Get a Medical Record Submission Kit
Providers and facilities of all specialties are subject to inspections from the Department of Health Care Services (DHCS). Auditors assess the medical practice in the following categories:
- Access/Safety
- Personnel
- Office Management
- Clinical Services
- Preventive Services
- Infection Control
Following the onsite survey, the auditor shares the score with the provider or facility. They are then responsible for correcting the deficiencies and submitting proof of correction to the DHCS.
Below are the main areas your medical practice should review before a state audit.
CLIENT CHARTS
State auditors review the charts of active clients to verify that they include the following documentation:
- Demographic and identifying data
- A signed copy of the admission agreement
- Health questionnaire
- Authorization to release information
- A signed copy of client’s rights
- Medical referrals and clearances
- Biopsychosocial assessment
View a Complete Intake Assessment Checklist PERSONNEL FILES
When reviewing personnel files, state auditors ensure that each staff member’s role is clearly identified and that they are only performing the duties that they are qualified and licensed for. Each personnel file should contain the following:
- Application for employment and resume
- Copy of valid licenses
- Employment confirmation statement
- Job description and duty statement
- Salary schedule and salary adjustment information
- Employee performance evaluations
- Health records including a health screening report or health questionnaire and valid TB test results. (Download the DHCS Staff Health Questionnaire)
- Other personnel actions (e.g. commendations, discipline, status change, employment incidents and/or injuries).
SITE REQUIREMENTS
The primary building requirements mandated by the state include sanitation and accessibility for individuals with physical disabilities. Additionally, they require that the following notices are posted in visible areas:
- Hours of operation
- Client rights
- The program code of conduct
If you need help preparing for your state agency visit, Datapro is here to help.
