • Two unused sterilizers removed from premises.
  • New log created for the sterilizer.
  • New and separate log created for the autoclave.
  • Designated process challenge device (PCD) used for every load.
  • Written policies and procedures that are an umbrella statement referring to Public Health Ontario (PHO) Best Practices documents.
  • All staff to begin the PHO Core Competency course; to be completed and logged for six-month re-inspection review by Toronto Public Health (TPH).
  • All staff completing reprocessing duties to begin PHO Reprocessing in the community course; to be completed and logged for six-month re-inspection review by TPH.
Date all corrective measures were 
confirmed to have been completed

Interim Report Comments

Any additional comments PHO courses to be started; completion in six months

 

Final Report

Date of Final Report posting: March 15, 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 PHO courses completed

Final Report Comments

Any additional comments

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) Birchmount Dental Group
2000 Eglinton Avenue E, #3H
Scarborough, ON, M1L2M6
Type of premise/facility: (E.g. clinic, personal services setting) Dental clinic
Date Board of Health became aware of  IPAC lapse February 12, 2020
Date of Initial Report posting  February 24, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical and critical instruments
  • inadequate one-way flow in the reprocessing area
  • inadequate re-qualification of sterilizers
  • inadequate storage of clean and sterilized instruments

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) Audit conducted by Toronto Public Health (TPH) on February 14, 2020.

Items to be addressed include:

  1. Ensure all semi-critical instruments are reprocessed as per manufacturer’s instructions for use (MIFUs), including quality assurance and its documentation.
  2. Perform sterilizer re-qualification for each sterilizer on-site and each cycle used as per MIFU.
  3. Ensure there is one-way flow from dirty to clean in the reprocessing room. This was corrected during inspection.
  4. Ensure hinged instruments are reprocessed in open and unlocked positions.
  5. Ensure clean and sterilized instruments are stored securely in a manner that prevents contamination. This was corrected during inspection.

Stop performing Immediate Use Steam Sterilization (also known as Flash Sterilization).
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Not applicable

Initial Report Comments

Any Additional Comments Not applicable

Final Report

Date of Final Report posting: February 24, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken As of February 20, 2020, TPH verified compliance with February 14, 2020 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed		 February 20, 2020

Final Report Comments

Any Additional Comments 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) Scarborough Health Network Hospital – Centenary Site
2867 Ellesmere Road
Toronto, Ontario
M1E 4B9
Type of premise/facility: (E.g. clinic, personal services setting) Diagnostic imaging unit in hospital
Date Board of Health became aware of  IPAC lapse November 18, 2019
Date of Initial Report posting  February 14, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
  • noted that intravenous (IV) tubing for catscan (CT) contrast procedure was inappropriately set-up
  • possible that a section of single-use CT contrast tubing was not discarded immediately after use and that there may have been re-use of this section of tubing

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented?
  • Ensure single-use CT contrast tubing is discarded immediately after each use.
Please provide further details/steps
  • On-site visits conducted.
  • Ensure strict monitoring of trainees and new staff to ensure adherence to policies and procedures.
  • Ensure clear assignment of staff, and documentation of procedures.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Not applicable

Initial Report Comments

Any Additional Comments 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) Warden Woods Medical Centre
99 Firvalley Court
Scarborough, ON M1L1P2
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of  IPAC lapse June 10, 2019
Date of Initial Report posting  February 13, 2020
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical instruments
  • inadequate management of multi-dose vials

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Infection Prevention and Control (IPAC) Audit conducted by Toronto Public Health (TPH) on July 3, 2019 and July 10, 2019.

Items to be addressed include:

  1. Ensure all semi-critical instruments are reprocessed as per manufacturer’s instructions for use (MIFUs), including quality assurance and its documentation required related to high-level disinfection.
  2. Ensure there is one-way flow from clean to dirty in the reprocessing room.
  3. Dispose of open multi-dose vials according to MIFU.
  4. Make available appropriate personal protective equipment (PPE).
  5. Create Infection Prevention and Control (IPAC) policies/procedures based on current provincial best practices.
  6. Educate all staff on updated IPAC policies/procedures and reprocessing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) July 10, 2019 – Health Protection and Promotion Act (HPPA) Verbal Order was served.

Initial Report Comments

Any Additional Comments Not applicable

Final Report

Date of Final Report posting: February 13, 2020
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 10, 2019 – Health Protection and Promotion Act (HPPA) Verbal Order was served.
Brief description of corrective measures taken As of January 28, 2020, TPH verified compliance with July 10, 2019 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed		 January 28, 2020

Final Report Comments

Any Additional Comments 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) 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:
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) 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.

 

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