Safe Workplace Plan

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10 Points to be completed, PRIOR to Reopening Dental Office:

1. Patient Communication: Most Important Step. Explain to every patient how the use ofPersonal Protective Equipment (PPE) Works.

2. Seat patients in operatory immediately: Only allow the number of patients that theoffice operatory capacity will allow (1 patient in, 1 patient out).

3. Change Appointment Confirmation Style: Explain new safety policies over phoneappointment confirmation calls. Ask if patient has any symptoms of fever.

4. Modified Patient Check-In: Reception room is closed. Check-in is done over the phone.Patients wait to be called-in for appointment once previous patient is gone and sanitationis complete.

5. Office entry Restricted: Only patients may enter office for appointment. Spouses,friends, caregivers, and parents need to wait outside. They can assist the patient to thefront door and handoff to office personnel.

6. Remove Non-essential Items: Any non-clinical items should be stored (i.e. dentaldisplay models, flyers, brochures, nightguard samples implant displays, etc.).

7. Dental Supply Deliveries: All supply deliveries from package carriers or dental suppliersmust be accepted outside and immediately sanitized once inside practice.

8. Contain all Aerosol Spray: Use rubber dam to contain aerosol spray. Dental Hygienistsshould have use of a high-volume ejector (HVE) for all hygiene procedures and useaerosol reducing armamentarium.

9. Dedicated Sanitation Technician: Have a roaming team member that is most qualifiedfor this job. They are responsible for sanitizing all areas of concern.

10. Take Patient Temperatures: Most difficult for dentists. You are not diagnosing orrecommending medical steps to the patient based on temperature. You are simplyprotecting yourself, your team, and your patients.

Reproduced with permission of Dr. William Balanoff https://www.smileperfected.com/reopen-dental-office-post-covid-19/

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Dental Team Protocols for Office Visits

x Patients and/or their Parent/Guardian “Check-In” from their car upon arrival at

the office.

x The Patient and/or their Guardian/Parent will wait in the car until the office

calls/texts the patient into the office.

x The patient (if a minor) will be escorted to the office door by the

parent/guardian. Only the patient is allowed in the office.

x The Parent/Guardian will “handoff" their minor child to the dental auxiliary at

the door.

x The temperature of every patient will be taken before they come into the

office Patient must be cleared by the Office Administrator to enter the Dental

Office.

Reproduced with permission of Dr. William Balanoff https://www.smileperfected.com/reopen-dental-office-post-covid-19/

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Patient Interaction

x A “greeter” (assistant) from the office will escort the patient directly to the

treatment area/chair (after hand sanitizing/washing).

x Patient Post Treatment: Upon completion of the dental service, the patient’s

guardian/parent will be notified by phone to come to the front door.

x The Patient will use hand sanitizer/soap and water prior to leaving the office.

(They use it twice; upon arrival and before departure.)

x The patient will be “handed-off” to their parent/Guardian who is outside by the

door and NOT in the office.

x If a payment is required, the patient will be required to make the payment before

leaving the office.

x If the patient is using pens to sign payment receipts, ensure that all used pens

are placed in a separate “used pen” container and disinfected before those pens

are reused. Each pen should be disinfected before it is placed back into the

“unused pen” container.

x If needed, a follow-up appointment will be given at the time of payment.

Reproduced with permission of Dr. William Balanoff https://www.smileperfected.com/reopen-dental-office-post-covid-19/

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Personal Protective Equipment PPE for ALL Team Members

Office team members:

1. Level 1 surgical mask;

2. Protective eyewear;

3. Lab coat or disposable gown;

4. Hand washing/sanitizer every 15 minutes or after any patientinteraction.

Clinical Team Members:

1. Level 3 surgical mask /KN95/N95 respirators during ANY procedure;

2. Face shield;

3. Protective eyewear;

4. Head covering;

5. Disposable lab coat or gown;

6. Clinical scrubs and shoes (to be worn in office ONLY, donned and doffed prior to

starting shift and removed prior to exiting office);

7. Gloves.

Patient:

1. Be prepared to wait in car until appointment to observe social distancing;

2. Answer COVID19 survey questionnaire (Appendix 2) and sign the COVID-19

Dental Treatment Consent Form (Appendix 3);

3. Have temperature taken by team member;

Copyright Dental Whale, LLC 2020 5

4. NOTE: DO NOT treat a symptomatic patient. If a patient identifies COVID-19

symptoms or other COVID-19 exposure concerns in response to this

questionnaire, it is our policy to reschedule that patient's dental appointment to a

later time, consistent with the recommended 14-day incubation period. If

necessary, provide the patient with a Letter to a Symptomatic Patient on the

Need to Reschedule Appointment (Appendix 4).

