Thank you for your participation in the IEHP Network and partnering with us to offer our members the highest quality care and service they need. Facility Site Reviews are the required standards by the California Department of Health Care Services (DHCS)/Medi-Cal Managed Care Division (MMCD) for all primary care provider (PCP) sites. Below you will find various resources in regards to DHCS information, Physical Accessibility Reviews (PARS), Facility Site Review (FSR), and Medical Record Reviews (MRR) as well as IEHP’s addendum tools for your reference.
Department of Health Care Services (DHCS)
- 2024 Facility Site Review Standards (FSR) (PDF) Download 2024 Facility Site Review Standards (FSR) (PDF)
- 2024 Facility Site Review Tool (FSR) (PDF) Download 2024 Facility Site Review Tool (FSR) (PDF)
- 2024 Medical Record Review Standards (MRR) (PDF) Download 2024 Medical Record Review Standards (MRR) (PDF)
- 2024 Medical Record Review Tool (MRR) (PDF) Download 2024 Medical Record Review Tool (MRR) (PDF)
- APL 22-017 - Facility Site Review and Medical Record Review (PDF) Download APL 22-017 - Facility Site Review and Medical Record Review (PDF)
- APL 18-016 - Health Education (PDF) Download APL 18-016 - Health Education (PDF)
- APL 15-023 - Physical Accessibility Review (PDF) Download APL 15-023 - Physical Accessibility Review (PDF)
- PL 12-006 - Revised FSR Tool (PDF) Download PL 12-006 - Revised FSR Tool (PDF)
IEHP Addendum Tools
- Att 06 - 2024 IEHP Urgent Care Evaluation Tool (PDF) Download Att 06 - 2024 IEHP Urgent Care Evaluation Tool (PDF)
- IEHP Interim Review (PDF) Download IEHP Interim Review (PDF)
PARS
- APL with PARS C (PDF) Download APL with PARS C (PDF)
- APL with PARS D & CBAS (PDF) Download APL with PARS D & CBAS (PDF)
- PAR-FSR-C_PARS - Survey (PDF) Download PAR-FSR-C_PARS - Survey (PDF)
- PAR-FSR-D_PARS - Ancillary (PDF) Download PAR-FSR-D_PARS - Ancillary (PDF)
- PAR-FSR-E_PARS - CBAS (PDF) Download PAR-FSR-E_PARS - CBAS (PDF)
Facility Site Review
Facility Site Review Audit Tool Sections
References
- Emergency Exit Routes Fact Sheet (PDF) Download Emergency Exit Routes Fact Sheet (PDF)
- Sample Evacuation Routes (PDF) Download Sample Evacuation Routes (PDF)
- Sample Oxygen Tank Set (PDF) Download Sample Oxygen Tank Set (PDF)
- Sample of Sizes of Ambu-Bags Download Sample of Sizes of Ambu-Bags
- Workplace Violence OSHA (PDF) Download Workplace Violence OSHA (PDF)
Sample Forms
- Glucometer Log (PDF) Download Glucometer Log (PDF)
- Hemocue Log (PDF) Download Hemocue Log (PDF)
- Medical, Non-Medical Emergency Protocols (PDF) Download Medical, Non-Medical Emergency Protocols (PDF)
- Pre-filled Emergency Medications Dosage Chart (PDF) Download Pre-filled Emergency Medications Dosage Chart (PDF)
References
- Checklist for Safe Vaccine Storage and Handling (PDF) Download Checklist for Safe Vaccine Storage and Handling (PDF)
- P&P Distribution of Sample Medications (PDF) Download P&P Distribution of Sample Medications (PDF)
- Plan for Vaccine Protection in Case of Power Outage (PDF) Download Plan for Vaccine Protection in Case of Power Outage (PDF)
- Radiology Inspection Report Sample (PDF) Download Radiology Inspection Report Sample (PDF)
- Radiology - Notice to Employees (PDF) Download Radiology - Notice to Employees (PDF)
- Vaccine Storage (PDF) Download Vaccine Storage (PDF)
- Vaccine Information Sheet (VIS) Protocol (PDF) Download Vaccine Information Sheet (VIS) Protocol (PDF)
