Talking with the Toothcop

Needlestick injuries have been cropping up again in the last few months. These injuries are considered "occupational hazards" in dentistry—but should they be? Why is it happening? What's the contributing cause? In this episode of Talking With The Toothcop, Andrea and I talk about this costly "never event" and how to best prevent it.

Outline of This Episode

• [0:52] The protocol with needlestick Injuries
• [5:25] Coordinating testing with patients
• [8:20] Annual Sharps Evaluation + Usage
• [10:59] Live OSHA Safety Coordinator Training

The high cost of needlestick injuries

The CDC came out with some statistics that said the average needlestick injury costs $700–$750. That's a load of crap. If you can't get a negative test from the source patient, the employee must be treated as though an infection occurred. The post-exposure treatment includes taking costly antiviral medications.

If a hygienist slices their fingers open or someone gets poked by a root tip, you have to ask the source patient to get a blood test. But OSHA doesn't outline who pays for the patient's blood draw. I recently helped an office with a patient that didn't want to get a blood draw. I followed up to understand what her concerns were. Turns out, she didn't mind doing the blood test—she just couldn't afford it. So we arranged transportation and the practice paid for the blood test. It saved a lot of headache—and medication usage—for the employee.

Andrea points out that the majority of people understand that you're human and make mistakes. They're willing to do the right thing and are reasonable. You just have to be honest. Some of the recent incidents have involved pediatric patients. It's uncomfortable to have to ask a parent to take a child for a Hepatitis B or HIV test but it's a conversation you have to have.

Start taking preventative measures

While it's considered an occupational hazard, a needlestick injury is a "never event" that should never happen. Sharps containers should be located as close as feasible to the point of use. One simple thing that could be implemented is having the doctor break down their own needle. At that point, the odds of a staff getting stuck with a needle go down to almost zero. But a lot of dentists would rather have their staff do it for them.

Proper sharps usage is imperative

It's clearly defined under the bloodborne pathogen standard that dental offices must use sharps with engineered sharps injury protection (SESIPs). These needles have a built-in safety mechanism that reduces exposure. There are only two products that meet this threshold. One is the Verena SimpleCAP. The other is the Septodont Ultra Safety Plus XL Safety Syringe.

We recommend doing a yearly sharps training to educate your staff on how to properly use needles. Make sure all non-management clinical staff that works with these needles participates in the annual evaluation. Keep those records with your OSHA training records.

Resources & People Mentioned

• Live OSHA Safety Coordinator Training
• Measuring the Cost of Sharps Injury Prevention
• Septodont Ultra Safety Plus XL Safety Syringe
• Verena SimpleCAP

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

In this episode of Talking with the Toothcop, we're sharing a few more important reminders and things to stay on top of in 2021. This includes evaluating X-ray equipment, quarterly water testing, new CE requirements, completing CPR courses, and handling your exclusions monitoring. Why is it so important to stay on top of these things? Find out in this episode!

Outline of This Episode

• [2:27] X-ray equipment
• [6:26] Quarterly water testing
• [7:53] Human trafficking CE
• [9:51] CPR courses
• [12:04] Exclusions monitoring

Do NOT neglect your X-ray equipment

Texas has some of the most stringent enforcement in the country. X-ray rules were updated in 2019 and effective today. If you have digital X-ray machines, you're required to have a Quality Assurance/Quality Control (QA/QC) process. That means you need to get out your X-ray manual and do an equipment performance evaluation (EPE).

For 2D technology, you must do this evaluation within 2 weeks of installation and every four years. If you have a 3D X-ray machine, the evaluation is required within 30 days of install and every year thereafter (in a time-period no later than every 14 months).

If you miss the inspection, you may get lucky with a slap on the hand. If it happens again? A $4,000 fine. Don't mess this up.

Get your quarterly water testing completed

Now would be a great time to do quarterly water testing. You want to make sure that your output meets safe drinking water standards (500 CFU or less). It doesn't matter what treatment protocol you have—you need to verify it's working properly with water testing. You can do it yourself, or mail a sample off. If you don't have one in place, I recommend ProEdge Dental.

Complete a hands-on CPR course

The state audits 5% of all licensees every year in the state of Texas. This year, people are getting busted for not completing the hands-on CPR courses. You can't try to sneak by with the online-only courses. You have to do a hands-on skills evaluation or it will be rejected. If they reject it—and you waited until the last minute to complete your certification—your license may expire. That could mean you're practicing without a valid license, which is punishable.

The bottom line? Track your credentials. We know they all expire at different times, so set up a calendar and plan. Make sure you meet your requirements for the year. You can also compile the expirations for all of your staff and get a reminder in the calendar 45 days before. Don't wait until the last minute.

Exclusions monitoring

If you work with Medicaid, a federally qualified healthcare center, private dental practice/DSO, and you provide service to Medicare or Medicaid patients, you must do exclusions monitoring. Check before you hire someone and every month after hire. The more frequently you check, the fewer claims will be affected. If one of your staff members is on the exclusions list—even if they're administrative—every claim filed will be tainted. You might have to return hundreds of thousands of dollars of claims that have been paid to you. Minimize your risk by doing your due diligence. Check every doctor and staff member monthly, no matter their role.

