By Duane “The Toothcop” Tinker | Dental Compliance Specialists
Picture this conversation in a dental office:
“Who is checking our sterilization reports?”
“The assistant who left used to handle that.”
“Who took over?”
Nobody has an answer.
That is one preventable way dental compliance falls apart. An employee leaves, gets promoted, transfers to another location, or takes extended leave. The practice covers the schedule. Meanwhile, the compliance responsibilities that came with that person’s job never get reassigned.
The old name stays in the manual. Reminders go to an abandoned inbox. Everyone assumes someone else has it covered.
The employee left. The responsibility stayed.
If your answer to “Who handles that?” starts with the name of someone who no longer works there, that is your opportunity. Fix it.
Compliance duties that can get left behind
OSHA training and written programs
Start with the dates and documents someone used to track. OSHA requires review and updating of the exposure control plan at least annually. Employees with occupational exposure need bloodborne-pathogens training when initially assigned and at least annually thereafter, with additional training when relevant exposure risks change. [1]
Then check the hazard communication program, hazardous chemical list, and access to safety data sheets. HazCom training is required at initial assignment and when a new chemical hazard that employees have not been trained about enters their work area. [2]
Who tracks those duties now? Can the team find the post-exposure procedure and explain whom to contact? A coordinator’s departure does not suspend the employer’s OSHA obligations. [1] [2]
Infection control monitoring and follow-up
CDC recommends assigning at least one person trained in infection prevention to coordinate the program. Is that person is still there and actually doing the work? [3]
Look at sterilizer monitoring log first. CDC recommends mechanical monitoring for every load, an internal chemical indicator in every package, and biological monitoring with a matching control at least weekly and for every load containing implantable devices. Someone also needs to review the results, maintain the records, and respond to failures. [4]
Then check dental unit waterlines. CDC recommends routine water-quality monitoring according to the equipment manufacturer’s recommendations and using treatment products according to their instructions. [5]
A test result sitting unread in a former employee’s inbox deserves attention. Ask who receives it, who reviews it, and who follows through when something is wrong.
Radiation equipment performance evaluations
Who knows when each X-ray unit’s equipment performance evaluation, or EPE, is due? Who schedules it, gets the report, and follows up on deficiencies?
Texas illustrates why equipment details matter: intraoral, panoramic, and cephalometric machines need an EPE every four years; dental CT systems need one annually, with no more than 14 months between evaluations. Texas also requires an EPE within 30 days after installation, reinstallation, or repair of a component that affects radiation output. [6] [7]
Give each machine its own entry on the compliance calendar. Confirm the applicable schedule for your state and equipment.
Digital sensor and image receptor quality control
Track sensor quality assurance (QA) and quality control (QC) separately from the EPE.
Texas requires the manufacturer’s digital-imaging QA/QC protocol. If a manufacturer protocol cannot be established, the practice must develop one; its required elements include test images from each receptor at intervals no longer than three months and comparison with previous images. The rule also requires documentation. [6]
Ask someone to show you the protocol, identify every receptor covered, and retrieve the latest test images. “We take X-rays every day” does not answer those questions.
The Texas intervals above are a state-specific example. CDC recommendations are guidance; check your dental board and other applicable rules for enforceable infection-control requirements. [8]
Six ways to keep responsibilities from disappearing
Here is what I recommend building into your practice’s management routine.
1 Assign a person and a trained backup
Write down who owns each task, who covers an absence, and which leader checks completion. Use names. “The back office” leaves too much room for assumptions. For multiple locations, identify the person responsible at each office. Give them the time, training, and authority appropriate to the assignment.
2 Make the handoff part of every staffing change
Before a planned departure, transfer the task list, next due dates, last completed records, vendor contacts, and unresolved problems. Have the incoming person confirm receipt and understanding. Include promotions, location transfers, and extended leave. If someone leaves unexpectedly, assign interim coverage immediately. Waiting to hire a permanent replacement leaves the work unattended.
3 Put deadlines on a shared calendar
Use a practice-controlled calendar or task system that the owner, backup, and reviewing leader can access. Include the task, equipment or location, due date, applicable rule or manufacturer instruction, and link to the record. Set advance reminders and an escalation when work becomes overdue. A reminder that only one person can see is a weak arrangement.
4 Keep records and access under practice control
Store procedures, test results, EPE reports, training records, and vendor information where authorized staff can retrieve them. Update report recipients when roles change. Give replacements their own appropriate account access and remove departing staff access through your offboarding process. Verify that the new owner can actually open the files and receive the results.
5 Have the replacement demonstrate the work
Ask the new owner and backup to walk through the task. Can they find the instructions, perform their assigned steps within their qualifications, document the result, and explain when to escalate a problem? Let them practice while help is available. A signature acknowledging a new assignment tells you very little about whether someone can carry it out.
6 Review evidence and close the loop
I recommend a brief monthly leadership review of upcoming deadlines, overdue items, and unresolved findings. That is a management check; individual tests still follow their own required schedules. Ask to see the report or log. If a result is unacceptable, identify who owns the correction and how completion will be verified. Treat urgent safety concerns immediately.
Try this at your next team meeting
Pick four duties: nitrous oxide/sedation safety/medical emergency preparedness, sterilizer monitoring, X-ray machine calibration checks, and digital sensor QA/QC. For each one, ask:
Who owns it today?
Who covers when that person is out?
When was it last completed, and when is it due again?
Where is the evidence, and who reviewed the result?
Is there an unresolved problem that needs action?
If the team cannot answer, assign someone to verify the status and report back. If the work was missed, document the gap honestly and start the appropriate correction.
You can replace an employee and still leave part of the job vacant. Check the compliance duties before you call the transition complete.
Here’s a free checklist you can deploy to help you stay on top of these changes.
Need help finding the duties that fell through the cracks? Contact Dental Compliance Specialists at DentalCompliance.com or email Duane@DentalCompliance.com or click here to schedule a call to discuss your practice’s compliance needs.
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References
Sources checked October 2026. Federal requirements, CDC recommendations, and the Texas examples are identified separately in the article. The six prevention steps are operational recommendations.
[1] OSHA Bloodborne Pathogens standard
29 CFR 1910.1030(c)(1)(iv), (g)(2), and (f)(3)
[2] OSHA Hazard Communication standard
29 CFR 1910.1200(e)(1), (g)(8), and (h)(1)
[3] CDC Administrative Considerations
Administrative measures and program evaluation
[4] CDC Best Practices for Sterilization Monitoring in Dental Settings
Mechanical, chemical, and biological monitoring; records
[5] CDC Best Practices for Dental Unit Water Quality
Recommendations and manufacturer instructions
[6] Texas Radiation Control Regulations for Dental Radiation Machines
25 TAC 289.232(j)(5)(J) and (j)(14); printed pages 232-44 to 232-45 and 232-50 to 232-52
[7] Texas DSHS Regulatory Guide 4.4 Dental Facilities
Page 5 equipment performance evaluations; guidance accompanying the rule
[8] CDC Best Practices in Dental Infection Prevention and Control
Reminder on CDC recommendations and state regulatory agencies