CENTER DENTIST

Pre-Compliance AssessmentQuestions

Please provide responses to the following questions 1 week prior to the health specialists’ arrival on center for the Health and Wellness Compliance Assessment. Responses should be typed.

The purpose of thecompliance assessment is to verify and clarify compliance with PRH requirements and applicable laws, as well as to highlight program qualities and strengths. Please coordinate with the Health and Wellness Manager to ensure all information (e.g., data, forms, materials, logs, surveys, specific student health records) necessary to support your responses is available for the review.

Name of Center Dentist
Dental Subcontractor if applicable
Phone number
E-mail
Number of years/months in position
Dentist schedule (days/hours)
Dental Hygienist schedule (days/hours)
Dental Assistant schedule (days/hours)
Oral health services are delivered / ______on center______off center
  1. In the past 12 months, how many applicant files have you reviewed? ____
  2. Who conducts the dental readiness inspection (DRI)? Is anyone else trained and authorized to conduct the DRI?
  3. What is the mechanism for Wellness personnel to refer serious oral health conditions to you and how do you handle them?
  1. Approximately what percentage of students in the past year consented to receive elective oral examinations?
  1. Describe the consent process for both exams and treatment. Include minor students.
  1. How many students were sent to off center specialists for care for conditions beyond the expertise of your center dentist in the past 12 months?
  1. What is the approval process for specialty care referrals? Describe your referral agreementsand include information on the payment arrangement.
  1. Describe how students are taught about dental hygiene, a good diet promoting dental health, and the importance of oral health
  1. How do students make oral health appointments for examinations and treatment?
  1. What is the wait for an oral examination? ______weeks
  1. What is the wait for basic oral care? ______weeks
  1. Approximately, what percentage of appointments over the past year were “no shows”? How are no-shows handled?
  1. Who takes the x-rays? Where are x-rays stored? Is it film or digital?
  1. Is there an informed consent process for any dental services? ____ Yes ___ No If so, which services require informed consent and describe your informed consent process. How is minor informed consent obtained?
  1. Check the priority classifications you treat: ___P1 ___P2 ___P3 ___P4
  1. How do you keep track of students’ priority classifications?
  1. List the oral health procedures that students receive in the scope of Oral Health and Wellness Program’s basic oral care:

____ anterior and posterior restorations

____extraction of pathological teeth

____ root canal therapy on anterior/other strategic teeth

____ replacement of missing upper anterior teeth with a removable prosthesis

____ dental hygiene treatment for periodontal disease

____ other: ______

  1. List any dental equipment and instruments are insufficient in quantity or unusable, faulty or require frequent repairs due to their age or condition:
  1. List any dental equipment and supplies you are lacking in order to perform basic oral health care:
  1. How often is spore testing on the autoclave done? Please have the log available for review during the assessment.
  1. In the past 12 months, how many students received medical separations or medical separations with reinstatement rights (MSWR) for oral health conditions? ____ students
  1. Are students surveyed on the opinions about the quality of the oral health and wellness program? ___ Yes ___ No If yes, how often is this survey conducted? If no, how are student inputs gathered?
  1. How do you access the PRH and the Oral Health and Wellness Program Desk Reference Guide and other oral health program materials?
  1. Describe any unique or innovative aspects of the Oral Health and Wellness Program. Does the Oral Health and Wellness Program work with other center programs?
  1. Over the past 12 months, how many Oral Health Personnel teleconference calls have Oral Health and Wellness calls have been attended by the:
  2. Center Dentist ____
  3. Dental Hygienist___
  4. Dental Assistant ____

Completed by: ______

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June 2016