Facility Site Review (FSR) and Medical Record Review (MRR) DHCS Resources

Clinic Policies for Primary Care Provider Settings

Instructions:

All participating provider(s) sites are required to establish safety, member rights and general policies and procedures for their practice. Please review all sample policies and procedures in our educational packet and customize any or all of the policies and their respective attachments you wish to adopt based on your clinic’s practice and processes. Please complete the Approval date, Approved by, Effective Date, and Revision date for each of the adopted policies. All providers and staff shall receive trainings/in-services on all clinic policies and procedures. Annual trainings/in-services are required for Blood-Borne Pathogens Exposure Control, Biohazardous Waste Management, and Infection Control/Standard/Universal Precautions. All clinic policies and evidence of training shall be kept on site or made available upon request.

FSR Provider Training 2022 — Video

SCAN Health Plan Provider Portal – Eligibility Search Guide (CIN)

If you have any questions or need help, please contact the Delegation Oversight Coordinator(s), Clinical
afrias@scanhealthplan.com
sgonzalez2@scanhealthplan.com
j.baek@scanhealthplan.com

Facility Site Review Table of Contents

Description

FSR and MRR Preparation Checklist & Clinical Policies Requirement

CRITICAL ELEMENTS

Critical Element Summary

Site Access/Safety Criteria

Emergency Exit Route Evacuation Routes Diagram Facility Site Resource List

Fire Safety and Non-Medical Emergency • Fire Safety and Non-Medical Emergency – Education • Fire Safety and Non-Medical Emergency - Policy and Procedures • Employee Alert System

Medical Emergency • Emergency - Policy and Procedure • Emergency Protocol and Contact List • Emergency Medication Dosages - Management of Anaphylaxis, Opioid Overdose, Chest Pain, Asthma, and Hypoglycemia - Form 1 • Emergency Medication Dosages - Management of Anaphylaxis, Opioid Overdose, Chest Pain, Asthma, and Hypoglycemia - Form 2

Medical Lab Equipment - Policy and Procedures Facility Resource List

Personnel

Personnel • Notice to Patients (On-site licensed MD only) • Notice to Consumers (On-site licensed DO only) • Notice to Consumers (On-site licensed NP only) • Notice to Consumers (On-site licensed PA only) • Identifications: Name Tags • Staff Qualifications - Policy and Procedures • Unlicensed Staff - Policy and Procedures (On-site Medical Assistant) • Medical Assistant Training Verification • Non-Physician Medical Practitioners - Policy and Procedures (On-site NP and/or PA)

NP Standardized Procedure (Example)

PA Practice Agreement Requirement PA Practice Agreement (Example)

Staff Training/ Orientation/ Continuing Education Staff Training - Policy and Procedures • Fire safety and prevention  • Emergency non-medical procedures • Medical Emergency Equipment • Infection Control/Universal Precaution (Annual Training)     • Infection Control/Universal Precaution - Education     • Infection Control/Universal Precaution - Communicable Disease Protocol     • Infection Control/Universal Precaution - Cleaning and Decontamination Policy and Procedure     • Infection Control/Universal Precaution - Cleaning Log     • Infection Control/Universal Precaution - Policy and Procedures • Blood Borne Pathogen/Exposure Control Plan (Annual Training)     • Blood Borne Pathogen/Exposure Control Plan - Education     • Blood Borne Pathogen/Exposure Control Plan - Sharps Injury Log      • Blood Borne Pathogen and Biohazard Waste - Policy and Procedures • Biohazard Waste (Annual Training)     • Biohazard Waste – Education     • Biohazard Waste - Medical Waste Tracking Log     • Biohazard Waste - Biohazard Sign • Confidentiality      • Confidentiality - Education      • Confidentiality Agreement      • Confidentiality - Policy and Procedures      • Confidentiality - Medical Record Release Form • Informed Consent     • Informed Consent -Education     • Informed Consent - Policy and Procedures     • General Consent to Treat Agreement • Sensitive Services     • Sensitive Services - Policy and Procedures • Prior Authorization/Referral Process/Procedures/Resources     • Prior Authorization/Referral - Policy and Procedures     • Prior Authorization/Referral Log - Form 1     • Prior Authorization/Referral Log - Form 2 • Member Grievance      • Member Grievance - Policy and Procedures     • Policy Member Grievance Form • Adult/Child Abuse & Domestic Violence Reporting      • Abuse and Violence Reporting - Education      • Abuse and Violence Reporting - Mandated Reporter Acknowledgment      • Child Abuse Reporting - Policy and Procedures       • Child Abuse Reporting - Form       • Domestic Violence Reporting - Policy and Procedures      • Elderly Violence Reporting - Policy and Procedures • Cultural and Linguistics      • Cultural and Linguistics – Education      • Cultural and Linguistics - SCAN Interpretation Service Hotline      • Cultural and Linguistics - Interpretation Service Refusal Form      • Cultural and Linguistics - Medical Interpretation Service Resources List      • Cultural and Linguistics - Policy and Procedures • Disability Rights and Provider Obligations      • Disability Rights and Provider Obligations - Education      • Disability Rights and Provider Obligations - Policy and Procedures       • Notice of Civil Rights - less than 15 employees       • Notice of Civil Rights - 15+ employees

