Previous Infection Prevention & Control (IPAC) Investigations

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

Bathurst Walk-In Dental Centre (Initial, Interim & Final Reports)

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	Inappropriate packaging of items to be sterilized. Incomplete quality assurance of the sterilization process. Improper reprocessing of devices with lumen. Inappropriate labelling of hazardous products. Lack of alcohol-based hand rub (ABHR) dispensers available in the reprocessing area. Inconsistent use of sharps containers. Inappropriate use of single use cleaning brushes. Improper storage of medications. 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	All items to be sterilized are packaged appropriately with internal chemical indicators and in a way that they are not overlapped. Process challenge device (PCD) and Internal Chemical Indicators (CI) must be consistently used. Manufacture instructions are followed for reprocessing of devices with lumen. Disinfectant products dispensed from the original container should be labeled as per WHMIS requirements. ABHR must be available in the reprocessing area. Sharps containers must be mounted in all point of care and reprocessing areas. Single use cleaning brushes for reprocessing must be discarded after each use. Store medications according to manufacturer’s direction. 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

Bloor West Dentistry (Initial & Final Reports)

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

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

Craiglee Nursing Home (Initial & Final Reports)

Initial Report	Details
Premise/facility under investigation (name and address)	Craiglee Nursing Home 102 Craiglee Dr Toronto, Ontario M1N 2M7
Type of premise/facility: (e.g. clinic, personal services setting)	Long Term Care Home (LTCH)
Date Board of Health became aware of IPAC lapse	October 31, 2023
Date of Initial Report posting	December 6, 2023
Date of Initial Report update(s) (if applicable)	N/A
How the IPAC lapse was identified	Referral from Public Health Ontario
Summary description of the IPAC lapse	No dedicated area for reprocessing at LTCH, Improperly placed sharps bin, No dedicated handwashing sink in the service area, Inadequate and inconsistent sterilizer quality assurance testing, monitoring, and record keeping, Sterilizer not used as per Manufacturer’s Instruction of Use (MIFU), 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?	Yes
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	LTCH proactively stopped providing footcare services with instruments that had been reprocessed on-site. Sterilizer decommissioned and labelled “not for use until further notice from TPH.” LTCH plans to choose single use device (SUD) footcare instruments for when they resume footcare.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	November 9, 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:	March 21, 2024
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	N/A
Brief description of corrective measures taken	LTCH plans to choose single use device (SUD) footcare instruments for when they resume footcare.
Date all corrective measures were confirmed to have been completed	November 9, 2023

Final Report Comments	Details
Any additional comments (Do not include any personal information or personal health information)	PHO risk assessment was conducted and no further action required.

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

Dr. Leonard Jerome (Initial, Interim & Final Reports)

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	August 10 2022
Date of Initial Report update(s) (if applicable)	August 10 2022
How the IPAC lapse was identified	Other
Summary description of the IPAC lapse	Inadequate labelling of sterilization packages. Inconsistent record keeping of the sterilizer’s physical parameters. Incomplete quality assurance of the sterilization process. Sterilization was not maintained until the point of use. Dental Unit Water Lines (DUWLs) were not maintained in a sanitary manner Single use devices were reprocessed. No policies or procedures on site. 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	Sterilization packages are to be labelled with: Date of sterilization Load number Reprocessing personnel’s initials Reprocessing physical parameters must be maintained in a log for every cycle. 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. All sterilized equipment must be stored in their sterile packages until the point and time of use DUWLs must be cleaned and disinfected on a regular basis. All single use devices are to be disposed of after use, at point of care. Policies & Procedures are to be developed as per Public Health Ontario’s (PHO) Best Practices for the following: General infection prevention & control, Management of blood and body fluid spills/exposures, 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, Healthy workplace policy, which includes a clear expectation that staff do not come to work when ill, Immunization for staff, as recommended by National Advisory Committee on Immunization (NACI). 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. 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	All sterilized packages appropriately labelled. Logbook maintained with all physical parameters. A process challenge device and a control BI used every day the sterilizer is in use. Sterilized equipment is stored in sterile packages until the time of use. DUWL’s cleaned and disinfected regularly. 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

Forest Hill Institute for Aesthetic Plastic Surgery (Initial, Interim & Final Reports)

