DCH-1293, Public Dental Prevention Program Application

Michigan Department of Health and Human Services (MDHHS)

PA 161: Public Dental Prevention Program

Request for Operation as Defined in MCL 333.16625 (2005 PA 161)

(Revised 3-26)

New Program	Renewal (PA 161 Office-based)	Renewal (PA 161 registered with Mobile Dental Facility Permit

Renewal PA 161 with mobile dental facility permit submit pages 1-8 only. New Program and Renewal PA 161 only submit the following required documents

section 1

Agency/Entity Name

Program Name

Mailing Address	City	State	Zip Code

Counties Served

Responsible Party of Agency (Required)	Contact Person (Required)

Contact Person Telephone Number	Contact Person Email Address

section 2 – fees and billing

Indicate Types of Reimbursement Accepted

No Compensation	Private Pay	Insurance (private)

Medicaid	Healthy Michigan Plan	Other

Tax-Exempt *Include Tax-Exempt ID Number

Entity Type 2 Agency NPI Number (Required)

section 3 – agency/entity/non-profit DESIGNATION

Choose Area and Description

Public

County	District	City

Non-Profit

Community Clinic	Federally Qualified Health Center	Other (Non-Profit Agency)

School

School of Dentistry or Dental Hygiene	Kindergarten Oral Health Assessment (KOHA) Program

Other (describe)

section 4

By signing below, I agree to comply with all parts of this application. I acknowledge that all facts, statements, and answers contained in this application are true and correct. In responding to the foregoing, I am not omitting any information, which might be of value to the MDHHS Oral Health Program in determining applicant qualifications. I agree to cooperate with the MDHHS staff and provide the staff with any documents to verify compliance, including access to the PA 161 program to ensure compliance with the PA 161 Public Dental Preventive Program.

Signature of Applicant	Date (month/date/year)

Print Name	Print Title

section 5 – DESCRIPTION OF THE UNASSIGNED POPULATION(S) TO RECEIVE PREVENTIVE SERVICES

Describe the Unassigned Population(s) to Receive Preventive Services (Check all that apply)

Patients of a Public Health Agency
Patients of a Federally Qualified Health Center
Patients of a Community Dental Clinic
Students in a School-Based/School-Linked program
Early Head Start, Head Start Students or Other Underserved Preschoolers
Kindergarten Oral Health Assessment (KOHA) Program
Assisted Living Residents
Adult Foster Care Residents
Nursing Home Residents
Seasonal Farm Workers
Native Americans
Juvenile Home Residents
Inmates of Prison System
Homeless Individuals
Other (describe)

SECTION 6 – CLINICAL SETTINGS

Describe the Clinical Setting(s) in which the Services are to be Provided (Check all that apply)

Public Health Agency Federally Qualified Health Center Community Dental Clinic School School-based/School-linked Health Center Mobile Dental Facility Head Start/Preschool Centers Nursing Home Assisted Living	Adult Foster Care Facility Tribal Health Centers Faith Based Organization Juvenile Home Correctional Facility Patient Home Homeless Shelter Farm Labor Camp Other (describe)

SECTION 7 – PREVENTIVE SERVICES TO BE PROVIDED

Preventive Services to be Provided (Check all that apply) (Radiographs and Debridement Not Allowed)

Assessments Prophylaxis Topical Fluoride Application	Sealants Silver Diamine Fluoride (SDF) Other (describe)

section 8 – REQUIRED DOCUMENTS

Submit the following documents (*see instruction sheet for definitions of the following):

Supervision Protocol
Patient Referral and Follow-up Protocol
Memorandum of Agreement (MOA) with dentist(s) or oral health agency(s) that will accept your referrals
If sealants are performed, provide the evaluation measures that will be taken to ensure long-term retention of the sealants
Child/Elder Abuse Reporting Attestation
Infection Control Checklist
Patient Registration/Application Form
Patient Health History
HIPAA Privacy Notice
Parent/Guardian Permission Slip/Consent Form
Evidence of non-profit status. Must include 501c3 or current Articles of Incorporation from the state of Michigan (if not a local public health department).
Proof of general liability insurance covering the PA 161 Project is required

Send complete PA 161 Public Dental Prevention Program Application including all supporting documents to: Michigan Department of Health and Human Services Oral Health Program Attention: PA 161 PO Box 301956 Lansing, MI 48909 For more information contact the MDHHS Oral Health Program at: MDHHS-MobileDentistry@michigan.gov.

