I waited to write about this story for a long time. I didn't want to jump on the hype band wagon. Every dental blogger out there is writing about this story. Then I realized, I have a different take. This is the real story that needs to be told. This is long, so print it out and read it at your leisure, just make sure you READ this. You could be next.
Recently the media reported the story of Dr. W. Scott Harrington, the Tulsa dentist whose office was investigated following the receipt of “an official complaint” that “described the violations, including "multiple sterilization issues, multiple cross-contamination issues, (and) the drug cabinet was unlocked and unattended.”
The media reported the health department notified the dental board of a “potential hepatitis C infection”, which was reportedly attributed to Dr. Harrington’s practice. A number of issues were reported including:
· Multiple sterilization issues
· Multiple cross contamination issues
· Unsecured, unattended drug cabinet
· No drug inventory logs
· Expired drugs
· No evidence of purchase of sedation drugs
· Unlawful practice of dentistry by dental auxiliaries/ impermissible delegation of duties
· Failure to follow basic “universal precautions” for bloodborne pathogens
· Providing dental surgery in unsanitary conditions
· Possession of rusty instruments
· “being a menace to the public health”
It was reported Dr. Harrington surrendered his license and that criminal charges may follow. Additionally, 7,000 patients of Dr. Harrington are being tested for bloodborne diseases.
In March 2013 there was an infection control case involving Dr. Paul J. Matrullo of Cranston, R.I. that did not make the news. The Rhode Island Department of Health, Board of Dental Examiners inspected and found:
· No written health program to include policies, procedures or guidelines regarding education, training, immunization, exposure prevention and post-exposure management in place
· No documentation of employee HBV vaccination or bloodborne pathogen exposure training records available
· Overfilled sharps containers and no additional containers
· No ‘red bag’ receptacles
· No alcohol-based products available and no lotions available for skin care for dental team (though soap was present).
· Lack of sufficient PPE
· No written guidelines about contact dermatitis or latex hypersensitivity, and there was no ‘latex free’ room or supply kit
· No presence of use of heavy-duty utility gloves by staff person who processed dirty instruments
· Employee did not have side shields on her glasses while she processed instruments
· Impression trays were found hanging on a wall
· The ultrasonic cleaner was on the same counter where instruments were packed for sterilization. A sink separated clean and dirty areas. There were no guidelines, checklists or manuals for the use of the ultrasonic cleaner.
· No sterilization monitoring logs to record time, temperature, pressure and chemical indicators.
· Spore testing records were sporadic and completed on a monthly basis.
· Most recent spore test was completed in December 2012 (4 months prior)
· Sterilized instrument trays were no dated
· Manufacturer’s instructions for use of the steam sterilizer was not available
· Packaging of instruments exceeded the capacity f what the package should contain to be considered sterile.
· Sterilizer was overfilled not allowing instruments to be properly sterilized.
· Water-stained and moist instruments with water beading inside the packets, were found in patient exam rooms.
· Sterile packets that had been opened and left for further use.
· Presence of obvious organic (t)issue or other debris found on multiple ‘sterile’ instruments in exam rooms
· Over-packed instrument packages had been punctured by sharp instruments, which can create exposure to microorganisms and puncture hazards to workers
· No EPA-registered disinfecting products in the office
· No use of protective barriers in chair switches and overhead light handles.
· Oral suction device handles were visibly soiled.
In yet another case in Rhode Island in April 2012 involving Dr. John Begg of Lincoln, R.I. the Rhode Island Department of Health, Board of Dental Examiners inspected and found:
· Disorderly, disheveled office
· Dental instruments stored in an unsterile manner
· Nitrous oxide nose piece contained residue
· Emergency kit contained drugs that were expired
· X-ray machine had ‘drifted’
· Irrigation and air hoses for hygienist activities were sealed with scotch tape
· Air hose for hygienist cleaning activities were frayed, exposing rubber tubing
· Biohazardous was not properly contained and/ or disposed
· Dentist administered nitrous oxide without a license
The Rhode Island facts were obtained from the Board of Dentistry website where the dentists’ disciplinary orders are posted as public information.
Are these serious allegations? You better believe it! Sadly, as shocking as these situations are, these problems are more common than most people would care to know.
As a compliance consultant I encounter these conditions frequently (though not usually all one office, but occasionally I do). My clients call me in because they realize they may have problems, but perhaps are at a loss of how to correct them (lest we not judge until we have walked in their shoes). These problems result in the stories like those referenced above.
There are a number of reasons why these problems occur such as disconnect (failure) between the dentist and staff, perhaps there are conflicts between staff members. Perhaps complacency, ritual, inherited misconceptions and routine play a role. Whatever the case, infection control has to be adequately addressed in every dental office to avoid becoming a CNN feature story.
Every state has requirements for infection control in dental offices. Some states requirements are very specific while others are vague and implicit. However, most states recognize ADA and CDC recommendations for infection control as the (minimum) standard for their jurisdiction. At very least, adherence to those recommendations is expected and is what is often enforced.