Sample Forms
- Clean and Dirty Sign (PDF) Download Clean and Dirty Sign (PDF)
- Controlled Substance Distribution Log (PDF) Download Controlled Substance Distribution Log (PDF)
- Monthly Expiration Date & Verification Log (PDF) Download Monthly Expiration Date & Verification Log (PDF)
- Patient Distribution Log for Samples (PDF) Download Patient Distribution Log for Samples (PDF)
- Refrigerator Temperature Log (PDF) Download Refrigerator Temperature Log (PDF)
References
- AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Download AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF)
- Communicable Disease (ISOLATION) Protocol (PDF) Download Communicable Disease (ISOLATION) Protocol (PDF)
- Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF) Download Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF)
- Isolation & Transmissions Based Precautions (PDF) Download Isolation & Transmissions Based Precautions (PDF)
- P&P Autoclave (PDF) Download P&P Autoclave (PDF)
- P&P Autoclaving Instruments in Peel (PDF) Download P&P Autoclaving Instruments in Peel (PDF)
- P&P Chemical Disinfection (PDF) Download P&P Chemical Disinfection (PDF)
- P&P Spore Testing Download P&P Spore Testing
- P&P Transport for Reusable Instruments (PDF) Download P&P Transport for Reusable Instruments (PDF)
- Medical Gowns_FDA (PDF) Download Medical Gowns_FDA (PDF)
- Medical Waste Programs (PDF) Download Medical Waste Programs (PDF)
- Safety Needle Fact Sheet (PDF) Download Safety Needle Fact Sheet (PDF)
- Transfer Stations and Treatment Facilities (PDF) Download Transfer Stations and Treatment Facilities (PDF)
Sample Forms
- Autoclave Log (PDF) Download Autoclave Log (PDF)
- Biohazardous Sign (PDF) Download Biohazardous Sign (PDF)
- Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Download Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF)
- Cleaning Schedule (PDF) Download Cleaning Schedule (PDF)
- Instrument Transportation Log (PDF) Download Instrument Transportation Log (PDF)
- OSHA Employee Injury Report Form (PDF) Download OSHA Employee Injury Report Form (PDF)
- Sharps Injury Log Sample (PDF) Download Sharps Injury Log Sample (PDF)
References
- Access Standards (PDF) Download Access Standards (PDF)
- After Hour Script (PDF) Download After Hour Script (PDF)
- CLAS Standards (PDF) Download CLAS Standards (PDF)
- Referral Process (PDF) Download Referral Process (PDF)
- Wait Time Survey Tool (PDF) Download Wait Time Survey Tool (PDF)
Sample Forms
- Confidentiality Form (PDF) Download Confidentiality Form (PDF)
- Fax Sheet (PDF) Download Fax Sheet (PDF)
- Medical, Non-Medical Emergency Protocols (PDF) Download Medical, Non-Medical Emergency Protocols (PDF)
- Letter to Members - Authorization Notification Download Letter to Members - Authorization Notification
- Letter to Specialist Follow-up Consultation Download Letter to Specialist Follow-up Consultation
- Medical Record Release (PDF) Download Medical Record Release (PDF)
- On-Call Provider Schedule and Contact Numbers (PDF) Download On-Call Provider Schedule and Contact Numbers (PDF)
- PCP Referral Tracking Log (PDF) Download PCP Referral Tracking Log (PDF)
- Standards of Interpreter Services_Provider Process (PDF) Download Standards of Interpreter Services_Provider Process (PDF)
References
- Accessibility Obligations of Medical Practices (PDF) Download Accessibility Obligations of Medical Practices (PDF)
