What Reviewers Look for During a Provider Medical Office Site Review

Access Appearance

  • Practice is identified with a prominently displayed sign
  • Patient and handicapped parking are identified and adequate for the volume of patients
    • Handicapped spaces and a designated access ramp are available
  • Elevator is available for offices above the first floor
  • Bilingual signs are prominently displayed
    • Information, directions
  • Office appearance
    • Waiting area:
      • Neat and clean
      • Adequate seating
      • Educational literature available
      • Patient bill of rights and responsibilities posted
      • Office hours displayed
  • Restrooms
    • Clean
    • Rail equipped
    • Wheelchair accessible
  • DEA licenses are in public view
  • Provider Reference Guide is accessible to office personnel
  • Access to services
    • Wait time for urgent appointment (within 24 hours or triage in an urgent care facility)
    • Wait time for adult or child appointment (first available)
    • Access system for physician after hours and during lunch hours
    • On-call physician arrangements
    • Physician call-back time and routine treatment call (average time)
  • Appearance
    • Construction of exam rooms, dressing rooms and reception areas provide and maintain privacy during interviews, exams, treatment and consultations
    • Exam rooms have no Rx pads, sharps or syringes, medications, or cleaning solutions in cupboards
    • Lighting is adequate
    • Equipment includes:
      • Blood pressure cuff
      • Ophthalmoscope
      • Otoscope
      • Thermometer

Fire Safety

  • Fire extinguishers visible and current inspection tag or gauge indicates “full”
  • Fire alert equipment visible (at least one of the following):
    • Fire alarm
    • Smoke detectors
    • Sprinklers
  • Date of last inspection by authorized fire marshal
  • “No Smoking” signs prominently displayed
  • Written or posted emergency plan for fire or disaster

Infection Control Policies

Note: All reasonable measures should be taken to provide a safe environment for patients, personnel and visitors.

  • Universal precaution equipment and procedures to minimize transmission of infection
    • Mask
    • Gown
    • Gloves
    • Eyewear
  • Designated area or isolation procedure for contagious patients
  • Clinical equipment maintenance documented in a log
  • Access to hand-washing facility
  • Sharps containers in each exam room
  • Sharps and biohazardous waste is collected by a contracted disposal company
  • Biohazardous waste is collected in a proper container

Medication Safety and Storage

  • Refrigerator has a thermometer and a monthly check log is maintained (36-46 F or 2-7 C)
  • No food is stored in the refrigerator
  • Multiple vials of injectables are labeled with “Date Opened”
  • Multi-dose injectables with preservatives are discarded according to manufacturer guidelines (usually six months) and are checked for integrity prior to injection
  • Expiration dates of samples and other drugs are checked and documented quarterly
  • Controlled drugs are stored in a locked area
  • Other drugs and samples are stored in a secured area
  • A log of controlled drug dispensing and usage is maintained (controlled drugs are classes 2 through 5, for example, VALIUM, TALWIN, MORPHINE tablets, DEMEROL and TYLENOL with CODEINE)

Urgent and Emergency Preparation

  • There is a written procedure for medical emergencies
  • Emergency items located in a designated area
  • Emergency drug tray or cart is checked quarterly and results of the check documented in a log
  • Emergency equipment is available and easily accessible
  • Quarterly emergency equipment maintenance logs are maintained
  • At least one person present in office has current CPR certification