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 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 Details
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 Details
Any additional comments
Final Report Details
Date of Final Report posting August 10, 2023
Date of any order(s) or directive(s) were issued to the owner/operator (if applicable) N/A
Brief description of corrective measures taken N/A
Date all corrective measures were confirmed to have been completed  May 25, 2022
Comments Dec 5, 2022 – 6 month follow up completed.

No further action.

If you have any further questions, please contact:

Cecilia Alterman
Manager, Control of Infectious Diseases/Infection Control
Cecilia.Alterman@toronto.ca
416-338-8400

Initial Report Details
Premise/facility under investigation (name and address) Bloor West Dentistry, 2420 Bloor St West, Toronto
Type of premise/facility: (e.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of IPAC lapse November 3, 2022
Date of Initial Report posting November 23, 2022
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other: Dental Office self-reported
Summary description of the IPAC lapse Report of unsterilized dental handpieces and scaling tips used on a limited number of patients on one day due to one-time error by an office staff member.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? RCDSO
If yes, was the issue referred to the regulatory college? RCDSO notified
Were any corrective measures recommended and/or implemented? Yes, the office implemented corrective measures and notified TPH immediately for next steps.
Please provide further details/steps IPAC and Reprocessing audit conducted, including review of how staff are to verify sterilization has been completed.

Type 5 integrators added to each package prior sterilization

Staff re-trained in re-processing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) N/A
Initial Report Comments Details
Any additional comments TPH requested a risk assessment by Public Health Ontario to ascertain if patient notification is required. Report on file.

Patients’ notification letters sent Nov 23, 2022
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting: June 26, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken Dental office in compliance with all TPH recommendations
Date all corrective measures were confirmed to have been completed June 29, 2023
Final Report Comments Details
Any additional comments No known transmissions

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) 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 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. 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: March 23, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken Corrective measures implemented.

IPAC Infractions identified from initial TPH audit, now observed to be in compliance.
Date all corrective measures were confirmed to have been completed March 23 2023
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

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

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

1188B Eglinton Ave. W., Toronto, ON M6C 2E3
Type of premise/facility: (e.g. clinic, personal services setting) Plastic Surgery Clinic
Date Board of Health became aware of IPAC lapse  August 16, 2022
Date of Initial Report posting August 22, 2022
Date of Initial Report update(s) (if applicable) August 22, 2022
How the IPAC lapse was identified Referral from regulatory college
Summary description of the IPAC lapse
  1. Sterilization was not maintained until the point of use.
  2. Single use devices were reprocessed.
  3. Inadequate labelling of sterilization packages.
  4. No manufacturer instructions for certain items and instruments available onsite.
  5. Staff members not trained on IPAC policies and procedures.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? College of Physicians and Surgeons of Ontario (CPSO)
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order made under authority of Section 13(7) of the HPPA on August 18, 2022:

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

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

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

August 22, 2022 – Letter of Recommendation with directions sent to owner.
Initial Report Comments Details
Any additional comments

 

Interim Report Details
Date of Interim Report posting: August 24, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) August 18, 2022
Brief description of corrective measures taken
  1. Items were reprocessed and kept in sterilization packages until point of use.
  2. Single use devices were discarded and pre-packaged single use devices were available onsite.
  3. Observed correct labelling of sterilized packages.
  4. Single use items and instruments were purchased to replace items with no manufacturer instructions. Manufacturer instructions available onsite for these replacement items and instruments.
Date all corrective measures were confirmed to have been completed August 23, 2022
Interim Report Comments Details
Any additional comments Toronto Public Health notified the Ministry of Health and Long-Term Care and CPSO that the clinic is in compliance of Public Health Ontario’s Best Practices and that the clinic may resume normal operations as of August 23, 2022.
Interim Report Details
Date of Interim Report posting: November 9, 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken Policy and procedures have been updated and reviewed by all staff.
Date all corrective measures were
confirmed to have been completed		 October 4, 2022
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information) A re-inspection was conducted on October 4, 2022. No infractions were observed at the time of inspection.