Resources & People Mentioned

• Pro Edge Dental
• OIG Compliance
• Toothcop Compliance Training
• Human Trafficking Training

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

What's new in 2021? CE requirements are changing, PMP self-query rules are in effect, and e-prescribing has officially kicked off. Andrea and I talk about all of the changes—and where to learn more—in this episode of Talking With The Toothcop. Don't miss it!

Outline of This Episode

• [0:21] The first episode of 2021!
• [2:26] PMP Self-query
• [4:20] Check patient history
• [6:04] E-prescribing rules
• [9:07] NEW CE requirements

PMP Self Query

According to Rule 111.2, if you have a DEA registration (or multiple) you're required to check your prescriber history at least once a year in the PMP platform. Login and enter the dates you wish to check. You don't need to document it—the state automatically records that you've checked. If you don't, you may end up in front of the state board for lack of compliance. In Andrea's words, "Check yourself before you wreck yourself."

Diligently check patient history

As of March 1st, 2020 every time you prescribe a controlled substance you have to check the patient's history in the PMP. This can be delegated to another staff member to do (under their login—not yours). This helps you make an informed decision about what to prescribe.

E-prescribing rules in Texas

Effective 1/1/2021, Texas dental providers are required to e-prescribe. There are standalone systems available or some that tie into your current software (linked in the resources). It's not cheap, but you need to do it. The state board does allow for some exceptions, including if you prescribe fewer than 25 prescriptions a year (i.e. all of 2020).

NEW CE requirements

Dentists used to be required to take a two-hour CE course every three years regarding opioid and controlled substance use in their dental practice. As of 9/1/2020, dentists with a DEA registration need to take a course on prescribing and monitoring controlled substances.

Rule 104.2 takes effect 1/1/2021: every dentist with direct patient care responsibilities must complete two hours of education per year—or four hours per renewal period—on pain management. Duane has hired some clinicians to teach this course, check out the resources for the link to our training!

If you took the old prescribing and monitoring course on or before 8/31/2020, it's completely different from what's required after 9/1/2020. You have to take it again. Secondly, if you don't have direct patient care responsibilities (i.e. you're a consultant with a dental license or a teacher) you don't have to do the training. The bottom line? If you touch a patient, you should take the course.

Listen to the whole episode for all of the details!

Resources & People Mentioned

• Dental Compliance Training LIVE Courses
• Texas Administrative Code Chapter 111
• Dentistry Rules + Regulation Changes in Texas
• The DEA and Dentistry [Need to Know Updates]
• Texas State Board E-Prescribing Waiver
• E-Prescribing Waiver Form
• iPrescribe
• Allscripts
• iCoreConnect
• Veradigm
• MD Toolbox
• Surescripts

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

If COVID has taught us anything, it's given us clarity. The first thing you should question for 2021 is "What do you want?" Dentists are realizing that "I might" or "I should" needs to turn into a solid plan. Do you want to recover losses? Do you want to grow? Do you want to slow down?

Sometimes the best way to implement goals is to have someone come alongside you to help you through the process. That's where Tonya Burns comes in. Tonya is a consultant working exclusively with pediatric dental practices. Her mission is to empower dental practices to reach success—whatever that looks like for them. Listen to this episode of Talking with the Toothcop to learn more!

Outline of This Episode

• [2:20] Tonya Burns: Pediatric Dental Consultant
• [3:41] Tonya is MORE than a consultant
• [6:33] How to implement goals in your practice
• [12:32] What years of consulting have taught us
• [29:41] Implementing automation in dentistry
• [37:49] Tracking metrics with clients
• [39:20] Systems are great—so is accountability
• [41:58] Learn how to embrace change
• [43:07] How to connect with Tonya Burns

Tonya is MORE than a consultant

Tonya feels the word "Consultant" often comes with bad connotations. She wants to change the stigma. She comes into dental practices to help devise plans based on that office's wants and needs. She crafts her approach to each practice and what they're capable of. She reinvents the wheel all the time. She enjoys being involved in every part of the process, from goal formation to implementation. She's there to hold them accountable and give them direction. Sometimes she helps them fine-tune their own systems and redesign them.

Her goal is for a practice to achieve their goals without leaving any patients behind. No one should fall through the cracks. A lot of patients falling through the cracks in pediatrics. Why? Because there's so much volume. You need to identify holes in your practice and fix them before it's too late. That's where a wonderful consultant like Tonya can step in and be a game-changer for your people and your business.

Implement SMART goals in your practice

Tonya emphasizes that right now is a great time to be in pediatric dentistry. It isn't feeling the effects like other specialties and general dentistry has. Parents will always do for their kids what they won't do for themselves. Dental practices are also doing a great job at making their patients feel safe.

Tonya also points out that now is a great time to set SMART goals (specific, measurable, attainable, results-oriented, and timebound). Do you want to recover losses? Do you want to grow? Do you want to slow down? What do you need to do to get the practice in the right position? You should set realistic goals that you can measure and attain. Let your team set some goals as well. What would they like to see happen? Have you realized you need more education to be more efficient?

Consultants CAN empower change

Tonya was hired to work with a practice that had a toxic environment. The dentist said, "I just want them to be happy." The dentist had bought out another office, merged the practices, and told them "This is how it is." They had broken processes. No one had any respect for each other. There were power struggles. They would even cuss each other out through their headsets.

