Central California  Alliance For Health


Facility Site Review Binder

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    I.   Welcome Letter to Provider

    II.  Facility Site Review Process

    III. Scoring sheets and guidelines:
          Site Review Guidelines
          Site Review Survey Scoring Sheet
          Medical Record Review Guidelines
          Medical Record Review Survey Scoring Sheet
          Site Review Update Summary

    IV.  Physicians Orders for Life Sustaining Treatment (POLST)

Facility Site Review Policies and Procedures

1. Access and Safety

    A. Earthquake and Fire Emergency Office Procedures
    B. OSHA Fire Extinguisher Technique
    C. Emergency Equipment Requirements
    D. Airway Management

2. Personnel

    A. Medical Assistant - Training & Scope of Practice Policy (Form)
    B. Nurse Midwife Policy
    C. Non-Physician Medical Practitioner Policy
    D. Personnel Orientation/Training Checklist
    E. Domestic/Elder/Child Abuse Reporting Guide (Form)
    F. Suspected Child Abuse - Form
    G. Suspected Elder or Dependent Adult Abuse - Form
    H. Emergency Numbers Domestic Violence (Santa Cruz)
    I. National Sexual Assault Online Hotline
    J. Additional Abuse & Violence Resources
    K. Complaint Form - MediCal Fraud and Elder Abuse
    L. Grievance/Complaint Guidelines
    N. Member's Rights - English, Spanish & Hmong
    O. Confidentiality Statement (Form)
    P. A Patient's Guide To HIPAA
    Q. Member Access to Self-Referred Services Policy
    R. Minor's Rights Statement and Documentation of Self-Sufficient Minor Status

3. Office Management

    A. Telephone Triage Policy
    B. Telephone Advice Guidelines
    C. Accessibility - Appointments and Scheduling Policy
    D. Missed Appointment and Patient Recall Policy
    E. After Hours Availability Policy
    F. Interpreter Services Policy
    G. 12 Tips to Working with an Interpreter
    H. Alliance Key Contact Numbers
    I. Requirements for Referral of Members to Specialty Providers
    J. Referral Consultation Request Process Policy
    K. Referral Consultation Request Sample Form
    L. Instructions for Referral Consultation Request Form
    M. Authorization Process for Referrals to Out of Service Area Providers Policy
    N. Authorization Request Sample Form

4. Clinical Services

    A. Pharmaceuticals Storage, Handling and Dispensing Guidelines
    B. Drug Expiration Log (Form)
    C. Master DEA List (Form)
    D. Controlled Drug Inventory (Form)
    E. Refrigerator/Freezer Log (Form)

5. Preventive Services

    A. Adult Preventive Care
       1. Adult Preventive Care Policy
       2. Adult Immunization Schedule
    B. Summary of Recommendations for Adult Immunizations
    C. Adult Immunization Wallet Card
    D. Adult Vaccination Record Sheet
    E. Childhood Preventive Care
       1. Childhood Preventive Care Policy
       2. AAP Periodicity
    F. Alliance Well Child Schedule
    G. Summary of Recommendations of Child Immunizations
    H. Child/Teen Vaccination Record Sheet
    I. Vaccines for Children Information
    J. Vaccine Code List - MediCal
    K. PPSV Vaccine Pocket Guide
    L. Flu Vaccine Pocket Guide
    M. IZ Resource Reference Card
    N. VIS information and instructions
    O. VIS sheets for Flu
       1. VIS Patient Info Sheet Inactivated - English
       2. VIS Patient Info Sheet Live Intranasal - English
    P. Dental Work for Medi-Cal Members Policy
    Q. Using the PM160 to Document BMI Percentile
    R. BMI Growth Charts
       1. Boys 2-20 yrs
       2. Girls 2-20 yrs

6. Infection Control

    A. Infection Control Policy
    B. Bloodborne Pathogens Training Program
       1. Training Packet
       2. Answer Key
    C. Biohazardous Waste Disposal Guidelines
    D. Autoclave and Cold Sterilization Guidelines
    E. Autoclave Run Log (Form)
    F. Spore Testing for Autoclaves Procedure
    G. Sharps Injury Log (Form)
    H. Sharps Disposal

7. Medical Records

    A. Medical Records Policy
    B. Common Medical Record Deficiencies
    C. Pre-Review Chart Survey Check List
    D. Signature Page (Form)
    E. Initial Health Assessment Policy
    F. Informed Consent
       1. Sterilization Consent Protocol
       2. Consent Form - PM330
    G. Staying Healthy Assessments
       1. SHA Information Page
       2. SHA Questionnaires
    H. Advance Health Care Directive
       1. English
       2. Spanish
    I. Advance Directive Offered (Medical Record form)
       1. English
       2. Spanish
    J. WIC Program Guidelines

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