- Domestic Violence (PDF) Download Domestic Violence (PDF)
- Online Resources for Required Employee Training (PDF) Download Online Resources for Required Employee Training (PDF)
- Employee File Checklist (PDF) Download Employee File Checklist (PDF)
- IEHP Cultural and Linguistics Training (PDF) Download IEHP Cultural and Linguistics Training (PDF)
- IEHP Grievance Resolution Process - English (PDF) Download IEHP Grievance Resolution Process - English (PDF)
- IEHP Grievance Resolution Process - Spanish (PDF) Download IEHP Grievance Resolution Process - Spanish (PDF)
- IEHP P&P Child Abuse Reporting (PDF) Download IEHP P&P Child Abuse Reporting (PDF)
- IEHP P&P Elder or Adult Abuse Reporting (PDF) Download IEHP P&P Elder or Adult Abuse Reporting (PDF)
- IEHP P&P Sensitive Services-Access Standards (PDF) Download IEHP P&P Sensitive Services-Access Standards (PDF)
- Medication Administration Procedures (PDF) Download Medication Administration Procedures (PDF)
- SB697 Practice Agreement (PDF) Download SB697 Practice Agreement (PDF)
- SB697 Practice Agreement FAQ (PDF) Download SB697 Practice Agreement FAQ (PDF)
- Standardized Procedures for Nurse Practitioner (PDF) Download Standardized Procedures for Nurse Practitioner (PDF)
Sample Forms
- Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Download Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF)
- Confidentiality Form (PDF) Download Confidentiality Form (PDF)
- IEHP Evidence of Staff Training (PDF) Download IEHP Evidence of Staff Training (PDF)
- Medical Assistant Letter of Competency - Fillable (PDF) Download Medical Assistant Letter of Competency - Fillable (PDF)
- Mid-level Supervision of Medical Assistant (PDF) Download Mid-level Supervision of Medical Assistant (PDF)
- Notice to Consumer NP Sign - English (PDF) Download Notice to Consumer NP Sign - English (PDF)
- Notice to Consumer DO Sign - English (PDF) Download Notice to Consumer DO Sign - English (PDF)
- Notice to Consumer - MD English (PDF) Download Notice to Consumer - MD English (PDF)
- Notice to Consumer PA Sign - English (PDF) Download Notice to Consumer PA Sign - English (PDF)
- Notice to Consumer PA Sign - Spanish (PDF) Download Notice to Consumer PA Sign - Spanish (PDF)
- Notice to Consumer - MD Spanish (PDF) Download Notice to Consumer - MD Spanish (PDF)
- Physician Associate Practice Agreement Sample (PDF) Download Physician Associate Practice Agreement Sample (PDF)
- SOC 341 (Adult/Elder Abuse Reporting Form) Download SOC 341 (Adult/Elder Abuse Reporting Form)
- Suspected Child Abuse Report (PDF) Download Suspected Child Abuse Report (PDF)
References
- CDC - HIV - STSH PrEP Brochure - English/Spanish (PDF) Download CDC - HIV - STSH PrEP Brochure - English/Spanish (PDF)
- Pure Tone Audiometer (PDF) Download Pure Tone Audiometer (PDF)
- Sample Eye Charts (PDF) Download Sample Eye Charts (PDF)
- Visual Acuity Screen Tips (PDF) Download Visual Acuity Screen Tips (PDF)
- IEHP Facility Resource Contacts (PDF) Download IEHP Facility Resource Contacts (PDF)
Medical Record Review
Medical Record Review Audit Tool Sections
References
- Adult Sterilization & Special Consent P&P (PDF) Download Adult Sterilization & Special Consent P&P (PDF)
- Alcohol Resources (PDF) Download Alcohol Resources (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF) Download Intimate Partner Violence (IPV) Screening Tools (PDF)
- Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) Download Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF)
- PHQ & GAD Instructions (PDF) Download PHQ & GAD Instructions (PDF)
- Hypertension Guidelines (PDF) Download Hypertension Guidelines (PDF)
- Referral to Treatment Brief Intervention AUDIT_DAST (PDF) Download Referral to Treatment Brief Intervention AUDIT_DAST (PDF)
- SBIRT Care (PDF) Download SBIRT Care (PDF)
Sample Forms
- ACES Screening (PDF) Download ACES Screening (PDF)
- Adult Health History (PDF) Download Adult Health History (PDF)
- AUDIT-C (PDF) Download AUDIT-C (PDF)
- Brief Addiction Monitor (BAM) (PDF) Download Brief Addiction Monitor (BAM) (PDF)
- Comprehensive Adult Health Assessment and Tools (PDF) Download Comprehensive Adult Health Assessment and Tools (PDF)
- Comprehensive Health Assessment Forms (PDF) Download Comprehensive Health Assessment Forms (PDF)
- CRAFFT - 2.0 Clinician Interview (PDF) Download CRAFFT - 2.0 Clinician Interview (PDF)
- AD8 Dementia Screening Interview (PDF) Download AD8 Dementia Screening Interview (PDF)
- Cudit-R-Screening (Cannabis Use Disorder) (PDF) Download Cudit-R-Screening (Cannabis Use Disorder) (PDF)
- DAST - 10 Download DAST - 10
- DAST - 10 - Spanish Download DAST - 10 - Spanish
- DAST 20 - Drug Use Questionnaire Download DAST 20 - Drug Use Questionnaire
- GPCOG - English (PDF) Download GPCOG - English (PDF)
- Hepatitis Risk Assessment Tool (PDF) Download Hepatitis Risk Assessment Tool (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF) Download Intimate Partner Violence (IPV) Screening Tools (PDF)
- Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) Download Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF)
- PHQ-2 - Sample (PDF) Download PHQ-2 - Sample (PDF)
- PHQ-9 - Sample (PDF) Download PHQ-9 - Sample (PDF)
- PRAPARE - English (PDF) Download PRAPARE - English (PDF)
- PRAPARE - Spanish (PDF) Download PRAPARE - Spanish (PDF)
- Social Needs Screening Tool (PDF) Download Social Needs Screening Tool (PDF)
- Social Needs Screening Tool - Spanish (PDF) Download Social Needs Screening Tool - Spanish (PDF)
- Standardized English Mini-Cog (PDF) Download Standardized English Mini-Cog (PDF)
- Spanish Mini-Cog (PDF) Download Spanish Mini-Cog (PDF)
- STD-HIV Risk Screening Tool (PDF) Download STD-HIV Risk Screening Tool (PDF)
- TAPS Tool - English (PDF) Download TAPS Tool - English (PDF)
- TAPS Tool - Spanish (PDF) Download TAPS Tool - Spanish (PDF)
- TB Risk Assessment Adult (PDF) Download TB Risk Assessment Adult (PDF)
Sample Forms
- Adult Progress Note - Sample (PDF) Download Adult Progress Note - Sample (PDF)
- Letter to Members - Authorization Notification (PDF) Download Letter to Members - Authorization Notification (PDF)
- Letter to Specialist Follow-up Consultation Report (PDF) Download Letter to Specialist Follow-up Consultation Report (PDF)
- Missed Appointment Log - Sample (PDF) Download Missed Appointment Log - Sample (PDF)
- Pediatric Progress Note - Sample (PDF) Download Pediatric Progress Note - Sample (PDF)
Sample Forms
- Adult General Consent to Treat (PDF) Download Adult General Consent to Treat (PDF)
- Advance Health Care Directive Acknowledgement Form (PDF) Download Advance Health Care Directive Acknowledgement Form (PDF)
- CAIR Sharing Request (PDF) Download CAIR Sharing Request (PDF)
- General Consent to Treat Minor (PDF) Download General Consent to Treat Minor (PDF)
