Facility Site Review (FSR) and Medical Record Review (MRR) DHCS Resources

Clinic Policies for Primary Care Provider Settings

Instructions:

All participating provider(s) sites are required to establish safety, member rights and general policies and procedures for their practice. Please review all sample policies and procedures in our educational packet and customize any or all of the policies and their respective attachments you wish to adopt based on your clinic’s practice and processes. Please complete the Approval date, Approved by, Effective Date, and Revision date for each of the adopted policies. All providers and staff shall receive trainings/in-services on all clinic policies and procedures. Annual trainings/in-services are required for Blood-Borne Pathogens Exposure Control, Biohazardous Waste Management, and Infection Control/Standard/Universal Precautions. All clinic policies and evidence of training shall be kept on site or made available upon request.

FSR Provider Training 2022 — Video

If you have any questions or need help, please contact the Delegation Oversight Coordinator(s), Clinical
afrias@scanhealthplan.com
sgonzalez2@scanhealthplan.com
m.hernandez@scanhealthplan.com

Facility Site Review Table of Contents

Description
FSR and MRR Preparation Checklist & Clinical Policies Requirement
CRITICAL ELEMENTS
Critical Element Summary
Site Access/Safety Criteria
Emergency Exit Route
Evacuation Routes Diagram
Facility Site Resource List

Fire Safety and Non-Medical Emergency
Fire Safety and Non-Medical Emergency – Education
Fire Safety and Non-Medical Emergency - Policy and Procedures
Employee Alarm System

Medical Emergency
• Emergency - Policy and Procedure
• Emergency Protocol and Contact List
• Emergency Medication Dosages - Management of Anaphylaxis, Opioid Overdose, Chest Pain, Asthma, and Hypoglycemia
Medical Lab Equipment - Policy and Procedures
Facility Resource List
Personnel
Personnel
Notice to Patients (On-site licensed MD only)
Notice to Consumers (On-site licensed PA only)
Identifications: Name Tags
Staff Qualifications - Policy and Procedures
Unlicensed Staff - Policy and Procedures (On-site Medical Assistant)
Medical Assistant Training Verification
Non-Physician Medical Practitioners - Policy and Procedures (On-site NP and/or PA)
NP Standardized Procedure (Example)
PA Practice Agreement Requirement
PA Practice Agreement (Example)
Staff Training/ Orientation/ Continuing Education
Staff Training - Policy and Procedures
• Fire safety and prevention 
Emergency non-medical procedures
Medical Emergency Equipment
Infection Control/Universal Precaution (Annual Training)
    • Infection Control/Universal Precaution - Education
    • Infection Control/Universal Precaution - Communicable Disease Protocol
    • Infection Control/Universal Precaution - Cleaning and Decontamination Policy and Procedure
    • Infection Control/Universal Precaution - Cleaning Log
    • Infection Control/Universal Precaution - Policy and Procedures
• Blood Borne Pathogen/Exposure Control Plan (Annual Training)
    • Blood Borne Pathogen/Exposure Control Plan - Education
    • Blood Borne Pathogen/Exposure Control Plan - Sharps Injury Log 
    • Blood Borne Pathogen and Biohazard Waste - Policy and Procedures
Biohazard Waste (Annual Training)
    • Biohazard Waste – Education
    • Biohazard Waste - Medical Waste Tracking Log
Confidentiality
     • Confidentiality - Education
     • Confidentiality Agreement
     • Confidentiality - Policy and Procedures
Informed Consent
    • Informed Consent -Education
    • Informed Consent - Policy and Procedures
    • General Consent to Treat Agreement
Sensitive Services
    • Sensitive Services - Policy and Procedures
Prior Authorization/Referral Process/Procedures/Resources
    • Prior Authorization/Referral - Policy and Procedures
    • Prior Authorization/Referral Log
• Member Grievance 
    • Member Grievance - Policy and Procedures
    • Policy Member Grievance Form
• Adult/Child Abuse & Domestic Violence Reporting
     • Abuse and Violence Reporting - Education
     • Abuse and Violence Reporting - Mandated Reporter Acknowledgment
     • Child Abuse Reporting - Policy and Procedures 
     • Domestic Violence Reporting - Policy and Procedures
     • Elderly Violence Reporting - Policy and Procedures
• Cultural and Linguistics
     • Cultural and Linguistics – Education
     • Cultural and Linguistics - SCAN Interpretation Service Hotline
     • Cultural and Linguistics - Interpretation Service Refusal Form
     • Cultural and Linguistics - Policy and Procedures
• Disability Rights and Provider Obligations
     • Disability Rights and Provider Obligations - Education
     • Disability Rights and Provider Obligations - Policy and Procedures 
Office Management
Office Management
    • Access to 24/7 Care Policy and Procedures
    • Triage Policy and Procedures
    • Patient Appointment Policy and Procedures
Medication/Clinical Services
Pharmaceuticals
    • Pharmaceuticals Policy and Procedures
    • Drug Administration Rights (Basic)
    • Pharmaceuticals Controlled Substance Log
    • Pharmaceuticals Emergency Power Outage Policy and Procedures
    • Pharmaceuticals Refrigerator/Freezer Do Not Unplug Signage
    • Pharmaceuticals/Emergency Kit/Lab Supply Monthly Service Log
Pharmaceuticals Vaccine
    • Pharmaceuticals Vaccine Storage - Education
    • Pharmaceuticals Vaccine Storage - Temperature Logs
    • https://www.youtube.com/watch?v=hvGt45qCCZ8
    • https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf
    • Pharmaceuticals Vaccine Information Sheet and CAIR - Education
    • Pharmaceuticals Vaccine Information Sheet - Policy and Procedures
Lab Services
    • CLIA - Education
    • Lab Services Policy and Procedures
Radiology Policy and Procedures 
Preventive Services
Preventive Services
    • Preventive Services Policy and Procedures
    • Health Education Policy and Procedures
    • Vision Exam Requirements
Infection Control
Cold Sterilization
    • Cold Sterilization Education
    • Levels of Cold Chemical Use - Education (Sterilization and Disinfection)
Autoclave
    • Autoclave Education
    • Autoclave Run Log
    • Autoclave Maintenance Log
Cold Sterilization and Autoclave - Policy and Procedures