5. Wash hands and forearms thoroughly, prior to sitting in dental chair;

6. Rinse/gargle with hydrogen peroxide (provided) for 1 minute prior to procedure

commencement;

7. Don protective eyewear.

Copyright Dental Whale, LLC 2020 6

Office Reopen Activities

Reproduced with permission of SafeLink Consulting 7

Reproduced with permission of SafeLink Consulting 8

PPE Related OSHA COMPLIANCE: Respiratory Protection

Program

1. The Practice Operations Leader should serve as the designated Respiratory

Protection Administrator (“RPA”).

2. The Respiratory Protection Program (“RPP”) is REQUIRED by OSHA to ensure

that those individuals who use N95/KN95 respirators are appropriately protected

in conformity with federal and state guidelines.

3. The RPA “Train the Trainer” workshop should be conducted to assure full

understanding of the RPP OSHA requirements. This training will ensure that the

RPA is properly instructed on how to administer the RPP.

4. Dental Whale's Compliance Department has created Respirator Training and

Preparedness Checklists for both the Practice (RPA) and each employee that has

been medically cleared to wear respirators to fully understand the OSHA

requirements behind the RPP and N95/KN95 respirator use. Both Practice and

Employee Checklists are found below for reference, and separately attached as

Appendices 5 and 6.

5. The checklists will be used as a learning tool during the “Train the Trainer” RPP

Training. The Respirator Training and Preparedness Checklist for the Dental

Health Provider will also be used to document completion of the required RPP

training videos, which must be completed before Respirators are used.

6. Both checklists reference the fact that, at this time, the CDC has approved re-use

of respirators, so long as the requisite guidelines are followed. The Respirator

Extended Use Recommendations Checklist is found below and attached as

Appendix 7.

Copyright Dental Whale, LLC 2020 9

HIPAA Compliance

1. More than ever, in this climate, privacy scams of various forms prevail. We mustbe vigilant and remember the company's policy on HIPAA compliance.

2. Please review the Practice’s email PHI email policy, attached as Appendix 8,which aims to insure protection of PHI (protected health information) and otherpersonal information. Supplement 1 to the policy, which includes informationabout securely transmitting information via SendInc.

3. The Practice is committed to the highest standards of ethical, legal, and clinicalconduct, including compliance with federal and state laws. These laws includethe Health Insurance Portability and Accountability Act ("HIPAA") and HealthInformation Technology for Economic and Clinical Health Act (“HITECH).

4. In keeping with this commitment, the Practice requires all employees to ensureHIPAA compliance and appropriate use of the email system when transmittingpatient records and/or any records containing Protected Health Information("PHI") and ePHI. The purpose of this policy is to assure that this requirement ismet.

5. Please have each employee who is returning to work (or who has not alreadydone so) review the PHI Email policy below and return the Acknowledgment ofReceipt form (Appendix 9) to your practice leader or compliance coordinator.

Copyright Dental Whale, LLC 2020 10

Dental Practice Reopening Considerations and State-By-State Re-Opening Analysis Chart

CDC UPDATE:

What’s new in CDC recommendations on Dental Practices?

The requirements to:

• Address asymptomatic and pre-symptomatic transmission, • Implement source control (require facemasks or cloth face coverings) for everyone entering the

dental setting (dental healthcare personnel [DHCP] and patients), regardless of whether they have COVID-19 symptoms.

• Actively screen everyone on the spot for fever and symptoms of COVID-19 before they enter the dental setting.

• Actively screen DHCP on the spot for fever and symptoms before every shift.

SOURCE: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

What you, as a Dental Health Care Provider, need to know and consider before you reopen your dental practice.

