Below are listed Infection Prevention And Control (IPAC) investigations that are older than 12 months.

Initial Report

Premise/facility under investigation (name and address) Brimley Dental Office
123 Montezuma Trail
Scarborough, ON M1V 1K4
Type of premise/facility: (E.g. clinic, personal services setting) Dental Clinic
Date Board of Health became aware of  IPAC lapse September 2, 2016
Date of Initial Report posting  November 17, 2016
Date of Initial Report update(s) (if applicable) n/a
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse
  • Inadequate reprocessing of critical instruments and devices
  • Inadequate hand hygiene performed by a dental healthcare provider between patients
  • No records documenting quality assurance testing of the Sterilizer
  • Inadequate chemical integrator (CI) used with packaged reprocessed instruments
  • No sharps containers are the point of use
  • Dental instruments and devices not stored in packages after reprocessing (eg. Dental handpieces, critical instruments, dental burs)
  • Expired healthcare products (local and topical anaesthetic) stored in patient care area with non-expired products
  • Alcohol based hand rub did not meet Health Canada standards

 

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 Recommendations include:

  • Ensure all re-usable critical instruments are reprocessed in the Sterilizer within the appropriate sterile packaging prior to use on another patient
  • Ensure quality assurance is conducted and documented on a daily basis
  • Document the reprocessing and related quality assurance
  • Ensure that where required, all chemicals used at the Premises have the required a Health Canada Drug Identification Number (DIN) and that the chemicals are appropriate for use in the healthcare setting (eg. Alcohol Based Hand Rub requires a minimum concentration of 70% alcohol)
  • Discard all expired chemicals and products used in patient care at the Premises
  • Place an approved sharps bin at point of use in any and all rooms where sharps are used, in addition to the reprocessing room
  • Ensure Infection Prevention & Control (IPAC) policies and procedures are available on site that all staff at the Premises are following IPAC best practices acceptable to the Royal College of Dental Surgeons of Ontario (RCDSO) while providing dental care
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal Order served on September 9, 2016

Written Order served on September 23, 2016

 

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) n/a

Final Report

Date of Final Report posting: February 16, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Verbal Order served on September 9, 2016

Written Order served on September 23, 2016

Brief description of corrective measures taken  As of September 9, 2016, all previously identified IPAC issues were corrected except the following:

  • Failed to ensure regular preventive maintenance, including regular cleaning schedule of the sterilizers, is performed according to manufacturer’s instructions
  • All work surfaces are to be of non-porous and cleanable material
  • Failed to ensure eye wash facilities are available wherever reprocessing is done

As of January 27, 2017, all previously identified IPAC issues were corrected except for :

  • Failed to ensure regular preventive maintenance, including regular cleaning schedule of the sterilizers, is performed according to manufacturer’s instructions
Date all corrective measures were
confirmed to have been completed
n/a

 

 Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) On January 27, 2017, TPH was informed that the outstanding item was being addressed

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) Life Labs
520 Ellesmere Road, 1st floor
Toronto, Ontario M1R 0B1
Type of premise/facility: (E.g. clinic, personal services setting) laboratory/phlebotomy services
Date Board of Health became aware of  IPAC lapse 2016/02/18
Date of Initial Report posting  2016/03/02
Date of Initial Report update(s) (if applicable) n/a
How the IPAC lapse was identified Other
Summary description of the IPAC lapse Re-use of visibly soiled blood collection tube holder for phlebotomy

 

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? n/a
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps TPH recommended Life Labs staff to:

  • discard blood collection tube holder if visibly soiled
  • follow manufacturer’s instructions for use and reprocessing of blood collection tube holders
  • review hand hygiene with staff to ensure compliance
Date any order(s) or directive(s) were issued to the owners/operators (if applicable) Verbal order issued by TPH on Feb 18, 2016

 

Initial Report Comments

Any additional comments  (Do not include any personal information or personal health information) N/a

Final Report

Date of Final Report posting: 2017/01/12
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
Verbal order issued by TPH on Feb 18, 2016
Brief description of corrective measures taken Re-inspection April 25, 2016

  • Discarding collection tube holder if visibly soiled
  • Reviewing hand hygiene with staff to ensure compliance

Re-inspection October 28, 2016

 

Date all corrective measures were
confirmed to have been completed
*April 25, 2016

*(Exception: Corporate procedure for managing blood collection tube holders

 

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) Head office required to update procedure corporately for locations, regarding following manufacturer’s instructions for reprocessing and management of blood collection tube holders.

