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 Danielle Steinman at 416-338-8400.

Initial Report

Premise/facility under investigation (name and address) Aphrodite Aesthetic Clinic ( AAC)
3311 Bayview Ave, Unit # 101
Toronto, ON M2K 1G4
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse August 13, 2019
Date of Initial Report posting  September 19, 2019
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • Unpackaged non-sterile surgical instruments (forceps, scissors, and a haemostat), and two comedone extractors with sharps points were observed with an inadequate method of sterilization at the premises and inappropriately stored.
  • Two unpackaged non-sterile dermarollers were observed at the premises.
  • Re-usable instruments such as eyelash extension tweezers, scissors and microblading hand pieces were not adequately reprocessed between clients.
  • Unpackaged, single-use blades were not discarded into an approved sharps container immediately after use.
  • An approved sharps container was not available 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? Yes
Were any corrective measures recommended and/or implemented? On August 14, 2019 a Verbal Order under Section 13 of the Health Protection and Promotion Act was given to the owner of the premises to stop providing services that require the use of injections and sharps. All open items were discarded.
Please provide further details/steps On August 17, 2019 the Premises was re-inspected. Charges were laid under Ontario Regulation 136/18 for failing to keep clients records and not having a sharps container on-site while providing invasive services.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) August 14, 2019 Verbal Order and on August 27, 2019 Written Order served.

Initial Report Comments

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

If you have any further questions, please contact:

Name 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) Toronto Beauty Clinic
551 Wilson Heights Blvd
Toronto, ON
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse July 10, 2019
Date of Initial Report posting  September 4, 2019
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • partially used open syringes with unlicensed (Health Canada) cosmetic dermal fillers stored in the refrigerator
  • expired vial of dysport
  • tubes used for platelet rich plasma (PRP) service found without a manufacture name (unknown if Health Canada approved)

 

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? On July 10, 2019, an inspection was conducted, Verbal Order under Section 13 of Health Protection and Promotion Act (HPPA) given to the owner to:

  • Discard expired vial and unlicensed products.
  • Discard and only to use cosmetic products licenced by Health Canada.
  • Stop using PRP tubes until proven that they are licenced by Health Canada.
Please provide further details/steps Not applicable
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) July 10, 2019, Verbal Order issued.

Initial Report Comments

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

Final Report

Date of Final Report posting: September 4, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 On July 17, 2019 observed:

  • a box with sterile needles and cannula that were purchased on-line with no lot number, unknown if Health Canada approved
  • 9.5 per cent lidocaine observed with no drug identification number
  • decanting prescription medication from a larger container into smaller containers
Brief description of corrective measures taken On July 17, 2019, Verbal Order under Section 13 of HPPA given to the owner to:

  • Only use items that are confirmed to be Health Canada approved.
  • Discard and only use medications with a drug identification number.
  • Stop decanting prescription medication and keep product in the original package.
Date all corrective measures were
confirmed to have been completed		 July 26, 2019 — Visited premises and confirmed items removed from premises.

Final Report Comments

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

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Stars Beauty Salon
6055 Steeles Ave E C-129
Toronto, ON M1X 0A7
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse July 4, 2019
Date of Initial Report posting  August 13, 2019
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse Re-use of styptic Alum Crystal

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? No
Were any corrective measures recommended and/or implemented? July 5, 2019 inspection conducted.

Verbal Order under Section 13 of the Health Protection and Promotion Act (HPPA) given to the owner to stop using Alum Crystal and discard it immediately. Maintain accidental exposure records as required.
Please provide further details/steps July 10, 2019 re-inspection conducted.

Charges laid under Ontario Regulation 136/18, paragraph-4 of subsection 14 (1) for failing to maintain accidental exposure records.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) July 5, 2019.

Verbal Order under Section 13 of the HPPA.

Initial Report Comments

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

Final Report

Date of Final Report posting: August 13, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 5, 2019.

Verbal Order under Section 13 of the HPPA.
Brief description of corrective measures taken See below
Date all corrective measures were
confirmed to have been completed		 Re-inspection conducted on July 10, 2019, and premises passed inspection.

