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
- Emergency Exit Routes Factsheet (PDF) Download Emergency Exit Routes Factsheet (PDF)
- Evacuation Routes (PDF) Download Evacuation Routes (PDF)
- Glucometer Log (PDF) Download Glucometer Log (PDF)
- Hemocue Log (PDF) Download Hemocue Log (PDF)
- Medical Emergency, Earthquake, Fire Protocols (PDF) Download Medical Emergency, Earthquake, Fire Protocols (PDF)
- Emergency Exit Routes Factsheet (PDF) Download Emergency Exit Routes Factsheet (PDF)
- Pre-filled Emergency Medications Dosage Chart (PDF) Download Pre-filled Emergency Medications Dosage Chart (PDF)
- Sample Oxygen Tank Set (PDF) Download Sample Oxygen Tank Set (PDF)
- Workplace Violence (PDF) Download Workplace Violence (PDF)
- Checklist for Safe Vaccine Storage and Handling (PDF) Download Checklist for Safe Vaccine Storage and Handling (PDF)
- Clean and Dirty Sign (PDF) Download Clean and Dirty Sign (PDF)
- Controlled Substance Distribution Log (PDF) Download Controlled Substance Distribution Log (PDF)
- Controlled Substance Narcotic Log (PDF) Download Controlled Substance Narcotic Log (PDF)
- Monthly Expiration Date & Verification Log (PDF) Download Monthly Expiration Date & Verification Log (PDF)
- P&P Distribution of Sample Medications (PDF) Download P&P Distribution of Sample Medications (PDF)
- Patient Distribution Log for Samples (PDF) Download Patient Distribution Log for Samples (PDF)
- Plan for Vaccine Protection in Case of Power Outage (PDF) Download Plan for Vaccine Protection in Case of Power Outage (PDF)
- Radiology - Notice to Employees (PDF) Download Radiology - Notice to Employees (PDF)
- Sample Radiology Inspection Report (PDF) Download Sample Radiology Inspection Report (PDF)
- Vaccine Information Sheet (VIS) Protocol (PDF) Download Vaccine Information Sheet (VIS) Protocol (PDF)
- Vaccine Storage (PDF) Download Vaccine Storage (PDF)
- AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Download AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF)
- 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)
- 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)
- Instrument Transportation Log (PDF) Download Instrument Transportation Log (PDF)
- Isolation & Transmissions Based Precautions (PDF) Download Isolation & Transmissions Based Precautions (PDF)
- OSHA Employee Injury Report Form (PDF) Download OSHA Employee Injury Report Form (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 Cold Sterilization (PDF) Download P&P Cold Sterilization (PDF)
- P&P Transport for Reusable Instruments (PDF) Download P&P Transport for Reusable Instruments (PDF)
- Reusable Sharps Container (PDF) Download Reusable Sharps Container (PDF)
- Safety Needle Fact Sheet (PDF) Download Safety Needle Fact Sheet (PDF)
- Sharps Injury Log Sample (PDF) Download Sharps Injury Log Sample (PDF)
- Transfer Stations and Treatment Facilities (PDF) Download Transfer Stations and Treatment Facilities (PDF)
- Access Standards (PDF) Download Access Standards (PDF)
- After Hour Script (PDF) Download After Hour Script (PDF)
- CLAS Standards (PDF) Download CLAS Standards (PDF)
- Confidentiality Form (PDF) Download Confidentiality Form (PDF)
- Fax Sheet (PDF) Download Fax Sheet (PDF)
- Medical Emergency, Earthquake, Fire Protocols (PDF) Download Medical Emergency, Earthquake, Fire Protocols (PDF)
- Medical Record Release (PDF) Download Medical Record Release (PDF)
- Office Hours Sample Form (PDF) Download Office Hours Sample Form (PDF)
- On-Call Provider Schedule (PDF) Download On-Call Provider Schedule (PDF)
- PCP Referral Tracking Log (PDF) Download PCP Referral Tracking Log (PDF)
- Referral Process (PDF) Download Referral Process (PDF)
- Sample Office Hours (PDF) Download Sample Office Hours (PDF)
- Standards of Interpreter Services_Provider Process (PDF) Download Standards of Interpreter Services_Provider Process (PDF)
- Wait Time Survey Tool (PDF) Download Wait Time Survey Tool (PDF)
- Accessibility Obligations of Medical Practices (PDF) Download Accessibility Obligations of Medical Practices (PDF)
- Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Download Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF)
