Section 6.09 - Facility Permit D-P: Requirements for the Use and Provision of Portable and/or Mobile Anesthesia Services(1) A qualified dentist anesthesiologist who travels to dental facilities or practice sites for the purpose of delivering anesthesia services or sedation services at the site must hold a Mobile Facility D-P Permit for the use of portable and/or mobile anesthesia equipment, supplies and personnel.(2)Application. Each applicant shall submit an accurate and complete application on form(s) provided by the Board and accompanied by the permit fee to be determined annually by the Executive Office of Administration and Finance. The application shall, at a minimum, include the following: (a) Applicant name and Massachusetts dental license number, and copy of current Individual Anesthesia Permit number or copy of a permit application pending approval by the Board;(b) Name(s) of dental establishment(s), owner(s) of said establishment(s), and address(es) of the site(s) where mobile or portable anesthesia will be administered;(c) Documentation of provision and maintenance of equipment, materials, and drugs required for the administration of the type of anesthesia to be administered;(d) Request for an on-site inspection by the Board of the applicant's equipment, supplies, anesthesia administration protocols, and site(s) where anesthesia will be administered;(e) Names and qualifications of staff who will assist the applicant in the administration of anesthesia;(f) Copies of the following: 1. Proof of current ACLS (BLS for auxiliaries) certification for the applicant and other dental professionals, as applicable for the type of anesthesia or sedation to be administered by the applicant;2. Medical history form to be utilized by the applicant;4. Schedule of drug and equipment checks;5. Written protocol for management of emergencies;6. Schedule of emergency drills; and7. List of drugs and equipment that the applicant will provide at each site.(g) Other information as may be requested by the Board.(3) The holder of a Facility Permit D-P shall comply with requirements of 234 CMR 6.00 pertaining to the category of anesthesia/sedation to be administered including: (d) Pre-operative preparation;(e) Patient monitoring and documentation;(f) Management of recovery and discharge of patients;(g) Management of pediatric and special needs patients; and(h) Emergency management.(4) The holder of a Facility Permit D-P shall:(a) Comply with requirements of the Board pursuant to 234 CMR 5.05 and the reporting of adverse occurrences, pursuant to 234 CMR 6.17;(b) Employ and provide immediate supervision of at least one dental or clinical auxiliary who is trained and qualified to assist in anesthesia administration and who is fully familiar with the procedures and protocols of the permit holder at each site where anesthesia is being administered by said permit holder;(c) Schedule and perform maintenance checks of all equipment conducted by a certified equipment vendor at least once per year, and retain maintenance records for a minimum of three years;(d) Conduct annual emergency drills for all staff involved in the administration of anesthesia, and retain records that describe the dates of the training activities, content of the training, and the attendance roster for a minimum of three years; and(e) Place a copy of the anesthesia chart in the patient's dental record at the site where the anesthesia was administered.(5) The Facility Permit D-P, or a copy thereof, shall be prominently displayed in the facility by the qualified dental anesthesiologist whenever and wherever he/she is providing anesthesia services.(6) The operating dentist shall be responsible for verifying that the qualified dental anesthesiologist has the proper anesthesia permit and that the portable anesthesia service is appropriately permitted for the level of pain control and/or sedation to be provided.(7) The qualified dental anesthesiologist shall be responsible for verifying that the operating dentist and his/her clinical staff maintain current certification in ACLS or BLS for Healthcare Providers, as applicable given the type of anesthesia being administered.(8) There shall be a written and signed agreement between the Facility Permit D-P applicant and the operating dentist for each site where anesthesia is to be administered by the Facility Permit D-P holder which, at a minimum describes how emergency response training and protocols will be developed and practiced, procedures for verifying qualifications of personnel who assist in the care and monitoring of the patient, responsibilities for pre- and post- operative patient assessment and monitoring, responsibilities for obtaining informed consent, and how compliance with applicable board statutes and regulations will be achieved and maintained at the site.