Engage in the following analysis:

1. First, ask, ”Is the dental practice legally allowed to open or are there still limitations on dental treatment being essential/emergent only?” a. Step 1- look at State Governor’s order(s) [orders specific to Texas, Georgia, Illinois,

Michigan, Tennessee, Virginia and Florida have been compiled by Dental Whale Compliance Department] and linked and summarized found in the below chart.]

- ** Note that a Governor’s Executive Order has the force of law and, if there is any apparent conflict, the Governor’s Order trumps any guidance by dental boards or other professional organizations – whether state or federal – like state the dental associations, state dental boards, the CDC, or the ADA b. Step 2 - Check State Dental Board Rules/Guidance or guidance issued by State Dental

Associations [State-specific Board of Dentistry or Dental Association guidance have been compiled by Dental Whale Compliance for Texas, Georgia, Illinois, Michigan, Tennessee, Virginia and Florida. These guidance documents are linked and summarized in the below chart.]

- Some of the Governors’ Orders allow practices to open contingent upon specific conditions, delineated by State Dental Boards/State Dental Associations

2. Next, turn to location specific guidance (i.e. city or county ordinances) - Local orders will be particularly relevant to states where no governor-issued shelter in

place/emergency mandate ever went into effect or where counties within a given state are following separate reopening schedules.

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3. Second, ask ”Does the practice meet the required safety requirements (by OSHA, CDC, etc), including PPE?”

State-By-State Re-Opening Analysis Chart

Governor’s Order** State Dental Board/ Dental Association Guidance

Texas Click here for Executive Order GA 19 Relating to Hospital Capacity During the COVID19 Disaster All licensed health care professionals shall be limited in their practice by, and must comply with, any emergency rules promulgated by their respective licensing agencies dictating minimum standards for safe practice during the COVID- 19 disaster. (See State Board of Dentistry Guidance)

On April 30, 2020, the Texas State Board of Dental Examiners adopted an emergency rule interpreting Governor Abbott’s Executive Order GA-19, which ended Texas’ “stay at home” order. The Dental Board incorporated the emergency rule into Rule §108.7 Minimum Standard of Care, General, adding subsection (16). The rule sets forth multiple requirements for dental offices and dental treatment as it relates to COVID-19. Rule §108.7(16), summarized below delineates the now required procedures and protocols. Please ensure compliance with all requirements and protocols. Click here for Emergency Rule 108.7 in response to Governor Abbott’s Executive Order GA-19 – 4/30/2020. SUMMARY: Since Texas is now reopen for non-essential care, the Order does not say anything to conflict with the Governor’s order. For specific COVID19- related safety standard of practice, see pages 3-5 of the Emergency Rule. The minimum standards for safety are summarized here, and include: Pre appointment: - COVID-19 procedures and training on those procedures - Prioritization of DHCPs to provide care by risk exposure - DHCPs to self-monitor

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- Removing all items that may be touched, which are not routinely disinfected - Place signage in the dental office on cough etiquette, social distancing etc. - Patient screening protocol - Alter appointment-scheduleing enough to minimize possible contact between patients -Notify that patients may not bring a companion to their appointment, unless the patient requires assistance (companion screening must be done) During dental care: - Patient screenings include temperature checks - Standard precautions, including PPE, hand hygiene, respiratory hygiene/etiquette, disinfection protocols, sharps safety etc. - Transmission-Based Precautions, including N-95 respirator masks, KN-95 masks, or substantial equivalent for all DHCP who will be within six (6) feet of aerosol generating procedures -Adhere to standard sequence of PPE donning and doffing - Complete the full treatment of one patient before leaving the treatment area and moving on to another patient - Use only hand instruments and low speed polishing tools for hygiene services Clinical technique: - Patients to perform pre-procedure rinse - Reduce aerosol production as much as possible, including prioritizing use of hand instruments - Use dental isolation to minimize aerosol or spatter Post care: - Patients instructed to contact practice if experiencing symptoms within 14 days of visit - Change from PPE to personal clothing before leaving practice

