DCH-1293, Public Health Dental Disease ... - Michigan
|PUBLIC HEALTH DENTAL DISEASE PREVENTION PROGRAM APPLICATION |
|Michigan Department of Health and Human Services |
|PA 161: Public Dental Prevention Program |
|Request for Operation as Defined in MCL.333.16625 (2005 PA 161) |
| |New Program | |Renewal PA 161 Only | |Renewal PA 161 with Mobile Dental Facility Permit |
|Agency/Entity Name |
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|Program Name |
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|Mailing Address |
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|Counties Served |
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|Responsible Party of Agency (Required) |Contact Person (Required) |
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|Contact Person Telephone Number |Contact Person Email Address |
| | |
|Fees and Billing (Indicate Types of Reimbursement Accepted) |
| |No Compensation | |Private Pay | |Insurance (private) |
| |Medicaid | |Healthy Michigan Plan | |Other |
| |Tax-Exempt *Include Tax-Exempt ID# | | |
| |Entity Type 2 Agency NPI# (Required) | | |
| |
|Agency/Entity/Non-Profit Type (Choose Area and Description) |
| |Public | |State |
| | | |County |
| | | |District |
| | | |City |
| |Non-Profit | |Community Clinic |
| | | |Federally Qualified Health Center |
| | | |Other (Non-Profit Agency) |
| |School | |School (Pre-K – 12) |
| | | |School-Based Health Center |
| | | |School of Dentistry or Dental Hygiene |
| |Nursing Home | | |
| |Other (describe) | | |
| |
|Responsible Party of Agency Signature |
|By signing below, I agree to comply with all parts of this application. I acknowledge that all facts, statements, and answers contained in this application are true and |
|correct. In responding to the foregoing, I am not omitting any information, which might be of value to the MDHHS Oral Health Program in determining applicant |
|qualifications. I agree to cooperate with the MDHHS staff and provide the staff with any documents to verify compliance, including access to the PA 161 program to ensure|
|compliance with the PA 161 Public Dental Preventive Program. |
|Signature of Applicant |Date signed (month/date/year) |
| | |
|Print Name |Print Title |
| | |
|Describe the Unassigned Population(s) to Receive Preventive Services (Check all that apply) |
| |Patients of a Public Health Agency |
| |Patients of a Federally Qualified Health Center |
| |Patients of a Community Dental Clinic |
| |Students in a School-Based/School-Linked program |
| |Early Head Start, Head Start Students or Other Underserved Preschoolers |
| |Nursing Home Residents |
| |Assisted Living Residents |
| |Adult Foster Care Residents |
| |Native Americans |
| |Migrant Farm Workers |
| |Persons with Developmental Disabilities |
| |Juvenile Home Residents |
| |Inmates of Prison System |
| |Homeless Individuals |
| |Other (describe) | | |
| |
|Describe the Clinical Setting(s) in which the Services are to be Provided (Check all that apply) |
| |Public Health Agency | |Assisted Living | |Homeless Shelter |
| |Federally Qualified Health Center | |Adult Foster Care Facility | |Migrant Camp |
| |Community Dental Clinic | |Tribal Health Centers |
| |School | |Faith Based Organization Setting |
| |School-based/School-linked Health Center | |Juvenile Home |
| |Mobile Dentistry Facility | |Correctional Facility |
| |Head Start/Preschool Centers | |Patient Home |
| |Nursing Home | |Other (describe) | | |
| |
|Preventive Services to be Provided (Check all that apply) (Radiographs and Debridement Not Allowed) |
| |Fluoride Varnish | |Oral Health Education |
| |Pit and Fissure Sealants | |Topical Fluoride |
| |Prophylaxis | |Assessments |
| |Nutritional Counseling | |Tobacco Cessation |
| |Other Services (describe) | | |
| |
|Renewal PA 161 with mobile dental facility permit submit pages 1-5 only. |
|New Program and Renewal PA 161 only submit the following required documents |
|Required Documents: Check to Confirm Submission of the Following (See guidelines for definitions of the following) |
| |Supervision Protocol |
| |Patient Referral and Follow-up Protocol |
| |Memorandum of Agreement (MOA) with dentists or oral health agencies that will accept your referrals |
| |If sealants are performed, provide the evaluation measures that will be taken to ensure long-term retention of the sealants |
| |Child/Elder Abuse Reporting Attestation |
| |Infection Control Checklist |
| |Patient Registration/Application Form |
| |Patient Health History |
| |HIPAA Privacy Notice |
| |Parent/Guardian Permission Slip/Consent Form |
