TDC – Beyond the Bite

Closing a Dental Practice: Patient Safety Considerations

by Florida Dental AssociationAugust 23, 20181 Comment

By David O. Hester, FASHRM, CPHRM, Director, Department of Patient Safety and Risk Management, The Doctors Company

Dental practices undergo closure for many reasons, including dentist illness, death, relocation, or the dentist’s decision to sell, practice solo, join another group or retire. As a service to our members, the Department of Patient Safety and Risk Management of The Doctors Company provides this information to make the transition easier.

What should be done in an emergent situation?
During any change in practice, the continuity of patient care to ensure that no patient is neglected is of paramount concern. If the change is abrupt — as in the circumstance of a death — the safety measures below will assist in ensuring patient safety and continuity of care.

Review all previously scheduled appointments to determine the appropriate action. Immediately contact a dentist of the same specialty to arrange patient care or provide patients with a list of dentists of the same specialty within the area. You also should take the following steps:

Ensure the availability and accessibility of dental records as needed for the continuity of patient care.
Post a notice of closure in the office and in the local newspaper. (Contact your patient safety risk manager for a sample notice.)
Call all dentists who customarily refer patients to the practice and all contracted managed-care organizations, and the medical malpractice carrier.

Who should be notified if it is a non-emergent closure?
If the practice closure is non-emergent, notify the following individuals and entities:

all patients and legal representatives in the “active” caseload; this includes any patient seen in the past six months to three years or others the dentist considers “active,” and any patient in an acute phase of treatment
all peer dentists within the community
local dental societies
all third-party payers (including Medicare and Medicaid) and managed-care organizations
the DEA (if you are retiring or if you are moving to another state)
the state licensing board
professional associations in which you hold membership
your CPA or financial adviser
your employees
landlords, lenders and creditors
insurers that cover the practice, the employees and the physical facility

How should the notice be communicated?
Draft a letter to each patient that contains all the necessary details. The same letter can be used for everyone listed above. (Contact your patient safety risk manager for a sample letter.) It’s recommended that letters be sent with return receipt requested and that a copy of the letter and return receipt be kept. If a patient is considered high risk, send the letter certified with return receipt requested. Post a notice in a local newspaper to inform inactive patients or those who have moved away. Include directions for obtaining acute, critical or emergency care if a new dentist has not been selected by the time the practice closes.

Is there a time limit for sending the closure notice?
Yes. In a non-emergent situation, send the notice at least 60 days prior to the anticipated closure. This gives patients an opportunity to locate a new dentist and to obtain copies of their dental records without undue stress.

What other responsibilities should be undertaken by the practice that is closing?

Provide patients with easy access to their dental records by enclosing an authorization document in the notification letter you send to them. (Contact your patient safety risk manager for samples.) When the signed authorization is returned, you can provide copies and apply appropriate charges.
Provide information on where the dental records will be stored in the future, the length of time (in years) that the records will be retained, and a permanent mailing address or post office box number for all future record requests. Arrange a secure storage place for the original dental records that is safe from theft, fire, flood or other weather-related disasters.
Maintain the dental records in accordance with The Doctors Company’s recommendations: 10 years after the last adult visit and 28 years from birth for pediatric patients. The records should be easily accessible and retrievable.
DO NOT give original records to patients. The easiest method is to find another dentist to take over the practice and turn the records over to that provider or turn the records over to another dentist of the same specialty.
Stress the importance of continuing care for all patients. Provide information about where they can find another dentist, such as the Yellow Pages and the local or state dental society.
Make provisions for the completion of all dental records.
Place a notice of closure in your waiting room and in the local newspaper for at least one month, giving pertinent details of the closure.
Consult with your personal or practice attorney and the state licensing agency to ensure that you have met all regulations.
Destroy remaining prescription pads.
Keep the narcotics ledger for a minimum of two years.
Dispose of any drugs.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Altering Dental Records Can Result in Significant Penalties

by Florida Dental AssociationMay 3, 2018May 4, 20181 Comment

By Jon M. Pellett, JD, Managing Attorney – Administrative Defense, Medical Investigation Defense Unit, The Doctors Company

The Florida Board of Dentistry (BOD) takes a dim view of those who alter dental records. If a licensee is found to have altered a dental record, the BOD has a full range of penalties available to address the violation, including loss of the dental license and significant monetary penalties.

The Florida Department of Health (DOH) is the agency charged with investigating and prosecuting violations of the Dental Practice Act, including the issue of whether dental records have been altered in violation of the requirements of the BOD. The DOH has a wide range of statutory violations to choose from when presented with altered dental records.

Under the BOD’s Rule 64B5-13.005(3), if the DOH believes the alteration of the dental record was intentional and constituted fraud or making a false or fraudulent representation, it will seek a minimum mandatory fine not to exceed $10,000 for each count or separate offense, in addition to any other penalties outlined in the Board’s disciplinary guidelines.

Typical charges for altering the dental record include the following possible violations and subsequent penalties:

TDC table

Most professional licensing boards view altered records as evidence of a fundamental character flaw in the licensee and they will seek the higher range of penalties including suspension and loss of the license. The BOD is no different.

