Facility Site Reviews

Facility Site Reviews

Facility Site Reviews of Primary Care Provider Sites

Thank you for participating in the SFHP Primary Care Provider Network and partnering with us to offer our members the high quality care they need.

The California Department of Health Care Services (DHCS) requires all Medi-Cal Managed Care Plans to conduct a Full Scope Facility Site Review (FSR) and Medical Record Review (MRR) for all network PCP sites as part of the initial credentialing process and at least every 36 months thereafter. New PCP sites must pass their initial FSR before receiving SFHP member assignments. An Initial MRR is conducted approximately 3-6 months following the first member assignment.

The FSR and MRR are conducted by DHCS-Certified Nurse Reviewers and scored with standardized DHCS guidelines and audit tools. The purpose of the reviews is to help ensure consistent compliance with DHCS clinical and administrative standards. A detailed explanation of these standards can be found in DHCS Managed Medical Division Policy Letter 14-004.

SFHP has developed the following checklists to help providers prepare for the FSR and MRR:

The following information and resources will help you prepare to successfully pass the FSR and MRR. Please contact your medical group or Jackie Hagg, RN, MSN, LNC at 1(415) 615-5637 for assistance and more information.

Facility Site Review (FSR) Information and Resources

Detailed FSR scoring information can be found in the following DHCS documents:

The FSR consists of six individual sections with nine Critical Elements that are considered “must pass.” Any Critical Element deficiencies must be addressed in a Corrective Action Plan (CAP) within ten business days of the FSR. The Critical Elements are listed below.

  1. Exit doors and aisles are unobstructed and egress (escape) is accessible
  2. Airway management equipment, appropriate to practice and populations served, is present onsite
  3. Only qualified/trained personnel retrieve, prepare or administer medications
  4. Office practice procedures are utilized onsite that provide timely physician review and follow-up of referrals, consultation reports and diagnostic test results
  5. Only lawfully authorized persons dispense drugs to patients
  6. Personal protective equipment is readily available for staff use
  7. Needle stick safety precautions are practiced onsite
  8. Blood, other potentially infectious materials (specimens) and regulated wastes (sharps/biohazardous non-sharps) are placed in appropriate leak-proof, labeled containers for collection, processing, storage, transport or shipping
  9. Spore testing of each autoclave/steam sterilizer is completed (at least monthly), with
    documented results

Corrective Action Plans (CAPs) are also issued under the following circumstances:

  • Providers who score less than 90% on the FSR
  • Providers with deficiencies in the Infection Control and/or Pharmaceutical Services sections
  • At the discretion of the Certified Nurse Reviewer for any concerns that may potentially jeopardize patient safety

FSR Subsection Resources

Access and Safety

Personnel

Office Management

Clinical Services

Preventive Services

Infection Control

Medical Record Review (MRR) Information and Resources

Detailed MRR scoring information can be found in the following DHCS documents:

Corrective Action Plans (CAPs) are issued under the following circumstances:

  • Providers who score less than 90% on the MRR
  • Providers who score less than 80% in any individual MRR section, regardless of overall score
  • At the discretion of the Certified Nurse Reviewer for any concerns that may potentially jeopardize patient safety

MRR Subsection Resources

Format and Documentation

Pediatric Preventive

Adult Preventive

OB/Comprehensive Perinatal Services Program