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The Kentucky Oral Health Coalition (KOHC) is a statewide coalition of over 450 members and oral health stakeholders from every region of the Commonwealth. Membership includes dentists, dental hygienists, health professionals, family resource center coordinators, universities, managed care companies, business corporations, government entities, teachers, parents, educators, social workers, public health departments, community health advocates and many others. On behalf of  KOHC, we are writing this letter in response to the proposed regulation 201 KAR 8:600 – Mobile Dental Facilities and Portable Dental Units. 

Mobile dental services currently operating across the state play an important role in providing meaningful access to preventive care, assessing oral health treatments needs, and connecting children and families to dental care providers. However, we recognize the need to regulate the mobile dental services provided across the state to ensure safe and effective care is being provided and applaud the Board of Dentistry’s efforts in developing solutions to address the quality of dental care in the state. 

We recognize various positive aspects of this proposed regulation, including the provision that both mobile dental facilities and portable dental units will be held to the same standard of care as any other patient encounter as provided under KRS 313. In addition, we are supportive of Section 1 – Definitions, Section 7 – Registration, Renewal, and Reinstatement, and Section 8 – Notification Requirements. 

However, we do have concerns, outstanding questions, and recommendations regarding several sections in this proposed regulation, outlined below. 

Section 2. Scope and Applicability.

(1) Patient encounters conducted by a mobile dental facility or portable dental unit shall be held to the same standard of care as any other patient encounter as provided for under KRS Chapter 313.

(2) Mobile dental facilities and portable dental units engaged exclusively in charitable dental practices as governed by 201 KAR 8:581 shall be exempt from Sections 3(2)(b) and 7(2)(b) of this administrative regulation.

(3) Public health programs governed by KRS 313.040(8) and 201 KAR 8:562, Section 15, shall be exempt from the requirements of this administrative regulation.

(4) Any violations of KRS Chapter 313 or 201 KAR Chapter 8 related to the operation of a mobile dental facility or portable dental unit shall be subject to disciplinary action pursuant to KRS 313:080 and 313:100.

Concerns and recommendations:

  • We recommend exempting primary care centers, federally-qualified health centers, look-alikes, and rural health governed by 907 KAR 1:054 and 907 KAR 1:055 from the requirements of this administrative regulation.
    • This exemption would ensure safety-net dental clinics (PCC/FQHC/RHC Federally-designed clinics) can continue to provide targeted outreach to high-risk and underserved populations and essential dental outreach services to children around 200 elementary schools in 40+ counties.
    • An exemption would assure the continuation and growth  of this network as opposed to a heavier burden of oversight. This group is already subject to multi-layered regulations in the form of: 
  1. The two primary care Kentucky Administrative Regulations – 907 KAR 1:054 and 907 KAR 1:055
  2. The Federal Uniform Data System (UDS) reporting requirements to the Bureau of Primary Health Care’s (BPHC) health services and resources administration (HRSA)
  3. The Avesis mobile policy, and
  4. Each FQHC clinic is additionally required to be governed by a local board of directors

Outstanding questions:

  • Public Health Registered Dental Hygiene programs are exempt under this proposed regulation, but what about PHRDH programs that also use general supervision to expand services/access to care with a dentist contracted by a local health department?

 

Section 3. Registration of Mobile Dental Facilities and Portable Dental Units.

(1) Each mobile dental facility or portable dental unit doing business in Kentucky shall be registered with the board and abide by the provisions of this administrative regulation.

(2) To register a mobile dental facility or portable dental unit, the intended registration holder shall:

(a) Submit a completed and signed Application for Mobile Dental Facility or Portable Dental Unit Registration, which shall contain but not be limited to:

  1. The name of the intended registration holder;
  2. An official business or mailing address of record, which shall not be a post office box;
  3. An official phone number and email address of record; and
  4. The name and license number of any individual(s) licensed with the board who are providing services on behalf of or in partnership with the registration holder.

