Skip to Main Content

Facility Site Review

Provider Type

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

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

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)

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

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

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

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

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

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)

27. Provider Order Form - Health Education Materials - Cal MediConnect (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 

32c. Member Rights & Responsibilities - Cal MediConnect

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)

Section 8 – Preventive Care Physical Exam Forms


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.

Health Net and all other Medi-Cal and Cal MediConnect managed care health plans are required to collaborate in conducting facility site reviews (FSRs). On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a primary care physician (PCP) site. Copies of the FSR and related regulatory requirements are available online at

Representatives from the responsible plan contact the provider office prior to the FSR to discuss audit policies and procedures. A packet containing documentation materials is sent prior to the office site review to enable the provider office to prepare for the site visit. Preliminary office site review findings are communicated at the time of the review. In addition, written results are sent to the provider by the responsible health plan. The Health Net State Health Programs Quality Improvement Department (Cal MediConnect, Medi-Cal) is responsible for conducting collaborative review process for Health Net.

An FSR is conducted as part of the contracting process for new providers. New providers must receive a passing score of at least 80 percent prior to being admitted into the plan's provider network. Facility site review audit results are shared among Medi-Cal and Cal MediConnect managed care plans. Sites receiving a non-passing score on any audit from one plan are considered to have a non-passing score by all other Medi-Cal and Cal MediConnect managed care plans. A medical record review (MRR) is also conducted on new provider offices three to six months following inclusion in the network and assignment of members. The minimum passing score for the MRR is also 80 percent. Like the FSR results, MRR results are also shared and handled uniformly among participating plans.

Cap Submission and Implementation

Providers must correct deficiencies in critical elements within 10 business days following the date of the review. Providers scoring 90 percent or greater on the facility site review are not required to submit a corrective action plan (CAP) unless deficiencies are found in critical elements, including pharmaceutical services or infection control. Providers scoring 89 percent or less are required to submit a CAP (refer to CAP Submission and Implementation topic above for more information). CAPs must be submitted to the plan administering the review within 45 calendar days from the date of the review.

Providers may be re-reviewed in 12 months or sooner, if deemed appropriate to assess compliance with the CAP. New members are not assigned to a PCP who receives a non-passing score until corrections are verified and the CAP is closed.

After the initial audit, participating providers are re-audited at least every three years. A full-scope site audit, which includes both the FSR and MRR, is conducted at this time. Providers must receive a passing score of at least 80 percent on both reviews. Sites receiving a non-passing score from one plan are considered to have a non-passing score by all other Medi-Cal and Cal MediConnect managed care plans. New members are not assigned to a PCP who receives a non-passing score until corrections are verified and the CAP is closed. Providers who do not comply with the CAP within the established time frames are removed from the network.

Practitioners who do not comply with a CAP or fail to meet threshold scores on a FSR or MRR are forwarded to Health Net's Credentialing Committee for administrative termination. The termination is applicable to the Medi-Cal and Cal MediConnect contracting lines of business and practice locations and remains in effect for three years from the date of the committee's final decision. The provider must undergo an initial site review at the time of reapplication.

The affected practitioner is afforded rights to an informal appeal (reconsideration) of the committee's decision to administratively terminate. The reconsideration must be administered in accordance with Health Net's Medi-Cal Termination Appeals Process Policy & Procedure.

Provider sites that score below 80 percent in either the FSR or MRR for two consecutive reviews must score a minimum of 80 percent during the next site review in both the FSR and MRR, including sites with open CAPs in place. Sites that do not score a minimum of 80 percent in the FSR and MRR, despite ongoing monitoring, are removed from the network and members are appropriately reassigned to other providers. Health Net must notify affected members in writing 30 calendar days in advance of any provider terminations. 

Health Net re-audits the provider within 12 months if the provider scores below 80 percent on FSR or MRR on a full scope audit.

For more information, select any subject below:

Last Updated: 09/15/2021