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 and Inspection »
- Evidence of an Employee Alarm System »
- Medical Emergency Response Protocol »
- Emergency Phone Number Contacts »
- Family Violence Resources – SF 2019 »
- Maintenance of All Medical Equipment »
Emergency Health Care Services: 24/7 Availability and Accessibility
- Emergency Medical Management Supply Log Dosage Chart Mock Drill »
- Oxygen Tank Monitoring and Maintenance »
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 »
Non-Physician Medical Practitioners (NPMP) Scope of Practice
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: Sensitive Services/Minors’ Rights »
- Personnel Training: Cultural and Linguistics »
- Cultural and Linguistic Services Training »
- Personnel Training: Infection Control Universal Precautions »
- Personnel Training: Disability Rights and Provider Obligations »
Physician Coverage is Available 24/7
Sufficient Health Care Personnel
Health Care Services are Readily Available
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 »
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
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 and Sharps Injury Protocol »
- Blanket policy on OSHA Bloodborne Patho Standards and Waste Management Act »
Surface Decontamination to Cal-OSHA Standards
Reusable Medical Instrument Sterilization