| |Evidence of non-profit status. Must include current Articles of Incorporation from the state of Michigan (if not a local public health department. |
| |Proof of general liability insurance covering the PA 161 Project is required |
|Send complete PA 161 Public Dental Prevention Program Application including all supporting documents to: |
|Michigan Department of Health and Human Services, Oral Health Program |
|Attention: PA 161 |
|PO Box 30195 |
|Lansing, MI 48909 |
|For more information contact the MDHHS Oral Health Program at: MDCH-MobileDentistry@. |
|Authority: MCL.333.16625 (2005 PA 161). |
|Completion: Is voluntary, but is necessary to become a PA 161 Dental Prevention Program. |
|Consequences: Incomplete application submission will delay application process and may result in non-approval of PA 161 Program. |
|Michigan Department of Health and Human Services is an Equal opportunity employer |The Michigan Department of Health and Human Services (MDHHS) does not discriminate |
|services and programs provider. |against any individual or group because of race, religion, age, national origin, |
| |color, height, weight, marital status, genetic information, sex, sexual orientation,|
| |gender identity or expression, political beliefs or disability. |
|For MDHHS Official Use Only |
|Agency/Entity Name |Date Received | | |
| | | Approved | Not Approved |
|Approval Date |Expiration Date |
| | |
|Rationale |
| |
|Signature and Title |Date |
| | |
| |
|Supervision for PA 161 Program: The Supervision of the Registered Dental Hygienist Must Satisfy the Following |
| |Continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health |
| |professional. |
| |The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to |
| |the supervised individual to review records, and to further educate the supervised individual in the performance of the individual’s functions. |
| |The provision by the licensed supervising health professional of predetermined procedures and drug protocol. |
| |Supervision per PA 289 of 2012: dental assistants assigned by the supervising dentist can be used to assist the dental hygienist in certain circumstances. |
|Supervision Acknowledgement (One per dental hygienist or dental assistant under signature of supervising dentist) |
|Note: Please read and discuss the following statements with each dental hygienist and dental assistance you supervise for the |
|PA. 161 Program. A supervisor acknowledgement form is required for each dental hygienist or dental assistant. Please check boxes. |
| |A dental hygienist can only administer anesthesia and nitrous oxide analgesia or perform soft tissue curettage under the direct supervision of a dentist. This is |
| |NOT PA 161 activity. |
| |If special populations are the focus of care, providers are encouraged to have current CPR certification and continuing education regarding the provisions of dental|
| |care for these populations (i.e. geriatrics and special needs populations for long-term facilities; behavioral management and sealant placement courses for school |
| |settings, etc.). |
| |If a patient resides in a long-term care facility, a physician’s order for dental services is required for beneficiaries. The order cannot be a standing order. |
| |Standard infection control protocols will be adhered to for all services and locations. |
| |PA 161 Programs will be monitored for quality assurance and compliance. The MDHHS Oral Health Program may conduct record audits, perform site visits, request other |
| |quality assurance data such as sealant retention data and patient referral documentation, and notify the Michigan Board of Dentistry of the findings. |
| |The MDHHS Oral Health Program must be notified of any information changes within 30 days of the change. Changes to services, supervising dentists, dental hygienists|
| |and dental assistants need to be submitted on the change notification form. |
| |The PA 161 Program must be renewed every two years. It is the responsibility of the approved program to submit the new application. |
| |The supervising dentist should reside in Michigan or have an active volunteer license in the state of Michigan. |
| |A supervising dentist may supervise no more than a combined total 25 dental hygienists or dental assistants during a scheduled PA 161 activity. |
| |We have reviewed the Data Report form and agree to submission of the form, as indicated. |
| |We understand that this is a PREVENTION ONLY program. The hygienist can only provide preventive services and an oral assessment Codes: D0191, D1110, D1120, D1206, |