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	Sterilization was not maintained until the point of use. Single use devices were reprocessed. Inadequate labelling of sterilization packages. No manufacturer instructions for certain items and instruments available onsite. 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. Ensure labelling on reprocessed packaging includes the load number. 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. Maintain critical reusable items in sterilized packaging until point of use. 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. Provide MIFUs for brushes that are able to be reprocessed or provide a stock of single use brushes for reprocessing. 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. Ensure the reprocessing area has a one-way work flow. Send a plan on how the reprocessing room is to be set up. 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. Remove the laundry machine from the reprocessing room and relocate to another location in the clinic, to be dedicated for this purpose. 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. Do not reuse single-use devices (SUDs) or items. Ensure MIFUs are followed and staff are trained on use, reprocessing and maintenance of instruments. Provide MIFUs regarding reprocessing or single use of anesthesia masks. Follow MIFUs and recommendations in the best practices documents listed below. 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. 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	Items were reprocessed and kept in sterilization packages until point of use. Single use devices were discarded and pre-packaged single use devices were available onsite. Observed correct labelling of sterilized packages. 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.

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.

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

Hope Fertility Clinic - Central East Women’s Health (Initial, Interim & Final Reports)

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 not being 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:	October 4, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	N/A
Brief description of corrective measures taken	Dedicated reprocessing room in development, clinic continues to use single-use instruments. IPAC policies and procedures updated and reviewed by all staff. Staff completed PHO IPAC Core Competencies and Reprocessing modules.
Date all corrective measures were confirmed to have been completed	N/A

Interim Report Comments	Details
Any additional comments	TPH consultation with Public Health Ontario completed.

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:	December 22, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	N/A
Brief description of corrective measures taken	Renovation completed to include a dedicated reprocessing room with a one-way workflow. Staff completed PHO IPAC Core Competencies and Reprocessing modules.
Date all corrective measures were confirmed to have been completed	December 21, 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

Humber Dentistry (Initial, Interim & Final Reports)

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 (Do not include any personal information or personal health information)	Dental office continues work on Policies and Procedures.

Final Report	Details
Date of Final Report posting:	2023-10-20
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	N/A
Brief description of corrective measures taken	All requirements fulfilled: Sterilization cycle parameters for both autoclaves monitored and recorded continuously, BI tests done daily, and additional tests run with implants, Class V integrators placed in each steri-pouch Manual for re-processing re-usable instruments was developed and staff training provided No re-processing for single-use devices (SID) SIDs discarded immediately after use Policies and Procedures updated
Date all corrective measures were confirmed to have been completed	Re-inspection conducted on September 22, 2023

Final Report Comments	Details
Any additional comments	Investigation completed

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

Kiem Hac Nails (Initial & Final Reports)

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

Medscan Diagnostic Centres (Initial & Interim Reports)

Initial Report	Details
Premise/facility under investigation (name and address)	Medscan Diagnostic Centres 123 Rexdale Blvd, Unit #6 Toronto, Ontario M9W 1P1
Type of premise/facility: (e.g. clinic, personal services setting)	Clinic
Date Board of Health became aware of IPAC lapse	October 25 2023
Date of Initial Report posting	December 11 2023
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 room set-up, Inconsistent reprocessing record keeping, and Manufacturing Instructions For Use (MIFU) for Transvaginal Ultrasound Probes not available on-site.

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	To ensure sufficient enclosed space for reprocessing area, including flow from dirty to clean, To ensure reprocessing logs are maintained, and To ensure reprocessing is performed as per MIFUs
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	October 25, 2023 – Verbal Order November 8, 2023 – Letter of recommendation

Initial Report Comments

Details

Any additional comments

Verbal Order made under authority of Section 13(7) of the HPPA on October 22, 2023:

Stop providing any services that require High Level Disinfectant (HLD) immediately until Toronto Public Health has authorized you to resume providing these services. This includes Transvaginal Ultrasounds (TVUS).

Interim Report	Details
Date of Interim Report posting:	November 9, 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken	October 25, 2023 – Observed IPAC infractions, now observed to be in compliance on November 9 2023
Date all corrective measures were confirmed to have been completed	November 9, 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 (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

Med-Health Laboratories (Initial & Final Report)

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

Metro Central Ultrasound & Echocardiography (Initial, Interim, Second Interim & Final Report)

Initial Report	Details
Premise/facility under investigation (name and address)	Metro Central Ultrasound & Echocardiography 27 Queen St East Toronto, ON. M5C 2M6
Type of premise/facility: (E.g. clinic, personal services setting)	Ultrasound Clinic
Date Board of Health became aware of IPAC lapse	June 17, 2022
Date of Initial Report posting	July 11, 2022
Date of Initial Report update(s) (if applicable)	July 11, 2022
How the IPAC lapse was identified	Other
Summary Description of the IPAC Lapse	Notified by Ministry of Health’s Independent Healthcare Facility Branch (IHF) that transvaginal ultrasound transducers (probes) were not cleaned and disinfected as per Public Health Ontario’s Best Practices for Reprocessing.

