ࡱ> uxpqrst- 0J bjbj=@=@ .$_*d_*d[J+++++???8wd!?W*(.=>>>7?<sA,B>S@S@S@S@S@S@S$1Y[dS]+7C7?7?7C7CdS++>>4VcNcNcN7CF+>+>>ScN7C>ScNcNPFQ>p}CQ*SV0WQ,\D\FQ\+FQ7C7CcN7C7C7C7C7CdSdS)K:7C7C7CW7C7C7C7C\7C7C7C7C7C7C7C7C7C : PUBLIC HEALTH DENTAL DISEASE PREVENTION PROGRAM APPLICATIONMichigan Department of Health and Human ServicesPA 161: Public Dental Prevention Program Request for Operation as Defined in MCL.333.16625 (2005 PA 161) FORMCHECKBOX New Program FORMCHECKBOX Renewal PA 161 Only FORMCHECKBOX Renewal PA 161 with Mobile Dental Facility PermitAgency/Entity Name FORMTEXT      Program Name FORMTEXT      Mailing Address FORMTEXT      Counties Served FORMTEXT      Responsible Party of Agency (Required)Contact Person (Required) FORMTEXT       FORMTEXT      Contact Person Telephone NumberContact Person Email Address FORMTEXT       FORMTEXT      Fees and Billing (Indicate Types of Reimbursement Accepted) FORMCHECKBOX No Compensation FORMCHECKBOX Private Pay FORMCHECKBOX Insurance (private) FORMCHECKBOX Medicaid FORMCHECKBOX Healthy Michigan Plan FORMCHECKBOX Other FORMCHECKBOX Tax-Exempt *Include Tax-Exempt ID# FORMTEXT       FORMCHECKBOX Entity Type 2 Agency NPI# (Required) FORMTEXT      Agency/Entity/Non-Profit Type (Choose Area and Description) FORMCHECKBOX Public FORMCHECKBOX State FORMCHECKBOX County FORMCHECKBOX District FORMCHECKBOX City FORMCHECKBOX Non-Profit FORMCHECKBOX Community Clinic FORMCHECKBOX Federally Qualified Health Center FORMCHECKBOX Other (Non-Profit Agency) FORMCHECKBOX School FORMCHECKBOX School (Pre-K 12) FORMCHECKBOX School-Based Health Center FORMCHECKBOX School of Dentistry or Dental Hygiene FORMCHECKBOX Nursing Home FORMCHECKBOX Other (describe) FORMTEXT      Responsible Party of Agency SignatureBy 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 ApplicantDate signed (month/date/year)Print NamePrint Title Describe the Unassigned Population(s) to Receive Preventive Services (Check all that apply) FORMCHECKBOX Patients of a Public Health Agency FORMCHECKBOX Patients of a Federally Qualified Health Center FORMCHECKBOX Patients of a Community Dental Clinic FORMCHECKBOX Students in a School-Based/School-Linked program FORMCHECKBOX Early Head Start, Head Start Students or Other Underserved Preschoolers FORMCHECKBOX Nursing Home Residents FORMCHECKBOX Assisted Living Residents FORMCHECKBOX Adult Foster Care Residents FORMCHECKBOX Native Americans FORMCHECKBOX Migrant Farm Workers FORMCHECKBOX Persons with Developmental Disabilities FORMCHECKBOX Juvenile Home Residents FORMCHECKBOX Inmates of Prison System FORMCHECKBOX Homeless Individuals FORMCHECKBOX Other (describe) FORMTEXT      Describe the Clinical Setting(s) in which the Services are to be Provided (Check all that apply) FORMCHECKBOX Public Health Agency FORMCHECKBOX Assisted Living FORMCHECKBOX Homeless Shelter FORMCHECKBOX Federally Qualified Health Center FORMCHECKBOX Adult Foster Care Facility FORMCHECKBOX Migrant Camp FORMCHECKBOX Community Dental Clinic FORMCHECKBOX Tribal Health Centers FORMCHECKBOX School FORMCHECKBOX Faith Based Organization Setting FORMCHECKBOX School-based/School-linked Health Center FORMCHECKBOX Juvenile Home FORMCHECKBOX Mobile Dentistry Facility FORMCHECKBOX Correctional Facility FORMCHECKBOX Head Start/Preschool Centers FORMCHECKBOX Patient Home FORMCHECKBOX Nursing Home FORMCHECKBOX Other (describe) FORMTEXT      Preventive Services to be Provided (Check all that apply) (Radiographs and Debridement Not Allowed) FORMCHECKBOX Fluoride Varnish FORMCHECKBOX Oral Health Education FORMCHECKBOX Pit and Fissure Sealants FORMCHECKBOX Topical Fluoride FORMCHECKBOX Prophylaxis FORMCHECKBOX Assessments FORMCHECKBOX Nutritional Counseling FORMCHECKBOX Tobacco Cessation FORMCHECKBOX Other Services (describe) FORMTEXT      Renewal PA 161 with mobile dental facility permit