| |D1351. Radiographs are NOT permitted under PA 161. PA 161 patients are NOT assigned by a dentist. |
|As supervising dentist for this PA 161 Program, I certify that I have read and reviewed with the following dental hygienist/dental assistant the above protocols in |
|relation to our PA 161 Program. |
|PA 161 Program Name (print) |
| |
|Supervising Dentist (print) |Signature of Supervising Dentist |Date |
| | | |
|Dental Hygienist/Assistant Name (print) |Signature of Dental Hygienist/Assistant |Date |
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|Provider List |
|You are required to notify the MDHHS Oral Health Program of any changes in staff, supervision or services listed on the original application within 30 days. The |
|supervising dentist must formally sign the Change Notification form for stating that he/she agrees to supervise additional staff or state any changes to the original |
|application. An original signature must be submitted, blue ink, no faxes or Emails. Names, Individual NPI number and license numbers are required for additional staff |
|(except for assistants). |
|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
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|Name (Print) |Title |Email Address |Telephone Number |License Number |
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|Address (Number, Street, City, State and Zip Code) |NPI Number |
| | |
|Add an additional page with supervising dentist, dental hygienist, and dental assistant signatures, if necessary. All signatures must be original (not photocopied). |
|Faxed copies are not allowed. |
|Supervision Protocol |
|Supervising Dentist Role: The supervising dentist shall oversee or participate with the PA 161 hygienist(s) by performing the following functions: |
|a. |Continues communication in person, or by radio, telephone, or telecommunication with the PA 161 licensed dental hygienist(s). |
|b. |Participates in regularly scheduled reviews of the practice of the supervised PA 161 dental hygienist(s) in the permanence of their functions. |
|c. |Reviews with the PA 161 hygienist(s) predetermined procedures allowable in the program and drug protocols. |
|Instructions: In the space below described the role and nature of the supervising dentist(s) in the above areas. If appropriate, describe the difference in role for |
|different settings, such as fixed dental clinic versus mobile dental location. A protocol can be attached to the application instead of entering information in the |
|spaces below as long as it addresses each question. |
|Describe communication between the supervising dentist(s) and the PA 161 hygienist(s): |
| |
|Describe how often the supervising dentist(s) is available for consultation and reviews records of the PA 161 hygienist(s) activity: |
| |
|Describe the predetermined preventive procedures allowable for the PA 161 hygienist(s) and drug protocols: |
| |
|Patient Referral and Follow-Up Protocol |
|Instructions: In the space below described the specific referral protocol for all patients seen by the PA 161 Program providers. If appropriate, describe the difference |
|in role for different settings, such as fixed dental clinic versus mobile dental location. A protocol can be attached to the application instead of entering information |
|in the spaces below as long as it addresses each question. |
|Describe how the patient will be referred for emergency dental services: |
| |
|Describe how the patient will be counseled to seek an annual examination by a licensed dentist: |
| |
|Describe the follow-up mechanism that is in place to determine if the patient has received dental services following referral: |
| |
|Describe emergency after hour protocol for patients who were seen, but have an emergency after hours: |
| |
|Sealant Retention Protocol |
|If sealants are performed, provide the evaluation measures that will be taken to ensure long-term retention of the sealants. Describe the process of when or how often |
|sealants will be checked following their placement and the percentage of success you expect. |
|Instructions: In the space below describe the evaluation of sealant retention. A protocol can be attached to the application instead of entering information in the |
|spaces below as long as it addresses each question. |
|Which subsequent visits and how frequently will retention checks be conducted? Please describe: |
| |
|Sealant retention rates will be monitored with which retention goal percentage? Please describe: |
| |
|Describe the protocol if sealants are missing/lost: |
| |
|Public Dental Prevention Program PA 161 – Child Abuse & Neglect Reporting |
