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Facility Site Review

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
    (does not apply to HSP)

Attention: The following information applies to Cal MediConnect physicians. Please disregard the above reference, “Physicians (does not apply to Cal MediConnect).”

Prior to enrolling Medi-Cal and Cal MediConnect beneficiaries with a primary care physician (PCP), the Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS) require Health Net to perform a facility site review (FSR) as part of the initial credentialing process. Re-audits are conducted at least every three years as part of the recredentialing process. DHCS reviews the results of Health Net's site reviews and may also audit a random sample of provider offices to ensure they meet DHCS standards.

In an effort to decrease duplicative FSRs and minimize the disruption of member care at provider offices, Health Net and all other managed care health plans are required to collaborate in conducting FSRs. On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a PCP and administering a corrective action plan (CAP) when necessary. The responsible plan shares the audit results and CAP with the other participating health plans.

Scope of the Review

Health Net conducts office site reviews and inspections using the same criteria and inspection checklist used by the DHCS Medi-Cal Managed Care Division. Refer to these DHCS samples:

Refer to definition of facility site review for more information.

Reference and Training Materials

Health Net offers the following reference and training materials to help PCPs and their office staff prepare for office site visits:

Section 1 – Access/Safety

1. Site Accessibility by Individuals with Physical Disabilities (PDF)

2. Clean and Sanitary Environment (PDF)

2a. Office Cleaning Schedule (PDF)

2b. Office Cleaning Log/Schedule Year (PDF)

3. Fire Safety and Prevention and Emergency Non-Medical Procedures (PDF)

3a. Workplace Violence Protocol (PDF)

3b. Emergency Earthquake Plan (PDF)

3c. Emergency Fire Plan (PDF)

3d. Sample Site Evacuation Plan (PDF)

4. Medical and Lab Equipment Maintenance (PDF)

5. Emergency Health Care Services (PDF)

5a. Emergency Medication Dosage Chart (PDF)

5b. Emergency Protocol (PDF)

5c. Monthly Equipment and Medication Replacement Log (PDF)

5d. Emergency Supplies Inventory Checklist (PDF)

5e. Monthly Medication and Lab Supplies Inventory Checklist (PDF)

Section 2 – Personnel

6. Staff Qualifications (PDF)

6a. Medical Board of California Notice to Consumers (PDF)

6b. Disability Rights and Provider Obligations (PDF)

7. Non-Physician Medical Practitioners (PDF)

7a. Delegation of Services Agreement Supervision of Physician Assistants (PDF)

7b. Notice to Consumers Physician Assistants Licensure (PDF)

7c. Standardized Procedures Requirements for Nurse Practitioners Practice (PDF)

8. Unlicensed Personnel (PDF)

8a. Medical Assistant Training Letter (PDF)

8b. Medical Assistant Certification (PDF)

8c. Medical Assistant Venipuncture Certification (PDF)

9. Personnel and Staff Training (PDF)

9a. Staff Education Checklist (PDF)

10. Child Abuse Reporting (PDF)

10a. Suspected Child Abuse Report (PDF)

11. Elder Abuse Reporting (PDF)

11a. Report of Suspected Dependent Adult/Elder Abuse Form and General Instructions (PDF)

12. Domestic Violence Reporting (PDF)

12a. Suspicious Injury Report Form (PDF)

13. Informed Consent and Human Sterilization Consent (PDF)

14. Minor’s Rights to Sensitive Services (PDF)

15. Prior Authorizations/Referrals (PDF)

15a. Referral Tracking Log (PDF)

15b. Prior Authorization Requirements List - Medi-Cal (PDF)

15b. Prior Authorization Requirements List - Cal MediConnect (PDF)

Section 3 – Office Management and Medical Records

16. Member Grievances/Complaints (PDF)

16a. Member Complaint Log (PDF)

16b. Member Grievance/Complaint-English (PDF)

16b. Member Grievance/Complaint-English-CalViva Health (PDF)

16c. Member Grievance/Complaint – Hmong (PDF)

16c. Member Grievance/Complaint – Hmong – CalViva Health (PDF)

16d. Member Grievance/Complaint Form – Russian (PDF)

16e. Member Grievance/Complaint Form – Arabic (PDF)

16f. Member Grievance/Complaint Form – Armenian (PDF)