submit pages 1-5 only. New Program and Renewal PA 161 only submit the following required documentsRequired Documents: Check to Confirm Submission of the Following (See guidelines for definitions of the following) FORMCHECKBOX Supervision Protocol FORMCHECKBOX Patient Referral and Follow-up Protocol FORMCHECKBOX Memorandum of Agreement (MOA) with dentists or oral health agencies that will accept your referrals FORMCHECKBOX If sealants are performed, provide the evaluation measures that will be taken to ensure long-term retention of the sealants FORMCHECKBOX Child/Elder Abuse Reporting Attestation FORMCHECKBOX Infection Control Checklist FORMCHECKBOX Patient Registration/Application Form FORMCHECKBOX Patient Health History FORMCHECKBOX HIPAA Privacy Notice FORMCHECKBOX Parent/Guardian Permission Slip/Consent Form FORMCHECKBOX Evidence of non-profit status. Must include current Articles of Incorporation from the state of Michigan (if not a local public health department. FORMCHECKBOX Proof of general liability insurance covering the PA 161 Project is requiredSend 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: HYPERLINK "mailto:MDCH-MobileDentistry@michigan.gov"MDCH-MobileDentistry@michigan.gov.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 services and programs provider.The Michigan Department of Health and Human Services (MDHHS) does not discriminate 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 OnlyAgency/Entity NameDate Received FORMTEXT       FORMTEXT       FORMCHECKBOX  Approved FORMCHECKBOX  Not ApprovedApproval DateExpiration Date FORMTEXT       FORMTEXT      Rationale FORMTEXT      Signature and TitleDate FORMTEXT       Supervision for PA 161 Program: The Supervision of the Registered Dental Hygienist Must Satisfy the Following FORMCHECKBOX Continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional. FORMCHECKBOX 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 individuals functions. FORMCHECKBOX The provision by the licensed supervising health professional of predetermined procedures and drug protocol. FORMCHECKBOX 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. FORMCHECKBOX 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. FORMCHECKBOX 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.). FORMCHECKBOX If a patient resides in a long-term care facility, a physicians order for dental services is required for beneficiaries. The order cannot be a standing order. FORMCHECKBOX Standard infection control protocols will be adhered to for all services and locations. FORMCHECKBOX 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. FORMCHECKBOX 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. FORMCHECKBOX The PA 161 Program must be renewed every two years. It is the responsibility of the approved program to submit the new application. FORMCHECKBOX The supervising dentist should reside in Michigan or have an active volunteer license in the state of Michigan. FORMCHECKBOX A supervising dentist may supervise no more than a combined total 25 dental hygienists or dental assistants during a scheduled PA 161 activity. FORMCHECKBOX We have reviewed the Data Report form and agree to submission of the form, as indicated. FORMCHECKBOX 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) FORMTEXT      Supervising Dentist (print)Signature of Supervising DentistDate FORMTEXT       FORMTEXT      Dental Hygienist/Assistant Name (print)Signature of Dental Hygienist/AssistantDate FORMTEXT       FORMTEXT       Provider ListYou 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)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      Name (Print)TitleEmail AddressTelephone NumberLicense Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address (Number, Street, City, State and Zip Code)NPI Number FORMTEXT       FORMTEXT      