|Purpose: To protect children from child abuse and neglect. |
|The Children’s Protective Services (CPS) program is responsible for investigating allegations of child abuse and neglect. The Michigan Child Protection Law provides the |
|framework for what CPS must do. |
|Child Abuse: Harm or threatened harm to a child's health or welfare that occurs through nonaccidental physical or mental injury, sexual abuse, sexual exploitation, or |
|maltreatment, by a parent, a legal guardian, or any other person responsible for the child's health or welfare or by a teacher, a teacher's aide, or a member of the |
|clergy. |
|Child Neglect: Harm or threatened harm to a child's health or welfare by a parent, legal guardian, or any other person responsible for the child's health or welfare that|
|occurs through either of the following: |
|(i) Negligent treatment, including the failure to provide adequate food, clothing, shelter, or medical care. |
|(ii) Placing a child at an unreasonable risk to the child’s health or welfare by failure of the parent, legal guardian, or other person responsible for the child’s |
|health or welfare to intervene to eliminate that risk when that person is able to do so and has, or should have, knowledge of the risk. |
|Reporting Abuse & Neglect |
|Anyone, including a child, who suspects child abuse or neglect, can make a report by calling: 855-444-3911. In addition, the Child Protection Law requires certain |
|professional to report suspected child abuse or neglect. |
|The following link is a guide with more information and a model to customize and adapt, as needed, based on local resources and needs: |
| or visit mdhhs, Adult & Children’s Services, Abuse & Neglect, Keeping Kids Safe, Mandated |
|Reporters, and under Resources find: DHS-Pub-112, Mandated Reporters’ Resource Guide. If the document cannot be accessed, or for further information, contact your local |
|Michigan Department of Health and Human Services office. |
|Child Abuse & Neglect Reporting |
|Each PA 161 program must read and sign below, attesting they have a protocol in place regarding mandated child abuse and neglect reporting. |
|As a PA 161 program, we are aware of the above information and have reviewed the above-referenced information from the Michigan Department of Health and Human Services. |
|Agency/Entity Name |
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|PA 161 Program Name |
| |
|Mailing Address |
| |
|Contact Person (print) |Contact Person Telephone Number |Contact Person Email Address |
| | | |
|Responsible Party (print) |Responsible Party Signature |Date |
| | | |
|Public Dental Prevention Program PA 161 – Elderly Abuse Reporting |
|Purpose: To protect elderly from abuse and neglect. |
|Adult Protective Services investigators protect vulnerable adults from abuse, neglect and exploitation by coordinating with mental health, public health, law |
|enforcement, the probate courts, the aging network, community groups and the general public. |
|Definition of Elderly Abuse & Neglect: |
|Vulnerable: A condition in which an adult is unable to protect himself or herself from abuse, neglect, or exploitation because of a mental or physical impairment or |
|advanced age. |
|Abuse: Harm or threatened harm to an adult’s health or welfare caused by another person. Abuse includes, but is not limited to, nonaccidental physical or mental injury, |
|sexual abuse, or maltreatment. Abuse may be physical, sexual or emotional. |
|Neglect: Harm to an adult’s health or welfare caused by the inability of the adult to respond to a harmful situation (self-neglect) or the conduct of a person who |
|assumes responsibility for a significant aspect of the adult’s health or welfare. Neglect includes the failure to provide adequate food, clothing, shelter, or medical |
|care. |
|Exploitation: Misuse of an adult’s funds, property, or personal dignity by another person. |
|Reporting Abuse & Neglect: |
|If you are a part of a health care services professions, you may have a legal obligation to report any suspicions regarding vulnerable adults who you believe have been |
|harmed or are at risk of harm from abuse, neglect or exploitation. To make a report, call 855-444-3911 anytime day or night to make a report. Staff will investigate |
|allegations within 24 hours after the report is received. |
|The following link is a guide with more information and a model to customize and adapt, as needed, based on local resources and needs: |
| or visit mdhhs, Adults & Children’s Abuse & Neglect, Keeping Adults Safe, and |