SECTION 9 – MDHHS OFFICIAL USE ONLY

Agency/Entity Name	Date Received	Approved Not Approved

Approval Date	Expiration Date

Rationale

Signature	Date

You are required to notify the MDHHS Oral Health Program of any changes in staff, supervision or services listed on the original application within 30 days. The supervising dentist must formally sign the Change Notification form for stating that he/she agrees to supervise additional staff or state any changes to the original application.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
Michigan Department of Health and Human Services is an Equal opportunity employer services and programs provider.
AUTHORITY: MCL.333.16625 (2005 PA 161). COMPLETION: Is voluntary but is necessary to become a PA 161 Dental Prevention Program. CONSEQUENCES: Incomplete application submission will delay application process and may result in non-approval of PA 161 Program.

SECTION 10 – DENTAL HYGIENIST SUPERVISON ACKNOWLEDGEMENT

Supervision for PA 161 Program: The Supervision of the Registered Dental Hygienist must satisfy the following:

Continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.
The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual to review records, and to further educate the supervised individual in the performance of the individual’s functions.
The provision by the licensed supervising health professional of predetermined procedures and drug protocol.
Supervision per PA 289 of 2012: dental assistants assigned by the supervising dentist can be used to assist the dental hygienist in certain circumstances.

Supervision Acknowledgement (One per dental hygienist or dental assistant under signature of supervising dentist) Note: Read and discuss the following statements with each dental hygienist and dental assistance you supervise for the PA. 161 Program. A supervisor acknowledgement form is required for each dental hygienist or dental assistant. Check boxes.

A dental hygienist can only administer anesthesia and nitrous oxide analgesia or perform soft tissue curettage under the direct supervision of a dentist. This is not PA 161 activity.
If special populations are the focus of care, providers are encouraged to have current CPR certification and continuing education regarding the provisions of dental care for these populations (i.e. geriatrics and special needs populations for long-term facilities; behavioral management and sealant placement courses for school settings, etc.).
If a patient resides in a long-term care facility, a physician’s order for dental services is required for beneficiaries. The order cannot be a standing order.
Standard infection control protocols will be adhered to for all services and locations.
PA 161 Programs will be monitored for quality assurance and compliance. The MDHHS Oral Health Program may conduct record audits, perform site visits, request other quality assurance data such as sealant retention data and patient referral documentation, and notify the Michigan Board of Dentistry of the findings.
The MDHHS Oral Health Program must be notified of any information changes within 30 days of the change. Changes to services, supervising dentists, dental hygienists and dental assistants need to be submitted on the change notification form.
The PA 161 Program must be renewed every two years. It is the responsibility of the approved program to submit the new application.
The supervising dentist should reside in Michigan or have an active volunteer license in the state of Michigan.
A supervising dentist may supervise no more than a combined total 25 dental hygienists or dental assistants during a scheduled PA 161 activity.
We have reviewed the Data Report form and agree to submission of the form, as indicated.
We understand that this is a "Prevention only" program. The hygienist can only provide an oral assessment and preventive dental services that includes codes D0191, D1110, D1120, D1206, D1351. Radiographs are not permitted under PA 161 by reason that PA 161 patients are not assigned by a dentist.

As supervising dentist for this PA 161 Program, I certify that I have read and reviewed with the following dental hygienist/dental assistant the above protocols in relation to our PA 161 Program.

PA 161 Program Name (print)

Supervising Dentist (print)	Signature Supervising Dentist	Date

Dental Hygienist/Assistant Name (print)	Signature of Dental Hygienist/Assistant	Date

An original signature must be submitted, blue ink, no faxes or Emails. Names, Individual NPI number and license numbers are required for additional staff (except for assistants). Include personal address and phone number required. Add an additional page with supervising dentist, dental hygienist, and dental assistant signatures, if necessary. All signatures must be original (not photocopied). Faxed copies are not allowed.

section 11 – PA 161 Provider list

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

Full Name (Print)	Title	License Number	NPI Number

Email Address	Telephone Number

Address (Number and Street)	City	State	Zip Code

section 12 – supervison protocol

Supervising Dentist Role: The supervising dentist shall oversee or participate with the PA 161 hygienist(s) by performing the following functions: a. Continues communication in person, or by radio, telephone, or telecommunication with the PA 161 licensed dental hygienist(s). b. Participates in regularly scheduled reviews of the practice of the supervised PA 161 dental hygienist(s) in the permanence of their functions. c. Reviews with the PA 161 hygienist(s) predetermined procedures allowable in the program and drug protocols.
Instructions: In the space below described the role and nature of the supervising dentist(s) in the above areas. If appropriate, describe the difference in role for different settings, such as fixed dental clinic versus mobile dental location. A protocol can be attached to the application instead of entering information in the spaces below as long as it addresses each question.

