A single soiled instrument, a multi-dose vial entered with a used needle, a sterilizer that hasn't had its daily spore test — any one of these can become a bloodborne infection in a patient who came in for something routine. That is the real reason the College of Physicians & Surgeons of Alberta (CPSA) comes to community clinics and checks how they prevent infection. Most people call it an "IPC inspection." In CPSA's own language it's an IPAC practice visit / on-site assessment, and understanding what it actually is — and is not — is the first step to passing it for the right reasons.
What an IPC inspection actually is
In the Alberta community-clinic context, an "IPC inspection" is a CPSA IPAC on-site assessment — an infection prevention and control (IPAC) and medical device reprocessing (MDR) review carried out under CPSA's IPAC program. CPSA assessors regularly visit clinics to verify that they meet current best practices in IPAC and reprocessing. Where practices fall short, the physician(s) in charge can be required to undertake additional training and put resources in place to correct the gaps.
A few things it is not:
- It is not a simple pass/fail exam. The clinic sources describe a compliance review against the requirements, followed by remediation and, where needed, mandatory training — not a grade and not a one-and-done certificate. (CPSA's separate accreditation framework does use a formal meets / in-progress / does-not-meet category scheme, but that scheme is documented for NHSF accreditation, not for clinic IPAC visits.)
- It is not NHSF accreditation. Non-hospital surgical facilities go through a separate CPSA accreditation process — more on that boundary below.
- It is not a paperwork formality. Compliance is assessed through document review, direct observation of practice, and staff interviews — so a clinic that looks perfect in its binder but can't demonstrate the practice will still have findings.
The legal basis: the Health Professions Act
CPSA's authority to do any of this flows from its mandate under Alberta's Health Professions Act (HPA) to regulate the practice of medicine in the province — to license physicians, set and administer standards of practice and conduct, and, for facilities, to accredit and verify compliance.
In broad terms, practice visits and the inspection authority behind them sit within the HPA's continuing-competence and inspection provisions, and CPSA's IPAC standard of practice sets out the conduct expected of regulated members. The specific inspection powers — entering premises, examining records, copying documents, interviewing staff — and any explicit duty to cooperate are set out in the HPA and the IPAC standard of practice itself rather than in the clinic requirement documents; clinics should read those primary instruments directly for the exact wording. The point that matters here is simpler: the IPAC standard is the rule physicians are held to, not optional guidance.
Who gets inspected: clinics vs. accredited surgical facilities
This distinction matters, because the two processes are genuinely different.
The clinic IPAC program applies to CPSA regulated members practising in independently operated (non-government) medical clinics in Alberta — essentially any location where a regulated member provides services that is not a hospital and not an accredited facility. The IPAC requirements explicitly do not apply to prescribed health services that require accreditation under CPSA's bylaws.
Non-hospital surgical facilities (NHSFs) are those accredited services. They are not inspected under the clinic IPAC program — they go through CPSA NHSF accreditation instead:
- Assessed initially when the facility opens, then on a roughly four-year cycle.
- Reviewed by an assessment team doing both a desk audit and an on-site assessment.
- Non-conformances must be addressed within set windows — typically 90 days, with serious safety citations due in 30.
- Full accreditation is contingent on resolving all non-compliances.
If you run a surgical or procedural facility, the reprocessing and IPC expectations are even more exacting — our companion piece, Reprocessing & Sterilization in an NHSF, walks through that side. The rest of this article focuses on the community-clinic IPAC assessment.
What the inspection covers
CPSA frames IPAC as a multi-faceted approach. The named core domains are hand hygiene, point-of-care risk assessment, environmental cleaning and disinfection, and the reprocessing of reusable medical devices — and around those sit the administrative controls, PPE, and safe-injection practices that hold them together.
Named IPAC responsibility and written policies
A specific person has to own infection prevention and control at the clinic — either on staff or reliably on call, and properly schooled in IPAC fundamentals. This is a hard requirement, not a nice-to-have.
That person's program rests on a defined set of written, dated IPAC policies and procedures — covering hand hygiene, point-of-care risk assessment, PPE selection and use, environmental cleaning and disinfection, handling and decontamination of blood and body fluids, exposure management, immunizations, and MDR where applicable. Policies must be reviewed at least every five years, and again after any process change.
Hand hygiene
Hand hygiene draws on the 4 Moments of Hand Hygiene framework, so it has to happen at least at these four points in a patient encounter:
- The moment you approach a patient or anything in their immediate space, before you touch it.
