Facility site reviews (FSR)
FSR requirements
All primary care physician (PCP) sites participating in the Medi Cal Managed Care Program are required by California Code of Regulations (22 CCR § 56230) and Department of Health Care Services (DHCS) All Plan Letter 22-017 to:
- Complete an initial FSR and subsequent periodic full scope reviews and
- Complete corrective action plans (CAPs) within DHCS specified timelines for cited deficiencies.
Full scope reviews consist of completion of the DHCS Facility Site and Medical Record Review (FSR/MRR) and the Physical Accessibility Review Survey (PARS). FSRs are conducted to ensure that all contracted PCP sites have sufficient capacity to provide appropriate primary healthcare services and can maintain patient safety standards and practices. The FSR confirms the PCP site operates in compliance with all applicable local, state, and federal laws and regulations. MRRs are conducted to review medical records for format, compliance with legal protocols, and documented evidence of the provision of preventive care and of coordination and continuity of care services. The medical record provides legal proof that the patient received care. PARS are conducted to assess the physical adequacy of provider sites serving seniors and persons with disabilities.
FSR resources
- Child Abuse Reporting Instructions & Form
- Cleaning Log
- Cleaning Schedule
- Clinic Policies for Primary Care Provider Settings
- Comprehensive Health Assessment Forms
- Competency Assessment Checklist - Well Child Screenings
- Confidentiality Agreement
- Controlled Substance Distribution Log
- Domestic Violence Abuse & Suspicious Injury Report Instructions & Form
- Drug Inventory List
- Elder/Dependent Adult Abuse Reporting Instructions & Form
- Emergency Earthquake Plan
- Emergency Fire Plan
- Emergency Kit Inventory Log
- Emergency Medication Dosage Chart
- Emergency Phone Number List & Protocol
- Employee Language Skills Self-Assessment Form
- FSR MRR Preparation Checklist
- Frequently Missed Standards Review and Attestation
- Health Education
- Informed Consent Form
- Instrument Sterilization Log
- Interim Facility Site Review
- Interpreter Services Desktop Reference
- Medical Assistant Certification
- Medical Assistant Supervision Delegation Agreement
- Medical Waste Collection Tracking Log
- Member Grievance Form (English)
- Member Grievance Form (Spanish)
- Member Grievance Form (other languages)
- Member Grievance Log (English)
- Monthly Potency Verification Log for Medications and Laboratory Supplies
- Multi-Dose Vials Guide
- Notice of Civil Rights / Nondiscrimination (for clinics with less than 15 employees) – Sample
- Notice of Civil Rights / Nondiscrimination (for clinics with 15 employees or greater) – Sample
- Notice to Consumers for MD, DO, NP and PA
- On-site Documents Checklist
- OSHA Fact Sheet - Protecting Yourself When Handling Contaminated Sharps
- PCP Modification Request Form
- PCP Site Identification Form
- Pediatric Preventive Care Screening Training Attestation
- Post Site Review Satisfaction Survey
- Quality Control Log - Glucometer
- Referral Tracking Log — Blank
- Referral Tracking Log — Sample
- Safety & Member Rights Training Sign-In Sheet – for Groups
- Safety & Member Rights Training Sign-In Sheet – for Individuals
- Sharps Injury Log
- Sharps Injury Report Form
- Signature Log
- Site Evacuation Plan
- Sterilized Packages Inspection Log
- Sterilized Package Labels
- Vaccine Administration Record for Adults
- Vaccine Administration Record for Children & Teens
- Vaccine Emergency Response Worksheet
- Depression Screening Tool (PHQ-9)
- Depression Screening Tool for Adolescents (PHQ9A)
- Developmental Disorder Screening Tools (Ages and Stages Questionnaire)
- Developmental Disorder Screening Tools (SWYC)
- Domestic Violence Abuse & Suspicious Injury Report Instructions & Form
- Elder/Dependent Adult Abuse Reporting Instructions & Form
Please explore our training videos to learn more about Facility Site and Medical Record Reviews. For additional training resources, please visit our Provider Training Academy.
Contact our team
For general inquiries concerning FSR, please reach out to the Anthem FSR shared mailbox at FSR@anthem.com.
Please reach out to our FSR team manager or clinical liaisons for more specific questions.
Angel Perlas, RN
DHCS CMT
Provider Clinical Liaison,
GBD Quality Management
Email:
Angel.Perlas@anthem.com
Dennis Perlas, RN
DHCS CMT
Provider Clinical Liaison,
GBD Quality Management
Email:
Dennis.Perlas@anthem.com
Liz Tullis, MSN/MBA, RN
DHCS CSR
FSR Manager,
GBD Quality Management
Email:
Elizabeth.Tullis@anthem.com
For general provider inquiries unrelated to FSR, please contact Medi Cal Customer Care Center.
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Prior Authorization Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Reimbursement Policies
- Provider Manuals, Policies & Guidelines
- Referrals
- Forms
- Provider Training Academy
- Pharmacy Information
- Provider News & Announcements
Interested in becoming a provider in the Anthem network?
We look forward to working with you to provide quality services to our members.
Join our network