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.
IEHP Addendum Tools
Facility Site Review
Facility Site Review Audit Tool Sections
- Checklist for Safe Vaccine Storage and Handling (PDF)
- Clean and Dirty Sign (PDF)
- Controlled Substance Distribution Log (PDF)
- Controlled Substance Narcotic Log (PDF)
- Monthly Expiration Date & Verification Log (PDF)
- P&P Distribution of Sample Medications (PDF)
- Patient Distribution Log for Samples (PDF)
- Plan for Vaccine Protection in Case of Power Outage (PDF)
- Radiology - Notice to Employees (PDF)
- Sample Radiology Inspection Report (PDF)
- Vaccine Information Sheet (VIS) Protocol (PDF)
- Vaccine Storage (PDF)
- AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF)
- Autoclave Log (PDF)
- Biohazardous Sign (PDF)
- Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF)
- Cleaning Schedule (PDF)
- Communicable Disease (ISOLATION) Protocol (PDF)
- Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF)
- Instrument Transportation Log (PDF)
- Isolation & Transmissions Based Precautions (PDF)
- OSHA Employee Injury Report Form (PDF)
- P&P Autoclave (PDF)
- P&P Autoclaving Instruments in Peel (PDF)
- P&P Chemical Disinfection (PDF)
- P&P Cold Sterilization (PDF)
- P&P Transport for Reusable Instruments (PDF)
- Reusable Sharps Container (PDF)
- Safety Needle Fact Sheet (PDF)
- Sharps Injury Log Sample (PDF)
- Transfer Stations and Treatment Facilities (PDF)
- Access Standards (PDF)
- After Hour Script (PDF)
- CLAS Standards (PDF)
- Confidentiality Form (PDF)
- Fax Sheet (PDF)
- Medical Emergency, Earthquake, Fire Protocols (PDF)
- Medical Record Release (PDF)
- Office Hours Sample Form (PDF)
- On-Call Provider Schedule (PDF)
- PCP Referral Tracking Log (PDF)
- Referral Process (PDF)
- Sample Office Hours (PDF)
- Standards of Interpreter Services_Provider Process (PDF)
- Wait Time Survey Tool (PDF)
- Accessibility Obligations of Medical Practices (PDF)
- Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF)
- Confidentiality Form (PDF)
- Domestic Violence (PDF)
- Electronic Resources for Required Employee Training (PDF)
- Employee File Checklist (PDF)
- IEHP Cultural and Linguistics Training (PDF)
- IEHP Evidence of Staff Training (PDF)
- IEHP Grievance Resolution Process - English (PDF)
- IEHP Grievance Resolution Process - Spanish (PDF)
- IEHP P&P Child Abuse Reporting (PDF)
- IEHP P&P Elder or Adult Abuse Reporting (PDF)
- IEHP P&P Sensitive Services-Access Standards (PDF)
- Medical Assistant Letter of Competency - Fillable (PDF)
- Medical Assistant Venipuncture Form (PDF)
- Medication Administration Procedures (PDF)
- Mid-level Supervision of Medical Assistant (PDF)
- Notice to Consumer PA Sign - English (PDF)
- Notice to Consumer PA Sign - Spanish (PDF)
- Notice to Consumer - MD English (PDF)
- Notice to Consumer - MD Spanish (PDF)
- Physician Associate Practice Agreement (PDF)
- SB697 Practice Agreement (PDF)
- SB697 Practice Agreement FAQ (PDF)
- SOC 341 (PDF)
- Standardized Procedures for Nurse Practitioner (PDF)
- Suspected Child Abuse Report (PDF)
Medical Record Review
Medical Record Review Audit Tool Sections
- ACES Screening (PDF)
- Adult Health History (PDF)
- Adult Sterilization & Special Consent P&P (PDF)
- Alcohol Resources (PDF)
- AUDIT-C (PDF)
- Brief Addiction Monitor (BAM) (PDF)
- Comprehensive Health Assessment Forms (PDF)
- CRAFFT - 2.0 Clinician Interview (PDF)
- CRAFFT - 2.1N English (PDF)
- CRAFFT - 2.1N Spanish (PDF)
- AD8 Dementia Screening Interview (PDF)
- Hepatitis Risk Assessment Tool (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF)
- Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF)
- PHQ-2 - Sample (PDF)
- PHQ-9 - Sample (PDF)
- Social Needs Screening Tool (PDF)
- Standardized English Mini-Cog (PDF)
- Spanish Mini-Cog (PDF)
- TB Risk Assessment Adult (PDF)
- AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF)
- AAP Schedule (PDF)
- AAP Supplemental Information (PDF)
- Alcohol Resources (PDF)
- AUDIT-C (PDF)
- Blood Lead Family List of Sources – English/Chinese (PDF)
- Blood Lead Family List of Sources – English/Vietnamese (PDF)
- Blood Lead Testing Instructions – English/Chinese (PDF)
- Blood Lead Testing Record – English/Chinese (PDF)
- Blood Lead Testing Record – English/Vietnamese (PDF)
- Brief Addiction Monitor (BAM) (PDF)
- CDC BMI Growth Chart - Boys (PDF)
- CDC BMI Growth Chart - Girls (PDF)
- CDC Growth Chart Head Circumference - Boys (PDF)
- CDC Growth Chart Head Circumference - Girls (PDF)
- CDC Growth Chart Weight for Age - Boys (PDF)
- CDC Growth Chart Weight for Age - Girls (PDF)
- Child Health History - English (PDF)
- Child Health History - Spanish (PDF)
- Comprehensive Health Assessment Forms (PDF)
- CRAFFT - 2.0 Clinician Interview (PDF)
- CRAFFT - 2.1N English (PDF)
- CRAFFT - 2.1N Spanish (PDF)
- Edinburgh Postnatal Depression Scale (EPDS) (PDF)
- General Consent to Treat Minor (PDF)
- Getting Your Child Tested for Lead – Brochure (PDF)
- Getting Your Child Tested for Lead – Testing Instructions and Record (PDF)
- Hepatitis Risk Assessment Tool (PDF)
- Intimate Partner Violence (IPV) Screening Tools (PDF)
- Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF)
- Oral Health Risk Assessment Tool (PDF)
- PEARLS Assessment (PDF)
- PEARLS Teen Self-Assessment (PDF)
- PHQ-2 - Sample (PDF)
- PHQ-A - Sample (PDF)
- Social Needs Screening Tool (PDF)
- Sudden Cardiac Arrest Screening Form (PDF)
- Suicide Screening Tool (PDF)
- TB Risk Assessment Pediatrics (PDF)
- What Do You Eat (8-19 years) - English (PDF)
- What Do You Eat (8-19 years) - Spanish (PDF)
- What Does Your Child Eat (Birth - 8 years) - English (PDF)
- What Does Your Child Eat (Birth - 8 years) - Spanish (PDF)
- Youth Nutrition and Activity Assessment (8 - 19 years) (PDF)