A final inspection will be completed after clinic renovations are complete.
Final Report Details
Date of Final Report posting: May 23, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken
  • All sterilized packages appropriately labelled.
  • Logbook maintained with all physical parameters.
  • A process challenge device and a control biological indicator used every day the sterilizer is in use.
  • Sterilized equipment is stored in sterile packages until the time of use.
  • Single use devices disposed after each use.
  • Steam sterilizers replaced with a new sterilizer that has printing capabilities. All other sterilizers removed from the premises.
  • Reprocessing area renovated and has a one-way work flow.
  • Gas sterilizer removed from the premises.
  • Laundry machine removed from the reprocessing room. A dedicated laundry room is available onsite.
  • Ultrasonic cleaner sonification performance tested and logged.
  • Policy and procedures updated and reviewed by staff.
  • Staff completed PHO IPAC Core Competencies and Reprocessing modules.
Date all corrective measures were confirmed to have been completed May 23, 2023
Final Report Comments Details
Any additional comments Corrective measures implemented.

IPAC infractions identified from initial TPH audit, now observed to be in compliance.

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Hope Fertility Clinic
Type of premise/facility: (e.g. clinic, personal services setting) Clinic
Date Board of Health became aware of IPAC lapse June 23, 2023
Date of Initial Report posting August 10, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  • IPAC Best Practices for Reprocessing were not being followed:
  • Sterilizer not currently approved for use by Health Canada
  • Incomplete quality assurance of sterilizer:
    • including no daily Biological Indicators,
    • no process challenge device observed, and
    • inadequate and missing chemical indicators in sterile packages
    • inadequate documentation of sterilizer parameters
  • Inadequate pre-cleaning of instruments prior to sterilization
  • Items being not disassembled prior to reprocessing
  • Inadequate labelling and management of sterilized items
  • No dedicated reprocessing room
  • Inadequate 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? No
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Voluntary immediate move to single use devices.
  • Stopped use of sterilizer for reprocessing of instruments.
  • Sterilizer tested for quality assurance as per TPH direction as part of investigation.
  • IPAC Policies and procedures to be updated.
  • Staff to complete PHO IPAC modules.
  • TPH consultation with Public Health Ontario is ongoing.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Direction provided June 23, 2023
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Humber Dentistry

6100 Finch Ave West, Toronto
Type of premise/facility: (e.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of IPAC lapse April 3, 2023
Date of Initial Report posting April 11, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Other: Dental Office self-reported
Summary description of the IPAC lapse
  • Dental office self-reported use of unsterilized dental instruments on a limited number of patients on one day due to a reprocessing error.
  • On investigation, Toronto Public Health found that dental office was reprocessing and re-using single use devices.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? RCDSO

CDHO
If yes, was the issue referred to the regulatory college? RCDSO notified

CDHO notification pending
Were any corrective measures recommended and/or implemented? Yes.
Please provide further details/steps IPAC General and Reprocessing audits conducted, including review reprocessing quality assurance.

Toronto Public Health advised office staff to:

  • Add type 5 chemical indicators (integrators) to each package prior sterilization
  • Observe colour changes of integrators post-sterilization
  • Record physical parameters of sterilization process on log
  • Re-train staff in reprocessing
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) April 4, 2023: Sec 13 HPPA Verbal Order issued to Dentists to:

  • Stop reprocessing all single-use devices.
  • Discard immediately after use.
Initial Report Comments Details
Any additional comments Toronto Public Health has requested a Public Health Ontario Risk Assessment for next steps regarding potential for transmission of organisms.
Interim Report Details
Date of Interim Report posting: July 10, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) N/A
Brief description of corrective measures taken
  • PHO risk assessment completed, recommendations reviewed, advised owner
  • Affected client notification completed
  • Retrospective and prospective case finding for completed for 52 patients. None found at this time with available information.
Date all corrective measures were confirmed to have been completed July 10, 2023
Interim Report Comments Details
Any additional comments Any additional comments (Do not include any personal information or personal health information) Dental office continues work on Policies and Procedures.
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Kiem Hac Nails

8 Westmore Drive, Unit 1118, Toronto
Type of premise/facility: (e.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of IPAC lapse July 15, 2023
Date of Initial Report posting July 19, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  • No handwashing sink in the premises
  • No reprocessing sink in the premises
  • Manicure and pedicure instruments cleaned with soap and water in a bucket with water and not a reprocessing sink with hot and cold, running potable water
  • Manicure and pedicure instruments disinfected with expired 70% isopropyl alcohol
  • No disinfectant on site to disinfect foot bath
  • Client records not maintained
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? N/A
If yes, was the issue referred to the regulatory college? N/A
Were any corrective measures recommended and/or implemented? Yes.
Please provide further details/steps HPPA Section 13 Verbal Order served on premises owner requiring all operations on-site to immediately close.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) July 15, 2023
Initial Report Comments Details
Any additional comments On-site re-inspection to occur on July 21, 2023. Note: premises does not operate during the week.
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting: July 25, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken Owner voluntarily closed premises permanently.
Date all corrective measures were confirmed to have been completed July 21, 2023, on-site inspection conducted to confirm permanent closure of premises.
Final Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