IPAC Lapse Investigation	Results
Did the IPAC lapse involve a member of a regulatory college?	Yes
If yes, was the issue referred to the regulatory college?	Yes: College of Physicians and Surgeons of Ontario (CPSO) and College of Medical Radiation and Imaging Technologists of Ontario (CMRITO)
Were any corrective measures recommended and/or implemented?	Yes
Please provide further details/steps	Verbal Order on June 22, 2022 Letter of recommendation sent to owner June 24, 2022
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	Verbal Order made under authority of Section 13(7) of the HPPA on June 22, 2022: Stop providing any and all services and/or procedures that require multi-use medical devices that require reprocessing by either High Level Disinfectant (HLD) or sterilization, immediately until Toronto Public Health has authorized you to resume providing these services. This includes, but is not limited to, procedures such as Trans-vaginal Ultrasounds and sonohysterogram. Use only pre-packaged, sterile, single use devices in the services described in section 1 at Metro Central Ultrasound immediately, until Toronto Public Health has authorized you to resume providing service(s). Deliver service(s) using acceptable infection prevention and control practices as detailed above as corrective action required. The following recommendations were provided by TPH at the time of the audit and provided in a letter of recommendation: Clinic to use disposable Single Use Device (SUD) instruments only, where required to be sterilized or high level disinfected (eg. Single use, pre-packaged vaginal specula, sterile, single use, pre-packaged clamps, etc.) Remove all instruments from the clinic requiring reprocessing. Until further notice from TPH, immediately cease use of the sterilizer Midmark M11 UltraClave and place a sign on the sterilizer that will be provided by TPH. Once TPH allows services to resume, Transvaginal ultrasound services (TVUS) to be conducted in rooms that contain appropriate hand hygiene set up with a sink with hot and cold running water, liquid soap, and paper towel. No TVUS to be provided in room(s) without adequate hand hygiene set up. Develop and implement a step-by-step procedure reprocessing transvaginal ultrasound probes (cleaning and disinfection and rinsing and storage). Develop and implement a procedure for HLD and reprocessing maintenance, which includes testing, monitoring, documentation, and maintenance of HLD. Prior to resuming reprocessing with the sterilizer, you must obtain approval from TPH as there are specific requirements for recommissioning and ongoing quality assurance for the sterilizer. A separate dedicated room must be designated for reprocessing of TVUS probes, complete with a sink with hot and cold running water, liquid soap, paper towel. There must also be a sink dedicated for hand hygiene. There must be ample counter space to enable adequate cleaning and disinfection of the probes and space for supplies/containers and soaking containers. This room is to be for cleaning and disinfecting purposes only; this room may not be shared space for any other purpose. This area must be labelled accordingly with signage (reprocessing sinks and handwashing sink) to ensure that the 2 sinks are used appropriately. Please refer to the Ministry of Labour requirements for occupational health and safety when using chemicals as there are requirements for emergency eyewash station(s). Use single use, pre-packaged sterile sheaths for TVUS, as per the Manufacturer’s instructions for use for TVUS probes. Do not use latex condoms or gloves as a replacement option. The use of multi-use ultrasound gel is not recommended as a best practice. However, if using multi-use lubricant gel bottles due to high volume use, the multi-use ultrasound gel container/tube/bottle is to be dated when opened, and not to be used past 30 days after opening. Policies & Procedures are to be developed as per Public Health Ontario’s (PHO) Best Practices for the following: General infection prevention & control, Management of blood and body fluid spills/exposures, Prevention of blood-borne pathogens that includes a policy for hepatitis B vaccination and a record of documented immunity to hepatitis B by serology, post-exposure to blood borne pathogens, Healthy workplace policy, which includes a clear expectation that staff do not come to work when ill, Immunization for staff, as recommended by National Advisory Committee on Immunization (NACI). All Policies and Procedures are to be updated & reviewed by staff annually. A record of this is to be kept with date and staff signatures. Staff are to complete PHO IPAC Core Competencies course annually. A record of staff names and completion dates are to be kept.

Initial Report Comments	Details
Any additional comments	Ongoing consultation with Public Health Ontario to assess risk of transmission based on the information from the IHF and the clinic, as well as the observations at the clinic.

