Report No. 009-12

TO: Chair and Members of the Board of Health
FROM: Graham L. Pollett, MD, FRCPC, Medical Officer of Health
DATE: 2012 January 19

Ministry of Labour Occupational Health and Safety Orders Compliance Progress

Recommendation

It is recommended that Report No. 009-12 re Ministry of Labour Occupational Health and Safety Orders Compliance Progress be received for information.

Introduction

At the December 2011 Board of Health meeting, staff reported on the November 9, 2011, Ministry of Labour (MOL) field visit and inspection of the Health Unit 50 King Street premises and subsequent Orders issued under the Occupational Health and Safety Act.  The following report outlines the progress to date in addressing the requirements regarding the Health Unit’s occupational health and safety infection control policy and program, as well as an update on the determination of mould and asbestos in the basement boiler room. Board of Health Report No. 127-11and the MOL inspection findings from November 9^th are attached as Appendix A. 

MOL Infection Control Policy Order and Health Unit Response

The MOL Order may be summarized as follows:

1.   Review and update infection control policy and program; ensure a review of the occupational health and safety policy occurs at least annually;

2.   Integrate a Needle Safety/Safety Engineered Medical Sharps (SEMS) component which complies with OHSA regulation 474/07 into relevant policy and directives; and further

3.   Provide written policy and procedures for the Health Unit’s existing respirator fit testing program. 

In December 2011, an action plan was initiated to bring the Health Unit into compliance with the Ministry Order. This process is expected to take about 2 to 3 months in total. Managers, staff and members of the Joint Occupational Health and Safety Committee (JOHSC) have worked collaboratively to identify infection control policies, programs and practices for updating or improvement.  Ms. Cathie Walker, Manager, Infectious Disease Team, has taken a lead role in drafting major revisions to the Health Unit’s agency wide infection control and the terms of reference for a newly-formed Infection Prevention and Control Committee (IPAC). Ms. Pat Simone, Manager, Emergency Preparedness, has taken the lead in drafting the Respirator Fit Testing Policy.

Overview of Progress to Date

1.   Administration Policy Manual & Service Area Infection Prevention and Policy, Procedures and Practices review has begun and is ongoing. Review of policies and procedures re SEMS/Needle Safety updating undertaken.

2.   Resources on requirements and leading practices in occupational infection prevention and control and SEMS/Needle Safety regulation compliance identified and shared as appropriate.

3.   Relevant Service Areas and clinic consulted regarding exceptions to the use of SEMS. No exceptions reported by Health Unit Service Areas. One independently-operated clinic using non-safety engineered needles for some vaccines at the time of the MOL field visit has procured an ample supply of SEMS.

4.   Annual review of Administration Policy Manual occupational health and safety policies initiated.

5.   Order Compliance Planning and Reporting/Tracking Tool developed.

6.   A Health Unit Infection Prevention and Control Committee (IPAC) has been formed, with staff and management membership representative of the required expertise. Reporting to Directors Committee, the IPAC links to the JOHSC, and will provide leadership, support, and guidance toward the effectiveness of infection prevention and control procedures, policies and programs.

7.   IPAC Terms of Reference drafted.

8.   Redevelopment of Administration Policy 8-050 re Infection Control drafted. The redeveloped policy will house the Health Unit’s infection prevention and control program, provide detailed procedures, assessment and audit tools and set out requirements for training, program documentation follow up protocols and the annual cycle of program review and updating.

9.   Administration Manual Respirator Fit-Testing Policy to anchor the existing fit-testing program drafted.

It is anticipated that policy development items 7, 8 and 9 listed above will be presented to Directors Committee for approval on January 25^th.

MOL Boiler Room Samples Analysis Report

The November 2011 inspection of the boiler room noted black staining on walls and potential asbestos in pipe insulation. Subsequently in December, samples were taken for mould and asbestos determination. On January 4, 2012, MOL personnel delivered the analytical report. Two types of mould were identified: Cladosporidium and Stachybotrys. Chrysotile asbestos was found in the pipe insulation samples. Orders were issued to the building owner, Middlesex County, to remediate the mould-contaminated building materials, rectify the source of water infiltration in the boiler room and put an asbestos management program in place. According to the narrative of MOL field visit, once the asbestos program is in place, a copy of the record of asbestos-containing material will be provided to the Health Unit as tenant. The Field Visit Report and the Report of Analysis are attached as Appendix B.

Conclusion

Staff has put a plan in place and made significant progress toward compliance with the MOL occupational health and safety infection control policy and program order. Changes that will provide ongoing support for management, staff and the JOHSC to continue to improve the quality of the agency’s occupational infection prevention program have been incorporated into the plan and are being implemented. It is expected that the plan, along with compliance steps completed and firm timelines for outstanding items, if any, will be provided to the MOL before February 3, 2012. A final report on the disposition of the Order will be provided to the Board ofHealth at a subsequent meeting.

Mr. Mike Sauer, Interim Manager, Occupational Health & Safety and Management Co-Chair JOHSC, will be in attendance at the January 19^th meeting to address any questions regarding this report.

Graham L. Pollett, MD, FRCPC
Medical Officer of Health

This report addresses Policy No. 8-10 re Health and Safety as outlined in the MLHU Administration Policy Manual.