Dental Office Compliance - What you need to know
by Steven W. Haywood, DDS, FICOI, FAGD
BCDA President 2018-19
CDC recommendations, State requirements and OSHA regulations are constantly changing and are challenging to keep up with. Some of us have even experienced unannounced inspections. I believe we need to do a better job as a profession disseminating critical information that, as small businesses, seems both overwhelming and burdensome at times. Here is my first compliance recommendation:
Eyewash stations - According to 29CFR.1910.151, most of us are non-compliant. There have been recent and important changes that have not been distributed well by OSHA.
- There must be a documented eyewash training document with signatures of all trained.
- There must be a WEEKLY cleaning of the station documented on a log.
- There must be a sign indicating it is an eyewash station.
- It must be no more than 50 feet from hazardous materials
- You can’t have handles on the faucet (Yup, it has to be on at all times with diverter valve) because actuation must be only ONE motion!
- You can’t have hot water on the feed to the eyewash station (ANSI Z358.1) because the water must be able to be “tepid” (60-100 degrees for a time of 15 minutes minimum)
I recommend a free service by our local OSHA Office of “Consultation Services” in Baltimore County. An Industrial hygienist will come to your office free of charge and give you a precise report as well as help remediate any deficiencies without penalty. Their number is 410-527-4472. Be pro-active, be prepared, as well as safe!
The CDC has developed increasingly stringent guidelines for waterlines that have become key targets for unannounced inspections. I am talking about water deliver lines and specifically about systems that are self-contained. Key among the newest guidelines are:
- You must prove your waterlines are under 500 colony forming units. This is the level to certify water as drinkable by the EPA. Waterline testing kits cost over $300 for our last tests in our offices. Essentially the in-office kits are mini petri dishes that show colony growth over a specific time. They are actually pretty cool but expensive little things!
- You must log waterline maintenance and fluid changes. Essentially every bottle must have a “fluid log” listing when you filled that bottle or cleaned or shocked that system in each room! We are being required to record everything about every fluid in our offices. I can share a sample of the log form we use if you contact me.
- You must have a written waterline maintenance policy in your office.
- You should shock your system at least twice per year. Shock tabs and the procedure will take several hours if done properly.
- Bottles should be emptied and dried after the day is done.
- Waterlines must be bled for 20 seconds at the beginning of each work day and for each line used.
- Waterlines/Handpiece lines must again be bled between patients for 20 seconds.
- Your staff will need to recite the policy to any inspector and demonstrate compliance.
We all have smelled that stale (foul) water smell from certain dental water sources in the past. The CDC requires that issue to be addressed and the Maryland State Board of Dental Examiners will most certainly inspect for compliance. Call me personally if you’d like to discuss this or any other compliance issue at 410 258-7275.
The Top Ten “Fails" on CDC/OSHA Inspection
I asked recently asked an infection control presenter, to share her top findings when inspecting for the Maryland Board or for insurance companies doing spot inspections to certify compliance of participating offices or as a result of complaints. Here's her "Top Ten:"
- Hand washing is not accomplished before and after gloving!
- Improper use of PPE and disposal of same.
- Improper use or lack of use of utility gloves.
- Sterile areas not clearly organized with distinct work-flow - dirty to clean. (This one actually surprises me and is confirmed by several other supply company OSHA trainers!)
- Weekly spore tests not being done, tests not logged and tests not kept for 3 years. (We use Mesa Labs and all of our tests are online).
- Burs not “verified” sterilized in drawers and in a bag and the same for endo instruments (Throw out the glass bead sterilizer. They are non-compliant). ALL components of all handpieces sterilized.
- Motors of handpieces left on the hoses between patients and not sterilized.
- Disposable air/water syringe tips reused and not disposed of.
- No written and implemented waterline policy.
- Disposable tips either on resin or etch dispensers not being changed and contributing to cross contamination.
As dentists often in smaller practices, we bear the same responsibility as larger healthcare companies. We need to do a better job communicating and training for infection control compliance. I will consistently advocate for this kind of change. I hope that the compliance messages continue to be helpful. Call me directly with any questions at 410-258-7275.
Infection Control and OSHA
At the beginning of each year, we need to plan for the mandated Infection Control and OSHA required training for workplace safety. MOSH in Baltimore County (410 527-4447) offers a free consultation service for updating mandatory records and documentation. This is the checklist you need to perform for annual training that I received from our consultation. Each employee should print their name, sign their name and date the form and you need to keep it accessible in the training records files in your offices.
- “Sharps safer systems”- Employees must have ability to comment on problems and suggest changes to current systems and it must be specifically documented.
- Bloodborne Pathogens standard review- ADA OSHA Compliance Manual has a good template
- “Right to know” regulation review - Informing employees of hazardous materials or situations within our workplaces is a yearly requirement.
- Exposure Control Plan is reviewed and modified or updated as needed.