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Georgia The Governor’s April 23 Executive Order providing Guidance for Reviving a Healthy Georgia in Response to COVID-19 , found here. The Order allows Georgia licensed dental practices can reopen to elective care and clinics can provide the “full scope of their services” as long as they adhere to specific Guidelines. Full scope of services can be provided, provided that they adhere to: The ADA’s Interim Guidance for Minimizing Risk for COVID-19 Transmission and the ADA’s Interim Mask and Face Shield Guidelines. [Both of these documents are included in your DEPG Safe Work Place Plan, available on the Runners Portal]

See GDA Advisory of April 24, 2020 This advisory recommendations states as follows: The decision to return to your practices for full treatment must be made on an individual basis based on your professional judgment after due consideration of all current clinical recommendations/guidelines, workplace safety recommendations/guidelines, your personal circumstances, as well as those of your practices, patients and staff. However, the GDA’s Board of Trustees strongly urges that all Georgia dentists who wish to return to full practice should review the following science-based resources and use their best efforts to implement them as this situation continues to evolve: The advisory(linked here) identifies the resources to be reviewed, but the two sources identified as required are also identified below and found in the Governor’s orders: The ADA’s Interim Guidance for Minimizing Risk for COVID-19 Transmission and the ADA’s Interim Mask and Face Shield Guidelines. Both of these documents are included in your DEPG Safe Work Place Plan, available on the Runners Portal] Additionally, on May 1, the GDA issued additional clarification on its April 24, 2020 advisory stating: “Executive Orders have the force of law and must always be followed. Guidance documents and recommendations by organizations such as the CDC or ADA do not have the force of law. Guidance is good to consider and weigh as you make decisions on patient health care needs. An Executive Order from the Governor is the law. Recommendations from the CDC are not law or regulation, they are just that – non-binding recommendations. As the GDA Advisory of April 24, 2020 stated, Georgia dentists should follow the Governor’s

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Order, because the Governor’s Order took the matter out of the purview of both the CDC and the Georgia Board of Dentistry. (See also ADA Information and FAQ on the CDC Interim Guidance for Dental Settings.)”

Illinois State Governor’s Executive Order 2020-10 and subsequent related extensions/orders mandate dental practices to cease routine dental care immediately and requires dental offices to be limited to emergency and urgent dental care only (without aerosol generating equipment) until further notice. Stay-at-home order, Executive Order 2020-32 extended until May 30 and above requirements on non-essential care are still in effect. “Healthcare and Public Health Operations. For purposes of this Executive Order, individuals may leave their residence to work for or obtain services through Healthcare and Public Health Operations. Healthcare and Public Health Operations includes, but is not limited to: hospitals; clinics; dental offices….”

Based on the Governor’s order, continue providing emergency dental care only until May 30, 2020. In a press release, dated April 1, 2020, the Illinois State Dental Society Stated as follows: “Until further notice, the Illinois State Dental Society recommends that dentists cease all in-person dental treatment except for dental emergencies. Gov. J.B. Pritzker extended a "stay-at-home" order for all residents, directing people to remain in their homes except for essentials until the end of April to help stop the spread of COVID-19.

Until further notice, the Illinois State Dental Society recommends that dentists cease all in-person dental treatment except for dental emergencies.”

Based on the Governor’s extension of the Stay-at-Home/Shelter in place order, this remains applicable.

Michigan Stay-at-home order, Executive Order 2020-77 (rescinded previous stay at home orders orders) extended until May 28 and above requirements on non-essential medical and dental care are still in effect. As such, State Governor’s Executive Order 2020-17, which imposes temporary restrictions on non-essential medical and dental procedures, remains in effect until the “the state of emergency declared in Executive 2020-4 [remains] in effect.”

The Michigan Dental Association, recently-issued guidance found here and highlighted below, is in line and in concurrence with the Governor’s order. On May 7, Gov. Gretchen Whitmer issued Executive Order 2020-77, which extends the stay at home order until May 28 and says that masks must be worn in any enclosed public space. This Executive Order does not alter the previously issued Executive Order 2020-17.

