This Environmental Accessibility Health Policy Qualification (EAHPQ) document establishes the comprehensive standards that all Pacific Health Group (PHG) facilities, providers, and contracted entities must meet to ensure compliance with California Department of Health Care Services (DHCS) requirements regarding environmental accessibility, safety, and provider qualifications.

The scope of this policy extends to all PHG-owned and operated facilities, including primary care clinics, specialty care facilities, urgent care centers, and administrative offices where patient services are provided. Additionally, this policy governs all contracted provider offices and facilities that deliver care to PHG members, regardless of ownership structure. The requirements set forth apply equally to telehealth service environments, which must maintain appropriate privacy, technology accessibility, and environmental standards. Mobile health units and temporary service locations established for community outreach or disaster response must also adhere to accessibility standards appropriate to their configuration. Administrative offices with patient/member access for enrollment, grievance filing, or other member services are subject to the same accessibility requirements as clinical environments.

This policy is developed in accordance with and adheres to the following regulatory authorities:

2.1 State Regulations

The California Welfare and Institutions Code, Division 9 establishes the fundamental requirements for provision of healthcare services to Medi-Cal beneficiaries, including standards for accessibility and non-discrimination. The California Code of Regulations, Title 22, Division 3 provides specific implementation requirements for managed care organizations contracting with DHCS, with particular attention to network adequacy and facility standards.

DHCS All Plan Letters (APLs), particularly APL 22-018 regarding Facility Site Review Updates, establish the current assessment tools and minimum passing thresholds for facility evaluations. This APL introduced enhanced requirements for infection control, accessibility of medical equipment, and documentation standards that are incorporated throughout this policy.

DHCS Policy Letters DPL 22-004 addressing Provider Network Certification Requirements establish the verification standards for provider credentials, including enhanced requirements for primary care providers serving vulnerable populations.

The California Building Code (CBC) Title 24 Accessibility Requirements set specific standards for physical environment accessibility that exceed federal ADA requirements in many areas. These include enhanced path of travel specifications, restroom design parameters, and signage requirements specific to healthcare environments.

2.2 Federal Regulations

The Americans with Disabilities Act (ADA) of 1990, as amended, prohibits discrimination against individuals with disabilities in all areas of public life, including healthcare facilities. The ADA establishes baseline requirements for physical accessibility, effective communication, and policy modifications.

Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability in programs receiving federal financial assistance, which includes all PHG services provided to Medi-Cal beneficiaries.

The Patient Protection and Affordable Care Act, Section 1557 extends non-discrimination protections to individuals seeking healthcare and establishes specific requirements for accessible medical diagnostic equipment and language assistance services.

HIPAA Privacy and Security Rules establish requirements for patient privacy that must be integrated with accessibility modifications, particularly in reception areas, electronic communications, and physical space design.

2.3 Contract Requirements

The DHCS-MCP Contract Exhibit A, Attachment 4: Quality Improvement System establishes specific quality monitoring requirements related to facility assessments and corrective actions. These contractual obligations mandate regular evaluation of network facilities and implementation of remediation plans for identified deficiencies.

The DHCS-MCP Contract Exhibit A, Attachment 7: Provider Network sets forth network adequacy standards that include accessibility requirements as a component of determining whether a provider is considered “available” to serve members with disabilities.

The DHCS-MCP Contract Exhibit A, Attachment 9: Access and Availability establishes time and distance standards along with appointment availability metrics that must be considered alongside physical accessibility when evaluating network adequacy.

Accessibility: The extent to which a facility, service, or program can be approached, entered, operated, participated in, and/or used safely and with dignity by a person with a disability. This encompasses physical access to buildings and spaces as well as programmatic access to services and activities. Accessibility includes the removal of architectural, communication, and attitudinal barriers that might otherwise prevent full participation by individuals with disabilities.

Environmental Safety: The conditions and practices that contribute to the protection of health and safety of patients, staff, and visitors within a healthcare setting. This includes but is not limited to infection control measures, hazardous materials management, emergency preparedness, fire safety, and general facility maintenance that minimizes risk of injury or harm.

Facility Site Review (FSR): A comprehensive evaluation of a physical healthcare facility conducted to ensure compliance with regulatory requirements and standards. The FSR examines physical plant safety, accessibility features, clinical care areas, infection control practices, medication management, and administrative systems according to DHCS-established assessment tools and scoring criteria.

Medical Equipment Accessibility: The degree to which medical diagnostic equipment is accessible to and usable by individuals with disabilities. This includes examination tables, imaging equipment, weight scales, mammography equipment, and other diagnostic devices that must be usable by patients with mobility, sensory, and other impairments.

Provider Qualification: The verification that healthcare providers meet specified requirements regarding licensure, certification, education, training, and experience. For DHCS compliance, this includes validation of Medi-Cal enrollment status, absence of sanctions or exclusions, completion of required cultural competency training, and verification of specialty board certification where applicable.