16g. Member Grievance/Complaint Form – Farsi (PDF)

16h. Member Grievance/Complaint Form – Hindi (PDF)

16i. Member Grievance/Complaint Form – Japanese (PDF)

16j. Member Grievance/Complaint Form – Khmer (PDF)

16k. Member Grievance/Complaint Form – Korean (PDF)

16l. Member Grievance/Complaint Form – Laotian (PDF)

16m. Member Grievance/Complaint Form – Panjabi (PDF)

16n. Member Grievance/Complaint Form – Spanish (PDF)

16n. Member Grievance/Complaint Form – Spanish – CalViva Health (PDF)

16o. Member Grievance/Complaint Form – Tagalog (PDF)

16p. Member Grievance/Complaint Form – Thai (PDF)

16q. Member Grievance/Complaint Form – Chinese (PDF)

16r. Member Grievance/Complaint Form – Vietnamese (PDF)

17. Interpreter Services (PDF)

17a. Free Interpreter Services (PDF)

17a. Free Interpreter Services – CalViva Health (PDF)

17a. Free Interpreter Services – Cal MediConnect (PDF)

17b. Health Plan Interpreter Phone Numbers (PDF)

17c. Primary Language Assessment Labels (PDF)

17d. Interpreters Available Poster-Medi-Cal (PDF)

17d. Interpreters Available Poster-Cal MediConnect (PDF)

17d. Interpreters Available Poster-CalViva Health (PDF)

17e. Language Assistance Program and Cultural Competency Services (PDF)

17e. Language Assistance Program and Cultural Competency Services-Cal MediConnect (PDF)

17f. Interpreter Quality Standards Guidance and Requirements (PDF)

17g. Language Proficiency Assessment Resources (PDF)

18. Medical Records (PDF)

18a. Staff Signature Page Form for Member Medical Records (PDF)

18b. Pediatric Periodicity Schedule (PDF)

18c. Adult Health Maintenance (PDF)

18d. Adult Immunization Schedule (PDF)

18e. Adult Vaccine Administration Record (PDF)

18f. Adult Health Maintenance Checklist (PDF)

18g. Pediatric Health Maintenance Checklist (PDF) 

18h. Medical Record Documentation - Cal MediConnect (PDF)

18i. Advance Health Care Directives Info Sheet for English/Spanish (PDF)

18j. Advance Directive Labels for Member Medical Record (PDF)

18k. Skin Cancer Screening Form (PDF)

19. Provision of Services 24 Hours a Day (PDF)

19a. Timely Access to Office Requirements (PDF)

19a. Timely Access to Office Requirements-CalViva Health (PDF)

19a. Timely Access to Office Requirements-Cal MediConnect (PDF)

20. Appointments and Patient Recall (PDF)

21. Staying Healthy Assessment Policy (PDF)

21a. Staying Health Assessment Forms (PDF)

22. Triage (PDF)

Section 4 – Clinical Services

23. Laboratory Services (PDF)

24. Pharmaceutical Services (PDF)

24a. Refrigerator Temperature Log for Vaccines (Fahrenheit) (PDF)

24b. Refrigerator Temperature Log for Vaccines (Celsius) (PDF)

24c. Freezer Temperature Log for Vaccines (Fahrenheit) (PDF)

24d. Freezer Temperature Log for Vaccines (Celsius) (PDF)

24e. CDC - Questions about Multi-dose Vials (PDF)

24f. Controlled Substance Log Form (PDF)

25. Radiology Services (PDF)

25a. Standards for Protection against Radiation (PDF)

25b. Dexa Scanner (PDF)

25c. Radiologic Health Branch Contact Info (PDF)

Section 5 – Preventive Services

26. Preventive Services: Screening and Equipment (PDF)

26a. Audiometer Form (PDF)

26b. Hearing and Vision Graph (PDF)

27. Provider Order Form - Health Education Materials (PDF)

27. Provider Order Form - Health Education Materials - CalViva Health (PDF)

Section 6 – Infection Control

28. Bloodborne Pathogens and Waste Management (PDF)

28a. Blood and Body Fluid Exposure Report Form (PDF)

28b. Sharps Injury Log (PDF)

28c. Spill Kit Information (PDF)