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The order specifically enumerates the non-essential dental procedures that MUST be postponed during the governor-declared state of emergency. The language is found in Executive Order 2020-17 and highlighted below. “A plan for a covered facility that performs dental procedures must postpone, at a minimum: any cosmetic or aesthetic procedures (such as veneers, teeth bleaching, or cosmetic bonding); any routine hygiene appointments; any orthodontic procedures that do not relieve pain or infection, do not restore oral function, or are not trauma-related; initiation of any crowns, bridges, or dentures that do not relieve pain or infection, do not restore oral function, or are not trauma-related; any periodontal plastic surgery; any extractions of asymptomatic non-carious teeth; and any recall visits for periodontally healthy patients. If a covered facility that performs dental procedures chooses to remain open, its plan must exclude from postponement emergency or trauma-related procedures where postponement would significantly impact the health, safety, and welfare of the patient.

Executive Order 2020-17 restricts all health providers, including dentists, to performing only essential services. Executive Order 2020-17 expires at the same time as the emergency declaration. As of now, the emergency declaration is set to expire on May 28, 2020, at 11:59 p.m. However, this may be extended again. What does all this mean? Dentists continue to be limited to only providing emergency/essential services. Why? Because the end date of Executive Order 2020-17 (limiting health care workers to providing emergency care) is tied to the end date of the state of emergency, which is currently May 28, 2020. In addition, Executive Order 2020-77 (stay at home order) prevents patients from leaving their homes unless to seek emergency care or to sustain life. It also prevents dental team staff from leaving their homes unless it is to provide emergency care. Its current expiration date is May 15, 2020. Executive Order 2020-77 and Executive Order 2020-17 must be rescinded and/or modified for dental practices to return to normal operations. The MDA has a goal of getting Executive Order 2020-17 separated from the emergency declaration in order to provide more certainty on when restrictions for dental practice will end.

Tennessee While the Tennessee Shelter in Place Order expired on April 30, 2020, on April 29, 2020 Tennessee Governor issued Executive Order Number 31, An Order to Reduce the Spread of COVID-19 by Limiting Non-Emergency Dental Procedures. The Order (unless subsequently amended or extended) restricts dental practices from performing elective Non-Emergency Dental Procedures until May 6, 2020. Governor’s Order 31 specifically states as follows:

On its website the Tennessee Dental Association (TDA) spoke out on April 30, 2020, sin response to the Governor’s Executive Order Number 31. Based on the TDA’s statement (full statement found here and highlighted below) it appears that the TDA will rely on the ADA Return to Work Toolkit as the standard of care to be expected for dental practices to follow when fully reopening for elective care after May 6. “Executive Order No. 31 (“EO-31”) was issued late yesterday afternoon and dealt an unexpected blow to TDA members. Unfortunately, EO-31 and subsequent dialogue

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“WHEREAS, in light of only recent recommendations by the ADA and the CDC regarding safe dental practice, the Tennessee Board of Dentistry, the Tennessee Dental Association, and the Tennessee Dental Hygienists' Association are still working to develop appropriate guidelines to resume non-emergency dental practices safely in Tennessee [. . .] Dental service providers in the State of Tennessee, including but not limited to dentists, pediatric dentists, orthodontists, oral surgeons, periodontists, prosthodontists, and endodontists, shall not perform any non-emergency dental or oral procedures. Non-emergency dental or oral procedures include hygiene visits, cosmetic procedures, and other elective procedures. Emergency procedures for patients with acute dental or oral needs may still be performed, including treatment for pain, swelling, trauma, or an abscess.”

have created a misimpression with respect to the position and advocacy of the TDA.

The TDA did not advocate for or agree with a last minute modification to the existing restrictions on a return to dental practice. The TDA advocated aggressively for dentists to return to work on April 30 and made it clear that dentists had made preparations with staff and patients for a safe return to practice.

Certain language in EO-31 might be viewed as an indication that the TDA had expressed reservation regarding the professional judgment of members to pursue appropriate safety precautions, in light of the recent release of the ADA Return to Work Interim Guidance Tool Kit*. The ADA guidance was released on April 27. TDA did not express any reservations regarding the ability of its members to exercise independent professional judgment in resuming their dental practice activities and in fact emphasized that dentists have been using universal precautions since the 80’s. The new protocols associated with COVID-19 have been added to those precautions already in practice.”

