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

Initial Report

Premise/facility under investigation (name and address) Beecroft Sheppard Medical Clinic

48 Sheppard Ave West

Toronto, ON M2M 1M2

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

IPAC Lapse Investigation

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

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

Initial Report Comments

Any Additional Comments Not applicable

Final Report

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

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

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

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

Patient exam tables have been re-upholstered.

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

Needles are safety engineered medical sharps (SEMS).

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

All garbage cans have covered lids.

An eyewash plumbed station is to be within a 10 second walk from where chemical substances will be used/managed has been put in place.

Date all corrective measures were confirmed to have been completed  April 16, 2021

 

Final Report Comments

Any additional comments Not applicable

If you have any further questions, please contact:

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

Initial Report

Premise/facility under investigation (name and address) Dr. Paul Adam:

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

And

1371 Nielson Road, Suite 311
Toronto, Ontario
M1B 2Z8

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

IPAC Lapse Investigation

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

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

Initial Report Comments

Any Additional Comments

Interim Report

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

Interim Report Comments

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

Final Report

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

1) Policy and procedures have been updated.

2) All staff have been trained in infection prevention and control (IPAC) and reprocessing.

Date all corrective measures were confirmed to have been completed December 10, 2021

Final Report Comments

Any additional comments

If you have any further questions, please contact:

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