Reasonable Accommodation: A modification or adjustment to a policy, practice, or environment that enables a qualified individual with a disability to have equal access to healthcare services. Reasonable accommodations include physical modifications, communication assistance, modified procedures, and auxiliary aids that do not fundamentally alter the nature of services or impose undue financial or administrative burden.

Remediation Plan: A documented strategy to address identified deficiencies or non-compliance issues within a specified timeframe. The remediation plan includes concrete action steps, responsible parties, required resources, timeline for completion, and methods for verifying that corrective actions have successfully resolved the deficiency.

4.1 External Accessibility

All PHG facilities and contracted provider locations must maintain accessible parking configurations that meet or exceed California Building Code requirements. This includes a sufficient number of accessible spaces based on the total parking capacity, with a minimum of one van-accessible space with an adjacent access aisle of 96 inches width. The accessible spaces must be located on the shortest accessible route to the accessible building entrance, with a maximum travel distance of 200 feet from parking to entrance. Each accessible space must be clearly marked with the International Symbol of Accessibility both on the pavement and via vertical signage.

Accessible routes from parking to facility entrances must maintain a minimum width of 36 inches throughout the entire path of travel. The maximum slope for any portion of the accessible route shall not exceed 5% longitudinal slope and 2% cross slope. Where level changes occur along the accessible route, compliant curb cuts, ramps, or elevators must be provided. All walking surfaces must be stable, firm, and slip-resistant under all weather conditions, with adequate drainage to prevent water accumulation.

Building entrances must be accessible with a minimum clear opening width of 32 inches when the door is open at 90 degrees. Where manual doors are installed, the maximum opening force shall not exceed 5 pounds. Power-assisted or automatic doors are required at main entrances of larger facilities. Entrance areas must include level landing areas of at least 60 inches in depth to allow wheelchair maneuvering.

Signage throughout external areas must comply with CBC Title 24 standards, incorporating both visual and tactile elements. This includes raised characters and braille for identification signs, visual contrast between characters and backgrounds, and non-glare finishes. Directional and informational signs must be clearly visible and positioned consistently throughout the facility’s exterior.

Where level changes exceed 1/2 inch along any accessible route, compliant ramps or elevators must be provided. Ramps must have a maximum slope of 1:12, with handrails on both sides if the rise exceeds 6 inches. Level landings are required at the top and bottom of each ramp run, with intermediate landings for any ramp exceeding 30 feet in length.

4.2 Internal Accessibility

Within all PHG facilities and contracted locations, accessible routes must connect all public use areas with a minimum clear width of 36 inches. In corridors serving patient care areas, wider clearances of at least 44 inches shall be maintained to accommodate gurneys and other medical transport equipment. Turning spaces of 60 inches diameter or T-shaped spaces shall be provided at dead ends and where directional changes occur in corridors.

Each floor of a facility that contains public use areas must include at least one fully accessible restroom meeting current CBC requirements. This includes a 60-inch diameter turning radius to accommodate wheelchairs, properly positioned grab bars at toilets and in shower compartments where provided, fixtures mounted at accessible heights, and accessible operable parts including faucets and dispensers. Where multi-stall restrooms are provided, at least one accessible stall meeting dimensional requirements must be included, along with accessible lavatories.

Reception areas and service counters must incorporate sections lowered to a maximum height of 34 inches from the finished floor, with knee clearance extending at least 17 inches under the counter surface. The lowered section must be at least 36 inches wide to accommodate wheelchair users during administrative interactions. Adjacent to reception areas, waiting areas must include designated spaces for wheelchair users that do not obstruct circulation paths. These spaces shall be integrated within the general seating arrangement rather than segregated.

All doorways in patient accessible areas must provide a minimum clear width of 32 inches when the door is open at 90 degrees. Door hardware must be operable with a closed fist and not require tight grasping, pinching, or twisting of the wrist. The maximum force required to operate door hardware shall not exceed 5 pounds. Where fire doors are required to be kept closed, automatic door operators or power-assist devices shall be installed to ensure accessibility.

In multi-story facilities, elevator access must be provided to all public floors. Elevators must meet accessibility requirements including minimum car dimensions of 68 inches by 54 inches, centered control panels with tactile and braille characters, audible floor indicators, and two-way communication systems accessible to individuals with hearing or speech impairments.

Visual alarms and notifications must be integrated with audible emergency systems throughout all public use areas. Visual notification devices must be visible from any area where a person may be, including restrooms and enclosed rooms, to ensure that deaf or hard of hearing individuals are alerted to emergency situations.

4.3 Examination and Treatment Areas

Within clinical settings, each distinct specialty service must provide at least one fully accessible examination room configured to accommodate patients with disabilities. These rooms must be distributed throughout the facility to ensure accessibility within each department or service area. Where a provider offers multiple specialties, each specialty type must have a designated accessible examination room.

Examination tables in accessible rooms must be height-adjustable, with a minimum low position of 17 to 19 inches from the floor to facilitate transfers from wheelchairs. The tables must include features to support safe patient transfers such as transfer supports, rails, or straps. The control mechanisms for adjusting table height must be accessible to both patients and staff.