 

Medical Records Review Table of Contents

Format/Coordination of Care
Medical Record Policy and Procedure
Medical Record Signature Sheet
Notice of Privacy Information and Form 
Documentation
General Consent Form
Informed Consent Form
Advance Health Care Directive
    • Advance Health Care Directive Policy and Procedures
    • Advance Health Care Directive Education
    • Advance Health Care Directive Form 1
    • Advance Health Care Directive Form 2
Preventive Care
Comprehensive Health Assessment
    • Pediatric Preventive Health Care Recommendation (Bright Futures/American Academy of Pediatrics)
    • Pediatric Comprehensive Assessment (ages 0-20)
    • Adult Preventive Health Care Schedule – USPSTF
    • Adult Comprehensive Assessment (ages 21-49)
    • Geriatric Comprehensive Assessment (50+)
    • Mini-Cog Tool
Preventive Care Screening
    • CRAFFT - Alcohol, Drugs, Tobacco Screening Tool
    • NIDA - nmassist - Alcohol, Drugs, Tobacco Screening Tool
    • TAPS Tool Parts I and II V2 - Alcohol, Drugs, Tobacco Screening Tool
    • Hepatitis Risk Assessment Tool
    • PHQ2 - Depression Screening Tool
    • PHQ9 - Depression Screening Tool
    • Sexually Transmitted Infection Screening Tool
    • Preventive Care - TB Screening Tool
    • Immunization Schedule (0-18yrs)
    • Immunization Schedule (Adults)
    • VIS
    • https://www.immunize.org/vis/

 

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