If you have any further questions, please contact:

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

Letter of IPAC recommendations sent on August 17, 2022

Clinic to use disposable single use blood collection devices and tourniquets

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

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

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

2) Soap container must not be topped up, and

3) Alcohol Based Hand Rub (ABHR) must be available at point of care
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 4, 2022
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Final Report Details
Date of Final Report posting: November 17 2022
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken Corrective measures implemented.

IPAC Infractions identified from initial TPH audit, now observed to be in compliance.
Date all corrective measures were confirmed to have been completed November 10, 2022
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Mon Sheong Home for the Aged

36 D’Arcy Street

Toronto, Ontario

M5T 1J7
Type of premise/facility: (e.g. clinic, personal services setting) Long Term Care Home (LTCH)
Date Board of Health became aware of IPAC lapse June 12, 2023
Date of Initial Report posting June 19, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Referral from other Medical Officer of Health
Summary description of the IPAC lapse
  • Foot-care instruments not reprocessed correctly as per best practices.
  • No staff education on IPAC
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? No
Were any corrective measures recommended and/or implemented? Yes.
Please provide further details/steps
  • Facility now using single use devices for footcare.
  • Footcare sterilizer decommissioned
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) June 20, 2023
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Final Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) Mon Sheong Scarborough Long Term Care Centre

2030 McNicoll Ave

Toronto, Ontario

M1V 5P4
Type of premise/facility: (e.g. clinic, personal services setting) Long Term Care Home (LTCH)
Date Board of Health became aware of IPAC lapse June 12, 2023
Date of Initial Report posting June 20, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Other
Summary description of the IPAC lapse
  • Reprocessing of footcare instruments and Sterilizer management did not meet PIDAC best practices.
  • Inadequate labelling of sterilized instrument packages.
  • Inconsistent record keeping of the sterilizer’s physical parameters.
  • No footcare IPAC and reprocessing polices or procedures on site.
  • No footcare IPAC and reprocessing education provided to Staff
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes.
Please provide further details/steps Footcare Nurse is now using single use device footcare instruments and sterilizer has been decommissioned.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) June 12, 2023
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Final Report Comments Details
Any additional comments (Do not include any personal information or personal health information)

If you have any further questions, please contact:

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

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

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

M1S 5V9
Type of premise/facility: (e.g. clinic, personal services setting) Physiotherapy and Massage Clinic
Date Board of Health became aware of IPAC lapse January 3, 2023
Date of Initial Report posting January 18, 2023
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other: complaint
Summary description of the IPAC lapse Report of no plumbed hot and cold running water
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? CPO/CMTO
If yes, was the issue referred to the regulatory college? CPO/CMTO
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Verbal Order made under authority of Section 13(7) of the HPPA on January 18, 2022:

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

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

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

No policies or procedures onsite.

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

January 18, 2023 – Letter of Recommendation with directions sent to owner.
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting: February 7, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable) N/A
Brief description of corrective measures taken A dedicated and plumbed hand wash station with hot and cold running water was installed onsite.
Date all corrective measures were confirmed to have been completed February 3, 2023
Interim Report Comments Details
Any additional comments A re-inspection was conducted on February 3, 2023. No infractions were observed at the time of inspection.
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting: August 10, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 N/A
Brief description of corrective measures taken Policies and procedures updated.
Date all corrective measures were confirmed to have been completed July 11, 2023
Final Report Comments Details
Any additional comments N/A

If you have any further questions, please contact:

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

Initial Report Details
Premise/facility under investigation (name and address) QS Nail Salon, 75 Rylander Blvd
Type of premise/facility: (e.g. clinic, personal services setting) Personal Services Settings
Date Board of Health became aware of IPAC lapse August 31, 2023
Date of Initial Report posting September 13, 2023
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other
Summary description of the IPAC lapse No cleaning and disinfection of reusable nail tools between clients.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? N/A
Were any corrective measures recommended and/or implemented? HPPA Section 13 Order. Premises was ordered to close and operators ordered to reprocess all reusable nail tools.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 31, 2023 premises ordered to close and reprocess all reusable nail tools.
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) August 31, 2023
Brief description of corrective measures taken Reprocess all reusable nail tools by proper cleaning and disinfection.
Date all corrective measures were confirmed to have been completed September 1, 2023
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

