Welland McMaster Family Health Team Infection Control Inspection


Equipment was not disinfected/being used according to the manufacturer’s instructions for use. Sterilizer was not being utilized according to manufacturer’s instructions.

Diseases resulting from similar errors in infection control may include:

  • Respiratory infections
  • Skin / soft tissue infections


Public Health Nurse
Public Health Nurse
905-980-6000 ext. 7330, toll free 1-888-505-6074

Findings and Corrective Measures

A complaint was identified from a member of the public on November 15, 2023, 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 November 16, 2023.

An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.

Corrected Issues

IssueCorrectionDate Corrected
Sterilizer cycles not verified appropriately. ORDER has been issued on November 16, 2023 to ensure compliance.Verify sterilizer cycles for each cycle. ORDER rescinded on November 23, 2023. Dec. 19, 2023
Clean supplies stored on counter adjacent to and under sink.Clean supplies are to be stored away from sink and adjacent areas. Dec. 19, 2023
Semi-critical and critical items not cleaned and disinfected appropriately.Clean and disinfect semi-critical and critical items as appropriate.Dec. 19, 2023
Policies and procedures incomplete and/or not being followed.Policies to be based on current best practices and reviewed, followed and updated on a regular basis. Dec. 19, 2023
Workers not aware of proper work safe policies.Responsible physician(s) overseeing clinic to provide information, instruction or supervision on how to work safely.Dec. 19, 2023
Sterilization record(s) and high level disinfection records not maintained and reviewed. Maintain and review sterilization and high level disinfection record(s). Dec. 19, 2023
Personal protective equipment not available at point of care and worn based on risk assessment. Personal protective equipment to be provided in various sizes at point of care and worn according to risk of exposure.Dec. 19, 2023
Disinfectants used past expiry date.Disinfectants to be used before their expiry date and discarded thereafterDec. 19, 2023
The sterilizer Manufacturer’s Instructions for Use not followedFollow the sterilizer Manufacturer’s Instructions for Use.Dec. 19, 2023
Packaged medical equipment/devices not placed in the sterilizer appropriately. Place medical equipment/devices in the sterilizer according to the Manufacturer’s Instructions for Use. Dec. 19, 2023
Sterile critical medical equipment/devices not kept in their packaging until they are needed.Store sterile critical medical equipment/devices in their packaging before useDec. 19, 2023
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 reporocessing.Dec. 19, 2023
There is no designated reprocessing area with a one-way workflow from dirty to clean. Designate an appropriate reprocessing area with a one-way workflow from dirty to clean. Nov. 23, 2023
Medical equipment/devices not packaged or labeled appropriately.Package medical equipment/devices appropriately.Nov. 23, 2023

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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