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) North York Medical Group
704-240 Duncan Mill Road
Toronto, ON M3B 3S6
Type of premise/facility: (E.g. clinic, personal services setting) Doctor’s office
Date Board of Health became aware of  IPAC lapse August 3, 2017
Date of Initial Report posting  September 21, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Notified by the premises directly
Summary Description of the IPAC Lapse Sterilizer malfunction

 

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 Recommendations included:

  • Stop use of any re-usable sterilized instruments until sterilizer is approved for use
  • Obtain replacement sterilizer
  • Conduct quality assurance sterilizer
  • Reprocess all re-usable instruments prior to use, once sterilizer is approved or new sterilizer obtained
  • Review quality assurance program for autoclave and documentation
  • Update IPAC Policies for clinic

Provide training to staff on IPAC Best Practices

Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • August 3, 2017 – TPH verbal & email direction August 9, 2017 – TPH Letter of recommendation

 

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 21, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 See above
Brief description of corrective measures taken
  •  Sterilizer replaced
  • Quality assurance testing completed
  • Re-sterilization of all instruments to ensure sterility completed
  • Reprocessing documentation completed
  • Quality assurance program for autoclave and updated documentation completed
  • IPAC Policies for clinic completed
  • Training to staff on IPAC Best Practices (including reprocessing) completed
Date all corrective measures were
confirmed to have been completed
August 24, 2017

Final Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) No further action.

If you have any further questions, please contact:

Name 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) Universal Smile Dental Care Corp.
201-792 Kennedy Road.
Toronto, ON.  M1K 2C8
Type of premise/facility: (E.g. clinic, personal services setting) Dental Hygiene and Dentistry
Date Board of Health became aware of  IPAC lapse August 15, 2017
Date of Initial Report posting  October 6, 2017
Date of Initial Report update(s) (if applicable) Not Applicable
How the IPAC lapse was identified Complaint
Summary Description of the IPAC Lapse
  1. Absence of IPAC policies and procedure documents.
  2. Improper storage of clean dental instruments and equipment.
  3. Inadequate quality assurance testing and documentation for reprocessing.
  4. Dental instruments and devices not stored in sealed packages after reprocessing.
  5. Inability to differentiate between sterile instruments and non-sterile instruments.
  6. Expired products (eg. Formo Cresol)
  7. Dental equipment barriers not removed between each patient.
  8. Inappropriate management of biohazardous waste.

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps 1. Repackage and re-sterilize all re-usable dental instruments using IPAC Best Practices for reprocessing, including quality assurance.

  • Safely discard used single-use devices (SUDs) after each use, and not reprocess.
  • Do not reprocess any SUDs.
  • Discard all expired chemicals and products used in patient care.
  • Clearly label all chemicals and medications with name, expiry date and DIN or appropriate reference number to comply with Sections 37 and 38 of the Occupational Health and Safety Act R.S.O. 1990, CHAPTER O.1.
  • Remove all single-use barriers from dental equipment after each patient use, and then clean surfaces after each patient has left the dental operatory.
  • Dispose of all biohazardous waste in an approved biohazard waste bin.
  • Remove all food or drink from clinical areas and clinical storage areas, including the fridge used to store dental products.

2.Meet with TPH at a mutually agreeable time to discuss IPAC issues arising from the August 15, 2017 IPAC Audit conducted by TPH at the Premises.

3.Demonstrate to the satisfaction of TPH that all individuals working at the Premises are following Public Health Ontario’s (PHOs) Provincial Infectious Diseases Advisory Committee (PIDAC) IPAC Best Practice Documents.

4.Demonstrate and document to the satisfaction of TPH that all persons working at the Premises receive IPAC training upon hire and at least annually thereafter.

Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • August 15, 2017 – IPAC Audit;
  • August 15, 2017 – HPPA Section 13 verbal Order
  • August 18, 2017 – HPPA Section 13 written Order
  • August 25, 2017 – Re-inspection
  • Sept 6, 2017 – Re-inspection and Premise re-opened

 

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:  October 6, 2017
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 See initial report (above)
Brief description of corrective measures taken  As of September 6, 2017, TPH verified that all recommendations and items for which the Owner was ordered, are now in compliance for IPAC best practices.
Date all corrective measures were
confirmed to have been completed
September 6, 2017

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 and Final Report

Premise/facility under investigation (name and address) Hair Joy
4404 Bathurst St
Toronto, ON M3H 3R7
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse December 11, 2017
Date of Initial Report posting  January 9, 2017
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse On December 11, 2017, the premises was inspected in response to a complaint (skin scratch). During the inspection the following inadequate IPAC practices were observed:

  • Electric clippers used for hair styling and other client services were contaminated with hair debris potentially indicating that timely reprocessing was not performed. No clients were receiving services at the time of the inspection.
  • No records maintained for potential blood-borne infection exposures for clients who have received services at the premises.