Interim Report	Details
Date of Interim Report posting:	July 13, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)	July 11, 2022
Brief description of corrective measures taken	Add to procedure for Transducer (probe) cleaning & disinfection: When to use test strips on High Level Disinfectant (HLD), what is a “pass” on the test strip (colour) When to change HLD fluid Add to Hepatitis B policy: staff to provide evidence of Hepatitis B immunity by serology Owner/Operator updated Policy & Procedures
Date all corrective measures were confirmed to have been completed	July 11, 2022

Interim Report Comments	Details
Any additional comments	Toronto Public Health notified the Ministry of Health’s Independent Health Facilities (IHF) Branch that clinic is in compliance of Public Health Ontario’s Best Practices and that the Owner/clinic may resume intracavitary ultrasound services once IHF confirms date appointments and services for intracavitary ultrasound may begin.

Second Interim Report	Details
Date of Second Interim Report posting	July 18, 2022
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed

Second Interim Report Comments	Details
Any additional comments	Public Health Ontario consultation for risk assessment concluded. No follow up required for patient lookback or notification based on outcome of provincial consultation.

Final Report	Details
Date of Final Report posting	March 2, 2023
Date of any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken
Date all corrective measures were confirmed to have been completed
Comments	All IPAC infractions that were previously noted by TPH on initial visit, were 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

Mon Sheong Home for the Aged - Downtown Location (Initial, Interim & Final Reports)

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:	November 29 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken	LTC continues to use single use footcare equipment.
Date all corrective measures were confirmed to have been completed	September 27 2023

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

Mon Sheong Scarborough Long Term Care Centre (Initial, Interim & Final Reports)

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:	November 29 2023
Date any order(s) or directive(s) were issued to the owner/operator (if applicable)
Brief description of corrective measures taken	LTC continues to use single use footcare equipment
Date all corrective measures were confirmed to have been completed	September 27 2023

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

Pinnacle Vitality Rehab (Initial, Interim & Final Reports)

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

QS Nail Salon (Initial & Interim Reports)

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

Scarborough Eye Associates (Initial Report)

Initial Report	Details
Premise/facility under investigation (name and address)	Scarborough Eye Associates 2941 Lawrence Ave E, Scarborough, ON M1P 2V6
Type of premise/facility: (e.g. clinic, personal services setting)	Eye Care Clinic
Date Board of Health became aware of IPAC lapse	October 17, 2023
Date of Initial Report posting	October 24, 2023
Date of Initial Report update(s) (if applicable)	October 24, 2023
How the IPAC lapse was identified	Other
Summary description of the IPAC lapse	Sterilizer is not tested with a Biological Indicator (BI) (in a process challenge device) each day the sterilizer is used and with each type of cycle used that day. Reprocessed and sterile packages of instruments not labelled appropriate with date processed, sterilizer used, cycle or load number. Reprocessing log of parameters (time, temperature, and pressure) not maintained.

IPAC Lapse Investigation	Results
Did the IPAC lapse involve a member of a regulatory college?	CPSO
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) Verbal Order made under authority of Section 13(7) of the HPPA on October 16, 2023: Stop the use of the sterilizer for sterilization of instruments immediately until Toronto Public Health (TPH) has authorized you to resume providing these services. Stop the use of multi-use instruments that have been reprocessed by the sterilizer until the instruments have been reprocessed in a qualified and tested sterilizer. Only Single Use Disposable (SUD) Medical instruments are to be used until further notice. Conduct 3 consecutive biological challenges for the sterilizer and provide results to TPH.
Date any order(s) or directive(s) were issued to the owners/operators (if applicable)	October 16, 2023 – Verbal HPPA sec.13 Order served. October 19, 2023 – Letter of Recommendation with directions provided to owner.

Initial Report Comments

Details

Any additional comments

As of the October 19, 2023 re-inspection, all identified IPAC infractions from the initial visit were observed to be in compliance, including the following:

Voluntary immediate move to Single-Use Disposable (SUD) Medical instruments.
Stopped use of sterilizer for reprocessing of instruments.

Sterilizer tested for quality assurance as per Toronto Public Health (TPH) direction as part of investigation, and passing results provided to TPH.

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

Sunnybrook Health Sciences Centre (Initial & Final Reports)

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	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. 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. Quality Assurance processes were reviewed by hospital Infection Prevention and Control teams. 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

Sunnybrook – Holland Orthopaedic and Arthritic Centre (Initial & Final Reports)

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	Consultation with Toronto Public Health and Public Health Ontario completed. Infection Prevention and Control and Reprocessing teams conducted an investigation, completed a root cause analysis and implemented recommendations from the root cause analysis. Infection Prevention and Control and Reprocessing teams completed an audit and shared the results with Toronto Public Health. 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