(b) Pay the fee required by 201 KAR 8:520.

Outstanding questions: 

  • What is the proposed fee?  Are nonprofit dental clinics exempt or offered a reduced rate?  
  • Why is a physical location, not a post office box, specifically required?

 

Section 4. Emergency and Follow Up Care.

(1) A mobile dental facility or portable dental unit shall maintain a signed agreement with a fixed general practice or pediatric dental office within seventy (70) miles of the treatment location which will accept timely referrals for comprehensive, follow up, and emergency care.

(2) At the conclusion of each patient’s visit, the mobile dental facility or portable dental unit shall provide each patient with an information sheet that contains:

(a) Contact information that allows the patient to reach the registration holder or dentist of record for emergency care, follow-up care, access to dental records, or information about treatment received;

(b) The name of the dentist or dental hygienist, or both, who provided services;

(c) A description of the diagnostic findings, the treatment rendered; and

(d) A plan for follow-up care, including contact information to a dental office as provided for in subsection (1) of this Section.

(3) A mobile dental facility or portable dental unit which accepts a patient and provides preventive treatment, including prophylaxis, radiographs, and fluoride, but does not arrange for follow-up care when such treatment is clearly indicated, will be considered by the board to have abandoned the patient.

Concerns and recommendations:

  • We recommend aligning this standard with that outlined in KRS 304.17C-040 – Availability of Provider Network. 
    • We recommend defining how ‘timely referrals’ are defined and determined. 
      • In doing so, we recommend taking into consideration the availability of appointments in some areas of the state. For example, due to the backlog caused by the pandemic, it can take several months to get an appointment at most dental offices in rural parts of the state.  This is also true for offices in low-income urban communities.  
    • We recommend a longer timeframe to account for tech/IT difficulties instead of the current language that says, “at the conclusion of the visit to ensure patients receive an information sheet.” 
      • In order to account for the varying work environments of these programs, including those who are accessing an electronic health record (EHR) through a remote server. In these cases, providers are sometimes doing notes on paper and transcribing into the EHR later, and printing letters later, if there is not good internet access at a school or other remote location. 
  • We recommend adding clarity in how “follow up care” is defined. 
    • As written, subsections 2 and 3 are inconsistent in defining the necessary steps to provide follow up care.
    • Including language here about “abandonment of patient” is concerning and the expectations on providers need to be further defined to ensure providers are protected if they are making an effort to connect patients to care but other barriers are present such as difficulty contacting families, families not following through on referrals, etc.
  • We suggest the following alternative language within subsection (3): A mobile dental facility or portable dental unit which accepts a patient and provides preventive treatment, including prophylaxis, radiographs, and fluoride, but does nothing to arrange for follow-up care or does not meet the minimum standard of three documented attempts to encourage families to seek care when such treatment is clearly indicated, will be considered by the board to be practicing below the standard of care and therefore subject to disciplinary action.

 

Section 5. Patient Records and Communications.

(1) Mobile dental facilities and portable dental units shall maintain:

(a) A written or electronic record detailing the location where services are provided, the dates of each session, and the services administered.

(b) Patient records of prior treatment to have readily available during subsequent treatment visits; and

(c) All dental and official records at the address of record when not in transit.

(2) Mobile dental facilities and portable dental units shall maintain a reliable means of communication onsite and at the address of record to:

(a) Contact necessary parties in the event of a medical or dental emergency;

(b) Allow the patient or the parent or guardian of the patient treated to contact the provider for emergency care, follow-up care, or information about treatment received; and

(c) Allow a provider who renders follow-up care to request and receive treatment information, including radiographs.

(3) Mobile dental facilities and portable dental units doing business in Kentucky shall not perform services on minors without a signed consent form from the parent or guardian, which shall indicate that:

(a) If the minor already has a dentist, the parent or guardian should continue to arrange dental care through that provider; and

(b) The treatment of the child by the mobile dental facility may affect the future benefits that the child may receive under private and public insurance plans.

