In attached documents, please provide the following and return to the Director of Facility Assessments

1. A written outline of the duties and responsibilities of the Director/Owner.

1. An outline of the facility’s administration with an organizational chart.

1. Job descriptions, which include duties and responsibilities for all personnel.

1. The name(s) of the director(s) and owner(s) of the facility, including any members who have a direct or indirect financial interest in the facility.

1. Names of its officers and directors, if the facility is a dental corporation.

1. The names, credentials, and CPR status of all staff and dentists requesting privileges at the facility.  Please enclose a copy of their certificate.

1. A copy of the policy and procedure manual

1. Complete records of all dentists who have privileges at the facility, including their applications and schedules for procedures. 

1. Any service agreements need to be included.

Practice Profile

1. Name of Office:
1. Address:  _______________________________________________________________
2. Telephone: (       )___________________   Facsimile: (      ) ________________________
3. Owner(s):  _______________________________________________________________
4. List names of other dentists who provide treatment in office:  ________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. General Practice:          Specialist:          Specialty: ________________________________
2. Dental Assistants:
1. Names of Office Trained Assistants:  ________________________________________________________________________________________________________________________________________________
2. Names of Registered Dental Assistants:  ________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Hygienists: 
1. Names of Registered Dental Hygienists: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Other Staff and Their Position:  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Staff and Staff Health

1. Are all staff providing treatment working with in their scope of practice?

 Yes        If No, Please explain___________________________________________________

1. Does the facility require that health care workers be up to date in immunizations as per the Canadian Immunization Guide from Health Canada?                    

Yes        No

1. Does the facility have a policy for providing hepatitis B vaccine to all health care workers?

Yes        No

1. Does this facility have a policy in place for providing flu shots to all health care workers?

Yes        No

1. Does the facility have a policy in place for testing and follow up for health care workers and patients who may have been exposed t o blood borne pathogens?

Yes        No

1. Are policies in place for:

1. Sexual harassment policy
2. Infection control protocols
3. Inspection of quantity and viability (unexpired) of drugs
4. Security, storage and control in-office drugs to protect against abuse
5. Retrieving instruments from closed/uncontaminated locations  (i.e. drawers) in operatory 
6. Avoid cross contamination when transferring equipment or material between operatories (if applicable) 
7. Single use/disposable supplies protocols ensure proper disposal or disinfection techniques are acceptable and adequate
8. Emergency plan

1. Fire
2. Patient care
3. Violence
4. Medical

Yes       If No, please explain __________________________________________________

1. Are logbooks in place for:

1. Sterilization with spore test results
2. Monitored use of drugs stored in-office

Yes       If No, Please explain ____________________________________________________

Reception Area

1. Is your dental license visible to the public and registered?

Yes       No

1. Is your permit for use of Nitrous Oxide, IV/IM Sedation, or General Anesthetic current and visible to the public? (If applicable)

Yes       No

1. Does your front reception prevent disclosure of personal health information?

Yes       No

1. Are your charts stored in a secure manner? (chart information not viewable by unauthorized individuals)

Yes       No

1. Is your reception area computer:

1. In a secure location
2. Password protected
3. Monitor is not viewable by unauthorized individuals
4. Registers changes in patient record

Yes       If No, please explain______________________________________________

Operatories

1. Is equipment CSA certified where applicable?

Yes       No

1. Is your office in compliance with current mercury hygiene protocols?

Yes       No

1. Are all dental materials within expiry date?

Yes       No

1. Are appropriate barriers used for patients and staff?

Yes       No

Sterilization Area

1. Is a process in place to update staff on infection control practices?

Yes       No

1. Do you have infection control training as part as your new employee’s orientation?

Yes       No

1. How often does your office spore test?

              ____________________________________________________________________________

1. How many sterilizers are in your office?

____________________________________________________________________________

1. Are water lines flushed prior to usage without hand pieces? And how are water lines flushed after treatment?

____________________________________________________________________________

1. When are the evacuation lines cleaned?

_____________________________________________________________________________

1. Are curing lights tested and how?

____________________________________________________________________________

1. Are protocols in place for sterilization/disinfection of instruments/equipment:

1. Hand Instruments
2. Hand pieces- attachments and motors
3. Heat sensitive instruments or equipment
4. Dental materials
5. Dental impressions

Yes         If No, please explain______________________________________________________

1. Do you have a safety container for disposable sharps and a program to dispose of them?

Yes       No

1. What company do you use to dispose of Biomedical waste?

_____________________________________________________________________________

Central Radiograph Processing and Safety

1. Are all staff equipped with dosimeter badges?

Yes       No

1. How long to you keep a copy of your dosimeter results?

______________________________________________________________________________

1. Protocols in place to avoid cross contamination or radiographs, charts, processor and lead apron?

Yes       No

1. Do your lead aprons have thyroid collars?
2. Yes        No
3. Do you hang or fold your lead aprons?

_____________________________________________________________________________

1. When was the last time your radiograph equipment inspected?

_____________________________________________________________________________

1. Do you have a quality assurance program in place to ensure image?

_____________________________________________________________________________

Drugs and Emergency Kit 

1. Is your emergency kit up to date and easily accessible?

Yes       No

1. Is there secure storage access to authorized personal?

Yes       No

1. Do you regularly review to detect undocumented loss (two person)?

Yes       No

1. Are prescriptions written contemporaneously?

Yes       No

1. Are prescription pads secured and inaccessible to unauthorized personal?

Yes       No

1. Is prescription medication is stored under lock and key and accessed only by authorized personnel?

Yes       No

Other

1. Is your office compliant with WHMIS requirements?

Yes       No

1. Is your amalgam separator functioning (if applicable)?

Yes       No

Comments

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dentist Signature:  ______________________________   Date:  ________________________________