They worked through the problems and at the end of the relationship, she had all the "mean girls" texting her and thanking her. They didn't realize how bad they were. The practice turned around and did well. People want to trust who they're working with. It's all about finding a connection and making sure you're a good match. But you also have to walk away from people if you know you can't help them.

Implementing automation in dentistry

Tonya is now helping implement automation in dental offices as part of her consultation service. They take repeatable processes, put a bot into use, and then teach the team how to use it properly. This is a way to work leaner and help your overhead. Robots can do insurance verification, track claims, do payroll, and even send claims and statements. They've now taught the robots to read EOBs and they should be able to post payments soon. You can program the bot to do anything that you want.

But they still need a human running them. Implementing automation removes human error with small things and removes things that offices hate doing. It can clean up the process and streamline it. It all happened because Tonya met a pediatric dentist whose husband owned an automation business. She started helping to program them to work with a team in an office. Now they're going live with clients.

How long does it take to implement? If you want the robots customized to your practice—which is what Tonya advises—then the process takes about two weeks from testing and implementing to using.

Wonderful things are coming for the pediatric community. Listen to the whole episode for the full conversation about pediatric consulting, implementing new technology, and the future of dentistry.

Resources & People Mentioned

• Go to ProEdgeDental.com/Toothcop for a special offer!
• Connect with Tonya at TonyaBurns.com
• Tiny Bubbles by Don Ho

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

Texas has rolled out some regulations and rule changes that dentists need to stay on top of. From controlled substance CE changes and equipment performance evaluations to medical emergency preparedness training and sedation inspections—we cover it all in this episode of Talking with the Toothcop. Don't miss it!

Outline of This Episode

• [0:21] A trip down memory lane
• [4:41] Controlled Substance CE changes
• [13:57] Controlled Substances: EPCS + patient query
• [19:11] The Human Trafficking Course requirement
• [21:30] X-ray equipment performance evaluations
• [25:02] Step-wedge test + medical emergency preparedness training
• [27:30] What dentists are getting busted for in sedation inspections
• [34:17] Mail Bag: Does your office need to use respirators?
• [37:13] Georgetown Dental's violations

Changes to Controlled Substances Regulations

A lot of controlled Substance CE changes came out in 2016. Some dentists still aren't in compliance with these rules. Rule 111.1 is a CE requirement for every dentist in Texas with a DEA registration. Up until 9/1/2020, dentists were required to complete a two-hour CE course on opioids and the use of controlled substances in the dental practice. Now you're required to do an additional two-hour course on monitoring and prescribing practices for controlled substances.

This takes effective As of January 1st, 2021 all dentists with direct patient-care responsibilities are required to complete a pain management CE (Rule 104.1 ). It is a two-hour CE course that you must complete annually. Some CE requirements are annual OR every other year. I.e. the human-trafficking course must be completed per renewal period or every two years.

NOTE: A dentist is NOT required to have a DEA registration if you're not prescribing. But moving forward, the only way you can prescribe any controlled substance will have to be done through Electronic Prescribing of Controlled Substances (EPCS).

Controlled Substances: EPCS + patient query

Under rule 111.2, any dentist with a DEA registration is required to login to the PMP (Prescription Monitoring Program) and complete a self-query to review your prescribing history. Even if you don't prescribe controlled substances, you still have to log in and perform the search. Luckily, there's no need to document it. They monitor the keystrokes and searches you perform when you log in—which is why you have to do it.

Before issuing a prescription for a controlled substance to a patient, you're required to check the patient's history in the PMP (Rule 111.3). If you're administering a controlled substance from an office supply (and not ordering it or prescribing it) you don't need to do the search.

Rule 111.4 allows the state board to monitor dentists prescribing practices. In Texas, it's managed by the State Board of Pharmacy. Some dentists have disciplinary actions on their license for failure to comply with these rules—so we aren't just saying them to say them. They are important.

X-ray equipment performance evaluations (EPE)

The most common thing dentists get busted for is not having equipment performance evaluations (EPE) completed in time. It's simply a calibration check that must be performed by an outside party. The state requires it for two-dimensional x-rays every 4 years from the date of the last EPE. It's such a common violation that half to most dental offices have been busted for this. They don't give second warnings—you'll get a $4,000 fine after your first warning. This is one of the easiest rules to comply with. NOTE: If you have a three-dimensional x-ray machine, it must be checked annually.

What dentists are getting busted for in sedation inspections

The first thing dentists get busted for is expired AED pads OR not having pediatric AED pads. You have to have pediatric appropriate equipment if you administer nitrous to children under 13.

Another thing is not checking vital signs intraoperative or perioperative. That includes blood pressure, heart rate, O2 Sats, and respiratory rate every 10 minutes. I know dentists who are in hot water right now because they've failed multiple times. Don't let something so silly leave a black spot on your record.

Pull up your Pre-Op Sedation/Anesthesia Checklist and look at rule 110.3. Make sure your pre-op checklist has everything that's required and it's titled "Pre-Op Sedation/Anesthesia Checklist." No joke—if it doesn't say that, they will make you fix it. This is true for level 1 and Nitrous Oxide only as well.