- Medical Record Release Form (PDF) Download Medical Record Release Form (PDF)
- Sample Medication List (PDF) Download Sample Medication List (PDF)
- Signature Page - IEHP (PDF) Download Signature Page - IEHP (PDF)
Sample Forms
- Acknowledgment of Receipt of Notice of Privacy Practice (PDF) Download Acknowledgment of Receipt of Notice of Privacy Practice (PDF)
- Notice of Privacy Practices Sample (PDF) Download Notice of Privacy Practices Sample (PDF)
References
- Referral to Treatment Brief Intervention AUDIT_DAST (PDF) Download Referral to Treatment Brief Intervention AUDIT_DAST (PDF)
- Required Documentation Checklist for OB (PDF) Download Required Documentation Checklist for OB (PDF)
Sample Forms
- CPSP Initial and Trimester Assessment and Care Plan (PDF) Download CPSP Initial and Trimester Assessment and Care Plan (PDF)
- CPSP Postpartum Assessment and Care Plan (PDF) Download CPSP Postpartum Assessment and Care Plan (PDF)
- Edinburgh Postnatal Depression Scale (EPDS) (PDF) Download Edinburgh Postnatal Depression Scale (EPDS) (PDF)
References
- AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Download AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF)
- AAP Schedule (PDF) Download AAP Schedule (PDF)
- AAP Supplemental Information (PDF) Download AAP Supplemental Information (PDF)
- Alcohol Resources (PDF) Download Alcohol Resources (PDF)
- ASQ - Similarities and Differences (PDF) Download ASQ - Similarities and Differences (PDF)
- Blood Lead Levels in Children - English (PDF) Download Blood Lead Levels in Children - English (PDF)
- Blood Lead Family List of Sources – English/Chinese (PDF) Download Blood Lead Family List of Sources – English/Chinese (PDF)
- Blood Lead Family List of Sources – English/Vietnamese (PDF) Download Blood Lead Family List of Sources – English/Vietnamese (PDF)
- Blood Lead Testing Instructions – English/Chinese (PDF) Download Blood Lead Testing Instructions – English/Chinese (PDF)
- Blood Lead Testing Record – English/Chinese (PDF) Download Blood Lead Testing Record – English/Chinese (PDF)
- Blood Lead Testing Record – English/Vietnamese (PDF) Download Blood Lead Testing Record – English/Vietnamese (PDF)
- Getting Your Child Tested for Lead – Brochure (PDF) Download Getting Your Child Tested for Lead – Brochure (PDF)
- Getting Your Child Tested for Lead – Testing Instructions and Record (PDF) Download Getting Your Child Tested for Lead – Testing Instructions and Record (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF) Download Intimate Partner Violence (IPV) Screening Tools (PDF)
- Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) Download Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF)
- PHQ & GAD Instructions (PDF) Download PHQ & GAD Instructions (PDF)
- Referral to Treatment Brief Intervention AUDIT_DAST (PDF) Download Referral to Treatment Brief Intervention AUDIT_DAST (PDF)
- SBIRT Care (PDF) Download SBIRT Care (PDF)
Sample Forms
- ASQ - Similarities and Differences (PDF) Download ASQ - Similarities and Differences (PDF)
- AUDIT-C (PDF) Download AUDIT-C (PDF)
- Brief Addiction Monitor (BAM) (PDF) Download Brief Addiction Monitor (BAM) (PDF)
- CDC BMI Growth Chart - Boys (PDF) Download CDC BMI Growth Chart - Boys (PDF)
- CDC BMI Growth Chart - Girls (PDF) Download CDC BMI Growth Chart - Girls (PDF)
- CDC Growth Chart Head Circumference - Boys (PDF) Download CDC Growth Chart Head Circumference - Boys (PDF)
