Infection
Prevention and
Control Disclosure
Protocol, 2022
Ministry of Health
Effective: December 2022
ISBN 978-1-4868-6486-7 [PDF]
© King’s Printer for Ontario, 2022
Citation: Ontario. Ministry of Health. Infection prevention and control
disclosure protocol, 2022. Toronto, ON: King’s Printer for Ontario; 2022.
Infection Prevention and Control Disclosure Protocol, 2022
2
Preamble
The Ontario Public Health Standards: Requirements for Programs, Services, and
Accountability (Standards) are published by the Minister of Health under the authority
of section 7 of the Health Protection and Promotion Act (HPPA) to specify the
mandatory health programs and services provided by boards of health.
1,2
The
Standards identify the minimum expectations for public health programs and
services. Boards of health are accountable for implementing the Standards including
the protocols and guidelines that are referenced in the Standards. Protocols are
program and topic-specific documents incorporated into the Standards which
provide direction on how boards of health shall operationalize specific requirement(s)
identified within the Standards.
Purpose
Boards of health are required to publicly disclose (on their websites) results of all
routine infection prevention and control (IPAC) inspections of personal service
settings and licensed child care settings, in accordance with the Infection Prevention
and Control Protocol, 2018 (or as current) and complaint-based investigations where
IPAC lapses are identified, in accordance with the Infection Prevention and Control
Complaint Protocol, 2018 (or as current).
3,4
This protocol provides direction to boards of health about the online disclosure of all
IPAC routine inspections, and IPAC complaint and lapse investigations for the
following settings:
• Personal service settings as defined in section 1(1) of the HPPA;
2
and
• Licensed child care settings as defined in the Child Care and Early Years Act,
2014.
5
The disclosure requirements are also applicable to IPAC lapse investigations in
settings that are not routinely inspected, such as:
• Facilities in which regulated health professionals operate;
• Unlicensed child care settings;
• Community centres;
• Recreational facilities (including sports clubs);
Infection Prevention and Control Disclosure Protocol, 2022
3
• Schools (all levels, including public and private schools); and
• Temporary dwellings established for temporary or seasonal workers.
This does not include complaints specific to health hazards in the environment;
please refer to the Health Hazard Response Protocol, 2018 (or as current) under the
Healthy Environments Standard.
6
Note that this protocol addresses settings beyond those settings regulated as
personal service settings under O. Reg. 136/18 – Personal Service Settings under the
HPPA.
7
Boards of health should have reference to that regulation with regards to
requirements for personal service settings. The requirements as specified in this
protocol are not intended to replace any of the requirements noted for Personal
Service Settings in O. Reg. 136/18.
7
A hospital, long-term care home, or retirement home that has a public-facing PSS
(i.e., serving the general public in addition to residents of the hospital, long-term care
home, or retirement home) or operate independently are subject to the requirements
of O. Reg. 136/18 and do not qualify for an exemption under section 2(2) of O. Reg.
136/18.
7
Reference to the Standards
This section identifies the standards and requirements to which this protocol relates.
Effective Public Health Practice
Requirement 9. The board of health shall publicly disclose results of all inspections
or information in accordance with the Food Safety Protocol, 2018 (or as current); the
Health Hazard Response Protocol, 2018 (or as current); the Infection Prevention and
Control Complaint Protocol, 2018 (or as current); the Infection Prevention and Control
Disclosure Protocol, 2018 (or as current); the Infection Prevention and Control Protocol,
2018 (or as current); the Recreational Water Protocol, 2018 (or as current); the Safe
Drinking Water and Fluoride Monitoring Protocol, 2018 (or as current); the Tanning Beds
Protocol, 2018 (or as current); and the Tobacco, Vapour and Smoke Protocol, 2018 (or
as current).
Infectious and Communicable Disease Prevention and Control
Requirement 18. The board of health shall receive reports of complaints regarding
infection prevention and control practices and respond to and/or refer to appropriate
regulatory bodies, including regulatory colleges , in accordance with applicable
Infection Prevention and Control Disclosure Protocol, 2022
4
provincial legislation and in accordance with the Infection Prevention and Control
Complaint Protocol, 2018 (or as current); the Infection Prevention and Control Disclosure
Protocol, 2018 (or as current); and the Personal Service Settings Guideline, 2018 (or as
current).