Mail Bag: Does your office need to use respirators?

When most people hear the word "respirator" they automatically think of elastomeric respirators (i.e. a Darth Vader type mask). Dental offices do wear N-95 masks, but it's actually called a face-filtering respirator. It's still a type of respirator—just not what you think of. Texas (Rule 108.7 Subsection 16) requires the use of an N-95 Respirator mask when working within 6 feet of aerosol-generating procedures (anything where you use a handpiece). It applies to dentistry in Texas and other states.

Why you HAVE to follow the rules

OSHA reported that since the pandemic, there has been $1.4 million in fines issued to healthcare providers. There was only one dental office on that list—Georgetown Dental in Massachusetts. They were busted for over 7 violations, but here are a few:

• 1910.134(c)(1) – No Written Respiratory Protection Program. You need a written plan.
• 1910.134(e)(1) – No Medical Evaluations for Employees. You must provide them a medical evaluation to make sure they can use a respirator.
• 1910.134(f)(2) – No fit testing. They must be fit-tested before initial use of the respirator.
• 1910.134(k)(1). Employee training. The employer shall ensure that each employee can demonstrate knowledge of how to use, maintain, and store the respirator.

Any dental office needs to make sure they comply with these rules. To get the full details on all of the rules and regulations that have changed, give the whole episode a listen—and take notes.

Resources & People Mentioned

• SedationCE
• Sedation Inspections + EPCS + Continuing Education
• SOAR Health and Wellness Training
• 1910.134(c)(1) – No Written Respiratory Protection Program

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

Why do you need to monitor and audit your charting? Why is verifying that your billing is done correctly so important? Because your life and your livelihood depend on it. An ongoing evaluation process is so important to a successful compliance program. Are your standards and procedures accurate? Is your compliance program working? Are claims being submitted properly?

All of these questions are important to answer. So in this episode of Talking with the Toothcop, Andrea and I walk through the OIG standards for record monitoring and chart auditing. We share some important definitions, my auditing process, and other things that are important to track and monitor. Don't miss it!

Outline of This Episode

• [1:37] Recap of the last episode
• [4:03] The OIG Auditing and monitoring procedures
• [11:38] Avoid a Corporate Integrity Agreement (CIA)
• [13:08] The definition of an overpayment
• [13:56] Understanding the False Claims Act
• [15:00] Proper charting review and noting
• [19:57] The threshold for fraud is low
• [22:18] Guidance for compliance officers for CIAs
• [29:59] What do you focus on in a record audit?
• [34:03] Other things you need to monitor
• [37:00] Find the time to do audits
• [39:49] The OIG Self-Disclosure Protocol

What does the OIG consider an effective monitoring program?

An audit is one of the best ways a dentist can make sure they're following proper procedures with their charting and billing. It's also a great way to find problems and nip them in the bud before they continue. The OIG defines two types of review: (1) A standards and procedures review; and (2) a claims submission audit. I've found that a review of standards and procedures is almost nonexistent in most dental offices because most don't even have written standards and procedures.

The OIG states "In addition to the standards and procedures themselves, it is advisable that bills and medical records be reviewed for compliance with applicable coding, billing and documentation requirements." Who should be included in the audits? Ideally, the dentist, dental hygienist, and whoever is in charge of billing.

The OIG recommends that you take a snapshot i.e. a benchmark to track that your practice is reducing the number of claims that are overpaid or denied.

What do you focus on in a record audit?

A self-audit is primarily to determine:

• Bills are accurately coded and reflect the services provided
• Charting and documentation is being completed correctly
• The services provided are necessary

Are there any patient safety or qualitative issues? Look at any issues that will pose a problem to your license and your freedom. You're more likely to be audited on your higher-dollar items, but they'll often include records for limited exams and hygiene. There are just a few of the things you need to monitor:

• Vital sign records for sedation (document at certain time intervals, time and amount given, etc.). Calculate your time correctly, you will be scrutinized on it.
• Improper coding and billing
• Document tooth number and surfaces
• Make sure you've gotten proper consent
• Exclusions monitoring
• Pre-hire screening

You need to be adept at identifying non-compliance from patient intake through submission and payment. Through this process, you can identify what needs improvement. The OIG recommends that you conduct periodic audits at least once per year. They also recommend a random selection of patient records to review (but preferably 5+ per payor and 5+ per dentist). I share the process that I prefer, listen to learn how it's different (but still compliant).

What do you do when you find problems?

If you identify problems while doing your review(s) you need to determine whether it merits further training and education with staff or changes to your process. If you find risk areas or vulnerabilities, they need to be addressed. The OIG notes that the specific actions taken depend on the circumstances of the situation. It can be as simple as a repayment to a payor with an explanation of the overpayment.

I worked with a dentist whose clinical notes were inadequate to support what was billed. The acting dentist didn't take x-rays, note what teeth were affected, and didn't clarify why the work was done. When we uncovered that, they had to figure out how much was paid and return the money.

You have to do that to protect your integrity when you don't meet the criteria of what is expected of you. When the OIG comes knocking on your door because of a complaint, they can see your history of integrity. It could save your bacon. What do you do if your practice conducts a review and must notify the OIG? What process do you follow? What is the definition of an overpayment? Listen to find out.