Common Drug Problems
I commonly hear from dentists and their team members, “We don’t provide sedation, so we don’t have to worry about sort of thing.” I challenge that belief. Whether drugs are present in the office or not there ARE drug regulations that every dental office needs to know and adhere to. Here are common issues:
- Writing prescriptions for controlled substance while bearing expired DEA (or state authority);
- Use of expired drugs (emergency drugs, local anesthetics, OTC drugs, antibiotics);
– think standard of care here (and go check your drugs – ALL of them)
- Failure to secure prescription pads (or restrict access in EHR software that is capable of providing electronic or printed prescriptions) to prevent unauthorized access
- Failure to create and maintain written authorization of staff members who are allowed to call in prescriptions to pharmacy
- Failure to create and maintain accurate drug logs (incoming and dispensation logs are required)
- Failure to conduct biennial inventory of controlled drugs (some states require annually, and even by a specific date, such as Arizona);
- Failure to secure and controlled access to controlled drugs;
- Failure to acquire/ maintain multiple DEA registrations (when required);
- Prescribing any medication for a person who is not a patient of record (friends, family, self-prescribing), and/ or;
- Prescribing any medication that is not for a legitimate dental purpose (birth control, testosterone, steroid, analgesics, antibiotics, and etc.).
Many of these are administrative violations, but are also state and/ or federal crimes that can affect you and your staff – licensed or not!
I have no doubt I stepped on a few toes here. My intent is to educate, not offend, so take it for what it is and affect needed changes in your practice IMMEDIATELY!
OIG Recommendations and the Affordable Care Act
The Office of Inspector General (OIG) published recommendations in the late 1990’s for voluntary compliance practices. The core elements include:
1. Conducting internal monitoring and auditing*;
2. Implementing compliance and practice standards;
3. Designating a Compliance Officer or contact;
4. Conducting appropriate training and education;
5. Responding appropriately to detected offenses and developing corrective action;
6. Developing open lines of communication; and
7. Enforcing disciplinary standards through well-publicized guidelines.
* OIG recommends annual auditing/ monitoring
These are voluntary measures for many providers. However, section 6401 of the Affordable Care Act (ACA) makes compliance programs mandatory for all providers who submit claims to government programs (i.e. Medicaid and CHIPS). At present there are no specific standards or guidance beyond these core elements and there is no time-line as to when these measures have to be in place. I fully anticipate that in time ALL healthcare providers will have to have compliance programs.
What To Do
There are a number of things can (and should) do going forward. Here are a few suggestions to get you started:
· Dentists should learn about compliance and how to built an effective program for their practice
· Establish your commitment to compliance
· Make compliance and risk management a priority and embrace this with a positive attitude, as your staff will feed off your attitude
· Connect with the experts (more than one) to be in-the-know about rules and regulations, the way the are enforced and changes to the regulations
· Identify what the areas of risk are in our practice (where are your shortcomings)
· Seek an objective review of your proactive because what you don’t know about your practice CAN hurt you, your patients and staff
· Think of compliance as quality improvement (it takes some of the drudgery out of word compliance, which sounds just awful to some people)
· Be continually attuned to potential gaps in compliance and new risks that develop in your practice
· Implement changes as needed
There is more to compliance that just OSHA and HIPAA, which are vitally important to a dental practice. Compliance programs should incorporate adherence with regulations from ALL governing bodies (state and federal regulations) including, but not limited to OSHA, infection control, documentation and billing practices, HIPAA (and applicable state laws), labor regulations, drug regulations, EPA-hazardous waste disposal, radiation control, Dental Practice Act (and other applicable regulations), False Claims Act, Anti-kickback regulations, Stark regulations, Patient Solicitation Act and whatever other regulations pertain to dental providers.
We will take a closer look at the details of compliance programs in upcoming blog posts.
It is healthy for dentists and their team to discuss the Tulsa case with each other and with patients. Use this as a wake up call to self-check and correct (where necessary).
This is also a great opportunity to educate patients on what to expect from their visit to your office. This plays well with your commitment to providing excellent customer service, because your patients have other options.
Look Around– Evaluate your policies, practices and procedures and make sure you are not committing the violations listed in this article.
Take Action– If you find your office has some routines or practices that are unsafe or do meet generally acceptable (or lawful) standards, change.
Get Help– If you have questions, or problems and need some help, ask for it! I will not judge or condemn you, ever! My team and I are committed to making dental practices safer for patients and staff, and help dentists and their teams chart a course for safer waters.
As President & CEO of Dental Compliance Specialists — a company specializing in Dental office regulatory compliance and risk management– Duane Tinker has taken his expertise as a Law Enforcement Officer responsible for investigating criminal and civil complaints against Dentists and now uses this knowledge to assist Dental professionals in avoiding legal pitfalls. He is a much sought-after speaker, coach, trainer and ally. In this pursuit, today his PASSION is all about helping dentists find justice by preventing the problems that land them in court (or even worse)! After seeing too many good Dentists land in hot water for issues that were preventable, Duane decided to change teams and show good people how to protect their practices through compliance measures. Until now, no one with Duane’s background has been such a strong and supportive advocate for Dentists, teaching them how to protect their licenses, their assets and their FREEDOM! To check our blog or to sign up for FREE Compliance Tips go to www.DentalCompliance.com and enter your e-mail. You can contact Duane at (888) 994-4744 or info@DentalCompliance.com.