Facility Site Reviews ▸ Resources
Facility Site Review | Medical Record Review Survey | Physical Accessibility Survey | Training & Resources
Facility Site Review Survey Resources
A FSR (FSR-A) is a physical assessment of a primary care practice site that includes six areas: Accessibility/Safety; Personnel; Office Management; Clinical Services; Preventive Services; and Infection Control.
The review will include evaluation of procedures/practices, policies, accessibility, equipment, infection prevention protocol, medical and non-medical emergency preparedness, and some operational protocol.
DHCS FSR Survey Tools and Standards:
- DHCS FSR APL can be found here.
- DHCS FSR Standards can be found here.
- DHCS FSR Tool can be found here.
- Interim Monitoring Form can be found here.
(Click to view more)
Site Accessibility by Individuals with Physical Disabilities
- Accessibility by Individuals with Physical Disabilities »
- SF Application for (Blue) Curb Or Sign Designating Disabled-Parking Space »
Fire Safety and Prevention and Emergency Non-Medical Procedures
- Safety and Prevention Procedures »
- Exit Doors are Clearly Marked with “Exit” Signs »
- Clearly Diagramed Evacuation Routes Posted for Emergencies »
- Graph – Evacuation Route Template PDF »
- Graph – Evacuation Route Template Excel File »
- Fire Fighting/Protection Equipment is in Accessible Locations »
- Evidence of an Employee Alarm System »
- Maintenance of All Medical Equipment »
Emergency Health Care Services: 24/7 Availability and Accessibility
- Emergency Medical Management Supply Log Dosage Chart Mock Drill »
- Medical Emergency Response Protocol »
- Oxygen Tank Monitoring and Maintenance »
- Emergency Phone Number Contacts »
- Family Violence Resources – SF 2019 »
Additional Access/Safety Resources
Health Care Personnel Licensing and Certifications
- Professional Licenses and Certifications »
- Notice of Provider Licensing »
- Personnel Identification Badges »
- Notice to Consumers – Medical Doctors »
- Notice to Consumers – Physician Assistants »
Personnel Qualifications and Training
- Non-licensed Personnel Education/Training »
- Explanation – Standardized Procedure Requirements for Nurse Practitioner Practice »
- Cultural Awareness Training »
Non-Physician Medical Practitioners (NPMP) Scope of Practice
- Standardized Procedures Agreement (NP & CNM) »
- Physician Assistant Delegation of Services Agreement Policy »
- Physician Assistant Delegation of Services Agreement Resource Guide »
Site Personnel Safety Training/Information
- Evidence of Staff Training »
- Personnel Training: Child Abuse Reporting »
- Personnel Training: Elder Abuse Reporting »
- Personnel Training: Domestic Abuse Reporting »
- Personnel Training: Informed Consent and Human Sterilization Consent »
- Personnel Training: Prior Authorization/Referrals »
- Personnel Training: Member Grievances and Complaints »
- Personnel Training: Member Grievances and Complaints Resource Guide Template »
- Personnel Training: Sensitive Services/Minors’ Rights »
- Personnel Training: Pre-Authorization/Referrals »
- Personnel Training: Cultural and Linguistics »
- Personnel Training: Infection Control Universal Precautions »
Physician Coverage is Available 24/7
- Clinic Office Hours Sign for Patients »
- Patient Confidentiality »
- Timely Access to Care – English »
- Timely Access to Care – Spanish »
Sufficient Health Care Personnel
- Management of Medical Advice Telephone Calls »
- Telephone Protocol When Staff Not Available »
- Protocol for Monitoring System of How Clinic is Reached »
Health Care Services are Readily Available
- Protocol for Appointment Triage and Timeliness »
- Protocol for Notifying Patients of Appointments »
- Missed or Cancelled Appointments »
Referral Resources
Drug and Medication Supply Maintenance
Drug Handling and Storage
- Refrigerator Thermometer Temperature »
- Refrigerator Temperature Log »
- Freezer Thermometer Temperature »
- Freezer Temperature Log »
- Refrigerator/Freezer Thermometer Logs – Resource Guide Template »
- Proper Maintenance and Storage of Drugs »
- Proper Labeling of Drugs »
- Power Malfunction and Vaccine Management »
- CDC – Storage Best Practices for Frozen Vaccines »
- Temperature Monitoring Best Practices for Refrigerated Vaccines »
- CDC – Vaccines Storage and Handling Toolkit »
- Drug and Hazardous Substance Disposal »
- Preparing Vaccine Storage Units »
Drug Dispensary Regulations
- Drug Expiration Protocol »
- Preparing and Confirming Medication/Vaccine Prior to Administration »
- Vaccine Information Sheets Protocol »
- California State Board of Pharmacy Licensing »
- California Immunization Registry (CAIR) Protocol »
- Health Education Materials »
Clinical Laboratory Improvement Amendment (CLIA) Regulations
CDPH Radiological Inspection and Safety Regulations
Preventive Health Care and Detection of Asymptomatic Diseases
Health Education Services for Plan Members
General Policy
Infection Control Procedures
- Antiseptic Hand Cleaners »
- Waste Disposal Containers »
- Protocol for Isolating Infectious Patients »
- EPA Registered Antimicrobial Products Against TB, HIV, and Hep B »
- EPA Registered Tuberculocide Products »
- Reportable Diseases and Conditions »
OSHA Bloodborne Pathogens Standard & Waste Management Act Compliance
- Personal Protective Equipment for Standard Precautions »
- Needlestick Safety Precautions »
- Protocol for Sharps Incidents »
- Blanket policy on OSHA Bloodborne Patho Standards and Waste Management Act »
Surface Decontamination to Cal-OSHA Standards
Reusable Medical Instrument Sterilization