Ingrain chart auditing and monitoring into your practice

You have to find time in your busy schedule to do chart audits. You have to do this. It's not that difficult to create an audit checklist. You can train your staff how to conduct an audit and assign each of them 10 records to go over. Have them report back to you with the feedback you need to reduce your number of inaccurate claims.

I also recommend auditing some of your own records—and be tough on yourself. Allow yourself to be your own worst critic to get better at charting. If you find a problem, fix the errors with that record (with a note—do NOT change the original record). Do some additional snooping to make sure it's not a systemic problem. Dig until you find more and figure out how to report it.

Compliance is a scale. It might not be possible to hit 100% compliance. But my goal is to get you to a higher percentage on that scale. It's about putting systems into place to help you sustain positive changes long-term. If you'd like one of my sample checklists, shoot me an email! We cover this topic in-depth, so for more detail, listen to the whole episode!

Resources & People Mentioned

• OIG Compliance: Auditing and Monitoring
• OIG Self-Disclosure Information
• The Next Generation of Corporate Integrity Agreements
• Third-Party Medical Billing Compliance Program Guidance

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

Years ago, the federal judiciary realized that federal judges needed sentencing guidelines for healthcare fraud. In the process, they issued compliance guidelines for different healthcare industries. Each incorporates the seven elements of compliance to combat healthcare fraud. The ramifications of violating the false claims act are tremendous. So what do you need to do to protect your dental practice? What are the seven elements that need to be incorporated into compliance programs? Listen to this episode of Talking with the Toothcop to find out!

Outline of This Episode

• [10:22] The evolution of compliance programs
• [12:27] The 7 elements of compliance programs
• [16:21] #1: Implement written policies and procedures
• [21:50] #2: Designate a compliance officer
• [24:53] #3: Provide effective compliance training
• [30:16] #4: Develop effective lines of communication
• [36:08] #5: Conduct internal monitoring and auditing
• [43:38] #6: Enforce standards through disciplinary guidelines
• [44:56] #7: Respond promptly to violations and take corrective action
• [47:54] #8: Whistleblower protections in New York state
• [50:41] Give us some feedback! How can we serve you better?

What are the seven core elements of a compliance program?

Every healthcare provider that participates with Medicare or Medicaid has to establish a healthcare compliance program that incorporates these seven elements:

1. Implement written policies and procedures
2. Designate a compliance officer and compliance committee
3. Conduct effective compliance training and education
4. Develop effective lines of communication
5. Conduct internal monitoring and auditing
6. Enforce standards through well-publicized disciplinary guidelines
7. Respond promptly to violations and take timely corrective action

Any organization that has been busted for healthcare fraud—rather than being kicked out of the Medicaid program—has to establish a compliance program. It also comes with a babysitter for 5 years and compliance with a Corporate Integrity Agreement. It's five years of probation. It's also why it's imperative that you read, understand, and implement each of these elements.

Implement written policies and procedures

You need to create policies and procedures for whatever compliance risks you face as a practice. Some of the risks you might face could be related to sedation (general anesthesia), patient information and HIPAA regulations, infection control, electronic billing reference materials (CDT coding books), controlled substances/drug policies, medical emergencies and much, much more.

You need to identify your risk areas and write policies and procedures to serve as a reference guide for your staff. How do you establish them? Write down a brain-dump list of every risk you can think of that your dental practice might face. Ask the questions: Can I lose money? Can I lose my license? Can I lose freedom? If you can answer yes to any of those questions, it's time to frame up some policies and procedures.

The bottom line is that the government wants to see that you have policies and procedures in place to deal with overpayments and your response to an identified overpayment. Andrea and I take a deep-dive into element #2—so keep listening.

Provide effective compliance training and education

There are certain things every staff member should be trained on including code of conduct training, fraud, waste, & abuse training, continued education for billing staff, OSHA and HIPAA training, infection control training, and more. It's your job to figure out what needs to be done and who needs to complete it. It's not an excuse to say "I didn't know."

The code of conduct is somewhat of a catch-all. You can't predict every situation that might happen in your practice. It's just not possible. Your written code of conduct is a set of principles that you want your staff to use to problem-solve. It should communicate your practice's values, mission, vision, and purpose. Train your new employees on your code of conduct immediately. Effective training isn't just giving someone information—you have to make sure they're retaining the information, too.

Keep listening to hear why element #4—developing effective lines of communication—is so important.

Conduct internal monitoring and auditing AND enforce corrective action

Two elements absolutely HAVE to be implemented—number #5 & #7. They involve checking your work—and fixing your mistakes. Having both processes in place is important. You need people in place to keep things in check. Put systems in place to track and stay on top of those things that you need to monitor.

Review your employee handbook periodically and update it to reflect current regulations. It should outline disciplinary guidelines. Many follow a progressive guideline such as a write-up, suspension, time off without pay, etc that leads up to termination—while reserving the right to fire when necessary. It needs to be well-published and applied evenly and fairly at every level of the organization. If you have a bad apple, you have a responsibility to carve them out of your organization before they harm someone.

Listen to the rest of the episode to hear about element #6 as well as the important topic of exclusion monitoring—if you don't do this you can bankrupt your business.