Office Management

Office Management     • Access to 24/7 Care Policy and Procedures     • Triage Policy and Procedures     • Patient Appointment Policy and Procedures     • Medical Record Release Authorization Form

Medication/Clinical Services

Pharmaceuticals     • Pharmaceuticals Policy and Procedures     • Drug Administration Rights (Basic)     • Pharmaceuticals Controlled Substance Log     • Pharmaceuticals - Sample Medication Log     • Pharmaceuticals Emergency Power Outage Policy and Procedures     • Pharmaceuticals Refrigerator/Freezer Do Not Unplug Signage     • Pharmaceuticals/Emergency Kit/Lab Supply Monthly Service Log Pharmaceuticals Vaccine     • Pharmaceuticals Vaccine Storage - Education     • Pharmaceuticals Vaccine Storage - Temperature Logs     • Meeting CDC Recommendations for Vaccine Storage - Video     • https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf     • Pharmaceuticals Vaccine Information Sheet and CAIR - Education     • Pharmaceuticals Vaccine Information Sheet - QR Codes     • Pharmaceuticals Vaccine Information Sheet - Policy and Procedures

Lab Services     • CLIA - Education     • Lab Services Policy and Procedures

Radiology Policy and Procedures

Preventive Services

Preventive Services     • Preventive Services Policy and Procedures     • Health Education Policy and Procedures     • Vision Exam Requirements

Infection Control

Infection Control     • CDC Environmental Cleaning Procedures 4.2.1 Cold Sterilization     • Cold Sterilization Education     • Cold Sterilization (Quick Guide)     • Levels of Cold Chemical Use - Education (Sterilization and Disinfection) Autoclave     • Autoclave Education     • Autoclave Run Log     • Autoclave Maintenance Log     • Cold Sterilization and Autoclave - Policy and Procedures

 

Medical Records Review Table of Contents

Description

MRR Preparation Checklist & Clinical Policies Requirement

Format/Coordination of Care

Medical Record Policy and Procedure Medical Record Signature Sheet Notice of Privacy Information and Form

Documentation

General Consent Form Informed Consent Form Advance Health Care Directive     • Advance Health Care Directive Policy and Procedures     • Advance Health Care Directive Education     • Advance Health Care Directive Form 1     • Advance Health Care Directive Form 2

Preventive Care

Comprehensive Health Assessment     • Pediatric Preventive Health Care Recommendation (Bright Futures/American Academy of Pediatrics)     • Pediatric Comprehensive Assessment (ages 0-20)     • Adult Preventive Health Care Schedule – USPSTF (last rev. 12.2024)     • Adult Comprehensive Assessment (ages 21-49)     • Geriatric Comprehensive Assessment (50+)     • Comprehensive Assessment (All Adults - Generic IHA and Preventive Care Screening Tool) Risk Assessment     • Mini-Cog Tool (Geriatric)     • Risk Assessment Tool     • AAFP - Social Determinants of Health Risk Assessment Preventive Care Screening Tools Alcohol, Drugs, Tobacco Screening     • Alcohol, Drugs, Tobacco Approved Tools     • CRAFFT - Alcohol, Drugs, Tobacco Screening Tool     • NIDA - nmassist - Alcohol, Drugs, Tobacco Screening Tool     • TAPS Tool Parts I and II V2 - Alcohol, Drugs, Tobacco Screening Tool Hepatitis Screening     • Hepatitis Risk Assessment Tool Form 1     • Hepatitis Risk Assessment Tool Form 2 Depression Screening     • PHQ2 - Depression Screening Tool     • PHQ9 - Depression Screening Tool STI Screening     • Sexually Transmitted Infection Screening Tool TB Screening     • Preventive Care - TB Screening Tool ACIP Guidelines     • Immunization Schedule (0-18yrs)     • Immunization Schedule (Adults)     • VIS     • Vaccine Information Statements