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:
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
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