#83 Year End Dental Compliance Reminders

Are you gearing up for 2023! In this episode, the Divas will help you wrap up 2022 on a successful compliance note with these timely year end reminders. Take away OSHA, Infection Control, HIPAA and HR tips you can immediately use to close out the year safely and successfully. 

• OSHA Safety and Health Topics - Dentistry - https://www.osha.gov/dentistry
• CDC Infection Prevention Checklist - https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/appendix-a.html
• Dept. of Health and Human Services - Reporting of Breaches Affecting Fewer than 500 individuals  -https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html

                                                 https://www.thecompliancedivas.com

Transcript

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SPEAKER_00 0:04

Welcome. I'm Leslie Kannon. I'm Mary Gavoni. I'm Linda Harvey.

SPEAKER_02 0:10

I'm Olivia Juan, and together we are the Compliance Divas. Welcome to the Compliance Divas podcast. My name is Olivia Juan and I'll be your moderator. In this episode, we are focusing on end-of-year reminders. It's that time of year we're gearing up for 2023. So we want to talk about reminders for OSHA, HIPAA, infection control, NHR. As the Compliance Divas, we bring clarity and simplicity to compliance by navigating regulatory world to keep you on course. Please subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website. Resources we mentioned during this episode can be found on our website, thecompliancedevas.com. Please submit your questions to support at thecompliancedivas.com. Linda, would you like to start us off with five or ten HIPAA reminders that our listeners can benefit from?

SPEAKER_01 1:14

Sure, Olivia, this would be great. I've I love the idea that we're doing this year-in podcast just to help offices really kind of close out the year on a great note. And so what I would do is I would pare it down to even three, Olivia, and put it into form of like a triangle. This is a triad. First is people. And the people include your team members and your business associates. So being sure that you have conducted HIPAA training for your team this year, both policies related to your policies and procedures and cyber risk security training. And then from the business associate perspective, be sure that you have all your current business associate agreements on file, as well as keeping your old business associate agreements, because under the HIPAA laws, you're required to retain all HIPAA-related documentation for six years. And I would just briefly like to remind our listeners, Olivia, that this is not related to the patient dental record. This is just related to the HIPAA documentation in the practice. So the first P is people training your team members and checking on those business associate agreements. The second P is policies. Every office should have a customized set of policies and procedures related to the HIPAA privacy rule and the HIPAA security rule. And that they are customized and there's not a binder that blanks haven't been filled in and that they've been read and that you are following your policy. So that's my second P. The third is the plans. The HIPAA laws require that you have several types of plans in place. And so it's important that you recognize in your practice if you have these plans. One is your security risk analysis that's conducted yearly. Second is your risk management plan that comes out of that analysis. And I would like to remind our listeners, Olivia, that this does not include just a simple checklist they might have downloaded from the internet or maybe that their IT company gave them. And then the two other plans that that's required come into play if you have some kind of disaster. You get ransomed, you get shut down. So you need to have a contingency plan and a disaster plan. So again, Olivia, those are the three Ps that I would pare down for the HIPAA reminders at the end of the year. People, policies, and plans. And I encourage our listeners to go back to their HIPAA documentation, pull that binder down off the shelf. Hopefully, it's not one that's full of dust and they've used it throughout the year and checked on it, and look for those three Ps, Olivia.

SPEAKER_02 3:31

I love that analysis, Linda. Thank you. Leslie, we'd like for you to speak to us on infection control reminders. What would be your top five or ten reminders for our listeners?

