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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)

Counties Covered

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

Prior to enrolling Medi-Cal and Cal MediConnect beneficiaries with a primary care physician (PCP), Health Net is required by the Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS) 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 utilizing the same criteria and inspection checklist used by the DHCS Medi-Cal Managed Care Division (samples of the Medi-Cal/Cal MediConnect Facility Site Review Tool (PDF) and Site Review Survey Guidelines (PDF) are available; refer to the Overview document in the Medical Records section for additional tools, guidelines and information on the Medi-Cal/Cal MediConnect medical Record Review Tool (PDF) and the Medi-Cal/Cal MediConnect Medical Record Review Guidelines (PDF)). The scope of the facility site review includes:

  1. adequacy of the physical plant or facility
  2. accessibility and accommodations for Seniors and Persons with Disabilities
  3. emergency plan
  4. fire and safety standards
  5. infection control procedures
  6. storage and handling of pharmaceuticals
  7. laboratory services, if any
  8. radiology services, if any
  9. office administration, including telephone access, scheduling and appointments, missed appointments, referral appointment procedures, and follow-up procedures
  10. medical records storage, administration, organization, and documentation
  11. Child Health and Disability Prevention (CHDP) program services
  12. Comprehensive Perinatal Services Program (CPSP) services
  13. preventive care for adults and children
  14. health education materials and activities
  15. interpreter services and education materials for limited-English proficient (LEP) members
  16. staff credentials
  17. staff knowledge of office protocols and procedures
  18. staff training for:
    1. bloodborne pathogens (annually)
    2. universal precautions (on new hire)
    3. domestic violence (spouse, child, elder, etc.)
    4. fire safety
    5. grievance procedures
    6. confidentiality

Refer to definition of facility site review for more information.

Deficiencies in critical elements must be corrected by the provider 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. CAPs must be submitted to the plan administering the review within 45 calendar days from the date of the review.

Health Net re-audits the provider in 12 months if the provider requires more than 120 days to complete the corrective actions specified in the CAP.

Critical Elements

Nine facility site review criteria have been classified as critical elements, indicating a higher potential for adverse effects on member health when unmet. Critical elements are worth two points when met, and all other elements are worth one point.

Sites found to be non-compliant with critical elements are required to correct the deficiencies within 10 business days of the site review date.

The nine critical elements are:

  1. Exit doors and aisles are unobstructed and egress (escape) accessible.
  2. Airway management equipment, appropriate to practice and populations served, are present on site.
  3. Only qualified and trained staff retrieve, prepare or administer medication.
  4. Office practice procedures are utilized on site that provide timely physician review and follow-up of referrals, consultation reports and diagnostic test results.
  5. Only lawfully authorized persons dispense drugs to members.
  6. Personal protective equipment (PPE) is readily available for staff use.
  7. Needle-stick safety precautions are practiced on site.
  8. Blood, other potentially infectious materials (specimens) and regulated wastes (sharps and biohazardous non-sharps) are placed in appropriate leak-proof, labeled containers for collection, processing, storage, transport, or shipping.
  9. Spore testing of autoclave steam sterilizer is completed at least monthly, with documented results.

Contaminated, deteriorated or expired medications that cannot be returned to the manufacturer must be disposed of by placing these in a sealed biohazard container and removed by a professional biohazard waste hauler. Documentation of the destruction of all scheduled medications must be in accordance with California Drug Enforcement Agency (DEA) and Occupational Safety and Health Administration (OSHA) policies.

Unopened, expired medications that may be returned to the manufacturer or wholesaler for credit should be brought to the attention of the nurse, administrator or physician in order to be returned.

