Facility Site Review

Provider Type

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

Prior to enrolling Medi-Cal abeneficiaries 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 Policy & Procedure (PDF)

2. Clean and Sanitary Environment Policy & Procedure (PDF)

2a. Office Cleaning Schedule (PDF)

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

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

5. Emergency Health Care Services Policy & Procedure (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 Policy & Procedure (PDF)

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

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

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

6b. Disability Rights and Provider Obligations (PDF)

7. Non-Physician Medical Practitioners Policy & Procedure (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 Policy & Procedure (PDF)

8a. Medical Assistant Training Letter (PDF)

8b. Medical Assistant Certification (PDF)

8c. Medical Assistant Venipuncture Certification (PDF)

9. Personnel and Staff Training Policy & Procedure (PDF)

9a. Staff Education Checklist (PDF)

10. Child Abuse Reporting Policy & Procedure (PDF)

10a. Suspected Child Abuse Report (PDF)

11. Elder Abuse Reporting Policy & Procedure (PDF)

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

12. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings Policy & Procedure (PDF)

12a. Suspicious Injury Report Form (PDF)

12b. Personnel Training: Intimate Partner/Domestic Violence Reporting P&P (PDF)

12c. Hurt, Insulted, Threatened with Harm and Screamed (HITS) Domestic Violence Screening Tool (PDF)

13. Informed Consent and Human Sterilization Consent Policy & Procedure (PDF)

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

15. Prior Authorizations/Referrals Policy & Procedure (PDF)

15a. Referral Tracking Log (PDF)

Section 3 – Office Management and Medical Records

16. Member Grievances/Complaints Policy & Procedure (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 – Punjabi (PDF)

16m. Member Grievance/Complaint Form – Punjabi – CalViva Health (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 Policy & Procedure (PDF)

17a. Free Interpreter Services (PDF)

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

17b. Health Plan Interpreter Phone Numbers (PDF)

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

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

17e. Language Assistance Program and Cultural Competency Services

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

17g. Language Proficiency Assessment Resources (PDF)

18. Medical Records Policy & Procedure (PDF)

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

18b. Pediatric Periodicity Schedule (PDF)

18c. Adult Health Maintenance

18d. Adult Immunization Schedule (PDF)

18e. Adult Vaccine Administration Record (PDF)

18f. Adult Health Maintenance Checklist (PDF)

18g. Pediatric Health Maintenance Checklist (PDF) 

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

18k. Skin Cancer Screening Form (PDF)

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

19a. Timely Access to Office Requirements (PDF)

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

20. Appointments and Patient Recall Policy & Procedure (PDF)

21. Triage Policy & Procedure (PDF)

Section 4 – Clinical Services

23. Laboratory Services Policy & Procedure (PDF)

24. Pharmaceutical Services Policy & Procedure (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

24f. Controlled Substance Log Form (PDF)

24g. Sample Policy and Medication Log (PDF)

25. Radiology Services Policy & Procedure (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 Policy & Procedure (PDF)

26a. Audiometer Form (PDF)

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

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

27a. Preventive Services: Health Education Policy & Procedure (PDF)

Section 6 – Infection Control

28. Bloodborne Pathogens and Waste Management Policy & Procedure (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 Policy & Procedure (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 Policy & Procedure (PDF)

31. Instrument Sterilization (PDF)

31a. Autoclave Maintenance and Run Log (PDF)

31b. Equipment Transfer Log for Sterilization (PDF)

31c. Cold Sterilization or High Level Disinfection Log (PDF)

Section 7 – Miscellaneous Reference Documents

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

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

32b. Fluoride Varnish (PDF)

32c. Member Rights & Responsibilities

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

32h. Breast Cancer Screening Tip Sheet

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)

33m. Hepatitis Risk Assessment Tool (PDF)

33n. Suicide Risk Screening Tool (PDF)

33o. Understanding the Importance of Pediatric Cardiac Risk Assessment (PDF)

33p. Pediatric Sudden Cardiac Death Risk Assessment Form (PDF)

34. PHQ-9 modified for Adolescents (PHQ-A) (PDF)

34a. Patient Health Questionnaire-9 (PHQ-9) (PDF)

34b. Patient Health Questionnaire-9 (PHQ-9) Without Scoring (PDF)

35. Psvchosocial Assessment (PDF)

35a. Social Needs Screening Tool (PDF)

Section 8 – Preventive Care Physical Exam Forms

Medical Record Review Guidelines Inservice


1 – 2 months (PDF)

3 – 4 months (PDF)

5 – 6 months (PDF)

7 – 9 months (PDF)

10 – 11 months (PDF)

Under 1 month (PDF)


12 – 15 months (PDF)

16 – 23 months (PDF)


2 years (PDF)

2 ½ years (30 months) (PDF)

3 years (PDF)

4 – 5 years (PDF)

6 – 8 years (PDF)

9 – 12 years (PDF)


13 – 16 years (PDF)

17 – 20 years (PDF)


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.