- Just before starting a clean or aseptic task.
- As soon as there's been any exposure — or possible exposure — to blood or body fluids.
- Once you've finished with the patient or stepped away from their surroundings.
Sinks set aside for hand hygiene are required, stocked with warm running water, a plain liquid soap, and paper-towel dispensers. As for alcohol-based hand rub, the product itself is generally 60–90% alcohol carrying a Health Canada DIN or NPN — that specification comes from Health Canada's licensing norms and is spelled out in CPSA's surgical-facility (NHSF) standards rather than appearing as a line item in the clinic IPAC requirements, which simply direct that ABHR be used according to recommended procedures.
Point-of-care risk assessment
A point-of-care risk assessment must be done at first interaction with each patient — watching for communicable-disease indicators (a fever, a cough, diarrhea, vomiting, a rash, and the like) — with appropriate precautions put in place promptly.
PPE
Gloves, sterile gloves, gowns, eye protection, procedure masks, and N95 respirators (where applicable) must be readily available, correctly donned and doffed, and appropriately sized or fitted. Single-use PPE is discarded after each use; reusable items are cleaned or disinfected between uses.
Safe injection and sharps
- Needles and syringes are one patient, one procedure — never reused across patients.
- Every time a multi-dose vial is accessed, it gets a fresh needle and syringe — no exceptions.
- Multi-dose vials are disinfected with alcohol before each entry, labelled with the open date, and discarded within 28 days unless the manufacturer specifies otherwise.
- Medical sharps must be safety-engineered per provincial law.
- Sharps containers have to be the CSA-compliant kind — clearly marked, impossible to puncture or tamper with, sealable, and unable to leak — so a full one can be handled and stored safely. They're swapped out once the fill line is reached, used once (never emptied and put back into service), and dropped at the point of use rather than carried around the clinic.
Environmental cleaning and disinfection
Surfaces are cleaned and disinfected on a regular schedule and whenever visibly soiled, with clinical contact surfaces handled between patients. Disinfection only counts if the surface was physically cleaned first — you cannot disinfect over visible soil. And any disinfectant in use has to hold a Health Canada Drug Identification Number (DIN), with staff leaving it on the surface long enough to actually work — the label's wet-contact time, which commonly runs a minute to three minutes.
Medical device reprocessing
Reprocessing follows the Spaulding risk classification:
- Critical devices (entering sterile tissue) must be sterilized.
- Semi-critical devices (contacting mucous membranes) need high-level disinfection at minimum.
- Non-critical devices need cleaning plus low- or intermediate-level disinfection.
Reusable semi-critical and critical devices are reprocessed in line with CPSA's Reusable & Single-Use Medical Device Requirements and each device's manufacturer's instructions for use (MIFU) — clean first, then high-level disinfect or sterilize. CPSA's clinic MDR requirements are built on the national standard CAN/CSA-Z314-18 (2018); the current edition, Z314-23, is the basis for CPSA's NHSF standards. Either way, the CSA Z314 family explicitly applies across all health-care settings — from private offices through to large hospitals — so community clinics that reprocess are squarely in scope. Sterilizers, ultrasonic cleaners, and lasers must hold valid Health Canada medical device licences, and the relevant MIFUs must be obtained, followed, and kept on hand — a requirement that traces back to Health Canada's federal rules on manufacturer reprocessing instructions under the Medical Devices Regulations.
Why it matters
The stakes aren't abstract. At a population level, healthcare-associated infections (HAIs) are common: national acute-care surveillance has found that roughly 1 in 9 Canadian hospital patients picks up an HAI, with cited estimates of around 220,000 cases and at least 8,000 deaths a year in hospitals, and a point-prevalence survey finding about 7.9% of patients with at least one HAI.
A caveat worth stating plainly: those numbers are hospital and acute-care figures, not community-clinic rates. We cite them to frame why infection control matters — not to suggest clinics see the same incidence.
The specific risk these requirements guard against is bloodborne transmission — hepatitis B, hepatitis C, HIV — which is exactly what safe injection technique, proper sharps handling, and correct reprocessing exist to prevent. Bloodborne viruses move in more than one direction in a clinical setting: the Public Health Agency of Canada, for example, publishes a dedicated guideline on preventing transmission from infected healthcare workers to patients. The patient-directed safeguards in this article address a different pathway — protecting patients from contaminated devices, needles, and surfaces — and that pathway is the everyday business of routine IPAC practice.