Concerns and recommendations:

  • We recommend within section 5, subsection 3 be deleted. 
  • Although we understand the need to ensure parents know that a mobile or portable dental unit is not intended to be their provider for ongoing preventive care, we have several questions and concerns about the minor consent form and the language of subsection (3) (a) and (b):
    • We are concerned that because the language in this section is unclear, it has the potential to inadvertently cause confusion and or fear in parents or guardians.
    • If a parent indicates they have used a specific dentist in the past, does this imply they have to go back to that same dentist for follow up care and cannot choose any provider they want?
    • We are concerned that this language is discouraging parents to sign a consent for services.  While families may have a dentist they have visited, parents often face barriers to accessing preventive care – including transportation, office hours, long wait periods etc.  
    • Most consent forms clearly state that by giving permission to treat the child, the parent is also giving permission to bill their insurance.  Does this language mean providers would need to add a statement about how this dental visit may affect the child’s insurance coverage for future visits?
      • If so, this is true for any office. It can happen in any fixed location that a dentist sees a new patient who went somewhere else first and is not eligible for an exam, prophy, bitewings, etc. – but offices are not required to have patients sign a consent for this. This language could lead to  scaring parents away from using mobile services.
    • This language may also cause parents or guardians to fear the repercussions for signing their children up for the programs or they may feel that they will be unable to afford to pay for care later or that there will be repercussions imposed on them by a previously seen dentist. 

 

Section 6. General Operating Requirements. Mobile dental facilities and portable dental units shall:

(1) Operate under the direct supervision of a dentist licensed in accordance with 201 KAR 8:532, who shall be responsible for all aspects of patient care.

(2) Display in or on the mobile dental facility or portable dental unit a current valid registration issued pursuant to this administrative regulation in a manner which is readily observable by patients or visitors;

(3) Conform to all applicable federal, state, and local laws, regulations, and ordinances dealing with radiographic equipment, flammability, construction, sanitation, zoning, infectious waste management, universal precautions, Occupational Safety and Health Administration guidelines, and Centers for Disease Control and Prevention protocols; and

(4) Be driven or transported by a driver possessing a valid Kentucky driver’s license appropriate for the operation of the vehicle.

Concerns and recommendations:

  • We recommend the following language changes to section 6 subsection 1: Operate under the direct supervision of a dentist Appoint or employ a licensed dentist as a dental director (DMD or DDS) in accordance with 201 KAR 8:532, who shall be responsible for all aspects of patient care and program management.
    • We are concerned that the language “direct supervision” is not clear as to whether dental hygienists can work on the mobile units or on the portable equipment under general supervision without the dentist physically present. 
    • We believe the language regarding “direct supervision” needs to be revised to clarify that it is not limiting the scope of practice of dental hygienists working under general supervision, as dental hygienists’ ability, skills, or licensure designation does not change based on what building they are in, or the age of the patient. 
  • We recommend removing ‘Kentucky’ in section 6 subsection (4) to allow those who commute across state lines to work to operate mobile and portable dental units. 
    • We are concerned that requiring the driver to have a Kentucky driver’s license does not consider mobile operations in cities and towns that are very close to neighboring states and may employ out-of-staters, such as Murray, Paducah, Henderson, Owensboro, Louisville, Covington, Newport, Ashland, and others. 

In addition to the specific concerns outlined above, we are concerned that neither KOHC, who has a wide network of dental professionals around the state, nor any model programs operating mobile dental services were included in the process to draft this regulation. When stakeholders are not engaged, unintentional consequences and barriers can be created for those programs and providers. While we understand the intent to regulate programs that are not meeting standards of care, we believe it is essential to also ensure programs doing this vital and necessary work well are not negatively impacted.

KOHC thanks the Board of Dentistry for their work on this proposed regulation and we hope our recommendations and concerns outlined here will be addressed in the final version of this regulation.