The following equipment is required for all facilities serving Child Health and Disability Prevention (CHDP) program members:

  1. refrigerator maintained at 35 degrees to 45 degrees F or 2 degrees to 8 degrees C
  2. freezer maintained at 2 degrees to 7 degrees F or -14 degrees to -17 degrees C
  3. biologicals present and not expired (according to AAP guidelines):
    1. diphtheria-tetanus-pertussis (DPT)
    2. diphtheria and tetanus (DT) (under age 7)
    3. tetanus and diphtheria (Td) (adult) (over age 7)
    4. inactivated poliovirus (IPV)
    5. measles, mumps and rubella (MMR)
    6. haemophilus influenzae type b (HIB)-conjugated
    7. rotavirus (RV)
    8. pneumococcal (PCV) for children younger than age 5; age 2 for pneumococcal polysaccharide vaccine (PPSV), as indicated by the Centers for Disease Control and Prevention (CDC)
    9. hepatitis B vaccine (HBVAC)
    10. hepatitis A (Hep A)
    11. varicella
    12. meningococcal
    13. influenza
    14. tuberculosis (PPD) (Mantoux)
  4. syringes, safety syringes (engineered sharps injury prevention (ESIP*)) and tuberculin syringes
  5. needles and safety (ESIP*) needles
  6. examination table with paper
  7. stethoscope
  8. blood pressure cuff (adult, child and obese)
  9. thermometer (oral, tympanic)
  10. ophthalmoscope
  11. otoscope and ear speculum
  12. percussion hammer
  13. tongue depressors
  14. exam gown for older children
  15. covered waste containers
  16. pediatric scale
  17. length measuring device with a right angle block - pediatric
  18. tape measuring device (1/8" or 1 mm increments for head circumference)
  19. adult balance beam scale
  20. adult wall measure device with a right angle block
  21. appropriate eye chart, such as Snellen c
  22. illiterate eye chart with a 10, 20/40 line or equivalent
  23. heel line marked at 10' or 20'
  24. disposable eye occluder
  25. approved audiometer - calibrated
  26. quiet room for audiometric testing
  27. Hgb or Hct equipment - calibrated
  28. urine specimen containers
  29. urine dipstick for sugar, protein and blood

Refer to the Office Equipment and Supplies Maintenance Log (PDF) for the following:

  1. epinephrine (adrenaline) injectable
  2. Benadryl® (diphenhydramine) injectable
  3. full oxygen equipment, with secured flow meter and with attached tubing and canula
  4. airway (adult, child, and infant)
  5. Ambu bags (adult and child)
  6. posted emergency and poison center telephone numbers

*Engineered Sharps Injury Protection (ESIP) - defined as the anti-stick safety feature of a sharp that must be built into the device and effectively reduce the risk of an exposure incident.

Post the following emergency telephone numbers and information near all telephones. If these numbers and contacts are not posted, complete and distribute this form to the provider facility.

  • Name of Building:
  • Address:
  • Emergency Contacts:
    • Fire:
    • Police
    • Ambulance
  • Emergency Response Coordinator:
  • Security:
  • Facility Management:
  • Poison Control:

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 www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/PL2014/
PL14-004.pdf

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.

Providers receiving non-passing scores on an audit are required to complete a corrective action plan (CAP) (refer to CAP Submission and Implementation topic above for more information). 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. 

All medications, including syringes and needles, must be stored in a locked cabinet or medication room.

Medications for internal use are to be stored separately from medications for external use.

Controlled substances must be stored in a locked cabinet. Only licensed medical or nursing staff may be responsible for in-office dispensing and record keeping of all controlled substances. The physician has overall responsibility for dispensing and record keeping under California Drug Enforcement Agency (DEA) license.

An ongoing inventory record must be maintained for all controlled substances on hand. It is recommended that a printed log be produced that lists only those controlled substances stocked by the office or clinic.

Biologicals and other thermolabile medications must be stored in a refrigerator with the temperature maintained at 35 degrees to 46 degrees F (2 degrees to 8 degrees C). Daily checks of the refrigerator temperature must be done and the results recorded in a log.

Refer to the Centers for Disease Control and Prevention website for appropriate vaccine storage and handling information. 

Health Net offers the following reference and training materials to help primary care physicians (PCPs) and office staff prepare for office site visits:

The Health Net Facility Site Review (FSR) Compliance Department produces the template policies and the adult and pediatric documentation forms. Contact the Health Net FSR Compliance Department for more information on any of these materials. Refer to the Contacts topic for the FSR Compliance Department telephone number in each county.

For more information, select any subject below:

Last Updated: 03/30/2021