- Confidentiality Form (PDF) Download Confidentiality Form (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 Evidence of Staff Training (PDF) Download IEHP Evidence of Staff 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)
- Medical Assistant Letter of Competency - Fillable (PDF) Download Medical Assistant Letter of Competency - Fillable (PDF)
- Medical Assistant Venipuncture Form (PDF) Download Medical Assistant Venipuncture Form (PDF)
- Medication Administration Procedures (PDF) Download Medication Administration Procedures (PDF)
- Mid-level Supervision of Medical Assistant (PDF) Download Mid-level Supervision of Medical Assistant (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 English (PDF) Download Notice to Consumer - MD English (PDF)
- Notice to Consumer - MD Spanish (PDF) Download Notice to Consumer - MD Spanish (PDF)
- Physician Assistant Practice Agreement Download Physician Assistant Practice Agreement
- SB697 Practice Agreement (PDF) Download SB697 Practice Agreement (PDF)
- SB697 Practice Agreement FAQ (PDF) Download SB697 Practice Agreement FAQ (PDF)
- SOC 341 (Adult/Elder Abuse Reporting form) Download SOC 341 (Adult/Elder Abuse Reporting form)
- Standardized Procedures for Nurse Practitioner (PDF) Download Standardized Procedures for Nurse Practitioner (PDF)
- Suspected Child Abuse Report (PDF) Download Suspected Child Abuse Report (PDF)
- Pure Tone Audiometer (PDF) Download Pure Tone Audiometer (PDF)
- Visual Acuity Screen Tips (PDF) Download Visual Acuity Screen Tips (PDF)
- IEHP Phone List (PDF) Download IEHP Phone List (PDF)
Medical Record Review
Medical Record Review Audit Tool Sections
- ACES Screening (PDF) Download ACES Screening (PDF)
- Adult Health History (PDF) Download Adult Health History (PDF)
- Adult Sterilization & Special Consent P&P (PDF) Download Adult Sterilization & Special Consent P&P (PDF)
- Alcohol Resources (PDF) Download Alcohol Resources (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)
- DAST - 10 Download DAST - 10
- DAST - 10 - Spanish Download DAST - 10 - Spanish
- DAST 20 - Drug Use Questionnaire Download DAST 20 - Drug Use Questionnaire
- 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)
- 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)
- 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)
- Adult Progress Note - Sample (PDF) Download Adult Progress Note - Sample (PDF)
- Missed Appointment Log - Sample (PDF) Download Missed Appointment Log - Sample (PDF)
- Pediatric Progress Note - Sample (PDF) Download Pediatric Progress Note - Sample (PDF)
- 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 (PDF) Download Medical Record Release (PDF)
- Sample Medication List (PDF) Download Sample Medication List (PDF)
- Signature Page - IEHP (PDF) Download Signature Page - IEHP (PDF)
- Acknowledgment of Receipt of Notice of Privacy Practice (PDF) Download Acknowledgment of Receipt of Notice of Privacy Practice (PDF)
- 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)
- Required Documentation Checklist for OB (PDF) Download Required Documentation Checklist for OB (PDF)
- 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)
- AUDIT-C (PDF) Download AUDIT-C (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)
- 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 (PDF) Download Comprehensive Health Assessment Forms (PDF)
- Comprehensive Pediatric Health Assessment and Tools (PDF) Download Comprehensive Pediatric Health Assessment and Tools (PDF)
- CRAFFT - 2.0 Clinician Interview (PDF) Download CRAFFT - 2.0 Clinician Interview (PDF)
- CRAFFT - 2.1N English (PDF) Download CRAFFT - 2.1N English (PDF)
- CRAFFT - 2.1N Spanish (PDF) Download CRAFFT - 2.1N Spanish (PDF)
- DAST - 10 Download DAST - 10
- DAST - 10 - Spanish Download DAST - 10 - Spanish
- DAST 20 - Drug Use Questionnaire Download DAST 20 - Drug Use Questionnaire
- 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 – 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)
- 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)
- 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)
- 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)
- Resources for Medical Record Review (PDF) Download Resources for Medical Record Review (PDF)