Final Report Comments

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

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

Premise/facility under investigation (name and address) Toronto Head and Neck Clinic
101-491 Eglinton Ave W
Toronto, ON
M5N 1A7
Type of premise/facility: (E.g. clinic, personal services setting) Clinic
Date Board of Health became aware of  IPAC lapse November 21, 2018
Date of Initial Report posting  June 27, 2019
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 critical and semi-critical instruments
  • inadequate reprocessing of nasopharyngeal scopes
  • inadequate quality assurance and documentation for reprocessing
  • inappropriate workflow in reprocessing area
  • inconsistent disposal of expired medication

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? No
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Stop providing services requiring multi-use instruments and scopes until permitted by TPH to resume.
  • Reprocess all scopes and semi-critical and critical instruments as per manufacturer’s instructions including reprocessing quality assurance.
  • Provide adequate flow of instruments in reprocessing area from dirty to clean to sterile.
  • Ensure occupational health and safety standards are met including available personal protective equipment and an eyewash station.
  • Discard expired medication.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order served on November 23, 2018

Letter of Recommendations – December 19, 2018

Initial Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Terminal Barber #2
150 Dundas Street West, Unit 105
Toronto, ON M5G 1C6
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse February 14, 2019
Date of Initial Report posting  February 26, 2019
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse Re-use of styptic pencil on clients

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? No
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps February 15, 2019 — Inspection conducted and operator advised not to use styptic pencil and item was removed.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) February 15, 2019

Initial Report Comments

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

Final Report

Date of Final Report posting: February 26, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 Not applicable
Brief description of corrective measures taken Re-inspection conducted and premises passed inspection.
Date all corrective measures were
confirmed to have been completed		 February 19, 2019

Final Report Comments

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

 

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
email address Cecilia.Alterman@toronto.ca
Phone number 416-338-8065

Initial Report

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

IPAC Lapse Investigation

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

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

Items to be addressed include:

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

Initial Report Comments

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

Final Report

Date of Final Report posting: July 11, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 December 20, 2018 – HPPA Verbal Order
Brief description of corrective measures taken As of July 8, 2019, TPH verified compliance with Dec 20, 2018 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed		 July 8, 2019

Final Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) SKT Jewellers & Textiles Ltd.
2062 Lawrence Ave., E
Toronto, Ontario
M1H 3H3
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of IPAC lapse December 9, 2018
Date of Initial Report posting December 21, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • unsanitary storage of an ear piercing device
  • re-use of single-use disposable adapters

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? No
Were any corrective measures recommended and/or implemented?
  • December 10, 2018 – Stop providing ear piercing services and closure.
  • December 13, 2018 – Re-inspection conducted, service closed and posted.
Please provide further details/steps
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) December 10, 2018 – Health Protection and Promotion Act (HPPA) Section 13 Verbal Order was served.

Initial Report Comments

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

Final Report

Date of Final Report posting: January 16, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 December 20, 2018 – Health Protection and Promotion Act (HPPA) Section 13 Written Order was served.
Brief description of corrective measures taken The operator discontinued ear piercing services.
Date all corrective measures were
confirmed to have been completed		 December 20, 2018

Final Report Comments

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

If you have any further questions, please contact:

Name Cecilia Alterman
Title Manager, Control of Infectious Diseases/Infection Control
Email address Cecilia.Alterman@toronto.ca
Phone number 416-338-2639

Initial Report

Premise/facility under investigation (name and address) Sherway Medical Clinic
190 Sherway Drive, Suite 417
Toronto, Ontario
M9C 5N2
Type of premise/facility: (E.g. clinic, personal services setting) Medical Clinic
Date Board of Health became aware of IPAC lapse October 12, 2018
Date of Initial Report posting  December 10, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of semi-critical instruments
  • inadequate quality assurance and documentation for reprocessing

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Stop providing services that require re-usable semi-critical and critical instruments until the sterilizer quality assurance can be verified and demonstrated to Toronto Public Health (TPH), such that TPH can approve resuming of sterilizer use.
  • Once sterilizer quality assurance is verified to TPH, instruments are to be reprocessed according to best practices prior to resuming services that require re-usable semi-critical and critical instruments.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • October 23, 2018 – Health Promotion and Protection Act (HPPA) Verbal Order was served.
  • November 14, 2018 – Letter to medical director with additional recommendations was sent.