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 ProtocolSupervising 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): FORMTEXT      Describe how often the supervising dentist(s) is available for consultation and reviews records of the PA 161 hygienist(s) activity: FORMTEXT      Describe the predetermined preventive procedures allowable for the PA 161 hygienist(s) and drug protocols: FORMTEXT       Patient Referral and Follow-Up ProtocolInstructions: 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: FORMTEXT      Describe how the patient will be counseled to seek an annual examination by a licensed dentist: FORMTEXT      Describe the follow-up mechanism that is in place to determine if the patient has received dental services following referral: FORMTEXT      Describe emergency after hour protocol for patients who were seen, but have an emergency after hours: FORMTEXT       Sealant Retention ProtocolIf 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: FORMTEXT      Sealant retention rates will be monitored with which retention goal percentage? Please describe: FORMTEXT      Describe the protocol if sealants are missing/lost: FORMTEXT       Public Dental Prevention Program PA 161  Child Abuse & Neglect ReportingPurpose: To protect children from child abuse and neglect. The Childrens 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 childs health or welfare by failure of the parent, legal guardian, or other person responsible for the childs 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 & NeglectAnyone, 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:  HYPERLINK "http://www.michigan.gov/documents/dhs/Pub-112_179456_7.pdf" http://www.michigan.gov/documents/dhs/Pub-112_179456_7.pdf or visit  HYPERLINK "http://www.michigan.gov/mdhhs" www.michigan.gov/mdhhs, Adult & Childrens Services, Abuse & Neglect, Keeping Kids Safe, Mandated Reporters, and under Resources find: HYPERLINK "http://www.michigan.gov/documents/dhs/Pub-112_179456_7.pdf"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 ReportingEach 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 FORMTEXT      PA 161 Program Name FORMTEXT      Mailing Address FORMTEXT      Contact Person (print)Contact Person Telephone NumberContact Person Email Address FORMTEXT       FORMTEXT       FORMTEXT      Responsible Party (print)Responsible Party SignatureDate FORMTEXT       FORMTEXT       Public Dental Prevention Program PA 161  Elderly Abuse ReportingPurpose: 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 adults 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 adults 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 adults health or welfare. Neglect includes the failure to provide adequate food, clothing, shelter, or medical care. Exploitation: Misuse of an adults 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:  HYPERLINK "http://www.michigan.gov/documents/dhs/DHS-Pub-269_423962_7.pdf" http://www.michigan.gov/documents/dhs/DHS-Pub-269_423962_7.pdf or visit  HYPERLINK "http://www.michigan.gov/mdhhs" www.michigan.gov/mdhhs, Adults & Childrens Abuse & Neglect, Keeping Adults Safe, and  HYPERLINK "http://www.michigan.gov/documents/dhs/DHS-Pub-269_423962_7.pdf" 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 FORMTEXT      PA 161 Program Name FORMTEXT      Mailing Address FORMTEXT      Contact Person (print)Contact Person Telephone NumberContact Person Email Address FORMTEXT       FORMTEXT       FORMTEXT      Responsible Party (print)Responsible Party SignatureDate FORMTEXT       FORMTEXT       Infection Control ChecklistPA 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. 