Requirement 19. The board of health shall inspect and evaluate infection prevention
and control practices in personal service settings in accordance with the Infection
Prevention and Control Complaint Protocol, 2018 (or as current); the Infection
Prevention and Control Disclosure Protocol, 2018 (or as current); and the Personal
Service Settings Guideline, 2018 (or as current).
Operational Roles and
Responsibilities
Disclosure of Routine Inspection
1) The board of health shall publicly disclose a summary report of each routine
inspection in accordance with the Infection Prevention and Control Complaint
Protocol, 2018 (or as current), and the Infection Prevention and Control Protocol,
2018 (or as current).
3,4
2) Reports:
a) Shall be posted on the board of health’s website in a location that is easily
accessible by the public within two weeks of a completed inspection. Reports
must be posted for two years.
b) Shall contain the following:
i) The type of premises (and the type of services inspected for personal
service settings);
ii) The name and address of the premises;
iii) The date of the inspection;
iv) The type of inspection (e.g., routine, re-inspection, complaint);
v) Inspection status (e.g., pass/conditional/fail or presence of
critical/non-critical infractions or closure);
vi) A brief description of any corrective measures to be taken;
Infection Prevention and Control Disclosure Protocol, 2022
5
vii) A brief description of corrective measures taken (if applicable);
viii) The date all corrective measures were confirmed to be completed (if
applicable);
ix) The date(s) any order or directive was issued to the owner/operator (if
applicable); and
x) Contact information of the board of health for more information.
c) May be adapted to match the visual style of the board of health’s websites.
The board of health is encouraged to integrate the required content areas
listed below to existing disclosure programs.
d) Shall be compliant with relevant legislation, including the Accessibility for
Ontarians with Disabilities Act, 2005 (AODA), the French Language Services Act
(FLSA) (if applicable), the Municipal Freedom of Information and Protection of
Privacy Act (MFIPPA) and the Personal Health Information Protection Act, 2004
(PHIPA). No personal information or personal health information shall be
disclosed in a report.
,8,9,10,11
3) Where follow up inspections are required, the board of health shall post a
subsequent report or amend the posted report with additional information and
include the date(s) of the re-inspection(s) within two weeks from the date(s) or
earlier as needed. The board of health shall also consider the urgency of the new
relevant information, and whether a potential risk to the public exists if there is a
delay in updating the public report(s).
4) Where enforcement actions result in the issuance of tickets, summons, or
closures the board of health shall post the following information:
a) Name and address of the premises;
b) Short form wording of the ticket or summons in accordance with the Provincial
Offences Act; and
c) The date on which the ticket or summons was issued and date of conviction.
Note for personal service settings, operators are required to post the results of any
inspections conducted by public health inspectors in accordance with the public
health inspector’s request as per section 4 of O. Reg. 136/18.
7
Infection Prevention and Control Disclosure Protocol, 2022
6
Disclosure of IPAC Lapse
Investigation Reports
An IPAC lapse is defined as a failure to follow IPAC practices resulting in a risk of
transmission of infectious diseases to clients, attendees, or staff through exposure to
blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or
contaminated equipment and soiled items. IPAC practices include the most current
guidance available from the Provincial Infectious Diseases Advisory Committee,
Ontario Agency for Health Protection and Promotion (Public Health Ontario [PHO]),
the Ministry of Health, and any relevant Ontario regulatory college IPAC protocols
and guidelines.
The lapse could be identified as a result of a complaint, communicable disease
surveillance, and/or referral from a regulatory college, medical officer of health,
PHO, or the ministry.
If the board of health receives a complaint that involves regulated health
professionals and their clinic’s/office management of COVID-19, including but not
limited to masking, physical distancing (including the use of barriers), or
patient/visitor screening, as may be applicable, the board of health shall direct the
complaint to the appropriate regulatory college for direction and follow-up, and shall
notify the regulated health professional/clinic/office of the complaint.
Medical officers of health and designates may use all investigative material, including
risk assessments, to determine whether an IPAC lapse should be disclosed. If the
medical officer of health or designate does not believe that the lapse(s) would result
in an infectious disease transmission to the premises’ clients, attendees or staff,
public disclosure is not required. Decisions to post are ultimately at the discretion of
the medical officer of health or designate.
