Medcare Clinics @ Niagara Square Infection Control Inspection
- Address
7555 Montrose Rd Unit E2
Niagara Falls - Services
Physician
Summary
Semi-critical and critical items not reprocessed appropriately. Order issued to cease use of sterilizer and the use of reprocessed tools.
Diseases resulting from similar errors in infection control may include:
- Blood-borne infections
- Skin / soft tissue infections
- Sexually transmitted infections
Contact
Duty Officer
Public Health Inspector
905-980-6000 ext. 7590, toll free 1-888-505-6074
inspect@niagararegion.ca
Findings and Corrective Measures
A complaint was identified from a member of the public on October 30, 2024, related to infection prevention and control concerns.
This infection prevention and control lapse involved a member of the regulatory college.
Orally corrective measures were discussed at the time of inspection.
An initial onsite investigation was conducted on October 31, 2024.
An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.
Ongoing Issues
| Issue | Correction | Last Updated |
|---|---|---|
| Personal protective equipment not available in clinic setting/at point of care. | Provide personal protective equipment at point of care. | Nov. 4, 2024 |
| Semi-critical and critical items not cleaned and disinfected appropriately. | Clean/disinfect semi-critical and critical items as appropriate. | Nov. 4, 2024 |
| Sterilization record(s) not maintained and reviewed. | Maintain and review sterilization record(s). | Nov. 7, 2024 |
| Personal protective equipment not provided at point of care/the correct size. | Personal protective equipment to be provided in various sizes and at point of care. | Nov. 7, 2024 |
| Single-use critical and semi-critical devices/equipment are being reprocessed/reused. | Single-use critical and semi-critical medical equipment/devices to be discarded immediately after use. | Nov. 7, 2024 |
| There is no written process/guidance to inspect &/or reprocess new equipment/devices prior to use. | New equipment/devices to be inspected and reprocessed according to Manfacturer’s instructions for Use. | Nov. 7, 2024 |
| Contaminated equipment/devices not separated from clean medical equipment/devices. | Contaminated equipment/devices to be kept separate from clean equipment/devices. | Nov. 7, 2024 |
| Medical equipment/devices not disassembled for cleaning and/or sterilization. | Disassemble medical equipment/devices before cleaning/disinfection. | Nov. 7, 2024 |
| Cleaning equipment (i.e. brushes) are not cleaned or disinfected. | Multi-use cleaning equipment to be cleaned and disinfected after each use. | Nov. 7, 2024 |
| Critical and semi-critical medical equipment/devices not sterilized appropriately. ORDER has been issued on October 31, 2024 to ensure compliance. | Sterilize critical and preferably semi-critical medical equipment/devices appropriately. | Nov. 7, 2024 |
| The sterilizer Manufacturer’s Instructions for Use not followed. | Follow the sterilizer Manufacturer’s Instructions for Use. | Nov. 7, 2024 |
| Qualification/Re-qualification of sterilizer on-site not done appropriately. | Qualify/re-qualify the sterilizer on-site appropriately. | Nov. 7, 2024 |
| Medical equipment/devices not packaged appropriately. | Package medical equipment/devices appropriately. | Nov. 7, 2024 |
| Medical equipment/devices not packaged to appropriately allow steam to contact all surfaces. | Package medical equipment/devices to allow steam to contact all surfaces. | Nov. 7, 2024 |
| Packages undergoing sterilization not labeled appropriately. | Label packages undergoing sterilization appropriately. | Nov. 7, 2024 |
| Chemical Indicators not used appropriately during the sterilization process. | Chemical Indicators to be used appropriately for every package undergoing sterilization. | Nov. 7, 2024 |
| Medical equipment/devices not sterilized appropriately. | Sterilize medical equipment/devices according to the Manufacturer’s Instructions for Use. | Nov. 7, 2024 |
| Sterilizer cycles not verified appropriately. | Verify sterilization record(s) for each cycle. | Nov. 7, 2024 |
| Sterilizer not tested with a Biological Indicator appropriately. | Appropriately test sterilizer with a Biological Indicator. | Nov. 7, 2024 |
| Sterilizer not tested with a control Biological Indicator appropriately. | Appropriately test sterilizer with a control Biological Indicator. | Nov. 7, 2024 |
| Medical equipment/devices undergoing sterilization not qaurentined appropriately. | Quarentine medical equipment/devices undergoing sterilization appropriately. | Nov. 7, 2024 |
| Processed packages that are contaminated not reprocessed as appropriate. | Reprocess all contaminated processed packages. | Nov. 7, 2024 |
| Chemical Indicator(s) not checked prior to using the sterilized medical equipment/devices. | Do not use sterilized medical equipment/decives until the Chemical Indicator(s) on each have been checked. | Nov. 7, 2024 |
| Processed packages not reprocessed as appropriate after a Chemical Indicator failure. | Reprocess all processed packages if a Chemical Indicator fails. | Nov. 7, 2024 |
| Reprocessed medical equipment/devices not differentiated from items requiring reprocessing. | Differentiate between reprocessing equipment and equipment requiring reprocessing. | Nov. 7, 2024 |
