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
          Physical Accessibility Review Policy
         *New: 2019 Updated Site Review Guidelines
         *New: 2019 Updated Site Review Survey Scoring Sheet
         *New: 2019 Updated Medical Record Review Guidelines
         *New:  2019 Updated Medical Record Review Survey Scoring Sheet

    IV. Advance Care Planning:

         Advance Healthcare Directive

         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)
        A1. Medical Assistant Sample Letter
    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)
        H1. Additional Emergency Numbers Information for Monterey and
              Santa Cruz Counties
        H2. Valley Crisis Center
        H3. Valley Crisis Flyers
        H4. Adult & Child protective services numbers
    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. Minor's Rights Statement and Documentation of Self-Sufficient Minor Status

3. Office Management

    A. Telephone Triage Policy
    B. Telephone Advice Guidelines
    C. Timely Access to Care - Appointments and Scheduling Policy
    D. Missed Appointment and Patient Recall Policy
        D1. Missed Appointment Sample Letter
    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
    O. Member Access to Self-Referred Services

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
        A1. Adult Preventive Care Policy
        A2. Adult Immunization Schedule
    B. Summary of Recommendations for Adult Immunizations
    C. Adult Immunization Wallet Card
    D. Adult Vaccination Record Sheet
    E. Childhood Preventive Care
        E1. Childhood Preventive Care Policy
        E2. 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. Protect Yourself from Influenza Handout
    M. IZ Resource Reference Card
    N. VIS information and instructions
    O. VIS sheets for Flu
        O1. VIS Patient Info Sheet Inactivated - English
        O2. 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
        R1. Boys 2-20 yrs
        R2. Girls 2-20 yrs

6. Infection Control

    A. Infection Control Policy
    B. Bloodborne Pathogens Training Program
        B1. Training Packet
        B2. 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 Medical Chart Check List
    D. Signature Page (Form)
    E. Initial Health Assessment Policy
    F. Informed Consent
        F1. Sterilization Consent Protocol
        F2. Consent Form - PM330
    G. Staying Healthy Assessments
        G1. SHA Information Page
        G2. SHA Questionnaires

Age Range Language
0-6 months English
7-12 months English
1-2 years English
3-4 years English
5-8 years English
9-11 years English
12-17 English
Adult English
Senior English

    H. Advance Health Care Directive
        H1. English
        H2. Spanish
    I. Advance Directive Offered (Medical Record form)
        I1. English
        I2. Spanish
    J. WIC Program Guidelines

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