MANITOBA DENTAL ASSOCIATION
To Be completed by all members and returned by a specific date
In attached documents, please provide the following and return to the Director of Facility Assessments
- A written outline of the duties and responsibilities of the Director/Owner.
- An outline of the facility’s administration with an organizational chart.
- Job descriptions, which include duties and responsibilities for all personnel.
- 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.
- Names of its officers and directors, if the facility is a dental corporation.
- The names, credentials, and CPR status of all staff and dentists requesting privileges at the facility. Please enclose a copy of their certificate.
- A copy of the policy and procedure manual
- Complete records of all dentists who have privileges at the facility, including their applications and schedules for procedures.
- Any service agreements need to be included.
- Name of Office:
- Address: _______________________________________________________________
- Telephone: ( )___________________ Facsimile: ( ) ________________________
- Owner(s): _______________________________________________________________
- List names of other dentists who provide treatment in office: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
- General Practice: Specialist: Specialty: ________________________________
- Dental Assistants:
- Names of Office Trained Assistants: ________________________________________________________________________________________________________________________________________________
- Names of Registered Dental Assistants: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Names of Registered Dental Hygienists: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Other Staff and Their Position: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Staff and Staff Health
- Are all staff providing treatment working with in their scope of practice?
Yes If No, Please explain___________________________________________________
- Does the facility require that health care workers be up to date in immunizations as per the Canadian Immunization Guide from Health Canada?
- Does the facility have a policy for providing hepatitis B vaccine to all health care workers?
- Does this facility have a policy in place for providing flu shots to all health care workers?
- 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?
- Are policies in place for:
- Sexual harassment policy
- Infection control protocols
- Inspection of quantity and viability (unexpired) of drugs
- Security, storage and control in-office drugs to protect against abuse
- Retrieving instruments from closed/uncontaminated locations (i.e. drawers) in operatory
- Avoid cross contamination when transferring equipment or material between operatories (if applicable)
- Single use/disposable supplies protocols ensure proper disposal or disinfection techniques are acceptable and adequate
- Emergency plan
- Patient care
Yes If No, please explain __________________________________________________
- Are logbooks in place for:
- Sterilization with spore test results
- Monitored use of drugs stored in-office
Yes If No, Please explain ____________________________________________________
- Is your dental license visible to the public and registered?
- Is your permit for use of Nitrous Oxide, IV/IM Sedation, or General Anesthetic current and visible to the public? (If applicable)
- Does your front reception prevent disclosure of personal health information?
- Are your charts stored in a secure manner? (chart information not viewable by unauthorized individuals)
- Is your reception area computer:
- In a secure location
- Password protected
- Monitor is not viewable by unauthorized individuals
- Registers changes in patient record
Yes If No, please explain______________________________________________
- Is equipment CSA certified where applicable?
- Is your office in compliance with current mercury hygiene protocols?
- Are all dental materials within expiry date?
- Are appropriate barriers used for patients and staff?
- Is a process in place to update staff on infection control practices?
- Do you have infection control training as part as your new employee’s orientation?
- How often does your office spore test?
- How many sterilizers are in your office?
- Are water lines flushed prior to usage without hand pieces? And how are water lines flushed after treatment?
- When are the evacuation lines cleaned?
- Are curing lights tested and how?
- Are protocols in place for sterilization/disinfection of instruments/equipment:
- Hand Instruments
- Hand pieces- attachments and motors
- Heat sensitive instruments or equipment
- Dental materials
- Dental impressions
Yes If No, please explain______________________________________________________
- Do you have a safety container for disposable sharps and a program to dispose of them?
- What company do you use to dispose of Biomedical waste?
Central Radiograph Processing and Safety
- Are all staff equipped with dosimeter badges?
- How long to you keep a copy of your dosimeter results?
- Protocols in place to avoid cross contamination or radiographs, charts, processor and lead apron?
- Do your lead aprons have thyroid collars?
- Yes No
- Do you hang or fold your lead aprons?
- When was the last time your radiograph equipment inspected?
- Do you have a quality assurance program in place to ensure image?
Drugs and Emergency Kit
- Is your emergency kit up to date and easily accessible?
- Is there secure storage access to authorized personal?
- Do you regularly review to detect undocumented loss (two person)?
- Are prescriptions written contemporaneously?
- Are prescription pads secured and inaccessible to unauthorized personal?
- Is prescription medication is stored under lock and key and accessed only by authorized personnel?
- Is your office compliant with WHMIS requirements?
- Is your amalgam separator functioning (if applicable)?
Dentist Signature: ______________________________ Date: ________________________________