Facility Site Review

Facility Site Reviews are the application of prescribed standards by the California Department of Health Care Services (DHCS) for all primary care provider (PCP) sites who wish to participate in the Medi-Cal Managed Care Program. Per the California Code of Regulations 22 CCR § 56230 and the DHCS All Plan Letter 22-017, all participating PCPs are required to 1) complete an initial facility site review and subsequent periodic full scope reviews and 2) complete corrective action plans (CAPs) within the DHCS-specified timeline for cited deficiencies. Full scope reviews are comprised of a completed DHCS facility site review (FSR), medical record review (MRR) and the Physical Accessibility Review Survey (PARS).

All network PCP sites receive:

  • An Initial Facility Site Review (FSR) which is part of the credentialing process.
  • New PCP sites must pass their Initial FSR and correct any noted deficiencies before being added to the Molina Medi-Cal network and receiving Molina member assignments.
  • An Initial MRR is conducted approximately 3-6 months following the first member assignment.
  • A Periodic Full Scope FSR and MRR are conducted every 36 months.  If a site fails either the FSR or MRR audit, then site will undergo an annual full scope review.
  • An Interim Monitoring Review is conducted every 18-months via an attestation form.
  • Focused Reviews may be conducted as needed.
 
Facility Site Review (FSR) Audit

FSRs are conducted to ensure that all contracted primary care provider (PCP) sites have sufficient capacity to provide appropriate primary health care services and can maintain patient safety standards and practices. The FSR also confirms the PCP site operates in compliance with all local, state, and federal laws and regulations. FSRs are conducted by DHCS-Certified Nurse Reviewers.

 
Facility Site Review (FSR) Audit Resources
Bleach Comparison Chart

Clinic Policies for Primary Care Provider Settings
Cleaning Log
Confidentiality Form
Controlled Substance Distribution Log
Drug Inventory List
Emergency Earthquake Plan
Emergency Fire Plan
Emergency Kit Inventory Log Sample
Emergency Medication Dosage Chart
Emergency Phone List
Facility Site Review Standards
Facility Site Review Tools
Facility Site Review Worksheet
Grievance Log
Informed Consent
Instrument Sterilization Log
Instrument Sterilization Presentation
MD DO Midlevel Agreement to Supervise MA
Medical Assistant Letter of Competency
Medical Waste Log Sheet
Medical Waste Log for Clinics in Medical Buildings
Monthly Expiration Date Log
Notice To Consumers for DO, MD, PA NP
NP Standardized Procedures Sample
Outside Housekeeping Cleaning Schedule
PA Practice Agreement Sample
Policies and Procedures Checklist
Policies and Procedures Checklist Signature Page
Referral Tracking Log Blank
Referral Tracking Log Sample
Sharps Injury Log by Year
Site Evacuation Plan
Staff Training Checklist
Suspicious Injury Report Instructions
Where Is VIS Date Located Info Sheet
Workplace Violence Protocol

 

 

Medical Record Review (MRR) Audit

MRRs are conducted to review medical records for format, legal protocols and documented evidence of the provision of preventive care and coordination and continuity of care services. The medical record provides legal proof that the patient received care. MRRs are conducted by DHCS-Certified Nurse Reviewers.

 

Medical Record Review (MRR) Audit Resources

Medical Record Review Audit Standards
Medical Record Review Audit Tool 
Comprehensive Health Assessment Forms
Comprehensive Health Assessment Progress Note

 

Screening Tools

 

Physical Accessibility Review Survey Audit

PARS is a physical evaluation of a healthcare facility (“site”) that provides care to Medi-Cal members who are seniors and/or persons with disabilities (SPDs). These sites are Primary Care Provider sites, Community Based Adult Services sites, High Volume Specialist sites, or other Ancillary sites (as appropriate). PARS are conducted by DHCS Certified Auditors and other designated staff.

The onsite evaluation includes six areas: Parking; Exterior Building; Interior Building; Restroom; Exam Room; and Exam Table/Scale. The review establishes if the facility has Basic Access or Limited Access for members with disabilities.

PARS Standards and Tool and APL 12-006

Medi-Cal Managed Care Letters

Medi-Cal Managed Care communicates with Medi-Cal managed care plans (MCPs) by means of All Plan and Policy Letters.

All Plan Letters (APLs) are the means by which Medi-Cal Managed Care conveys information or interpretation of changes in policy or procedure at the Federal or State levels, and provides instruction to contractors, if applicable on how to implement these changes on an operational basis.

Policy Letters (PLs) provide guidance to MCPs about changes in Federal or State law and Regulation that affect the way in which they operate or deliver services to Medi-Cal beneficiaries.

Below are APLs and PLs that pertain to the Facility site review process and/or DHCS standards for FSR/MRR/PARS audit.

FSR/MRR/PARS audit APLs and PLs