Regulatory Compliance: Maintaining a Regulatory File

CDA Practice Support

Most dental practices are aware that they must have employment posters, a HIPAA notice of privacy practices and written plans required by OSHA. Certain documents, however, continue to be overlooked, as observed by CDA Practice Support staff. This column reviews these items so dental practices can review their regulatory documentation and ensure it is up to date. A “Regulatory Compliance Checklist” is available on cda.org/practicesupport.

Maintain radiation machine registration application and proof of fee payment.

Machine owners are required to register their machines with the California Department of Public Health Radiologic Health Branch. Equipment manufacturers and distributors do not and cannot complete this documentation on behalf of the machine owner. When the department finds that a machine has not been registered, it can collect fees for the years it should have been. Registration fees are billed biennially, and it is recommended that dental practices retain proof.

Complete a written radiation safety plan.

A radiation safety plan template, “Radiation Safety in Dental Practice,” is available at cda.org/practicesupport. A dental practice also is required to maintain records of occupational exposure to radiation. There are two methods for creating those records. One is to hire a health physicist to perform the calculations for your practice. The second and most common method is to have staff wear personnel dosimeters for a period of time (for example, three months) and then extrapolate the results to obtain an annual exposure. This method should be repeated periodically, no more than every five years and whenever equipment is changed or moved.

Dental practices in Los Angeles and San Diego counties are required to submit plan checks to the Los Angeles County Environmental Health Department and San Diego County Radiological Health Program, respectively. More information can be found on their websites.

Individuals licensed by the dental board are required to maintain continuing education certificates for a period of three license renewal periods. C.E. certificates are not normally submitted to the board when renewing a license, so each licensee must ensure they maintain these certificates in case of an audit. Organization of those certificates is especially important for licensees whose licenses expired between March 2020 and February 2021 because the Department of Consumer Affairs issued orders allowing extended time to complete required continuing education. Prior to the pandemic, the board was actively auditing licensees’ certificates. The board is expected to continue this work once extensions for completing required continuing education are no longer issued.

A dental practice may not have a written injury and illness prevention plan if it has relied solely on the American Dental Association or a consultant located outside California for assistance with OSHA compliance. Cal/OSHA has requirements that are in addition to OSHA requirements, and one major requirement is a written IIPP. Not having a written IIPP is the most frequent violation cited against dental practices by Cal/OSHA. Another Cal/OSHA requirement is the mandate for a sharps injury log. The requirement for the log is part of the bloodborne pathogens regulation. California dental practices must also have a COVID-19 prevention plan.

When it comes to HIPAA, some dental practices believe the only necessary documentation is the notice of privacy practices. Dental practices that are HIPAA-covered entities are required to have a lot of documentation — a detailed and thorough risk analysis and policies and procedures describing how they comply with HIPAA requirements. Resources are available from the CDA, ADA, U.S. Health and Human Services and HealthIT.gov. See “HIPAA and California Medical Information Act Compliance Checklist” on cda.org/ practicesupport for more information.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.