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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 FORMTEXT      Completed By FORMTEXT      Mailing Address FORMTEXT      Contact Person (print)Contact Person Telephone NumberContact Person Email Address FORMTEXT       FORMTEXT       FORMTEXT      Responsible Party (print)Responsible Party SignatureDate FORMTEXT       FORMTEXT       Infection Control ChecklistInfection Control Program Operating ProceduresYesNoCommentsIs there a written infection control program? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a designated person(s) responsible for program oversight? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are there methods for monitoring and evaluating the programs? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a training program for dental health-care personnel (DHCP) (Initial and ongoing) in infection control policies and practices? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      ImmunizationsYesNoCommentsThere 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) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      What about TB screening? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Hand HygieneYesNoCommentsAre sinks available close to the area where care is provided? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      If not, are alcohol-based hand sanitizers available? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is staff properly trained in the use of alcohol hand rub products? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Personal Protective Equipment (PPE) (e.g., gloves masks, protective eyewear, protective clothing)YesNoCommentsIs there a protocol that outlines what PPE are worn for which procedures? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is PPE storage available and close to care? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are facilities available to disinfect PPE (DHCP eyewear, patient eyewear, heavy duty utility gloves)? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Environmental Surfaces: Clinical Contact Surfaces (e.g., light handles and countertops)YesNoCommentsIs there a list of what surfaces will be cleaned, disinfected or barrier protected and the process and products to be used? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      If chemical disinfectants are used, is there a protocol for how they are managed, stored and disposed? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Housekeeping Surfaces (e.g., floors, walls)YesNoCommentsIs there a list of which housekeeping surfaces will need to be cleaned and disinfected and how often? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Safe Handling of Sharp Instruments and DevicesYesNoCommentsAre DHCP trained in the safe handling and management of sharps? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are sharps containers safely located at close as possible to the user? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a written protocol for transporting and disposing of sharps and sharps containers? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Management and Follow-Up of Occupational ExposuresYesNoCommentsIs there a written procedure manual for post-exposure management? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a designated person responsible for post-exposure management? 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FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Where is the closet medically facility for wound care and post-exposure management? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a mechanism to refer to the source and DHCP for testing and follow-up? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a mechanism for expert consultation by phone? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are post-exposure prophylaxis medications readily available onsite, at an emergent care facility or nearby pharmacy? