Facility Site Reviews ▸ Resources
Facility Site Review | Medical Record Review Survey Library | Physical Accessibility Survey | Other 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.
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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 »
- 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
Health Care Personnel Licensing and Certifications
- Professional Licenses and Certifications »
- Notice of Provider Licensing »
- Personnel Identification Badges »
- Provider Notice to Consumer »
Personnel Qualifications and Training
- Medication Retrieval, Preparation, and Administration »
- 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) »
- Standardized Procedures Agreement (NP & CNM) – Resource Guide Template »
- Physician Assistant Delegation of Services Agreement »
- Physician Assistant Delegation of Services Agreement – Resource Guide Template »
- Physician Assistant Delegation of Services Agreement with Sample »
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 »
Additional Access/Safety Resources
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 Handeling 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 and Universal Precautions »
- Blanket policy on OSHA Bloodborne Patho Standards and Waste Management Act »
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
- Equipment Routine Cleaning and Decontamination »
- Instrument/Equipment Sterilization Protocol »
- Instrument/Equipment Sterilization Protocol Written Schedule »
Reusable Medical Instrument Sterilization
- Instrument/Equipment Sterilization Protocol »
- Sterility of Equipment »
- Sterilization Process Management of Positive Mechanical/Chemical/Biological Indicators »
- Cleaning Reusable Instruments/Equipment Prior to Sterilization »
- Cold Chemical Sterilant Spill Protocol »
- Autoclave Log »
- Cold Chemical Sterilization Solution Log »
- Cold Sterilization Log »