Resources & People Mentioned

• Healthcare Fraud
• The False Claims Act
• Office of the Inspector General Website
• Corporate Integrity Agreements
• OIG Compliance for Individual and Small Group Physician Practices
• HEAT Provider Compliance Training Videos
• Measuring Compliance Program Effectiveness: A Resource Guide

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
• On Twitter
• On LinkedIn
• On Youtube

Did you know that October is the National Substance Abuse Prevention Month? In keeping with that theme, this episode of Talking with the Toothcop is all about drug regulatory issues and updates, schedule II drug monitoring, and substance abuse prevention. We share some helpful resources and DEA regulation updates—don't miss it!

Outline of This Episode

• [1:33] DEA drug regulatory changes
• [3:53] Medicare consolidating credentialing in TX
• [4:28] Electronic 222 forms for schedule II drugs
• [6:36] Why you NEED to keep inventory
• [9:34] The topic of background checks
• [12:27] Substance Abuse Prevention Month
• [13:32] Controlling patient information
• [14:42] Annual DEA CE now required
• [15:17] How to check a patient's drug history
• [21:36] The Professional Recovery Network

The DEA is making bank

The DEA is raising their fees. Effective 10/1/2020, the DEA registration fee is going from $721 to $888 per registration. For those of you that have multiple practices or registrations, it will get expensive.

What else is changing? The DEA will now require electronic 222 forms. You must fill out a 222 form to send to the DEA to order controlled substances for office use. You can use up the paper 222 forms until 10/31/2021. But what you don't use will have to be shredded.

We recommend that you don't keep too many of these forms on hand—or too many controlled substances. If they expire, you have to send them to a reverse distributor. You can't send them to the supplier you purchased them from. The fees you have to pay for expired drugs costs more than purchasing them in the first place.

Why you NEED to keep inventory

There are TWO things I recommend you do consistently:

1. You need an up-to-date drug log and inventory. The DEA requires an inventory count every-other-year. Track the total on-hand. Track each concentration and form separately.
2. Routinely get out your receipts and 222 forms and check your math. Make sure you aren't missing anything.

Doing these things help prevent improper use and abuse of controlled substances. I've seen situations where staff members order extra bottles that disappear. If someone is using your credentials to perform duties related to controlled substances—trust but verify. They're called controlled substances for a reason.

Do your background checks

Dental offices need to do background checks on employees. Some states are only allowed to allow full background checks in limited situations, such as when you've made a conditional job offer. But the DEA requires that anyone who works with controlled substances has a background check done on them. Ideally, it's a full criminal background check.

If you won't do a background check, you must do a basic screening for abuse or misuse potential. Secondly, if a staff member handles or prepares subscriptions, put the designation in writing and maintain a record of that. Most dentists are more comfortable doing the ordering themselves and I support that. If you use a designated agent or a power of attorney, you're still responsible for overseeing their activities.

How do you check a patient's drug history? When do you need to? What are some unexpected schedule II drugs? Listen for the details.

The Professional Recovery Network

If you or a dentist you know has a drug problem or mental health issue, there are professional recovery networks available. If you turn yourself in, you can get services confidentially. If a staff member turns you in it becomes a public health issue and it will be attached to your license. Keep yourself accountable. Don't face emergency suspension of your license. If you or someone you know has a problem, be proactive and get help.

If you're going through a rough time in your life they can help. It doesn't have to be severe drug abuse. It's okay to say you're not okay and reach out for help. Don't wait until you get arrested for a DWI. Substance abuse isn't the number of times you've done it. It's the reason why you're doing it and the fact that you did it in the first place.

Andrea points out that everyone is human. No one plans on becoming an addict. It takes one opportunity. One bad decision. No one says "I'm probably going to get hooked on it, but it's okay. It's worth it." Don't give yourself or someone else the opportunity to make one bad decision. Put systems in place to protect you from yourself as much as you keep your staff accountable. It doesn't matter if you claim you're a good guy, you have to walk the talk. Learn what else is changing and more valuable resources by listening to the episode!

Resources & People Mentioned

• Pizza Hut Commercial
• Designated Agent Screening Form
• DEA Power of Attorney Format
• Goodhire (background check)
• PMP CE Option
• Controlled Substances
• Professional Recovery Network: 800-727-5152

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
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Every five years, Texas conducts inspections of any practice that uses sedation. Some practices have recently undergone their initial inspections. From what I've heard, most have gone pretty well. Some are getting busted for things they consider nit-picky—like missing information on their preoperative checklist—but that the state board takes seriously. So in this episode of Talking with the Toothcop, Andrea and I chat about preoperative checklist requirements, the Electronic Prescribing of Controlled Substances (EPCS), as well as continuing education requirements. These are things you NEED to stay on top of—so don't miss it!

Outline of This Episode

• [4:10] Texas: Updates regarding sedation
• [10:34] Physical examination subsection C
• [13:09] Anesthesia-specific examination subsection B
• [13:48] Special pre-op considerations: pediatric or high-risk
• [15:25] Rules on equipment and use
• [16:24] EPCS: Electronic Prescribing of Controlled Substances
• [29:48] Continuing Education: Human Trafficking Training
• [33:17] How to keep everything straight

The required preoperative checklist for nitrous oxide + sedation + anesthesia

You can find the preoperative checklist in its entirety HERE. I'm referencing specific line items in this checklist that must NOT be neglected. Firstly, do NOT remove anything from the pre-op checklist. If you don't heed this warning, the state board will make you fix it.