- CDC Growth Chart Head Circumference - Girls (PDF) Download CDC Growth Chart Head Circumference - Girls (PDF)
- CDC Growth Chart Weight for Age - Boys (PDF) Download CDC Growth Chart Weight for Age - Boys (PDF)
- CDC Growth Chart Weight for Age - Girls (PDF) Download CDC Growth Chart Weight for Age - Girls (PDF)
- Child Health History - English (PDF) Download Child Health History - English (PDF)
- Child Health History - Spanish (PDF) Download Child Health History - Spanish (PDF)
- Comprehensive Health Assessment Forms by Age (PDF) Download Comprehensive Health Assessment Forms by Age (PDF)
- Comprehensive Pediatric Health Assessment and Tools (PDF) Download Comprehensive Pediatric Health Assessment and Tools (PDF)
- CRAFFT - Clinician Interview (PDF) Download CRAFFT - Clinician Interview (PDF)
- CRAFFT - English (PDF) Download CRAFFT - English (PDF)
- CRAFFT - Spanish (PDF) Download CRAFFT - Spanish (PDF)
- CUDIT- R Screening (Cannabis Use Disorder) (PDF) Download CUDIT- R Screening (Cannabis Use Disorder) (PDF)
- DAST - 10 (PDF) Download DAST - 10 (PDF)
- DAST - 10 - Spanish (PDF) Download DAST - 10 - Spanish (PDF)
- DAST 20 - Drug Use Questionnaire (PDF) Download DAST 20 - Drug Use Questionnaire (PDF)
- Edinburgh Postnatal Depression Scale (EPDS) (PDF) Download Edinburgh Postnatal Depression Scale (EPDS) (PDF)
- General Consent to Treat Minor (PDF) Download General Consent to Treat Minor (PDF)
- Getting your Child Tested for Lead - Testing Instructions and Record (PDF) Download Getting your Child Tested for Lead - Testing Instructions and Record (PDF)
- Hepatitis Risk Assessment Tool (PDF) Download Hepatitis Risk Assessment Tool (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF) Download Intimate Partner Violence (IPV) Screening Tools (PDF)
- Oral Health Risk Assessment Tool (PDF) Download Oral Health Risk Assessment Tool (PDF)
- PEARLS Assessment (PDF) Download PEARLS Assessment (PDF)
- PEARLS Teen Self-Assessment (PDF) Download PEARLS Teen Self-Assessment (PDF)
- PHQ-2 - Sample (PDF) Download PHQ-2 - Sample (PDF)
- PHQ-A - Sample (PDF) Download PHQ-A - Sample (PDF)
- Social Needs Screening Tool (PDF) Download Social Needs Screening Tool (PDF)
- Social Needs Screening Tool - Spanish (PDF) Download Social Needs Screening Tool - Spanish (PDF)
- STD-HIV Risk Screening Tool (PDF) Download STD-HIV Risk Screening Tool (PDF)
- Sudden Cardiac Arrest Screening Form (PDF) Download Sudden Cardiac Arrest Screening Form (PDF)
- Suicide Screening Tool (PDF) Download Suicide Screening Tool (PDF)
- TAPS Tool - English (PDF) Download TAPS Tool - English (PDF)
- TAPS Tool - Spanish (PDF) Download TAPS Tool - Spanish (PDF)
- TB Risk Assessment Pediatrics (PDF) Download TB Risk Assessment Pediatrics (PDF)
- What Do You Eat (8-19 years) - English (PDF) Download What Do You Eat (8-19 years) - English (PDF)
- What Do You Eat (8-19 years) - Spanish (PDF) Download What Do You Eat (8-19 years) - Spanish (PDF)
- What Does Your Child Eat (Birth - 8 years) - English (PDF) Download What Does Your Child Eat (Birth - 8 years) - English (PDF)
- What Does Your Child Eat (Birth - 8 years) - Spanish (PDF) Download What Does Your Child Eat (Birth - 8 years) - Spanish (PDF)
- Youth Nutrition and Activity Assessment (8 - 19 years) (PDF) Download Youth Nutrition and Activity Assessment (8 - 19 years) (PDF)
- Online Resources for Medical Record Review (PDF) Download Online Resources for Medical Record Review (PDF)