Site Review

​​​​​​​​New 2022 PCP/OB FSR and MRR Tool effective 07/01/2022

The Department of Health Care Services (DHCS) has updated the Facility Site Review (FSR) and Medical Record Review (MRR) criteria that PHC Nurse Reviewers use as the tools to conduct audits.

Criteria updates will be implemented on July 1st, 2022.

The updates are based on recommendations from national experts in prevention and evidence-based medicine and align with local, state, and federal guidelines to ensure the provision of preventive services are in accordance with:

      • American Academy of Pediatrics, Bright Futures;
      • US Preventive Services Task Force, Grade A and B recommendations;
      • American College of Obstetricians and Gynecologist/Comprehensive Perinatal Services Program; and
      • Advisory Committee on Immunization Practices

In order to assist you in preparing for these changes, PHC is providing the new DHCS Tools and Standards along with flyers that summarize the changes. Please see the links below.

Please review the documents in their entirety with your staff. This is your opportunity to modify existing policies and create new procedures as needed.

The DHCS and PHC understand that the implementation of the 2022 criteria will impact providers. We ask that you proactively assess your Electronic Medical Record or paper chart templates to ensure that your staff is documenting patient charts appropriately. If you have questions regarding the criteria the rationale for each is provided in the FSR and MRR Standards.

For additional questions or to schedule a training please contact us at fsr@partnershiphp.org.

You can also contact Tegan 530-999-6828 or Tami 530-999-6813.

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Site Review Tools

Click on the links below for the tools.

New PCP/OB Review Tools and Standards (Family Practice, Pediatrics, Internal Medicine) Effective 07/01/20222

OB Specialist Offices

Palliate Care Facilities

Wellness & Recovery Review

Site Review

Contracted sites are reviewed as a condition of participation in our provider network.

A site review is conducted during the initial contracting process. The site review consists of the Facility Site Review and Medical Record Review.  In addition, a Physical Accessibility Review Survey (PARS) is also conducted at the time of the site review.

Site reviews are conducted on a variety of practice types including PCP, OB/GYN, Non-Accredited, Private Duty Nursing, Palliative Care and Substance Use Disorder providers.

Periodic site reviews will be conducted up to every three years to assure each practice site continues to meet the standards set forth by local, state, and federal regulations. A Certified Site Review nurse, using the California Department of Health Care Services (DHCS) approved review tools, conducts the review.


What is a Facility Site Review (FSR)?

A Facility Site Review is an assessment of the facility's physical site including the building, accessibility, equipment, and policies/procedures for all contracted sites at the time of initial contracting and up to every three years thereafter. This assessment is conducted by a registered nurse, who is a DHCS-certified site reviewer. The site review tool is used to determine compliance with the standards set by the DHCS.

      • Accessibility/Safety
      • Personnel
      • Office Management
      • Clinical Services
      • Preventative Services
      • Infection Control

What is a Medical Record Review (MRR)?

A MRR is a review of randomly selected medical records of members assigned to a practice site. This type of review is conducted, three to six months after an initial Facility Site Review has been completed, and is repeated up to every three years thereafter. The DHCS approved tool and guidelines are used by the Certified Site Review Nurse. The site can operate as usual during the review.

      • Format
      • Documentation
      • Continuity of Care
      • Pediatric Preventive Care
      • Adult Preventive Care
      • OB/CPSP Preventive Care (if applicable)

What is a Physical Accessibility Review Survey (PARS)?

A PARS is an assessment of how well members who are seniors or persons with disabilities can navigate a practice site. This includes PCPs, High Volume Ancillary and Specialty Provider (HVASP) sites, and Community Based Adult Services (CBAS). Sites are assigned a designation of basic or limited accessibility based on the review findings. Sites may also be designated as having medical equipment if their site meets criteria. PHC's provider directory is updated regularly for member's to see which facilities meet their accessibility needs.

For more information, see the PARS FAQs below.


What is an OB Facility Site Review (OBT)?

A Facility Site Review at an OB specialist office is similar to that of a PCP office with just a few different questions specific to this type of office. The Medical Record Review tool used is the same as that for PCP offices. OB Facility Site Reviews are conducted on a periodic basis up to every three years by a Certified Site Review Nurse.


What is a Palliative Care Facility Site Review (PAL)?

A PAL Facility Site Review is an assessment of the staff’s health care certifications, and the facility’s collaboration with the Palliative Care Quality Network (PCQN). All contracted Palliative Care sites are reviewed at the time of initial contracting and up to every three years thereafter. This assessment is conducted by a registered nurse, who is a DHCS-certified site reviewer.