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? No
If yes, was the issue referred to the regulatory college? Not applicable
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  • Clean and disinfect electric hair clippers after each client by removing excess hair and spraying with a disinfectant such as 70 per cent alcohol or a disinfectant that is Tuberculocidal and has a drug identification number. After reprocessing store the instruments in a sanitary manner.
  • Establish and maintain a record for clients who have had a potential exposure to a blood-borne infection while receiving services at the Premises. Potential exposures can include a cut or surface scratch. Keep this record in a secure location at the Premises. Record the date, the site of the potential exposure, the client’s name, telephone number, address and the name of the person who provided the service. Each entry in the record shall be kept on the Premises for one year and on file for at least five years.
  • Ensure that adequate infection prevention and control (IPAC) practices are used before, during and after providing services to clients at the Premises, as set out in the documents that were provided to the owner: Routine Infection Control Practices for Personal Services Settings, Blood-Borne Diseases, Hairdressing and Barbering Infection Prevention and Control, and Blood and Body Fluid Exposures In Personal Services Settings – Response Procedures.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • December 13, 2017 – Charge laid under City of Toronto By-law.
  • December 28, 2017 – Written Order was served.

Initial Report Comments

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

If you have any further questions, please contact:

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

Initial and Final Report

Premise/facility under investigation (name and address)
Xian Ni Beauty Centre
4675 Steeles Ave. East, Unit #2C13
Toronto, Ontario
M1V 4S5
Type of premise/facility: (E.g. clinic, personal services setting) Personal Services Setting
Date Board of Health became aware of  IPAC lapse March 30, 2017
Date of Initial Report posting  May 15, 2017
Date of Initial Report update(s) (if applicable) Not applicable
How the IPAC lapse was identified Other
Summary Description of the IPAC Lapse On March 30, 2017, the following inadequate infection prevention and control (IPAC) practices were observed:

  • Unpackaged single-use items including several surgical needles with threads attached, and a used needle, re-usable lancet, scissors used in invasive procedures, were deposited together inside a plastic container, containing a clear liquid. The operator advised that the clear liquid was a 70 per cent alcohol disinfectant.
  • Unpackaged suture needles with threads, unpackaged scissors used in invasive procedures and haemostats were stored loosely in plastic bags.
  • No English instructions were observed on packages of suture needles and some injectable products.
  • A preloaded syringe was observed at the workstation. No client was present.
  • Three packages of an injectable solution with an expired best before date, stored inside a work cabinet.
  • Packages of syringes did not have safety-engineered needles.

 

IPAC Lapse Investigation

Did the IPAC lapse involve a member of a regulatory college? Yes
If yes, was the issue referred to the regulatory college? Yes
Were any corrective measures recommended and/or implemented? Yes
Please provide further details/steps
  1. Immediately stop providing services that require the use of scalpels, suture needles, threads, scissors used in invasive procedures, haemostats, or injectable substances at Xianni Beauty centre located at 4675 Steeles Avenue E, Unit #2C13, Toronto, Ontario, M1V 4S5 and any other locations in the City of Toronto, until such time as they are advised by TPH that they can resume these services.
  2. Ensure that only sterile, individually packaged instruments or sterile individually packaged, single-use items are used to provide services at the premises.
  3. Ensure that all used single-use items, used to provide services at the premises are discarded immediately after each use.
  4. Ensure all reusable items, used to provide services at the premises, are cleaned and then sterilized in an approved autoclave, according to manufacturer instruction.
  5. Ensure the autoclave is spore tested on a bi-weekly basis.
  6. Ensure all items and injectable products used to provide services at the premises have the necessary Health Canada approvals.
  7. Ensure that instructions in English are available on all injectable products used to provide services at the premises.
  8. Ensure that only hollow-bore safety-engineered needles are used to provide services at the premises. Ensure that all hollow-bore non-safety-engineered needles are removed from the premises immediately.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)
  • March 30, 2017 – Verbal Order was issued.
  • March 30, 2017 – Charge laid under City of Toronto By-law.
  • April 18, 2017 – Written Order was served.

Initial Report Comments

Any Additional Comments  (Do not include any personal information or personal health information) Issue of injectable medication use was referred to Health Canada and College of Physicians and Surgeons Ontario (CPSO).

Final Report

Date of Final Report posting:  July 12, 2018
Date any order(s) or directive(s) were issued to the owner/operator
(if applicable)
 Not applicable
Brief description of corrective measures taken  All items corrected at time of re-inspection.
Date all corrective measures were confirmed to have been completed  April 1, 2017

Final Report Comments

Any additional comments  (Do not include any personal information or personal health information) April 1, 2017 – Ticket was served.

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