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

Facility Site Review (Full Packet Content)

Medical Record Review (Full Packet Content)

If you have any questions or need help, please contact Delegation Oversight Coordinator(s)

afrias@scanhealthplan.com

sgonzalez2@scanhealthplan.com

m.hernandez@scanhealthplan.com

Facility Site Review Table of Contents

Description	Section
FSR Preparation Checklist & Clinical Policies Requirement	1
CRITICAL ELEMENTS
Critical Element Summary	2
Site Access/Safety Criteria
Emergency Exit Route & Evacuation Routes Diagram	3
Fire Safety and Non-Medical Emergency	4
Medical Emergency • Employee Alarm System • Emergency Protocol/Contact List • Information for Practitioners Office • Emergency Medication Dosages • Management of Anaphylaxis, Opioid Overdose, Chest Pain, Asthma, and Hypoglycemia	5
Medical Equipment & Facility Resource List	6
Personnel
Personnel • Staff Qualifications • Medical Assistant Training Verification • Identifications: Name Tags • Notice to Patients • Notice to Consumers	7
NP Standardized Procedure	8
PA Practice Agreement	9
Staff Training/ Orientation/ Continuing Education	10
Fire safety and prevention	4
Emergency non-medical procedures:	4
Medical Emergency Equipment	5
Infection Control/Universal Precaution (Annual Training)	11
Blood Borne Pathogen/Exposure Control Plan (Annual Training)	11
Biohazard Waste (Annual Training)	11
Confidentiality	12
Informed Consent	13
Sensitive Services	13
Prior Authorization/ Referral Process/Procedures/Resources	14
Member Grievance Policy and Procedure with Form	15
Adult/Child Abuse & Domestic Violence Reporting	16
Cultural and Linguistics	17
Disability Rights and Provider Obligations	18
Office Management
Office Management	19
Medication/Clinical Services
Pharmaceuticals	20
Pharmaceuticals Vax https://www.youtube.com/watch?v=hvGt45qCCZ8 https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf	21
Lab Services	22
Radiology	23
Preventive Services/Infection Control
Preventative Services	24
Cold Sterilization and Autoclave	25

 

Medical Records Review Table of Contents

Description	Section
MRR Preparation Checklist	1
Medical Records
Medical Record Policy and Procedure	2
Medical Record Signature Sheet	2
Notice of Privacy Information and Form	3
General Consent Form	4
Informed Consent Form	4
Advance Health Care Directive	5
Annual Comprehensive Health Assessment Form	6
Adult Preventive Health Care Schedule - USPSTF	6
Alcohol Screening - CRAFFT	7
Depression Screening – PHQ2 & PHQ9	8-9
Hepatitis Risk Assessment Tool	10
TB Screening Form (CDPH) & TB Screening Form (English/Spanish)	11
Adult Immunization Schedule https://www.immunize.org/cdc/schedules/ https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#table-age
Vaccine Administration Record	13
Where is the VIS Publication Date Located	13
VIS forms can be found at: https://www.immunize.org/vis/