[*The ADA Return to Work Interim Guidance Tool Kit is included in your DEPG Safe Work Place Plan, available on the Runners Portal]

Virginia The Governor’s Stay At Home Order

[Executive Order 55] is currently set to expire on June 10, 2020. Executive Order 55, in combination with a companion Order (Executive Order 53, found here), closes certain non-essential businesses, dictates certain requirements for those

The Virginia Dental Association Back to Work Task Force, chaired by Dr. Vince Dougherty, is preparing guidelines for returning to dental practice, which will be consistent with the ADA’s guidance*, and the guidance is still pending. Updates to follow as details become available.

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allowed to continue, and requires all residents to stay at home except for essential activities. Notwithstanding, the Governor’s Order on Non-Essential, elective dental procedures has now expired on midnight April 30, 2020 and has not been extended. Starting May 1, elective dental care has officially been endorsed by the Governor in his recent press conference, reported on here, where the Governor addressed elective surgeries and dental procedures. "Our hospitals, our clinics, our dental offices, these are safe, these are clean places to go and so while we have been through this pandemic I want to encourage all Virginians that your health care is important," said Northam.

[*The ADA Return to Work Interim Guidance Tool Kit is included in your DEPG Safe Work Place Plan, available on the Runners Portal] No officially statement was been made by the Virginia Board of Dental Examiners.

Florida Elective Procedures May Resume on May 4

The Governor announced his plan for Florida’s recovery, which will allow for elective procedures to resume in a hospital ambulatory surgical center, office surgery center, dental office, orthodontic office, endodontic office or other health care practitioners’ office on Monday, May 4 statewide.

The governor issued Executive Order 20-112, which outlines protocols that need to be met in order to restart elective procedures. This executive order supersedes the conflicting provisions of Executive Order 20-72.

The relevant language of the order regarding elective procedures is found in section 5 of the Order and below:

“Subject to the conditions outlined below, elective procedures prohibited by Executive Order 20-72 may resume when this order goes

The Florida Dental Association’s (FDA’s) Reopening Guidance relies on the ADA’s Return To Work Interim Guidance Toolkit .* The FDA’s latest COVID-update by the FDA found here, states as follows: “The American Dental Association has released new guidance on reopening dental practices in the form of a toolkit that was developed based on the work of the ADA’s Advisory Task Force on Dental Practice Recovery co-chaired by FDA President Dr. Rudy Liddell. This toolkit is focused on the short-term management of dental practices during the COVID-19 pandemic as providers return to non-emergent care and includes resources such as staff protection strategies, a chairside checklist for working in the operatory, a customizable letter to patients, guidance for pre-appointment screening, in-office patient registration, post-procedure patient exit and much more.

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into effect [May 4]. A hospital ambulatory surgical center, office surgery center, dental office, orthodontic office, endodontic office or other health care practitioners' office in the State of Florida may perform procedures prohibited by Executive Order 20-72 only if:

A. The facility has the capacity to immediately convert additional facility-identified surgical and intensive care beds for treatment of COVID-19 patients in a surge capacity situation;

B. The facility has adequate personal protective equipment (PPE) to complete all medical procedures and respond to COVID-19 treatment needs, without the facility seeking any additional federal or state assistance regarding PPE supplies;

C. The facility has not sought any additional federal, state, or local government assistance regarding PPE supplies since resuming elective procedures; and

D. The facility has not refused to provide support to and proactively engage with skilled nursing facilities, assisted living facilities and other long-term care residential providers.

As this is an evolving situation, Florida dentists and patients seeking news and updates should visit:

“The CDC’s COVID-19 webpage for the latest updates.

The OSHA guidelines on preparing workplaces for COVID-19.

The Florida DOH's COVID-19 webpage. The Governor’s Executive Orders and

Department of Health notifications for health care providers

The ADA’s ADA.org/virus webpage [. . . ]

The Florida DOH has a dedicated COVID-19 Call Center at 866.779.6121, available 24 hours a day, for any questions. You also can email COVID-19@flhealth.gov. The state surgeon general is holding weekly conference calls for health care providers every Tuesday at 6:30 p.m. The call-in information is below:

Date: Tuesday Time: 6:30-7:30 p.m. Call-in Number: 888.585.9008 Conference Room ID: 208.305.233 Along with the ADA, we will continue to provide you with important updates and information through our communications channels. Again, we ask you to read all communications from the FDA and ADA.”

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