The flow chart in Appendix A identifies when an Initial or Final Report of a lapse
identified via complaint, referral or through alternate source is required to be publicly
posted.
1) Complaint-based inspections shall be disclosed when:
a) The complaint is deemed substantiated and upon conducting a risk
assessment, the public health inspector has determined that the premises
requires an on-site inspection; and
Infection Prevention and Control Disclosure Protocol, 2022
7
b) There is a risk of disease(s) transmission or an IPAC lapse has occurred.
2) The board of health shall publicly disclose the results of complaint-based
inspection and of investigation reports of IPAC lapses on the board of health’s
website, in accordance with the Infection Prevention and Control Protocol, 2018 (or
as current) and the Infection Prevention and Control Complaint Protocol, 2018 (or as
current).
3,4
3) Reports:
a) Shall be posted on the board of health’s website in a location that is easily
accessible by the public within two weeks of the inspection. Reports must be
posted for two years.
4) If the investigation involves, or is expected to involve client/patient notification,
the board of health shall ensure that an Initial Report is not posted until
preliminary client/patient notification has occurred. Should subsequent
client/patient contact and/or testing need to take place as part of the ongoing
investigation, the Final Report shall not be posted until all aspects of the
investigation have been completed.
5) The board of health shall complete and post an Initial Report: in a location that is
accessible to the public; within two weeks of the identification of an IPAC lapse;
and containing the following information:
a) The date the medical officer of health or designate was notified about the
IPAC lapse
*
and/or the date the lapse was linked to the premises;
b) Source of IPAC lapse information (e.g., complaint, communicable disease
surveillance, referral from a regulatory college, medical officer of health, PHO
or the ministry);
c) The type of premises (e.g., dental office or premises that are multi-service
such as salon/piercing/massage);
d) The address and/or name of the premises;
*
If a lapse is traced to premises from a case of a disease, this date refers to the date that the link to the
premises was confirmed.
Infection Prevention and Control Disclosure Protocol, 2022
8
e) Summary description of the IPAC lapse identified containing a concise (4-5
sentences maximum) description of the service or concern related to the
lapse. If more than one deficiency in IPAC practices is identified, the board of
health shall summarize the lapses that require corrective measures and
indicate those deficiencies that present the greatest risk of infectious disease
transmission to clients, patients, attendees, or staff of the premises;
f) Referral to a regulatory college(s) (if applicable) and other stakeholders (e.g.,
the ministry or other Ministries as applicable); and
g) A concise description of the corrective measures required to address the
lapse, including:
i) The type of corrective measure(s) (e.g., following best practices for use of
equipment; following best practices for cleaning, disinfection and
sterilization; removal of equipment; addition of new equipment);
ii) The method(s) used to correct identified deficiencies (e.g., education, verbal
or written order); and
iii) The date(s) any order or directive was issued to the
owner/operator/director (if applicable).
A report template example is provided in Appendix B. The format of reports can
be adapted to match the visual style of board of health websites. Boards of
health are encouraged to integrate the required content areas listed below into
existing public disclosure programs. All posted reports shall comply with relevant
legislation including the AODA, the FLSA (if applicable), MFIPPA, and PHIPA.
8,9,10,11
6) The board of health shall update the Initial Report as more information becomes
available during the course of an investigation to ensure transparency of the most
relevant and current information. The date of revision(s) shall be indicated on the
report. The board of health shall determine the frequency of the update(s) by
considering the urgency of the new information, and whether a potential risk to
the public exists in the event of delays.
7) The board of health shall replace the Initial Report with the Final Report in the
same location on the board of health’s website within two weeks of confirmation
that all corrective measures were taken. The Final Report for disclosure of an
IPAC lapse shall contain the following information in addition to the information
specified in the Initial Report:
Infection Prevention and Control Disclosure Protocol, 2022
9
a) A brief description of corrective measures taken, such as:
i) The type of corrective measures (e.g., following best practices for use of
equipment; following best practices for cleaning, disinfection and
sterilization; removal of equipment),
ii) The method assisting the realization of corrective measures (e.g.,
education, verbal, or written order), and
b) The date all corrective measures were confirmed to be completed.
