Infection Control Complaints

Policy

Category: Control of Infectious Diseases
Subject: Infection Control Complaints
Division: Health Protection
Policy Number: CA.82.01.113
Effective Date: October 1, 2015

POLICY STATEMENT

It is the policy of the Wellington-Dufferin-Guelph Public Health (WDGPH) Control of Infectious Diseases (CID) program to receive and investigate complaints regarding infection prevention and control practices in accordance with the Infection Prevention and Control Complaint Protocol, 2008.

If an infection prevention and control (IPAC) complaint is received regarding a Regulated Health Professional (RHP), CID will follow the Infection Control Complaints Regarding Regulated Health Professionals guidance document which includes conducting an on-site inspection.

CID will contact the regulatory body overseeing the RHP in question to report the complaint received. CID will cooperate with the regulatory body to which it has referred a complaint.

SCOPE

This policy applies to all WDGPH employees on the CID team, including managers, supervisors, public health nurses, and public health inspectors.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure:  CA.82.02.113 Infection Control Complaints
CA.31.02.412 Guidelines:  Infection Control Complaints Regarding Regulated Health Professionals
CA. 86.01.103 and CA. 86.02.103 Notebook Documentation
CA. 86.01.104 and CA.86.02.104 Collecting Photographic Evidence
CA. 86.01.105 and CA. 86.02.105 Documentation
Infection Prevention and Control Practices Complaint Protocol, 2008
Infection Prevention and Control Best Practices for Personal Services Settings (PIDAC, January 2009)
Infection Prevention and Control for Clinical Office Practice (PIDAC, June 2013)
Routine Practices and Additional Precautions (PIDAC, November 2012)
Environmental Cleaning for Prevention and Control of Infections (PIDAC, May 2012)

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases and Tuberculosis

APPROVED BY

Director, Health Protection 


Procedure

Category: Control of Infectious Diseases
Subject: Infection Control Complaints
Division: Health Protection Division
Procedure Number: CA.82.02.113
Effective Date: October 1, 2015

PROCEDURE

1. Assessment of complaints

When a report of a complaint is received, the information is electronically recorded in an intake assessment in Excelicare. All complaints will be investigated and assessed within 24 hours of receiving the complaint.

Control of Infectious Diseases (CID) will assess the complaint and conduct a risk assessment in accordance with Infection Prevention and Control in Personal Services Settings Protocol (as current) or Best Practices for Infection and Control Programs in Ontario: In all Health Care Settings (PIDAC, as current), and with the Infection Prevention and Control Practices Complaint Protocol (as current).

All infection prevention and control (IPAC) complaints will be investigated by CID within 24 hours of receiving the complaint. If the complaint is about a Personal Service Settings (PSS) premises routinely inspected by WDGPH, CID will conduct a site visit to follow-up on the reported complaint. If the complaint is about a PSS premises not previously known to WDGPH, CID will attempt to locate the premises and conduct an on-site complaint investigation as per the CA.82.01.102 and CA.82.02.102 Personal Service Settings Inspection.

All follow-up is to be documented in Excelicare to facilitate review by the Manager/Supervisor during the investigation.

In response to complaints, the CID team will:

  • Provide education to ensure adherence to best practices;
  • Conduct a re-inspection to ensure adherence, if necessary;
  • Conduct contact tracing and discuss risk communication strategies if a potential public health risk is identified;
  • Inform the party under investigation of the necessary corrective action needed, and the procedural consequence for non-compliance. CID, in consultation with the CID Manager and based on the findings of the risk assessment, may take corrective action including issuing an order under the Health Protection and Promotion Act (HPPA);
  • Follow-up with the complainant to inform him/her of general inspection findings; and
  • Advise the complainant that the inspection report can be obtained either electronically via WDGPH’s website and the Check Before You Choose (CBYC) disclosure website or through a freedom of information request (MFIPPA) as per current privacy legislation.
2. Infection Prevention and Control (IPAC) Complaints

If the complaint received is regarding infection prevention and control (IPAC) concerns, regardless of the setting in which the event associated with the complaint occurred (e.g., PSS, RHP service, clinical setting, etc.), CID will document the complaint and begin the investigation within 24 hours.

Complaints will be investigated as per the Infection Prevention and Control Practices Complaint Protocol (as current) under the authority of the Health Protection and Promotion ActCID will use the Best Practices for Infection Prevention and Control Programs in Ontario: In all Health Care Settings (PIDAC); Infection Prevention and Control for Clinical Office Practice (PIDAC); Cleaning, Disinfection and Sterilization of Medical Equipment/Devices (PIDAC); Environmental Cleaning for Prevention and Control of Infections (PIDAC); and/or Infection Prevention and Control Best Practices for Personal Service Settings (as current) document to assist in the complaint investigation. (See guidance document CA.31.02.412 Infection Control Complaints Regarding Regulated Health Professionals when investigating Regulated Health Professional complaints. For infection control complaints against a Regulated Health Professional, see guidance document CA.31.02.412 Infection Control Complaints Regarding Regulated Health Professionals.)

RESPONSIBILITIES

Management will:
  • Consult with the Medical Officer of Health (MOH) about potential risks to public health, and  develop a plan to mitigate risk;
  • Ensure all complaint investigations are posted on WDGPH’s website within two weeks of the identification of the infection prevention and control (IPAC) lapse as per direction by the Ministry of Health and Long-Term Care; and
  • Report to the Regulatory College (this could be done by the MOH, Manager, or PHI/PHN investigators depending on the situation and in consultation with the MOH).
Employees will:
  • Respond to and investigate IPAC complaints and report complaints to the appropriate regulatory body;
  • Conduct follow-up in the form of re-inspections, education, or orders;
  • Notify the Manager and/or Supervisor of the complaint and any infection control lapses identified during the inspection, highlighting any finding which poses a significant risk to public health or if an order under Section 13, HPPA is written;
  • Document in Excelicare evidence of hazards or infection control breaches found during investigation or inspection – this includes photographic evidence;
  • Create an infection control summary of inspection findings to be posted on the WDGPH website and provide to the Manager and/or Supervisor for approval; and
  • Follow-up with the complainant as noted in Section 1 (above).

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy CA.82.01.113 Infection Control Complaints
CA.31.02.412 Infection Control Complaints Regarding Regulated Health Professionals Guidance Document
CA.86.01.103 and CA.86.02.103 Notebook Documentation
CA.86.01.104 and CA.86.02.104 Collecting Photographic Evidence
CA.86.01.105 and CA.86.02.105 Documentation
Health Protection and Promotion Act (HPPA)
Infection Prevention and Control Practices Complaint Protocol, 2008

Infection Prevention and Control Best Practices for Personal Services Settings (PIDAC, January 2009)
Infection Prevention and Control for Clinical Office Practice (PIDAC, June 2013)
Cleaning, Disinfection and Sterilization of Medical Equipment/Devices (PIDAC) Routine Practices and Additional Precautions (PIDAC, November 2012)
Environmental Cleaning for Prevention and Control of Infections (PIDAC, May 2012)

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases and Tuberculosis

APPROVED BY

Director, Health Protection