|DHS-Pub-269, The Michigan Model Vulnerable Adult Protocol. If the document cannot be accessed, or for further information, contact your local Michigan Department of |
|Health and Human services office. |
|Each PA 161 program must read and sign below, attesting they have a protocol in place regarding mandated child abuse and neglect reporting. |
|As a PA 161 program, we are aware of the above information and have reviewed the above-referenced information from the Michigan Department of Health and Human Services. |
|Agency/Entity Name |
| |
|PA 161 Program Name |
| |
|Mailing Address |
| |
|Contact Person (print) |Contact Person Telephone Number |Contact Person Email Address |
| | | |
|Responsible Party (print) |Responsible Party Signature |Date |
| | | |
| |
|Infection Control Checklist |
|PA 161 programs shall have an appropriate infection prevention policies and practices manual in place, including appropriate training and education of dental health care|
|personnel on infection prevention practices, and adequate supplies to allow all |
|PA 161 providers safe care and safe working environment. The infection control procedures shall be comprehensive, well-defined and specific to the PA 161 program. CDC |
|recommends that instruments utilized in an offsite clinic be cleaned in an ultrasonic and bagged prior to transporting the instruments to a sterilizer located in a |
|secondary location. |
|This Infection Control Checklist is an assessment tool modeled after the CDC Infection Prevention Checklist for Dental Settings and OSAP Infection Control Checklist for |
|Dental Settings Using Mobile Vans or Portable Dental Equipment, for |
|PA 161 programs to assess compliance with the expected infection prevention practices the Michigan Department of Health and Human Services Oral Health Programs has for |
|all PA 161 programs (stand alone and mobile). |
|Administrative policies and dental setting practices should be included in the site-specific written infection prevention and control program with supportive |
|documentation and include personnel compliance with the infection prevention and control practices that fulfill the expectations for dental health care settings. This |
|checklist can serve as an evaluation tool to monitor PA 161 compliance with the CDC’s recommendations and provide an assurance of quality control. |
|Note: The Michigan Department of Health and Human Services Oral Health Program has both the authority and the responsibility for effective oversight of eligible entities|
|that receive a PA 161 program status. The Department has established monitoring procedures that ensure an appropriate level of accountability and quality among the |
|eligible entities. Random agency site visits may be conducted to evaluate and score each PA 161 program to ensure that services are carried out in a manner consistent |
|with all federal, state, and local laws; administrative rules, regulations, and ordinances. |
|Instructions: Please review and evaluate each section of this infection control checklist to ensure all applicable policies and practices are in place for the PA 161 |
|program. Put a check in the Yes or No box for each category regarding the performance of the PA 161 program practices, and include comments for necessary explanation. |
|Certain sections may not apply to the |
|PA 161 program. Once complete, please review, sign and date attesting that all of the information is accurate and in place for the PA 161 program. |
|Each PA 161 program must read and sign below, attesting they have a protocol in place regarding an appropriate infection prevention policies and practices manual in |
|place, including appropriate training and education of dental health care personnel on infection prevention practices, and adequate supplies to allow all PA 161 |
|providers to provide safe care and safe working environment. |
|As a PA 161 program, we are aware of the above information and have completed the Infection Control Checklist. |
|Agency/Entity PA 161 Program Name |
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|Completed By |
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|Mailing Address |
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|Contact Person (print) |Contact Person Telephone Number |Contact Person Email Address |
| | | |
|Responsible Party (print) |Responsible Party Signature |Date |
| | | |
|Infection Control Checklist |
|Infection Control Program Operating Procedures |Yes |No |Comments |
|Is there a written infection control program? | | | |
|Is there a designated person(s) responsible for program oversight? | | | |