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) Sunnybrook Health Sciences Centre

2075 Bayview Ave

M4N 3M5
Type of premise/facility: (e.g. clinic, personal services setting) Hospital
Date Board of Health became aware of IPAC lapse February 17, 2023
Date of Initial Report posting March 2, 2023
Date of Initial Report update(s) (if applicable) N/A
How the IPAC lapse was identified Other
Summary description of the IPAC lapse A limited number of surgical and procedural instruments were inadvertently put back into circulation and some re-used on patient(s) prior to adequate sterilization.
IPAC Lapse Investigation Details
Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? N/A
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Hospital Risk Assessment and Infection Prevention and Control (IPAC) teams have reviewed the processes, and have notified affected patient(s) for baseline and source bloodwork and appropriate follow up. Quality Assurance processes are being reviewed by hospital IPAC.

Joint TPH and hospital risk assessment with Public Health Ontario: February 17, 2023

TPH staff to participate in IPAC audit at the hospital regarding reprocessing and management of medical instruments.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) February 17, 2023 (directions)
Initial Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Interim Report Comments Details
Any additional comments
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting: September 6, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 February 17, 2023 (directions)
Brief description of corrective measures taken
  1. Hospital Risk Assessment and Infection Prevention and Control teams completed an investigation, reviewed the processes, completed a root cause analysis and implemented recommendations from the root cause analysis.
  2. Hospital Risk Assessment and Infection Prevention and Control teams have notified affected patient(s) for baseline and source bloodwork and appropriate follow up is completed.
  3. Quality Assurance processes were reviewed by hospital Infection Prevention and Control teams.
  4. Audit was completed by Sunnybrook Health Sciences Centre regarding reprocessing and management of medical instruments. Results were shared with Toronto Public Health.
Date all corrective measures were confirmed to have been completed May 31, 2023
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

Mahad Nur
Manager, Communicable Disease Control
Mahad.Nur@toronto.ca
416-338-1173

Initial Report Details
Premise/facility under investigation (name and address) Sunnybrook Health Sciences Centre – Holland Orthopaedic and Arthritic Centre

43 Wellesley St E, Toronto, Ontario, M4Y 1H1
Type of premise/facility: (E.g. clinic, personal services setting) Hospital
Date Board of Health became aware of IPAC lapse February 23, 2023
Date of Initial Report posting March 14, 2023
Date of Initial Report update(s) (if applicable)
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Reprocessing quality assurance failure identified for orthopaedic surgical instruments. These instruments had already been distributed and re-used in other surgical procedures at the time the failure was identified.
IPAC Lapse Investigation Results
Did the IPAC lapse involve a member of a regulatory college? None identified
If yes, was the issue referred to the regulatory college?
Were any corrective measures recommended and/or implemented? Consultation with Toronto Public Health (TPH) and Public Health Ontario (February 23, 2023)

Hospital IPAC and Reprocessing team to conduct audit and root-cause analysis, with Toronto Public Health involvement.

Hospital facilitating communication and testing of potential source patients, with support from Toronto Public Health and Public Health Ontario Laboratory.

SHSC conducted patient notification for those affected by the lapse via letter.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) February 23, 2023 (directions)
Initial Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Interim Report Details
Date of Interim Report posting:
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Brief description of corrective measures taken
Date all corrective measures were
confirmed to have been completed
Interim Report Comments Details
Any additional comments (Do not include any personal information or personal health information)
Final Report Details
Date of Final Report posting: September 1, 2023
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 February 23, 2023 (directions)
Brief description of corrective measures taken
  1. Consultation with Toronto Public Health and Public Health Ontario completed.
  2. Infection Prevention and Control and Reprocessing teams conducted an investigation, completed a root cause analysis and implemented recommendations from the root cause analysis.
  3. Infection Prevention and Control and Reprocessing teams completed an audit and shared the results with Toronto Public Health.
  4. Sunnybrook Health Sciences Centre facilitated communication and testing of potential source patients, with support from Toronto Public Health and Public Health Ontario Laboratory.
Date all corrective measures were confirmed to have been completed May 31, 2023
Final Report Comments Details
Any additional comments

If you have any further questions, please contact:

Mahad Nur
Manager, Communicable Disease Control
Mahad.Nur@toronto.ca
416-338-1173