8) The board of health shall update the Final Report in the event that any
information is found to be incorrect. The date of revision shall also be indicated
on the report.
9) The board of health shall make all archived and full investigation reports
available upon request subject to applicable law (e.g., MFIPPA/ FIPPA and
PHIPA).
8,9
10) The board of health shall establish and implement a policy to ensure that the
public can access full investigation reports upon request.
11) The board of health shall include the following preamble on the web page on
which reports are posted:
Preamble
“This website contains reports on premises where an infection prevention and
control lapse was identified through the assessment of a complaint or referral, or
through communicable disease surveillance. It does not include reports of premises
which were investigated following a complaint or referral where no infection
prevention and control lapse was ultimately identified.
These reports are not exhaustive, and do not guarantee that those premises listed
and not listed are free of infection prevention and control lapses. Identification of
lapses is based on assessment and investigation of premises at a point-in-time, and
these assessments and investigations are triggered when potential infection
prevention and control lapses are brought to the attention of the local medical
officer of health.
Reports are posted on the website of the board of health in which the premises are
located. Reports are posted on a premises-by-premises basis, i.e., will correspond
Infection Prevention and Control Disclosure Protocol, 2022
10
with one site only. Should you wish to view a full investigation report for any posted
lapse, please contact [insert appropriate contact information].”
The board of health is encouraged to consult with its legal counsel regarding the
adequacy of this preamble and whether any additional legal disclaimers are
required from their perspective.
Multi-Jurisdictional Investigation
Reports
1) In cases where an IPAC lapse is found to have occurred at a multi-site premise
(e.g., practices affiliated with one another to form a corporation, or chain of
clinics/premise), the first board of health to become aware of the lapse shall
conduct an investigation of the site within their jurisdiction, and, where possible,
confirm IPAC concerns at additional locations within the board of health
jurisdiction.
2) The board of health shall inform the ministry and PHO of the multi-jurisdictional
premises in the event that multiple locations within and/or beyond the primary
public health unit area are suspected of IPAC lapse(s).
a) PHO will coordinate multi-jurisdictional teleconference(s) and, if deemed
necessary (may be based on risk assessment), engage/inform other relevant
boards of health that have the same multi-jurisdictional premises within their
jurisdictions to follow up, as required. The ministry will provide ongoing
support as necessary.
3) The board of health shall post reports as identified above for each individual site
confirmed to be impacted by an IPAC lapse (i.e., reports are site specific and not
only posted on the primary board of health website).
Reporting to the Ministry
1) The board of health shall:
a) Report occurrences of significance (i.e., non-compliance issues leading to a
media release) to the ministry prior to media release; and
Infection Prevention and Control Disclosure Protocol, 2022
11
b) Report cases of infectious/reportable diseases and outbreaks associated
with premises through the integrated Public Health Information System
(iPHIS) or any other method specified by the ministry.
Glossary
Independent Health Facilities (IHFs): licensed by the ministry to provide Ontario
Health Insurance Plan (OHIP) insured services in diagnostic and ambulatory care
facilities. The ministry IHF program area and College of Physicians and Surgeons of
Ontario (CPSO) and the College of Midwives of Ontario (CMO) jointly manage a
Quality Assurance Program for services provided in IHFs.
Out-of-hospital premises (OHPs): premises overseen by the College of Physicians
and Surgeons of Ontario where procedures are performed under different levels of
anesthesia and sedation.
Health hazard: (a) a condition of a premises, (b) a substance, thing, plant or animal
other than man, or (c) a solid, liquid, gas or combination of any of these, that has or
that is likely to have an adverse effect on the health of any person.
Infection prevention and control (IPAC) lapse: failure to follow IPAC practices
resulting in a risk of transmission of infectious diseases to clients, attendees or staff
through exposure to blood, body fluids, secretions, excretions, mucous membranes,
non-intact skin, or contaminated equipment and soiled items.
IPAC practices: may include the most current guidance available from the Provincial
Infectious Diseases Advisory Committee, Public Health Ontario, the ministry, and any
relevant Ontario regulatory college IPAC protocols and guidelines.