|Are there methods for monitoring and evaluating the programs? | | | |
|Is there a training program for dental health-care personnel (DHCP) (Initial and ongoing) in| | | |
|infection control policies and practices? | | | |
|Immunizations |Yes |No |Comments |
|There is written policy regarding immunizing DHCP, including a list of all of required and | | | |
|recommended immunizations for DHCP (e.g., hepatitis B, MMR (measles, mumps, rubella) | | | |
|varicella (chickenpox), Tdap (hepatitis, diphtheria, pertussis) | | | |
|What about TB screening? | | | |
|Hand Hygiene |Yes |No |Comments |
|Are sinks available close to the area where care is provided? | | | |
|If not, are alcohol-based hand sanitizers available? | | | |
|Is staff properly trained in the use of alcohol hand rub products? | | | |
|Personal Protective Equipment (PPE) (e.g., gloves masks, protective eyewear, protective |Yes |No |Comments |
|clothing) | | | |
|Is there a protocol that outlines what PPE are worn for which procedures? | | | |
|Is PPE storage available and close to care? | | | |
|Are facilities available to disinfect PPE (DHCP eyewear, patient eyewear, heavy duty utility| | | |
|gloves)? | | | |
|Environmental Surfaces: Clinical Contact Surfaces (e.g., light handles and countertops) |Yes |No |Comments |
|Is there a list of what surfaces will be cleaned, disinfected or barrier protected and the | | | |
|process and products to be used? | | | |
|If chemical disinfectants are used, is there a protocol for how they are managed, stored and| | | |
|disposed? | | | |
|Housekeeping Surfaces (e.g., floors, walls) |Yes |No |Comments |
|Is there a list of which housekeeping surfaces will need to be cleaned and disinfected and | | | |
|how often? | | | |
|Safe Handling of Sharp Instruments and Devices |Yes |No |Comments |
|Are DHCP trained in the safe handling and management of sharps? | | | |
|Are sharps containers safely located at close as possible to the user? | | | |
|Is there a written protocol for transporting and disposing of sharps and sharps containers? | | | |
|Management and Follow-Up of Occupational Exposures |Yes |No |Comments |
|Is there a written procedure manual for post-exposure management? | | | |
|Is there a designated person responsible for post-exposure management? | | | |
|Is there mechanism to document the exposure incident? | | | |
|Where is the closet medically facility for wound care and post-exposure management? | | | |
|Is there a mechanism to refer to the source and DHCP for testing and follow-up? | | | |
|Is there a mechanism for expert consultation by phone? | | | |
|Are post-exposure prophylaxis medications readily available onsite, at an emergent care | | | |
|facility or nearby pharmacy? | | | |
|Who is the responsible party for post-experience care costs? | | | |
|Have DHCP been trained in post-exposure management procedures? | | | |
|Reusable Patient Items |Yes |No |Comments |
|Are reusable patient items processed onsite? | | | |
|If yes: | | | |
|Is there a protocol for how and where contaminated instruments are cleaned and processed? | | | |
|Is there adequate space for the processing area to be divided into clean and dirty areas? | | | |
|Has the person who is performing the process been adequately trained? | | | |
|Is the sterilizer(s) spore tested at least weekly? | | | |
|Are protocols in place to handle positive tests? | | | |
|Can dental equipment and patient items be safely stored and secured if left on site? | | | |
|If no: | | | |
|Is there an adequate inventory of instruments for the number of patients to be treated? | | | |
|Are containers for holding or transporting contaminated instruments puncture-proof, secured | | | |
|& labeled as a biohazard? | | | |
|Single-Use (Disposable) Items and Devices |Yes |No |Comments |
|Is there a protocol for which single-use, disposable items will be used and how they will be| | | |
|disposed (e.g., gloves, tongue depressors)? | | | |
|Are disposable items unit-dosed for each patient? | | | |
|Are syringes that deliver sealant and composite material barrier-protected if they aren’t | | | |
|single-use, disposable syringes? | | | |
|Management of Dental Unit Water Quality |Yes |No |Comments |
|Is there a protocol for how dental unit water quality will be maintained and monitored? | | | |
|Management of Regulated and Non-Regulated Medical Waste |Yes |No |Comments |
|Is there a protocol and designated person responsible for proper disposal of regulated waste| | | |
|(e.g., sharps containers, extracted teeth) and nonregulated waste (regular trash)? | | | |
| | | | |
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