SPEAKER_00 3:47

Olivia, it's important for us to make sure we've maintained our documentation. And when it comes to infection control, water quality monitoring is so important these days. It's in the media, and we've been seeing rehash of the various events where children have become ill from dental unit water that had been causing infections. It happened again this year and in March. So I will encourage our listeners to tune into January 2023's podcast. We have a very important podcast from Dentistape on how to do dental unit water monitoring testing and why it's important. So that's important, maintaining records there. Spore testing, making sure that we have done our spore testing on a weekly basis on all of our sterilizers and that we have printed the results. Some state dental boards want to know that you're looking at the results and simply getting an email, pass or fail, is important. However, who's looking at the email and how do we prove that we looked at it, other than printing out that documentation? And then also another thing that I'm very passionate about is that we're not using any expired supplies. Disinfectants sometimes uh sit on the shelf for a while and they may be beyond their expiration date. We certainly wouldn't want to use milk beyond its expiration date. Let's not use our disinfectants beyond its expiration date. I encourage everybody to go through the operatory uh rooms where perhaps you have your anesthetic stored and take a look at the expiration date of your anesthetic, especially your short-acting anesthetic, because we don't use that as frequently as the routine type of anesthetics that we use. Oftentimes when I'm conducting an audit in a dental office, I will find expired anesthetic. And the dentist was surprised about that. So if we can be checking those things, checking the appearance of our practice when it comes to infection control, what is the condition of our PPE that we've been wearing all year? Is it starting to look a little tattered? And how about our reception room? Has someone done a little walkthrough of the reception room? You know, when it comes to infection control, we want our patients to know that it's important to us not only where they can see it, upon entry to our practice, can they see the sign of our building? Is there uh you know trash in the parking lot? When they come into the reception room, what do they see? Do they see the Kleenex box and the trash receptacle and the hand hygiene products? And so if it's important to us in that part of our practice, they'll assume that it's important to us in the areas that they can't see. And uh other things that we can be looking at just as briefly is equipment maintenance, making sure that our gaskets are maintained on our sterilizers and that the maintenance team, whoever that is, whether it be your outside vendor that comes in and does checking of those devices, that that work is done. Um, check on your equipment and your upholstery. Uh, is the upholstery getting tattered or torn a little bit? Is there some maintenance that might need to be done there? And is there perhaps a maintenance of tightening some screws or some nuts and bolts, like with the overhead light or the x-ray arm? Does it drift? So these are all things that we could be looking at at the end of the year, sort of to get us ready to come into 2023 with a bang.

SPEAKER_02 7:05

Thank you, Leslie, and I appreciate your enthusiasm. I'd like to go back to Linda for her to share her top five or 10 OSHA reminders.

SPEAKER_01 7:16

Sure, Olivia, but I can't help but just comment on what Leslie just said. I love the analogy, Leslie, of you wouldn't use expired milk. So our dental supplies, is anything expired there? And then looking at your own appearance for crying out loud. Um, you know, especially with some of these disposable gowns, we've seen some of them that are sterilizable and they can be reused, for example, or just have your scrub jackets gotten old and worn out. So we don't want to um give the wrong impression about the quality of care that's provided in our practices for sure. So that brings us over to OSHA then. So I'll I'll I've got a couple that I'd like to rattle off off the top of my head. And first again is training. Just like I said with the HIPAA, OSHA training, especially with the bloodborne pathogen standard, is required every 365 days. So that puts you into a routine of roughly when that training should occur every year and not just simply once in a calendar year. So that's very important that your training be done in a timely fashion. So, in other words, don't postpone your annual training because you're going to be hiring a new team member in two or three weeks because that person may change their mind, or maybe two or three months you're gonna be hiring and that person may change their mind and or they don't stay on with you and you keep postponing and postponing, and you're really out of compliance. Another aspect that's required is to review your exposure control plan on an annual basis and to document whether or not you've needed to make any changes. So those is that is something that OSHA would be looking for in the case that you have an unannounced inspection in your practice. Another one, Olivia, is a safe uh device evaluation. That's been an OSHA requirement since 2000, where offices are obligated to on an annual basis to evaluate the different sharps in their practice and identify if there's a safer device that can be used. In other words, a device that is has a safety engineered feature on it to prevent the either the doctor, but especially the employees, since OSHA is focused on employees from either being cut or poked with a needle. And a couple of different areas where they can be reevaluating would be safer needles that are on the market, safer scalpels and things along those lines. There's not a lot of variety, Olivia, and dental practices or dent in the field of dentistry for any safer devices, but nevertheless choosing you know to evaluate them is not an option, it's must-do. And I know in some states, particularly Tennessee, you've shared with us, Olivia, that Toshi also expects you to have the reasons and the list of items that you chose not to use and kind of take that a little further. Not just did we evaluate a device, yes or no, but what was the outcome and why or why not? And what devices did we not evaluate? So a couple of things there. Those are the top ones that I can think of. I'm gonna toss it back to you or Leslie for any other ideas you may have with OSHA.