 

Initial Report Comments

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

Final Report

Date of Final Report posting: December 10, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 No additional orders or directives served.
Brief description of corrective measures taken November 16, 2018 – Clinic has addressed and complied with Infection Prevention and Control (IPAC) requirements set out by TPH.
Date all corrective measures were
confirmed to have been completed		 November 16, 2018

Final Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Midtown Med Spa
567 Mount Pleasant Road
Toronto, M4S 2M5
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse September 19, 2018
Date of Initial Report posting  November 28, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Referral from other Medical Officer of Health
Summary Description of the IPAC Lapse
  • storing open syringes of dermal fillers
  • storing open packages of sterile items and expired items
  • unsanitary storage of sterile prepackaged items
  • use of items with no Health Canada approval

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes. Operator required to:

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

October 19, 2018 – Written Order was served.

Initial Report Comments

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

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

If you have any further questions, please contact:

Name
 Cecilia Alterman
Title
 Manager, Control of Infectious Diseases/Infection Control
Email address
 Cecilia.Alterman@toronto.ca
Phone number
 416-338-8065

Initial Report

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

 

IPAC Lapse Investigation

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

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

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

Initial Report Comments

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

Final Report

Date of Final Report posting: July 10, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 November 2, 2018 – HPPA Verbal Order
Brief description of corrective measures taken As of June 25, 2019, TPH verified compliance with Nov 2 and 14, 2018 IPAC recommendations.
Date all corrective measures were
confirmed to have been completed		 June 25, 2019

Final Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Dr. Christopher Aldridge
Family Practice and Pain Management Clinic
688 Coxwell Ave, Unit 202
Toronto, ON M4C 3B7
Type of premise/facility: (E.g. clinic, personal services setting) Family Medicine and OHP Interventional Pain Management Clinic
Date Board of Health became aware of  IPAC lapse September 10, 2018
Date of Initial Report posting  September 17, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Referral from regulatory college
Summary Description of the IPAC Lapse
  • infection Prevention and Control lapse in Interventional Pain Management Procedures (PMP) involving injections
  • failure to provide dedicated medication preparation area and dedicated (separate) hand hygiene sink
  • improper management of syringes containing medication
  • inadequate use of personal protective equipment
  • inadequate sterile technique for IPM procedures
  • inadequate hand hygiene specific for sterile procedures

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Referred to Toronto Public Health (TPH) by the Regulatory College.
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps Recommendations from Site visit on September 10, 2018:

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

Initial Report Comments

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

Final Report

Date of Final Report posting: November 14, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 See initial posting
Brief description of corrective measures taken All items corrected at time of re-inspection September 17, 2018.
Date all corrective measures were
confirmed to have been completed		 September 17, 2018

Final Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Marvin D. Obar, Dental Surgeon
2563 Eglinton Ave. West
Toronto, ON  M6M 1T3
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse July 31, 2018
Date of Initial Report posting  August 10, 2018
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • inadequate reprocessing of instruments
  • inadequate quality assurance
  • sterilization not maintained until point of use
  • inadequate routine practices and personal protective equipment use

IPAC Lapse Investigation

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

Initial Report Comments

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

Interim Report

Date of Interim Report posting: September 13, 2019
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 H.P.P.A. Section 13 Verbal Order served July 24th, 2019
Brief description of corrective measures taken Quarantine all reprocessed instruments (including high-speed and slow-speed handpieces) prior to use, until quality assurance (QA) verified. If not able to quarantine instruments prior to QA verification, insert Integrator (Class V chemical indicator (CI)) into each sterilization package prior to sterilization. Class V CI to be checked prior to storing sterile instruments prior to use, and at point of use.

Challenge sterilizer daily with a Process Challenge Device (PCD) for each day the sterilizer is in use, with a method appropriate for specified sterilizer.

Ensure integrity of sterilized packages have not been compromised, prior to use.
Date all corrective measures were 
confirmed to have been completed		 July 24, 2019

Interim Report Comments

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

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Isma Dent Dental Office
2 Thorncliffe Park Drive, Unit # 26
Toronto, Ontario
M4H 1H2
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse April 23, 2018
Date of Initial Report posting  June 20, 2018
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • maintaining items as sterile until point of use
  • inadequate quality assurance and policies related to reprocessing and infection control

 

IPAC Lapse Investigation

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

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

Initial Report Comments

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

Interim Report

Date of Interim Report posting: July 30, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)		 July 17, 2018 – Re-inspection
Brief description of corrective measures taken The items in the June 8, 2018 order are now in compliance as of Toronto Public Health’s (TPH) July 17, 2018 re-inspection.
Date all corrective measures were 
confirmed to have been completed

Interim Report Comments

Any additional comments  (Do not include any personal information or personal health information) Not applicable

Final Report

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

If you have any further questions, please contact:

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