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Who is the responsible party for post-experience care costs? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Have DHCP been trained in post-exposure management procedures? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Reusable Patient ItemsYesNoCommentsAre reusable patient items processed onsite? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      If yes: FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there a protocol for how and where contaminated instruments are cleaned and processed? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there adequate space for the processing area to be divided into clean and dirty areas? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Has the person who is performing the process been adequately trained? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is the sterilizer(s) spore tested at least weekly? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are protocols in place to handle positive tests? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can dental equipment and patient items be safeƤȤ̤tvҥϾ~yn[nHϾ$jh 5OJQJU^J$joh 5OJQJU^Jh 5OJQJ^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jh 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$j h 5OJQJU^Jʤ̤tvffv$$If^a$gdrd{$$If^a$gdrd{xkd$$Ifl40\BJ,B^ 4 lalf4ytrd{ҥԥ֥Ȧʦ̦ΦЦfhڻzgzZFڻ'j7h 5OJQJU\^Jh 5OJQJ\^J$jh 5OJQJU^Jh-Xh 5OJQJ^J$jKh 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu!jh 5OJQJU\^J'j[h 5OJQJU\^JΦvffv$$If^a$gdrd{$$If^a$gdrd{xkd$$Ifl40\BJ,B^ 4 lalf4ytrd{f֧vffv$$If^a$gdrd{$$If^a$gdrd{xkd$$Ifl40\BJ,B^ 4 lalf4ytrd{ħƧȧҧԧا¨ĨıϠh`[H$jh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jh 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$jh 5OJQJU^Jh 5OJQJ^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$j'h 5OJQJU^J֧ا¨ 2vffv$$If^a$gdrd{$$If^a$gdrd{xkd}$$Ifl40\BJ,B^ 4 lalf4ytrd{   "$.04̩ΩЩҩԩ Ͼ~yn[nHϾ$jUh 5OJQJU^J$jh 5OJQJU^Jh 5OJQJ^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jh 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$jyh 5OJQJU^J24ҩvffv$$If^a$gdrd{$$If^a$gdrd{xkdY$$Ifl40\BJ,B^ 4 lalf4ytrd{  ªĪ  <ڻzgzZFڻA h 5'jh 5OJQJU\^Jh 5OJQJ\^J$j1h 5OJQJU^Jh-Xh 5OJQJ^J$jh 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu!jh 5OJQJU\^J'jh 5OJQJU\^J ªvffv$$If^a$gdrd{$$If^a$gdrd{xkd5$$Ifl40\BJ,B^ 4 lalf4ytrd{>FL^vffv$$If^a$gdrd{$$If^a$gdrd{xkd$$Ifl40\BJ,B^ 4 lalf4ytrd{<>DFJL\`ثګܫޫ&(,<ҿݱҞݱlUMEh h 5h-Xh \,jh 5OJQJU\^JmHnHu'j h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$jh 5OJQJU^Jh-Xh 5OJQJ^J$jh 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \ h 5h-Xh 5^`ޫ*vffv$$If^a$gdrd{$$If^a$gdrd{xkd$$Ifl4P\BJ,B^ 4 lalf4ytrd{*,<`vffv$$If^a$gdrd{$$If^a$gdrd{xkds$$Ifl40\BJ,B^ 4 lalf4ytrd{<>Z\^`b~bdĠh`[H$jh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jh 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$joh 5OJQJU^Jh-Xh 5OJQJ^J$jh 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^Jbҭvffv$$If^a$gdrd{$$If^a$gdrd{xkdO$$Ifl40\BJ,B^ 4 lalf4ytrd{­ĭέЭԭʮ̮ήЮҮϾ~yn[nHϾ$j'!h 5OJQJU^J$j h 5OJQJU^Jh 5OJQJ^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jh 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$jKh 5OJQJU^JҭԭЮvffv$$If^a$gdrd{$$If^a$gdrd{xkd+ $$Ifl40\BJ,B^ 4 lalf4ytrd{ȯʯ̯ίЯ^`|ڻzgzZFڻ'jy#h 5OJQJU\^Jh 5OJQJ\^J$j#h 5OJQJU^Jh-Xh 5OJQJ^J$j"h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu!jh 5OJQJU\^J'j!h 5OJQJU\^Jίvffv$$If^a$gdrd{$$If^a$gdrd{xkd"$$Ifl40\BJ,B^ 4 lalf4ytrd{^ΰvffv$$If^a$gdrd{$$If^a$gdrd{xkd#$$Ifl40\BJ,B^ 4 lalf4ytrd{|~ʰ̰а24PRTVXtıϠh`[H$jE&h 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu'jU%h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$j$h 5OJQJU^Jh 5OJQJ^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$ji$h 5OJQJU^Jΰа2Vzvffv$$If^a$gdrd{$$If^a$gdrd{xkd%$$Ifl40\BJ,B^ 4 lalf4ytrd{tvxz|NPlnprtϾ~ywylYlFϾ$j(h 5OJQJU^J$j!