28d. Medical Waste Log Sheet (PDF)

28e. Medical Waste Collection Tracking Log (PDF)

29. Decontamination of Surfaces (PDF)

29a. Understanding Bleach (PDF)

29b. Clorox Regular Bleach (PDF)

29c. Ultra Clorox Germicidal Bleach (PDF)

29d. FDA Cleared Sterilants and High Level Disinfection

30. Standard and Universal Precautions (PDF)

31. Instrument Sterilization (PDF)

31a. Autoclave Maintenance and Run Log (PDF)

31b. Equipment Transfer Log for Sterilization (PDF)

Section 7 – Miscellaneous Reference Documents

32a. Health Net Provider Library-Medi-Cal (PDF)

32a. Health Net Provider Library-CalViva Health (PDF)

32a. Health Net Provider Library-Cal MediConnect (PDF)

32b. Fluoride Varnish (PDF)

32c. Member Rights & Responsibilities (PDF)

32c. Member Rights & Responsibilities - Cal MediConnect (PDF)

32d. TB Risk Assessment-English/Spanish (PDF)

32e. Standard of Care Guidelines for Childhood Lead Screening (PDF)

32f. Consent to Treatment of Minor (PDF)

32g. Autism Spectrum Disorder Services (PDF)

32h. Breast Cancer Screening Tip Sheet (PDF)

33a. Edinburgh Perinatal/Postnatal Depression Scale (EPDS) Questionnaire (PDF)

33b Bright Futures Promoting Oral Health (PDF)

33c. Oral Health Risk Assessment Tool (PDF)

33d. Supervising PA PAC Document (PDF)

33e. Women’s Folic Acid (PDF)

33f. Improve Diabetes Management (PDF)

33f. Improve Diabetes Management - CalViva Health (PDF)

33g. Improve Postpartum Care (PDF)

33g. Improve Postpartum Care - CalViva Health (PDF)

33h. Adverse Childhood Experiences (PDF)

33h. Adverse Childhood Experiences - CalViva Health (PDF)

33i. Childhood Immunizations (PDF)

33i. Childhood Immunizations - CalViva Health (PDF)

33j. Achieve Health Equity Through Culturally Competent Care for BIPOC Patients (PDF)

33j. Achieve Health Equity Through Culturally Competent Care for BIPOC Patients - CalViva Health (PDF)

33k. How to Provide Culturally Competent Care for Patients with Disabilities (PDF)

33k. How to Provide Culturally Competent Care for Patients with Disabilities - CalViva Health (PDF)

33l. Improve Quality and Inclusive Care for LGBTQ+ Patients (PDF)

33l. Improve Quality and Inclusive Care for LGBTQ+ Patients - CalViva Health (PDF)

Section 8 – Preventive Care Physical Exam Forms

Infants

1 – 2 months (PDF)

3 – 4 months (PDF)

5 – 6 months (PDF)

7 – 9 months (PDF)

10 – 11 months (PDF)

Under 1 month (PDF)

Toddlers

12 – 15 months (PDF)

16 – 23 months (PDF)

Children

2 years (PDF)

2 ½ years (30 months) (PDF)

3 years (PDF)

4 – 5 years (PDF)

6 – 8 years (PDF)

9 – 12 years (PDF)

Teens

13 – 16 years (PDF)

17 – 20 years (PDF)

Adults

21 – 39 years female (PDF)

21 – 39 years male (PDF)

40 – 49 years female (PDF)

40 – 49 years male (PDF)

50+ years female (PDF)

50+ years male (PDF)

Section 9 – Vaccine Storage

Checklist for Safe Vaccine Storage and Handling (PDF)

Emergency Response Worksheet (PDF)

Access other resources that are also included in the provider library under Topics located in the left navigation bar. Search under Education, Training and Other Materials to support better health outcomes or find provider notices under Updates and Letters.

Immunizations, vaccines and CPSP risk assessment tools

Health Net’s FSR Compliance Department promotes:

  • Immunization services that meet the DHCS requirements. Refer to Administration of Immunizations for more resources.
  • Tools for the Comprehensive Perinatal Services Program (CPSP) risk assessment from the California Department of Public Health. Refer to maternity benefits for coverage about comprehensive risk assessment and individualized care plan.
Last Updated: 06/17/2022