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Facility Site Review Resources


PDF icon Welcome Letter/Pre-Audit Checklist

Facility Site Review Forms


Please click on a form below to view a PDF printable version.
The files below are in PDF format (PDF icon)


Department of Health Care Services Review Tools and Guidelines


Facility Site Review Tool
Facility Site Review Guideline
Medical Record Review Tool
Medical Record Review Guideline
Interim Review of Critical Elements at 18 months
FSR Attachment C Physical Accessibility Tool

Facility Forms


 Cleaning P & P Form
 Members Rights and Responsibilities Poster (English)
 Members Rights and Responsibilities Poster (Spanish)
 Mandatory Annual Staff Training Completion Form
 Sensitive Services Policy
 Staff Language Capabilities Form
 Health Education Print Material Order Form
 Grievance Form (English)
 Grievance Form (Spanish)
 Grievance Information (Provider Manual)
 Confidentiality Statement

Facility Logs


 Autoclave Cleaning log
 Autoclave Load log
 Cleaning Schedule (Mandatory Initial Page)
 Emergency Drugs Inventory Log
 Emergency Pre-Calculated Dosage Chart
 Grievance Log
 HemoCue Log
 Monthly Medication Check Log
 Monthly Medication Verification and Equipment Log
 Referral Log
 Refrigerator-Freezer Temperature Log
 Sharps Injury Log

Medical Records - Frequently Needed Forms


 Adult Preventive Care Flow Sheet
 Adult TB Risk Assessment (English & Spanish)
 Adult and Peds TB Risk Assessment (English & Spanish)
 Advanced Directive Policy & Procedure
 Advanced Directive Information Sheet English
 Advanced Directive Information Sheet Spanish
 Advanced Directive Document English
 Advanced Directive Document Spanish
 Medication List
 Primary Language Spoken by Member Form (English & Spanish)
 Problem List
 Registration Form (English & Spanish)
 Signature Page
 Vision-Hearing Screening Form

If you experience any difficulties, please contact the administrator:

1(800) 526-8196 X 120118

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