At a minimum the preoperative checklist must include documentation of the following when applicable (summarized):

1. Medical history (allergies, surgical history, review of family surgical history, medications)
2. Confirmation that pre and post-operative instructions were delivered to the patient
3. Medical consults were conducted if needed
4. Physical examination and documentation (weight, blood pressure, pulse, respiration rate)
5. Anesthesia specific physical exam (airway assessment, ventilation and respiratory rate)
6. Pre-procedure equipment readiness check
7. Confirmation of pre-procedure treatment review
8. Special preoperative considerations as indicated for sedation/anesthesia administered to pediatric or high-risk patients.

So where are things getting missed?

The physical examination section clearly states that you must obtain: preoperative vitals, including height, weight, blood pressure, pulse rate, and respiration rate. This applies to every level of sedation, from nitrous oxide to general anesthesia. The issue that's coming up most frequently during inspections is that dentists and their staff aren't documenting the respiratory rate.

Now, a lot of pediatric dentists are not taught that they're required to document the respiratory rate. You may not be accustomed to it—but you need to start doing it. Not only that, but vital signs need to be recorded every ten minutes or less. It's the rules. So is recording the height and weight of an adult patient every appointment. It may not feel necessary, but you can't just say "It's not that big of a deal because it's only nitrous." You have to comply with the rules to stay out of trouble.

You must also make sure you're recording the Mallampati score and/or Brodsky score. The state board is looking for how you verified the respiratory or ventilation rate. They want that to be clear (and it can be documented by observation, auscultation, or capnography). Keep listening to hear more about pediatric and high-risk patients as well as equipment and use instructions that are being missed.

Want the latest version of my checklist? Shoot me an email at toothcop(at)dentalcompliance.com and I'll happily share it with you.

EPCS: Electronic Prescribing of Controlled Substances

Electronic prescribing of controlled substances is already a requirement in many states. As of January 1st, 2021 Texas will join the list. It will require dentists, physicians, and healthcare providers to e-prescribe schedule 2 drugs. If you need help finding a prescribing platform that works best for you, I've linked many options below.

But wait—don't confuse this with your PMP responsibilities. According to the state board rule 111.2: "Each dentist who is permitted by the Drug Enforcement Agency to prescribe controlled substances shall annually conduct a minimum of one self-query regarding the issuance of controlled substance through the Prescription Monitoring Program of the Texas State Board of Pharmacy." You can log in to PMP Aware to check your prescribing history to make sure there haven't been mistakes. If you find something blatant, figure out if you need to address it.

Another change? Until September 1st, you were required to do a 2-hour CE once every 3 years (use and prescribing in the course of dentistry). Now it's an annual requirement to do the CE and a self-query check. Every time you issue a prescription it needs to be justifiable and you have to perform a patient history search—every time. What are the exclusions from this? Who can do the PMP check? What is the maximum you can prescribe? Listen to find out!

Continuing Education: Human Trafficking Training

Human trafficking is becoming a pandemic in its own right. Texas isn't the first state to require it, but every healthcare provider—who is not a physician—is now required to complete a course on human trafficking. There are a lot of courses available online, but as of right now the state requires a Health and Human Services Commission approved course. It's required training before your next license renewal.

Are you wondering how you're supposed to keep everything straight? How do you track all the training, continued education, and compliance measures you're supposed to take? I've linked a detailed list below that should help you stay on track!

Resources & People Mentioned

• Required Preoperative Checklist
• iPrescribe
• Allscripts
• iCoreConnect
• Veradigm
• MD Toolbox
• Surescripts
• https://texas.pmpaware.net/login
• Texas State board rule 111.2
• Blx Training CE
• Dental Anesthesia CE
• Human Trafficking Training
• Continued Education Requirements

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
• On Facebook
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• On Youtube

Water is the lifeline of your dental practice. If your dental unit waterlines are covered in biofilm, you're in trouble. How do you test your water lines properly? How do you treat your systems? What do you do if you don't have a closed system? With the heightened awareness of spreading germs due to the Coronavirus crisis, it's more important than ever to be mindful of prevention in your practice. In this episode of Talking with the Toothcop, Dwight and I chat with Mike Rust and Kellie Thimmes from ProEdge Dental about what dentists can—and should be doing—to prevent infections.

Outline of This Episode

• [0:21] Mike Rust + Kellie Thimmes on the Toothcop
• [1:19] What people don't know about Kellie + Mike
• [4:27] How to test your water lines properly
• [11:40] The CDC will revise dental infection control guidelines
• [20:40] Indicators that a dental office does or doesn't care
• [28:28] Where does the problem originate?
• [31:58] Pro Edge's new Flow-Cytometry technology
• [38:15] The Anaheim case that changed everything
• [42:01] What could happen when the CDC reviews their guidelines?
• [43:33] What do you do about open systems
• [55:17] UV disinfection technology
• [58:25] How to connect with Mike + Kellie

Why biofilms originate in water lines

Biofilms usually form in waterlines because they're small, plastic, and the water sits stagnant. The bacteria sits there and thrives. It can also be found in anything with a filtration system—which can remove solids (like minerals and chlorine) but not small bacteria. So everything just sits there in their little pod and it's the perfect breeding ground for bacteria. That's why it's so important to purge anything connected to your waterline unit. The extra flow of water in between patients helps move the germicide through the system and helps keep it clean—and prevents biofilms.