| No device specific training for staff in the cleaning and/or sterilization of equipment/devices. | Device specific reprocessing training for staff involved in reprocessing required. | Nov. 7, 2024 |
| Processes are not in place in the practice for receiving and disseminating medical equipment/devices alerts and recalls originating from manufacturer(s) or government agencies. | Processes are in place in the practice for receiving and disseminating medical equipment/devices alerts and recalls originating from manufacturer(s) or government agencies. | Nov. 7, 2024 |
Corrected Issues
| Issue | Correction | Date Corrected |
|---|---|---|
| Appropriate self screening signage was not found at the clinic entrance/reception desk/entrance of exam room. | Illness sreening signage is to be located at the clinic entrance, reception desk and entrance of exam rooms. | Nov. 7, 2024 |
| Medication(s) not stored or prepared in a clean area. | Store/Prepare medication(s) in a clean area. | Nov. 7, 2024 |
| Multi-dose gel containers not properly labeled and identified. | Multi-dose gel containers to be labeled appropriately. | Nov. 7, 2024 |
| Needles not safety engineered. | Needles to be safety-engineered whenever possible. | Nov. 7, 2024 |
| Written infection control policies and procedures incomplete/not available. | Infection control policies to be based on current best practices and reviewed and updated on a regular basis. | Nov. 7, 2024 |
| Staff do not receive regular education related to infection, prevention and control. | Staff to receive regular education related to infection, prevention and control. | Nov. 7, 2024 |
| Staff attendance at education and training sessions not recorded. | There is to be a process for recording staff attendance at education and training sessions. | Nov. 7, 2024 |
| Staff members storing food in patient care areas. | Do not eat/drink, store food in the client/patient care areas. | Nov. 7, 2024 |
| There is not a eating/drinking storing food smoking applying cosmetics applying lip balm handling contact lenses policy that prohibits these activities in the client/patient care areas. | Implement a policy that prohibits eating/drinking storing food smoking applying cosmetics applying lip balm handling contact lenses client/patient care areas. | Nov. 7, 2024 |
| There is no designated reprocessing area. | Designate an appropriate reprocessing area. | Nov. 7, 2024 |
| One-way workflow from dirty to clean not implemented. | Implement a one-way workflow from dirty to clean. | Nov. 7, 2024 |
| Work surfaces not sufficient to handle the volume of work. | Provide adequate work surfaces to handle the volume of work. | Nov. 7, 2024 |
| Hand washing sinks/hand sanitizer not located in or near reprocessing area(s). | Hand washing sinks/hand sanitizer to be located in or near reprocessing area(s). | Nov. 7, 2024 |
| No written policy and procedure available detailing the regular cleaning schedule of the reprocessing area. | Provide a written policy and procedure detailing the regular cleaning schedule of the reprocessing area. | Nov. 7, 2024 |
| Chemical products used for disinfection or sterilization not appropriate. | Chemical products used for disinfection and sterilization to be used as per Manfacturer’s Instructions for Use. | Nov. 7, 2024 |
| There are no contingency plans in the event of a sterilizer failure. | Contingency plans required in the event of a sterilizer failure. | Nov. 7, 2024 |
| Staff not educated, trained or certified for the level of reprocessing that occurs within the clinic setting. | Staff to receive appropriate education, training and certification in reprocessing. | Nov. 7, 2024 |
| No policies outling the requirements, frequency of education &/or training for all staff in the clinic who are responsible for reprocessing. | Records to be maintained for staff orientation,education, training and certification based on their levels of reporocessing medical equipment/devices. | Nov. 7, 2024 |
| Policies and procedures for all aspects of reprocessing are not written,current or reviewed regularly on recognized standards/recommendations/MIFU as they become available. | Written policies and procedures for all aspects of reprocessing are current and are reviewed regularly on the standards/recommendations/MIFU as they become available. | Nov. 7, 2024 |
| Chemical products used/stored on site are not appropriate. Non-critical items and treatment areas are not cleaned and disinfected appropriately. | Chemical products used/stored on site are not appropriate. Non-critical items and treatment areas are not cleaned and disinfected appropriately. | Nov. 4, 2024 |
| Surfaces/items that come into direct contact with client’s blood or body fluids not cleaned and disinfected between clients. | Surfaces/items that come into direct contact with client’s blood or body fluids to be cleaned and disinfected between use. | Nov. 4, 2024 |
Health Risks and Inspections
In the event that a direct health risk is identified for clients who visited this establishment, Niagara Region Public Health will contact those at risk with advice around any medical follow-up.
For general updates regarding this investigation, continue to monitor this website.
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