Laboratories and specimen collection centres: licensed by the ministry and
accredited/inspected by the MOHLTC and/ or the Institute for Quality Management
in Health Care’s Centre for Accreditation.
Personal service settings (PSS): a premises at which personal services are offered
where there is a risk of exposure to blood or body fluids, and includes premises at
which hairdressing and barbering, tattooing, body piercing, nail services, electrolysis
and other aesthetic services are offered as defined in section 1(1) of the HPPA.
2
Risk assessment: an evaluation of the interaction of the worker, the client and the
work environment to assess and analyze the potential for exposure to infectious
Infection Prevention and Control Disclosure Protocol, 2022
12
disease, identify potential health hazards and determine the appropriate action
required.
Regulatory College: college of a health profession or group of health professions
established or continued under a health professions Act named in Schedule 1 to the
Regulated Health Professions Act, 1991.
12
Infection Prevention and Control Disclosure Protocol, 2022
13
References
1. Ontario. Ministry of Health. Ontario public health standards: requirements for
programs, services, and accountability. Toronto, ON: Queen's Printer for
Ontario; 2021. Available from:
https://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standard
s/docs/protocols_guidelines/Ontario_Public_Health_Standards_2021.pdf
2. Health Protection and Promotion Act, RSO 1990, c H.7. Available from:
https://www.ontario.ca/laws/statute/90h07
3. Ontario. Ministry of Health and Long-Term Care. Infection prevention and
control protocol, 2019. Toronto, ON: Queen's Printer for Ontario; 2019. Available
from:
https://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standard
s/docs/protocols_guidelines/Infection_Prevention_And_Control_Protocol_20
19_en.pdf
4. Ontario. Ministry of Health. Infection prevention and control complaint protocol,
2022. Toronto, ON: King's Printer for Ontario; 2022. Available from:
https://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standard
s/docs/protocols_guidelines/IPAC_Complaint_Protocol_2019_en.pdf
5. Child Care and Early Years Act, 2014, SO 2014, c 11, Sched 1. Available from:
https://www.ontario.ca/laws/statute/14c11
6. Ontario Ministry of Health and Long-Term Care. Health hazard response
protocol, 2019. Toronto, ON: Queens Printer for Ontario; 2019. Available from:
https://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standard
s/docs/protocols_guidelines/Health_Hazard_Response_Protocol_2019_en.p
df
7. Personal Service Settings. RSO 1990, O. Reg,136/18. Available from:
https://www.ontario.ca/laws/regulation/180136
8. Accessibility for Ontarians with Disabilities Act, 2005, SO 2005, c 11. Available
from: https://www.ontario.ca/laws/statute/05a11
9. French Language Services Act, RSO 1990, c F.32. Available from:
https://www.ontario.ca/laws/statute/90f32
Infection Prevention and Control Disclosure Protocol, 2022
14
10. Municipal Freedom of Information and Protection of Privacy Act, RSO 1990, c
M.56. Available from: https://www.ontario.ca/laws/statute/90m56
11. Personal Health Information Protection Act, 2004, SO 2004, c 3, Sched. A.
Available from: https://www.ontario.ca/laws/statute/04p03
12. Regulated Health Professions Act, 1991, SO 1991, c 18. Available from:
https://www.ontario.ca/laws/statute/91r18
13. Ontario. Ministry of Health and Long-Term Care. Roles and responsibilities in
community health care settings during potential infection prevention and
control lapse investigations: information for public health units and
stakeholders. Toronto, ON: Queen's Printer for Ontario; 2017
Document History
Revision Date Document Section Description of Revisions
November 2022 Entire Document New template.
November 2022 Disclos
ure of IPAC
Lapse Investigation
Reports
Added language to exempt
responding to COVID-19 IPAC lapse
complaints in settings where
regulated health professionals
operate. These complaints should be
deferred to the relevant regulatory
college for follow-up.
November 2022 Reporting to
Ministry
Removed the requirement for Boards
of Health to report section 13 health
hazard orders to the idpp@ontario.ca
email account. This information is
already collected annually as part of
standard activity reporting
requirements.