Describe communication between the supervising dentist(s) and the PA 161 hygienist(s).

Describe how often the supervising dentist(s) is available for consultation and reviews records of the PA 161 hygienist(s) activity.

Describe the predetermined preventive procedures allowable for the PA 161 hygienist(s) and drug protocols.

section 13 – patient referral and follow-up protocol

Instructions: In the space below described the specific referral protocol for all patients seen by the PA 161 Program providers. If appropriate, describe the difference in role for different settings, such as fixed dental clinic versus mobile dental location. A protocol can be attached to the application instead of entering information in the spaces below as long as it addresses each question.

Describe how the patient will be referred for emergency dental services.

Describe how the patient will be counseled to seek an annual examination by a licensed dentist.

Describe the follow-up mechanism that is in place to determine if the patient has received dental services following referral.

Describe emergency after hour protocol for patients who were seen, but have an emergency after hours.

section 14 – sealant retention protocol

If sealants are performed, provide the evaluation measures that will be taken to ensure long-term retention of the sealants. Describe the process of when or how often sealants will be checked following their placement and the percentage of success you expect.
Instructions: In the space below describe the evaluation of sealant retention. A protocol can be attached to the application instead of entering information in the spaces below as long as it addresses each question.

Which subsequent visits and how frequently will retention checks be conducted? Describe

Sealant retention rates will be monitored with which retention goal percentage? Describe

Describe the protocol if sealants are missing/lost.

section 15 – child abuse and neglect reporting

Purpose: To protect children from child abuse and neglect. The Children’s Protective Services (CPS) program is responsible for investigating allegations of child abuse and neglect. The Michigan Child Protection Law provides the framework for what CPS must do. Child Abuse: Harm or threatened harm to a child's health or welfare that occurs through nonaccidental physical or mental injury, sexual abuse, sexual exploitation, or maltreatment, by a parent, a legal guardian, or any other person responsible for the child's health or welfare or by a teacher, a teacher's aide, or a member of the clergy. Child Neglect: Harm or threatened harm to a child's health or welfare by a parent, legal guardian, or any other person responsible for the child's health or welfare that occurs through either of the following: (i) Negligent treatment, including the failure to provide adequate food, clothing, shelter, or medical care. (ii) Placing a child at an unreasonable risk to the child’s health or welfare by failure of the parent, legal guardian, or other person responsible for the child’s health or welfare to intervene to eliminate that risk when that person is able to do so and has, or should have, knowledge of the risk. Reporting Abuse & Neglect Anyone, including a child, who suspects child abuse or neglect, can make a report by calling: 855-444-3911. In addition, the Child Protection Law requires certain professional to report suspected child abuse or neglect. The following link is a guide with more information and a model to customize and adapt, as needed, based on local resources and needs: https://www.michigan.gov/mdhhs/adult-child-serv/abuse-neglect or visit www.michigan.gov/mdhhs, Adult & Children’s Services, Abuse & Neglect, Keeping Kids Safe, Mandated Reporters to complete the Michigan On-line Reporting System. For additional resources, or for further information, contact your local Michigan Department of Health and Human Services office. Child Abuse & Neglect Reporting Each PA 161 program must read and sign below, attesting they have a protocol in place regarding mandated child abuse and neglect reporting. As a PA 161 program, we are aware of the above information and have reviewed the above-referenced information from the Michigan Department of Health and Human Services.