The Texas dental board recently relaxed its Cavitron regulations to allow dentists to start using them again. Most dentists haven't been using them since mid-march of 2020. Why? Kellie points out that firstly, they create aerosols. Secondly, water lines tend to hold a lot of bacteria. Dentists don't want to worry about COVID and other bacteria. It's also because Cavitrons are harder to shock. The failure rate is over 50% and they have higher counts of CFU's than any other water line.

How to properly test your dental unit waterlines

You have to collect the water for the test from the right place. 9/10 times dentists that say they're testing pull a sample from an air-water syringe. But dentists should be testing from the dirtiest thing(s) in the dental practice: a water sample from the Cavitron or Ultrasonic. If you're passing your water test with samples from those you know you're doing well.

Kellie recommends taking a collective sample from each room in your dental practice If there's a failure, then you shock everything. Both Kellie and Mike advise using an aseptic technique when you're taking a sample. Take the handpiece off and use a new air water syringe tip. It's not as messy and easier to collect the sample. Test your water as if you were doing it for a new patient.

Are the current infection control guidelines enough?

It was recently announced that the CDC will be revising dental infection control guidelines—which has been overdue for a while. It makes you question: Are the current guidelines as effective as we think they are? The CDC recommends periodic testing but doesn't define the timeline. They say to defer to the manufacturer's instructions. You have to monitor your water regularly—at least quarterly if not monthly. Kellie and Mike agree that you must use an EPA approved shock product.

If you're not aware, the EPA regulates drinking water standards and anything that could impact groundwater. The FDA regulates medical devices (they review and approve). Everything you use in the dental office is a medical device. For you to use it, the manufacturer had to get approval from the FDA. Whenever you deviate or use a device other than its intended use, it's considered off-label use.

There are a lot of treatments for removing biofilm, so you have to find what works for your practice. Follow the IFUs for the products you've chosen and ask for help if you need it. Kellie states "I wish there was a magic bullet, but there's just not. It's called waterline maintenance for a reason—because it takes work." If you're committed to monitoring, you'll get better results.

What are indicators that a dental office is doing what they're supposed to for infection prevention? Listen to hear their take!

Sometimes you have to humanize the problem

The case that happened in Anaheim, CA impacted 71 families. 70 of the kids had major surgeries and some lost parts of their jaw from preventable infections. All because ONE dentist office didn't properly test or treat their water lines.

Some dentists don't want to test because if they find out there's a problem then they have to do something about it. But it is your responsibility to know. You have to humanize the problem. It's not about devices—it's about those child's faces.

No dentist goes to work and says "I want to hurt someone today." But do they go to work today and say "I want to make sure that we don't hurt anybody, ever." It's a huge difference. That's why it's so important that the CDC reviews its guidelines.

What to do if you have an open water system

Many older dental offices still use city water and can't introduce a germicide or antimicrobial into the system. You can treat your water, but you can't efficiently shock the water. What do they do? You should retrofit your open systems so you can shock the water. Add a closed bottle system for $200 a chair + labor. In 10 minutes you can shock them with bleach and sleep at night. You just have to take the time to do it.

Recently, In Corpus Christi Texas, they had water-boil advisories. Municipal water was contaminated. If you don't have a closed system, that effectively shuts down your practice. It'll cost you way more than converting your dental unit to closed bottles. Plus, you have to keep tabs on your city's boiled water advisories.

Keep listening to hear our conversation about tap water versus distilled water and what Kellie and Mike recommend using.

Pro Edge's new Flow-Cytometry water testing technology

Proedge has launched a Flo™ Dental Unit Waterline Testing Service Kit that allows you to get same or next-day test results. It takes one hour for them to process the results. They're counting the bacterial cells in the water with laser technology and fluorescent dye. Why does it matter so much? Other tests can take days or even weeks to get results.

Some practices have to remain closed when their water lines are being tested—only to find out they failed. That means they have to shock their systems, restest, and wait all over again. No longer. The price of this test is only a couple percent more. It's a premium service without the premium price. Check out the resources for a link to an amazing deal on this new product. I want people to do the testing, work with good people, and save money while doing it.

Resources & People Mentioned

• Special Dental Compliance ProEdge Offer
• Flo™ Dental Unit Waterline Testing Service Kit
• Dental Infection Control Washington state
• Mike Rust on LinkedIn
• Kellie Thimmes on LinkedIn
• ProEdge on Facebook
• Call ProEdge at 888-843-3343
• Environmental Protection Agency (EPA)
• U.S. Food and Drug Administration
• Boil-Water Advisory
• Dental Unit Waterline Contamination in Anaheim

Connect With Duane

• https://www.dentalcompliance.com/
• toothcop(at)dentalcompliance.com
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• On Youtube