Quality Facility Site Review Resources

Section 1 - Facility Site Review Overview

• DHCS Policy Letter
• Provider Overview Letter

Section 2 - Facility Site Review Forms

• Authorization to Release Healthcare Information (DHCS Form)
• Autoclave Logs
• Controlled Drug Inventory
• Emergency Contact List
• Emergency Drug/Medication Inventory Log
• Emergency Earthquake Plan
• Emergency Fire Plan
• Emergency Supplies Inventory Checklist
• Expired Drug Log
• Facility Site Review Self-Assessment
• Glucometer Quality Control Log
• Health Education Programs
  
• Language Assistance Program Requirements
  
• Medical Emergency Protocol
• Monthly Medication Verification Log and Equipment Log
• Notice to Consumers
• Office Cleaning Schedule
• Office Staff Signature Page
• Patient Grievance Log
• Referral Log
• Refrigerator and Freezer Temperature Log
• Sharps Injury Logs
• Site Evacuation Plan Sample
• Staff Education Checklist
• UnitedHealthcare Health Education Order Form
• Use and Maintenance of Medical Equipment
• Work Violence Protocol

Section 3 - Medical Record Review Forms

• Adult Preventive Care Flow Sheet
• Blood Lead Screening of Young Children
  
• Bright Futures Pediatric Periodicity Schedule
• CDC Adult BMI Resources
• CDC Adult Immunization Schedule (19+ Years of Age)
• CDC Children and Adolescent BMI Tables
• CDC Growth Charts
• CDC Pediatric Immunization Schedule (0-18 Years of Age)
• County of San Diego Behavioral Health Resources
  
• DHCS Stay Health Assessment Resources and Forms
• Industry Collaboration Effort Interpreter Quality Standards Guidance
  
• Industry Collaboration Effort Language Proficiency Assessment Resources
• Medical Record Review Self-Assessment Checklist
  
• Patient Chronic Diagnosis/Problem List
• Patient Language and Linguistic Information Form
• Patient Medication List Log
• Patient Registration Form
• Tuberculosis Risk Assessment
• WIC Fact Sheet 

Section 4 - Physical Accessibility Review Survey Regulations

• DHCS PL 12-006 

If you need additional resources or have questions, please email the California Community Plan Quality Department at UHCCSCAQualityDepartment_DL@ds.uhc.com.