Agency/Entity Name

PA 161 Program Name

Mailing Address	City	State	Zip Code

Contact Person (print)	Contact Person Telephone Number

Contact Person Email Address

Responsible Party (print)	Responsible Party Signature	Date

section 16 – elder abuse AND NEGLECT reporting

Purpose: To protect elderly from abuse and neglect. Adult Protective Services investigators protect vulnerable adults from abuse, neglect and exploitation by coordinating with mental health, public health, law enforcement, the probate courts, the aging network, community groups and the general public. Definition of Elderly Abuse & Neglect: Vulnerable: A condition in which an adult is unable to protect himself or herself from abuse, neglect, or exploitation because of a mental or physical impairment or advanced age. Abuse: Harm or threatened harm to an adult’s health or welfare caused by another person. Abuse includes, but is not limited to, nonaccidental physical or mental injury, sexual abuse, or maltreatment. Abuse may be physical, sexual or emotional. Neglect: Harm to an adult’s health or welfare caused by the inability of the adult to respond to a harmful situation (self-neglect) or the conduct of a person who assumes responsibility for a significant aspect of the adult’s health or welfare. Neglect includes the failure to provide adequate food, clothing, shelter, or medical care. Exploitation: Misuse of an adult’s funds, property, or personal dignity by another person. Reporting Abuse & Neglect: If you are a part of a health care services professions, you may have a legal obligation to report any suspicions regarding vulnerable adults who you believe have been harmed or are at risk of harm from abuse, neglect or exploitation. To make a report, call 855-444-3911 anytime day or night to make a report. Staff will investigate allegations within 24 hours after the report is received. The following link is a guide with more information and a model to customize and adapt, as needed, based on local resources and needs: https://www.michigan.gov/mdhhs/adult-child-serv/abuse-neglect or visit www.michigan.gov/mdhhs, Adults & Children’s Abuse & Neglect, Keeping Adults Safe, Mandated Report. For further information, contact your local Michigan Department of Health and Human services office. Each PA 161 program must read and sign below, attesting they have a protocol in place regarding mandated child abuse and neglect reporting. As a PA 161 program, we are aware of the above information and have reviewed the above-referenced information from the Michigan Department of Health and Human Services.

Agency/Entity Name

PA 161 Program Name

Mailing Address	City	State	Zip Code

Contact Person (print)	Contact Person Telephone Number

Contact Person Email Address

Responsible Party (print)	Responsible Party Signature	Date

section 17 – infection control checklist

PA 161 programs shall have an appropriate infection prevention policies and practices manual in place, including appropriate training and education of dental health care personnel on infection prevention practices, and adequate supplies to allow all PA 161 providers safe care and safe working environment. The infection control procedures shall be comprehensive, well-defined and specific to the PA 161 program. CDC recommends that instruments utilized in an offsite clinic be cleaned in an ultrasonic and bagged prior to transporting the instruments to a sterilizer located in a secondary location. This Infection Control Checklist is an assessment tool modeled after the CDC Infection Prevention Checklist for Dental Settings and OSAP Infection Control Checklist for Dental Settings Using Mobile Vans or Portable Dental Equipment, for PA 161 programs to assess compliance with the expected infection prevention practices the Michigan Department of Health and Human Services Oral Health Programs has for all PA 161 programs (stand alone and mobile). Administrative policies and dental setting practices should be included in the site-specific written infection prevention and control program with supportive documentation and include personnel compliance with the infection prevention and control practices that fulfill the expectations for dental health care settings. This checklist can serve as an evaluation tool to monitor PA 161 compliance with the CDC’s recommendations and provide an assurance of quality control. Note: The Michigan Department of Health and Human Services Oral Health Program has both the authority and the responsibility for effective oversight of eligible entities that receive a PA 161 program status. The Department has established monitoring procedures that ensure an appropriate level of accountability and quality among the eligible entities. Random agency site visits may be conducted to evaluate and score each PA 161 program to ensure that services are carried out in a manner consistent with all federal, state, and local laws; administrative rules, regulations, and ordinances. Instructions: Please review and evaluate each section of this infection control checklist to ensure all applicable policies and practices are in place for the PA 161 program. Put a check in the Yes or No box for each category regarding the performance of the PA 161 program practices, and include comments for necessary explanation. Certain sections may not apply to the PA 161 program. Once complete, please review, sign and date attesting that all of the information is accurate and in place for the PA 161 program. Each PA 161 program must read and sign below, attesting they have a protocol in place regarding an appropriate infection prevention policies and practices manual in place, including appropriate training and education of dental health care personnel on infection prevention practices, and adequate supplies to allow all PA 161 providers to provide safe care and safe working environment. As a PA 161 program, we are aware of the above information and have completed the Infection Control Checklist.