What is a Palliative Care Medical Record Review (PLM)?

A PLM Medical Record Review is a review of select medical records of members assigned to a Palliative Care site. This type of review is conducted at the same time as the Palliative Care Facility Site Review and is repeated up to every three years thereafter. Areas assessed as part of this review include documented patient care plan, advance care planning, and appropriate visit documentation.

What is a Substance Use Disorder Facility Site Review (SUD)?

A SUD Facility Site Review is an assessment of the facility's physical site including accessibility, personnel, and policies/procedures for all contracted Substance Use Disorder provider sites at the time of initial contracting and every year thereafter. This assessment is conducted by a Licensed Clinical Social Worker (LCSW). The site review tool is used to determine compliance with the standards set by the DHCS.

What is a Substance Use Disorder Medical Record Review (SUM)?

A SUM Record Review is a review of randomly selected medical records of members receiving treatment at a Substance Use Disorder practice site. This type of review is conducted, three to six months after an initial Substance Use Disorder Facility Site Review has been completed, and is repeated annually thereafter. The DHCS approved tool and guidelines are used by the Licensed Clinical Social Worker (LCSW).


What is a Non-Accredited Facility Site Review (NON)?

A Non-Accredited Facility Site Review is an assessment of the facility’s physical site including the building, accessibility, equipment, and policies/procedures for all contracted sites at the time of initial contracting and up to every three years thereafter. This assessment is conducted by a registered nurse, who is a DHCS-certified site reviewer. The site review tool is used to determine compliance with the standards set by the DHCS.


What is a Private Duty Nurse Facility Site Review (PDN)?

A PDN Facility Site Review is conducted to oversee the quality of care provided by a  Registered Nurses (RN) or Licensed Vocational Nurses (LVN) for in home medical services under the EPSDT Supplemental Services (SS) Program and Private Duty Case Management under APL 20-012. Areas assessed during this type of review include accessibility, personnel, clinical services, and infection control.


Facility Site Review FAQ

How long does a site review take?

Review times can vary depending on the type of review, the size of the facility, and the amount of providers being reviewed.

Do I need to close the office for the day?

No, the site can operate as usual during the review.

Does the physician(s) need to be present?

No, an office representative who is highly knowledgeable in the site's daily operations and policies/procedures is the only staff needed during the review. Some portions of the review require speaking with a clinical staff member.

Can I do anything to prepare for the review?

A letter from the nurse reviewer will be sent prior to the review outlining what you can do to prepare as well as the tools and guidelines the nurse reviewer uses during the review.

What if I don't pass?

On rare occasions, when providers don't receive a passing score, our nurse reviewers work with you to help you through the process so you are ready to see PHC members.

Medical Record Review FAQ

How long does the medical record review take?

Review times can vary depending on the amount of providers being reviewed and the size of the site. 

Do I need to close the office for the day?

No, during the review, the site can operate as usual.

Does the physician(s) need to be present?

No, an office representative that can provide access to the medical records and/or acquaint the reviewer with your EHR system is the only staff that is needed.

What can I do to prepare for the medical record review?

A letter from the nurse reviewer will be sent prior to the review outlining what you can do to prepare as well as the tools and guidelines the nurse reviewer uses during the review.

Is my participation mandatory?

As part of the contracting and credentialing process, all practice sites are obligated to participate in a medical record review.

What if I don't pass?

On rare occasions, when providers don't receive a passing score, our nurse reviewers work with you to help you through the process so you are ready to see PHC members.

PARS FAQ

Where can I find more information about this review?

More information is available on the DHCS website or by clicking here.

Is a mandatory correction plan required?

No, this review is for informational purposes to assist our members in selecting a provider accessible to their needs. Accessibility levels are noted in the Provider Directories.

What does Basic Accessibility mean?

Basic Accessibility means the facility demonstrates access in regards to all of the mentioned features.

What does Limited Accessibility mean?

Limited Accessibility means one or more of the features are missing or incomplete.

What areas are assessed during a PARS review?

Our provider directories are updated with the areas met by each site. The reviewer will evaluate accessibility related to the following indicators: 

= Parking 

EB = Exterior Building 

IB = Interior Building

= Restroom 

= Exam Room 

= Exam Table/Scale

ME = Medical Equipment (PCP only)

What does Medical Equipment mean?

​The Medical Equipment designation means that the practice site meets the following criteria:

    • Site has a height adjustable exam table that lowers to 17"-19" from the floor
    • Site has a wheelchair or scooter accessible weight scale


Contact Us​​ For More Information

Phone: (530) 999-6828
Fax: (530) 999-6950
Email: FSR@partnershiphp.org