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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
 Cultural and Linguistic Services
 ICE Bilingual Assessment Tool
 Members Rights and Responsibilities Poster (English)
 Members Rights and Responsibilities Poster (Spanish)
 Mandatory Annual Staff Training Completion Form
 Staff Language Capabilities Form
 Health Education Print Materials List
 Member Grievance Form (English)
 Member Grievance Form (Spanish)

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
 Medical Waste Tracking Log
 Monthly Medication Check Log
 Monthly Medication Verification and Equipment Log
 Referral Log
 Refrigerator Temperature Log
 Freezer Temperature Log
 Sharps Injury Log

Medical Records - Frequently Needed Forms


 Adult Body Mass Index Table
 Adult Preventive Care Flow Sheet
 Advance Healthcare Directive Information
 Adult TB Risk Assessment
 Pediatric TB Risk Assessment
 Authorization to Release Healthcare Information
 Medication List
 Pediatric Initial History Questionnaire
 Pediatric Preventive Healthcare Recommendations
 Percentile Growth Chart - Boys
 Percentile Growth Chart - Girls
 Primary Language Spoken by Member Form (English & Spanish)
 Problem List
 Registration Form (English & Spanish)
 Recommended Immunizations for Adults (English)
 Recommended Immunizations for Adults (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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