Agency/Entity PA 161 Program Name

Completed By

Mailing Address	City	State	Zip Code

Contact Person (print)	Contact Person Telephone Number

Contact Person Email Address

Responsible Party (print)	Responsible Party Signature	Date

Infection Control Program Operating Procedures	Comments
Is there a written infection control program?	Yes No
Is there a designated person(s) responsible for program oversight?	Yes No
Are there methods for monitoring and evaluating the programs?	Yes No
Is there a training program for dental health-care personnel (DHCP) (Initial and ongoing) in infection control policies and practices?	Yes No
Immunizations	Comments
There is written policy regarding immunizing DHCP, including a list of all of required and recommended immunizations for DHCP (e.g., hepatitis B, MMR (measles, mumps, rubella) varicella (chickenpox), Tdap (hepatitis, diphtheria, pertussis)	Yes No
What about TB screening?	Yes No
Hand Hygiene	Comments
Are sinks available close to the area where care is provided?	Yes No
If not, are alcohol-based hand sanitizers available?	Yes No
Is staff properly trained in the use of alcohol hand rub products?	Yes No
Personal Protective Equipment (PPE) (e.g., gloves masks, protective eyewear, protective clothing)	Comments
Is there a protocol that outlines what PPE are worn for which procedures?	Yes No
Is PPE storage available and close to care?	Yes No
Are facilities available to disinfect PPE (DHCP eyewear, patient eyewear, heavy duty utility gloves)?	Yes No
Environmental Surfaces: Clinical Contact Surfaces (e.g., light handles and countertops)	Comments
Is there a list of what surfaces will be cleaned, disinfected or barrier protected and the process and products to be used?	Yes No
If chemical disinfectants are used, is there a protocol for how they are managed, stored and disposed?	Yes No
Housekeeping Surfaces (e.g., floors, walls)	Comments
Is there a list of which housekeeping surfaces will need to be cleaned and disinfected and how often?	Yes No	a
Safe Handling of Sharp Instruments and Devices	Comments
Are DHCP trained in the safe handling and management of sharps?	Yes No
Are sharps containers safely located at close as possible to the user?	Yes No
Is there a written protocol for transporting and disposing of sharps and sharps containers?	Yes No
Management and Follow-Up of Occupational Exposures	Comments
Is there a written procedure manual for post-exposure management?	Yes No
Is there a designated person responsible for post-exposure management?	Yes No
Is there mechanism to document the exposure incident?	Yes No
Where is the closest medical facility for wound care and post-exposure management?
Is there a mechanism to refer to the source and DHCP for testing and follow-up?	Yes No
Is there a mechanism for expert consultation by phone?	Yes No
Are post-exposure prophylaxis medications readily available onsite, at an emergent care facility or nearby pharmacy?	Yes No
Who is the responsible party for post-experience care costs?
Have DHCP been trained in post-exposure management procedures?	Yes No
Reusable Patient Items	Comments
Are reusable patient items processed onsite?	Yes No
If yes:
Is there a protocol for how and where contaminated instruments are cleaned and processed?	Yes No
Is there adequate space for the processing area to be divided into clean and dirty areas?	Yes No
Has the person who is performing the process been adequately trained?	Yes No
Is the sterilizer(s) spore tested at least weekly?	Yes No
Are protocols in place to handle positive tests?	Yes No
Can dental equipment and patient items be safely stored and secured if left on site?	Yes No
If no:
Is there an adequate inventory of instruments for the number of patients to be treated?	Yes No
Are containers for holding or transporting contaminated instruments puncture-proof, secured & labeled as a biohazard?	Yes No
Single-Use (Disposable) Items and Devices	Comments
Is there a protocol for which single-use, disposable items will be used and how they will be disposed (e.g., gloves, tongue depressors)?	Yes No
Are disposable items unit-dosed for each patient?	Yes No
Are syringes that deliver sealant and composite material barrier-protected if they aren’t single-use, disposable syringes?	Yes No
Management of Dental Unit Water Quality	Comments
Is there a protocol for how dental unit water quality will be maintained and monitored?	Yes No
Management of Regulated and Non-Regulated Medical Waste	Comments
Is there a protocol and designated person responsible for proper disposal of regulated waste (e.g., sharps containers, extracted teeth) and nonregulated waste (regular trash)?	Yes No