And then there is professional risk. Because CPSA's authority runs through physician licensing, IPAC failures aren't just a facility problem — they attach to the regulated member responsible. Unresolved deficiencies can trigger required training, added oversight, and, in serious cases, escalation. Getting this right protects patients first, and the licence second.
What actually happens during a visit
An assessor reviews your written IPAC and MDR program, observes practice, and talks to staff. They may examine sterilizers and reprocessing equipment, ask to see policies and records, and watch how hand hygiene and a point-of-care risk assessment are actually performed. Findings are reviewed against the requirements, and anything short of meeting them comes with remediation — and, where warranted, mandatory training for the physician(s) in charge.
These reviews are active and current. CPSA's IPAC program reports that 158 clinics went through and cleared an MDR compliance review in 2025 — a concrete measure of how routine this has become.
The most common deficiencies
What inspectors keep finding clusters around documentation and quality-management gaps rather than outright bad technique. CPSA's review of 2025 MDR deficiencies surfaced recurring issues such as:
- Missing or outdated MDR policies and procedures.
- No written single-use-device policy.
- No scheduled policy review (CPSA recommends a one-year review cadence for MDR).
- Undocumented staff MDR training and competency.
- Sterilizer installation, operational, and requalification testing not performed or not recorded.
- Missing daily biological-indicator (BI) testing.
- MIFUs not accessible at the point of use.
- Incomplete sterility-assurance records and poor record retention.
The pattern is clear: most findings aren't about clinics doing the wrong thing — they're about clinics that can't prove they did the right thing. A deeper breakdown of these MDR deficiencies, with how to close each one, is in the works as a companion piece.
How to be genuinely ready — not just ready on paper
Because compliance is judged by observation and interview as much as by documents, real readiness means staff who can demonstrate, not just describe:
- Any clinician can perform the four moments of hand hygiene correctly and do a point-of-care risk assessment at first contact.
- Your named IPAC lead is identifiable, trained, and present in the program — not a name on an org chart.
- Written policies are current, dated, and match what the clinic actually does — reviewed on schedule.
- Sterilizer qualification, daily BI results, and chemical-indicator records are complete and can be produced on demand.
- The right MIFUs are findable at the point of use, and your disinfectants and devices carry the required Health Canada DINs and licences.
- There's a single-use-device policy in writing, and a way to track findings to closure so the same gap doesn't reappear next visit.
Before a visit, it is worth running your clinic against CPSA's own Self-Assessment Tool: IPAC Requirements for Medical Clinics — it mirrors what an assessor checks, so the gaps it surfaces are the ones to close first. For a step-by-step version you can work through, see our CPSA IPC inspection checklist for clinics.
How Zosimos helps
The clinics that sail through these assessments treat IPAC as a living system, not a binder they dust off before a visit. That's the gap we built our tools to close.
- PolicyHUB (our electronic policy library, launching soon) keeps your IPAC and MDR policies, SOPs, and MIFUs version-controlled, dated, and findable — with the review reminders that keep them from going stale past the required cadence.
- Compliance Tracker (also launching soon) is built to hold the records inspectors ask for: staff training and competency records, sterilizer qualification (IQ/OQ/RQ) and biological-indicator logs, MIFU libraries, review schedules, and corrective actions that you can track to closure.
We also help facilities build the program itself and run a mock IPAC/MDR review before the real one. See our CPSA IPC inspection readiness service for community clinics, or CPSA NHSF accreditation support if you operate a surgical facility — and get in touch, especially if you already have a visit on the calendar.
Zosimos is an independent company. Our tools support your readiness; they are not CPSA-endorsed, and no software guarantees compliance — that always rests on your practice and your records.
References & further reading
- CPSA — Infection Prevention and Control (IPAC) standard of practice
- CPSA — Self-Assessment Tool: IPAC Requirements for Medical Clinics (PDF)
- CPSA — Medical Clinics (Facilities & Clinics)
- CPSA — Using & Reprocessing Medical Devices (MDR)
- CPSA — Non-Hospital Surgical Facilities accreditation
- CSA Group — Reprocessing of reusable medical devices (CSA Z314 explainer)
- Public Health Ontario — Reprocessing (IPAC topic hub)
- Public Health Agency of Canada — Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings (PDF)