Although permittable, if you need to make a late entry in the dental record, to avoid any allegation that you are seeking to alter the dental record, you should follow the BOD’s rule on record keeping. Rule 64B5-17.002(2) states: “Record Alterations: Any additions, corrections, modifications, annotations or alterations (hereinafter ‘change’) to the original dental record entry must be clearly noted as such and must include the date when the change was made, must be initialed by the person making the change, and must have an explanation for the change. An original entry to the record cannot be partially or wholly removed. Rather, to represent the deletion of a record entry, the entry must be struck through where it will remain legible. A change made on the same date of the original entry must also include the time of change.”

This requirement is applicable to handwritten records and electronic records. If you have any doubts before you make alterations or changes to a dental record, consult with an attorney.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Referral and Negligent Referral in a Dental Practice

by Florida Dental AssociationJune 29, 2017June 29, 2017Leave a comment

By Kim Hathaway, RN, CPHRM, Patient Safety Risk Manager, The Doctors Company

Failure to diagnose and failure to refer are common issues seen in dental claims.

Dental practice claims alleging failure to refer, or failure or delay in diagnosis may arise from a general dentist’s lack of referral to a specialist. On occasion, patients have asserted their general dentist referred them to a specialist who provided substandard care and that the referral itself was negligent. Dentists referring care outside their background, experience or training must take care to avoid liability issues associated with referrals.

Case Study
During a routine prophylaxis visit, a middle-aged male reported a mass under his tongue, which his general dentist evaluated as an aphthous ulcer (benign and non-contagious). Several months later, another provider biopsied the mass and diagnosed Stage IV squamous cell carcinoma. Surgery and radiation treatment were undertaken, and plastic surgery was required. The patient alleged dental negligence and failure to refer to a specialist. The defendant dentist claimed that the patient had been told to follow up with his primary care physician (PCP) or an oral surgeon.

There was no documentation of a formal referral to a specialist or PCP, nor was there documentation of the dentist’s observations or referral recommendation. The adverse result in this case may have been avoided or the impact lessened if the dentist had documented his observation, evaluation and testing to demonstrate a low suspicion of cancer, or if there had been a documented referral with follow-up on the referral.

Clinical Comfort Level
When specialists are unavailable, or the necessary care takes a patient outside of his or her local community, the patient may ask you to provide the treatment. Treatment that is outside your training or experience may increase the risk of injury to the patient. The risk generally lessens if the treatment is undertaken by a specialist. In addition, the patient cannot waive your professional duty by consenting to a negligent act. If the patient is injured, you will be judged against the standard of care for that specialty.

Do not let the patient pressure you into a treatment plan beyond your comfort level. It is important that you know your own and your staff’s limitations. Explain that the referral is the best treatment plan for the patient. Discuss that choosing no treatment may result in an adverse outcome, disability or death. Spend more time helping the patient find the necessary specialist and clearly document your discussions with and counseling of the patient. If the patient refuses specialty care, carefully document an “informed refusal.” Consider terminating the patient from your practice if after thorough counselling the patient continues to refuse your recommendations.

The American Dental Association’s General Guidelines for Referring Dental Patients notes: “In some situations, a dentist could be held legally responsible for treatment performed by specialist or consulting dentists. Therefore, referring dentists should independently assess the qualifications of participating specialist or consulting dentists as it relates to specific patient needs.” Vicarious liability is a concern if you refer a patient to a specialist who lacks skill or judgment.

Patient safety is the primary focus when making a referral. Familiarize yourself with the specialists’ communication skills, clinical judgement and competence. Explore complaints or evidence of poor care provided by the specialist. Find another provider in the community if a pattern of poor care develops. Consult with colleagues before recommending a specialist who you do not know well. Solicit feedback from both the specialist and the patient.

Communication
Effective communication is critical to a successful referral. Explain to the patient why the referral is needed for a particular treatment or condition and that you will remain the general dentist. Let the patient know what to expect from the specialist and the treatment, and reassure the patient that you will remain in contact with everyone to ensure the best possible outcome. Schedule the appointment while the patient is still in your office. If the patient needs to reschedule or cancel, the patient may; however, your staff has facilitated the referral.

Proactively avoid miscommunication between the dentist and specialist by providing a formal written referral. Always document the details of phone referrals followed by a written referral after the call. Referral letters should include the following information:

patient demographics and identification
date of the referral and last date the referral may take place
evaluation and treatment completed to date
copies of diagnostics performed, including information about when it was collected
diagnosis and prognosis
desired evaluation or care the specialist is requested to complete
your plan for after-care following the specialist’s intervention
a request for a consultation report and ongoing status reports

Tracking
Tracking patient referrals and return visits is essential to efficient patient care. A centralized and uniform tracking process should be kept separate from the patient’s record. The tracking should cover the timeframe from the patient’s referral to the return visit to the general dentist. Have your staff make this return appointment at the time they make the specialist appointment to avoid missed attempts to follow up. The tracking system should provide a reminder or task to move the process along or documentation for why it has not progressed. If the referral is not completed in a timely manner, the process should include contacting the patient and specialist to facilitate care.

Documentation
Carefully document the referral process. In the event of a claim resulting from the referral and treatment, documentation is the best evidence. Documentation of the evaluation, treatment and discussions with the patient that lead to the referral is critical. Copies of written communications and evidence of verbal communication, including phone messages with both the patient and specialist, must be kept in the patient record. Refusal or nonadherence to care must be recorded, with evidence of efforts to overcome the refusal or nonadherence. Finally, if the patient fails to seek specialist care despite your efforts, carefully document the events that lead to a decision to withdraw from further treatment of the patient. This decision should be followed by a properly executed letter terminating the dentist-patient relationship.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.