SPEAKER_02 9:57

Perfect, Linda. I would just supplement making sure our safety data sheet collection is current and not overlooking the chemical inventory list because OSHA would ask for that. And thank you, Linda, for emphasizing training. Because hands down, when I'm working with a client that's been cited, either training was not done or the training roster was not OSHA compliant. So need to be sure that we have our rosters in line with OSHA's requirements. Did you have another thought, Linda?

SPEAKER_01 10:28

Olivia, I'd like to piggyback on your thought about the chemical inventory list. Many times over, offices are told, say, by a sales rep or someone that comes into their office that that's just a list of the products they buy from their company. But we all know that that is actually a list of the ingredients and the products in their office. It's what's in your disinfectant products, it's what's in your ultrasonic cleaner, it's what's in the restorative materials, all the different chemicals that are in the office have to be identified. So that is not something that to take lightly, because as you mentioned, when OSHA comes in, they're going to be looking for that information.

SPEAKER_02 11:03

So true, Linda. And obviously, we have to allocate the time. So with these end-of-year reminders, it's important to spend some time on our project. Leslie, did you have a supplemental thought?

SPEAKER_00 11:14

Yes, actually, I just wanted to ask a question because I think you answered this once before for us on a podcast. When it comes to the training roster, I think you told us that it was important that it not only be the person's name, but their position within the practice and that OSHA was looking for that. Am I right?

SPEAKER_02 11:31

Yes. So on the roster, we need to be sure that the instructor has their credentials listed, the topics that we cover. So we have to address all the requirements in the bloodborne pathogen standard, as well as the attendees. We have to list their name and their designation. So I have had aggressive inspectors here in Tennessee that cited a dental office because hygienists simply did not put RDH on the uh the roster. So those are good points, Leslie. I'd like to focus a minute on HR as we conclude year 2022 and go into year 2023. I'd like offices to think about do they have job descriptions? Job descriptions are key for performance to know what are the primary job duties as well as the secondary job duties that a team member is responsible for, especially if they have the role of as the safety coordinator or the HIPAA privacy or security officer. It's helpful that they have a job description to outline and describe their role and what they are accountable for. It's also a good time of year to look at our handbooks and make any updates to correspond with changes in the law, especially on a state level, or even as the practice is growing to modify maybe what some of our policies are internally, and to be sure we have a meeting with our team members and everyone sign the acknowledgement of receipt of the handbook. Also, it's a good time to plan our performance reviews. I know in my practices we always do it in January, just seems like a good way to start off the year and do the performance reviews on all the team members. And also look at our time records. Be sure that we are maintaining the time records and also the documentation to support any paid time off or vacation requests that are made. So we have all our paperwork in order should there be a discrepancy or the need for more discussion on it. So I would say in wrapping up HR, please take the time to look at your handbook. If you don't have a handbook, I mean it's not that it's absolutely that you required that you have a handbook, but the handbook would be the guiding force on if the Department of Labor question you on an issue in your practice. So we really encourage you to have good, solid handbooks in place. And the job descriptions I can share with you, really important in working with one dentist where the board was questioning scope of duties. It was so helpful that I had the job description for the dental assistant, which corresponded directly with the scope of duties outlined by the state. So it's a great time of year, and I really appreciate Leslie and Linda contributing their thoughts on how we can wrap up the year with some helpful reminders on OSHA infection control, HIPAA, as well as HR. So thank you, fellow Divas. We did miss Mary Gavoni on today's episode. We look forward to seeing her next week. As the Compliance Divas, we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions to support at thecompliancedivas.com. Any resources that we mentioned will be available on the website. Thank you again, and we'll see you next episode.