- Hazard Communication Standard review - evaluate your SDSs.
- Globally Harmonized System (GHS) and Pictograms should be reviewed.
- Annual Fire Safety - extinguisher inspection, exit plan reviewed and exit diagram posted.
- Waste Management Program - review, evaluate and update - is it in writing?
- Waterline Management Program - evaluate and update program and tracking logs of all kinds.
I hope that the compliance messages continue to be helpful. Call me directly with any questions at 410-258-7275.
We Need Clarity!
I'd like to discuss a problem we have as Maryland dentists and for which we need clarity! Our dental code allows the Maryland State Board of Dental Examiners (MSBDE) to expand upon CDC recommendations at their discretion. Perhaps this amendment was added at a time when the CDC or OSHA was not as engaged and effective for the dental community as it is today. It is our experience that the Maryland State Board of Dental Examiners is not communicating well about discretionary changes and that our practices, should we be inspected, are at risk of being singled out for non-compliance. The Baltimore County Dental Association Executive Board members have found it impossible to clearly understand the MSBDE regulations, because the regulations are not published nor is the MSBDE Newsletter touching upon these issues.
The University of Maryland School of Dentistry should be a progressive test site for infection control strategies. MSBDE inspectors and MSBDE members often work at the school. Educators at the Dental School need to recognize that what happens at the school is not always a CDC recommendation. Their work is important and may affect future CDC recommendations. However, I believe that the CDC should be the final say on what is reasonable for our profession locally and nationally.
It would be my recommendation that our Association advocate for a return to 100% acceptance of CDC and OSHA recommendations by the Maryland State Board of Dental Examiners without possibility for alteration. This would allow all of us to simply read published documents and comply without the uncertainty that we are missing something! At the time of this writing, the Maryland State Board of Dental Examiners has not responded to our request for comment.
There is an abundance of confusion about amalgam separators that are required in certain circumstances for dentists. It is not widely known that most specialties are EXEMPT! The EPA has made mandated compliance by July 14, 2020 for the rest of us!
The purpose of this law is to prevent dental amalgam from entering “air, water and land”. It is clear that the exempted specialties will, in fact, contribute to mercury entering the environment without amalgam separation, so this law is not perfect.
If you don’t place amalgam, you certainly will remove some. The threshold is impossibly low for a GP to be exempted though it is possible.
I am an environmentalist at heart and believe we can help by applying these systems to our offices. The problem seems to be the recurring costs of the filter replacement. It seems reasonable for a single practitioner placing composite restorations to establish an “amalgam removal room” with a filtration system sufficient for the amalgam removal expected. Should you still place amalgam, then it seems most reasonable to install a full office system. Do your research and check supply companies for the size you need and be aware of the recurring costs.
- You will need a one-time compliance report sent to the EPA.
- You need to keep records for three years subject to inspection.
- You will need to record waste disposal logs for the amalgam, signed and dated.
- You will need to inspect the device with date, inspector and results logged.
- You must keep the manufacturer’s instructions in your files.
- The standard for compliant devices is ISO 11143 2008. Make sure you can prove your system is currently compliant.
With some quick shopping, everyone should be able to find a system that is both adequate and affordable. Good luck with your installations!
Dental Assistants in Maryland - You may be surprised how little they're allowed to do!
Dental assistants are critical yet highly-restricted professionals in Maryland. (Check DANB.com for the current guidelines about scope of allowed duties). It is hard to find a dental assistant who can perform at minimally acceptable standards, let alone one who is highly qualified. Training programs in dental assisting are expensive and produce poor quality graduates - often unable to perform successfully in a modern dental setting. Dental assistants often do not have opportunity for salary increases and regularly find it hard to support families because there is limited opportunity for career growth. This may explain the poor retention rate for dental assistants in the profession. It is my contention that we should take a look at expanding the legal duties for all dental assisting professionals, while the Maryland State Dental Board could investigate the calamity of the current auxiliary training situation in Maryland.
I have my satellite practice in Pennsylvania and my Expanded Functions Dental Assistant (EFDA) can place fillings, polish teeth, polish restorations, adjust occlusion, place attachments for Invisalign and scan for impressions. She performs admirably in all that she does and can work in another room unsupervised when our work volume requires.
A Maryland Dental Assistant Qualified in General Duties (DAQGD) with the highest qualifications in Maryland can do none of these things. It’s time for us to take a serious look at addressing issues of access to care and the mid-level provider concept by first expanding the duties and potential income of our valued current staff members: our assistants. The Baltimore County Dental Association Executive Board is introducing this topic to the House of Delegates at the Maryland State Dental Association hopefully in May of 2019. Please check the Maryland State Board of Dental Examiners website or Dental Assisting National Board (DANB) for the current restrictions on your own dental assistants. You may be surprised how little they are allowed to do. Let’s try to change that!