Infection Prevention and Control Disclosure Protocol, 2022
15
Appendix A: Flow of Information and
When to Post and IPAC Lapse Identified
Via a Complaint or Referral
Source of complaint / referral
Member of the public
files a complaint
regarding IPAC in any
facility with a board of
health.
A regulatory college
notifies a board of
health of a complaint
regarding IPAC in a
regulated facility.
Board of health is made aware of
potential IPAC lapse through
alternate source (e.g., other boards of
health, ministry, or communicable
disease surveillance/investigation).
Board of health receives complaint regarding a potential IPAC lapse.
Does the complaint involve an Independent Health Facility (IHF), an Out-of-hospital premise
(OHP) or Laboratories/ Specimen Collection Centres?
YES
Genetics Branch for Laboratories/ Specimen Collection Centres).
NO
YES
Does the complaint involve a member of a regulatory college?
NO
Preliminary Actions and Assessment
The board of health shall contact the appropriate regulatory college and other
stakeholders (if applicable) and undertake all steps identified in the Infection Prevention
and Control Complaint Protocol, 2018 (or as current) and the Roles and Responsibilities in
Community Health Care Settings during Potential Infection Prevention and Control Lapse
Investigations document, 2017.
4,1
The board of health shall assess the complaint as per the Infection Prevention and Control
Complaint Protocol, 2018 (or as current).
4
Investigation and Follow-Up
Does the preliminary assessment
require further investigation?
YES
NO
I
f the complaint has been
deemed unsubstantiated, the
board of health shall notify
relevant stakeholders. A
public report is not
necessary.
The board of health shall investigate the complaint as per
the Infection Prevention and Control Complaint Protocol, 2018
(or as current).
4
Boards of health requiring assistance should contact Public
Health Ontario and the ministry for support.
Was an IPAC lapse identified and
corrective measures advised/ordered?
If an IPAC lapse was identified, the board of health shall notify relevant stakeholders, complete
an Initial Report, including details of any corrective measures recommended and make this
report publicly available.
If no IPAC lapses were
identified, the board of
health shall notify relevant
stakeholders. A public
report is not necessary.
The board of health shall complete a follow-up inspection to determine whether corrective
measures were implemented. The board of health shall notify relevant stakeholders, complete
a Final Report, including details of how the IPAC lapse concerns were addressed, and make
this report publicly available.
YES
NO
Infection Prevention and Control Disclosure Protocol, 2022
16
Appendix B: Sample Initial and
Final Report Template
This is a sample template of the required Initial and Final Report that must be posted once
an IPAC lapse has been identified. This copy below is for information purposes only.
Please do not include any personal information or personal health information on this
template. If you have any question about whether information constitutes personal health
information or personal information, please consult your legal counsel.
Sample: Infection Prevention and Control Lapse Report
Public Health Unit Infection Prevention and Control Lapse
Initial Report Last Updated on:
Premise/facility under investigation
(name and address)
Type of premise/facility:
(e.g., medical clinic, multi-service PSS)
Date Board of Health became aware of
IPAC lapse
Date IPAC lapse was linked to the
premise/facility
Date of Initial Report posting
Date of Initial Report update(s) (if
applicable)
Source of IPAC lapse information (e.g.,
routine inspection, public complaint etc.)
Summary Description of the IPAC lapse
IPAC Lapse Investigation
Did the IPAC lapse involve a member of
a regulatory college?
If yes, was the issue referred to the
regulatory college?
Were other stakeholders notified? (e.g.
Ministry)
Concise description of the corrective
required
Infection Prevention and Control Disclosure Protocol, 2022
17
Please provide further details/steps
Date any order(s) or directive(s) were
issued to the owners/operators (if
applicable)
Initial Report Comments and Contact Information
Any additional comments
(Do not include any personal information
or personal health information)
If you have any further questions, please contact:
Name Title
E-mail
Address
Phone
Number
Final Report Last Updated on:
Date of Final Report posting:
Date any order(s) or directive(s) were
issued to the owners/operators (if
applicable)
Brief description of corrective measures
taken
Date all corrective measures were
confirmed to have been completed
Final Report Comments and Contact Information
Any additional comments
(Do not include any personal information
or personal health information)
If you have any further questions, please contact:
Name Title
E-mail
Addres
s
Phone
Number