(h 5OJQJU^Jh 5OJQJ^JU h \h-Xh \,jh 5OJQJU\^JmHnHu'j1'h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$j&h 5OJQJU^JNrvffv$$If^a$gdrd{$$If^a$gdrd{xkd'$$Ifl40\BJ,B^ 4 lalf4ytrd{ly stored and secured if left on site? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      If no: FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Is there an adequate inventory of instruments for the number of patients to be treated? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are containers for holding or transporting contaminated instruments puncture-proof, secured & labeled as a biohazard? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Single-Use (Disposable) Items and DevicesYesNoCommentsIs there a protocol for which single-use, disposable items will be used and how they will be disposed (e.g., gloves, tongue depressors)?  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are disposable items unit-dosed for each patient? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are syringes that deliver sealant and composite material barrier-protected if they aren t single-use, disposable syringes? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Man,.0:<@ڻwdwWCڻ> h \'j*h 5OJQJU\^Jh 5OJQJ\^J$js*h 5OJQJU^Jh-Xh 5OJQJ^J$j)h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^Jh h 5h-Xh \,jh 5OJQJU\^JmHnHu!jh 5OJQJU\^J'j )h 5OJQJU\^J>vffv$$If^a$gdrd{$$If^a$gdrd{xkdw)$$Ifl40\BJ,B^ 4 lalf4ytrd{>@8`vffv$$If^a$gdrd{$$If^a$gdrd{xkdS+$$Ifl40\BJ,B^ 4 lalf4ytrd{2468:NPR\^bNPlnprtĠh`[H$j-h 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu'j,h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$jO,h 5OJQJU^Jh-Xh 5OJQJ^J$j+h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J`bNrvffv$$If^a$gdrd{$$If^a$gdrd{xkd/-$$Ifl40\BJ,B^ 4 lalf4ytrd{ "26JLhjlnpϾ~yqyqyqyqlaNa$j0h 5OJQJU^Jh 5OJQJ^J h \h-Xh 5 h 5h-Xh \,jh 5OJQJU\^JmHnHu'j.h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$j+.h 5OJQJU^J"4vffv$$If^a$gdrd{$$If^a$gdrd{xkd /$$Ifl40\BJ,B^ 4 lalf4ytrd{46Jnvffv$$If^a$gdrd{$$If^a$gdrd{xkd/$$Ifl4P\BJ,B^ 4 lalf4ytrd{ ">@BDFbdfhj~Ͼ~yn[nHϾ$ji2h 5OJQJU^J$j1h 5OJQJU^Jh 5OJQJ^J h \h-Xh \,jh 5OJQJU\^JmHnHu'j1h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^Jh-Xh 5OJQJ^Jjh 5OJQJU^J$j0h 5OJQJU^J Dhvffv$$If^a$gdrd{$$If^a$gdrd{xkdm1$$Ifl4X\BJ,B^ 4 lalf4ytrd{~ڻzgzZFڻA h 5'j4h 5OJQJU\^Jh 5OJQJ\^J$jE4h 5OJQJU^Jh-Xh 5OJQJ^J$j3h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh \,jh 5OJQJU\^JmHnHu!jh 5OJQJU\^J'j2h 5OJQJU\^Jvffv$$If^a$gdrd{$$If^a$gdrd{xkdI3$$Ifl40\BJ,B^ 4 lalf4ytrd{J R X j vffv$$If^a$gdrd{$$If^a$gdrd{xkd%5$$Ifl40\BJ,B^ 4 lalf4ytrd{agement of Dental Unit Water QualityYesNoCommentsIs there a protocol for how dental unit water quality will be maintained and monitored? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Management of Regulated and Non-Regulated Medical WasteYesNoCommentsIs there a protocol and designated person responsible for proper disposal of regulated waste (e.g., sharps containers, extracted teeth) and nonregulated waste (regular trash)? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        H J P R V X h l   : < > @ B ^ ` b d f z | ~      нۯМۯ~jSKh-Xh \,jh 5OJQJU\^JmHnHu'j7h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$j6h 5OJQJU^Jh-Xh 5OJQJ^J$j16h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh 5 h 5Uj l  @ d  vffv$$If^a$gdrd{$$If^a$gdrd{xkd5$$Ifl4P\BJ,B^ 4 lalf4ytrd{    vffv$$If^a$gdrd{$$If^a$gdrd{xkd7$$Ifl40\BJ,B^ 4 lalf4ytrd{    ҿݱҞݱlUMMIh-Xh-Xh \,jh 5OJQJU\^JmHnHu'j9h 5OJQJU\^Jh 5OJQJ\^J!jh 5OJQJU\^J$j 9h 5OJQJU^Jh-Xh 5OJQJ^J$j8h 5OJQJU^Jh 5OJQJ^Jjh 5OJQJU^J h \h-Xh 5 h 5 vffv$$If^a$gdrd{$$If^a$gdrd{xkd 8$$Ifl4P\BJ,B^ 4 lalf4ytrd{vfYv $If^gdrd{$$If^a$gdrd{$$If^a$gdrd{xkd9$$Ifl4X\BJ,B^ 4 lalf4ytrd{        G H I J }gd-Xxkdo:$$Ifl4\BJ,B^ 4 lalf4ytrd{    DCH-1293 (Rev. 1-18) Previous edition obsolete.  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