Each accessible examination room must provide a clear floor space of at least 60 inches in diameter to allow wheelchair users to make a 180-degree turn. This clear turning space must be maintained regardless of the positioning of the examination table, chairs, and other fixed equipment. A clear floor space of 30 inches by 48 inches must be provided adjacent to the examination table to facilitate transfers.

Medical equipment within these rooms must comply with Section 1557 accessibility requirements, including wheelchair accessible scales, mammography equipment that accommodates seated patients, and imaging equipment with transfer supports. Where specialized accessible equipment cannot be provided in every examination room, the facility must have documented procedures for relocating such equipment when needed or for scheduling patients requiring such equipment in the rooms where it is available.

Transfer aids including ceiling-mounted or portable patient lifts must be available in settings where patients with significant mobility impairments are treated. Staff must be trained in safe transfer techniques and the proper use of transfer equipment. Documentation of this training must be maintained in personnel records and updated annually.

Weight measurement is an essential component of most clinical encounters, requiring the provision of accessible scales capable of weighing patients who use wheelchairs. These scales must have ramped access, adequate platform size to accommodate various mobility devices, and weight capacity sufficient for both the patient and their mobility equipment. Digital displays must be positioned to allow viewing by seated individuals.

5.1 General Safety Requirements

Every PHG facility and contracted provider location must maintain current fire clearance certification from the appropriate local jurisdiction. This certification must be renewed according to local requirements, typically annually, and documentation must be readily available for inspection. The certification process includes verification of functioning fire suppression systems, adequate egress routes, and compliance with occupancy limitations.

Emergency exits and evacuation routes must be clearly identified throughout each facility with illuminated exit signs visible from any point within public areas. Evacuation route maps must be posted in conspicuous locations showing primary and alternative exit pathways. These maps must be oriented correctly from the viewing position and include “You Are Here” indicators. All exit pathways must remain clear of obstruction with a minimum width of 44 inches in corridors serving patient areas.

Fire detection and suppression systems must include functioning smoke detectors in all rooms and corridors, with additional heat detectors in kitchen and laboratory areas where appropriate. Sprinkler systems must be inspected quarterly with documentation of these inspections maintained on site. Fire extinguishers must be mounted in readily accessible locations, with signage identifying their locations, and must receive monthly visual inspections and annual certified maintenance.

All facilities must maintain emergency lighting systems with battery backup sufficient to illuminate exit pathways for a minimum of 90 minutes during power failures. These systems must be tested monthly with documentation of test results maintained on site. Full-load testing must be conducted annually by qualified personnel.

First aid kits and emergency medical equipment appropriate to the facility type must be maintained in accessible locations known to all staff. In primary care settings, emergency equipment must include at minimum: airway management supplies, emergency medications as specified by DHCS guidelines, automated external defibrillator with pediatric capabilities where pediatric services are provided, and oxygen administration equipment. The contents of emergency kits must be inventoried monthly with documentation of these checks maintained on site.

Hazardous materials including cleaning chemicals, laboratory reagents, and other potentially dangerous substances must be stored in secured areas with limited access. Safety Data Sheets (SDS) must be readily available for all such materials, with a master index of all hazardous substances maintained at a central location known to all staff. Storage must comply with incompatibility guidelines to prevent dangerous chemical reactions. Spill containment kits appropriate to the materials used must be available in all areas where hazardous materials are used or stored.

Each facility must implement an OSHA-compliant Injury and Illness Prevention Program that includes regular safety inspections, hazard correction procedures, safety training, and incident investigation protocols. This program must be documented in writing, with records of all activities maintained for a minimum of three years. All staff must receive orientation to this program upon hire and annual refresher training thereafter.

5.2 Infection Control Standards

In accordance with enhanced requirements in DHCS APL 22-018, all facilities must develop and implement comprehensive written infection control policies and procedures. These must address standard precautions, transmission-based precautions, post-exposure protocols, equipment disinfection and sterilization, and environmental cleaning. The policies must be reviewed annually and updated to reflect current CDC guidelines and state requirements.

Biohazardous waste management must follow California Department of Public Health regulations for medical waste handling, with designated containers that are clearly labeled, puncture-resistant when necessary, and regularly collected by licensed medical waste handlers. Documentation of proper disposal must be maintained for a minimum of three years. Staff handling such waste must receive specialized training in proper procedures and use of personal protective equipment.

Personal protective equipment appropriate to the services provided must be available in all patient care areas. This includes gloves in multiple sizes, masks, eye protection, and fluid-resistant gowns. Sterile gloves must be available for procedures requiring aseptic technique. N95 respirators or equivalent must be available for use with patients suspected of having airborne transmissible diseases, with staff having completed proper fit testing documented in their training records.

Hand hygiene facilities must be provided throughout each location, with sinks available in all examination rooms, treatment areas, laboratory spaces, and medication preparation areas. Hand washing sinks must be separate from sinks used for instrument cleaning or other purposes. Alcohol-based hand sanitizer dispensers must be installed at all entrances, outside each patient room, and in other strategic locations throughout public and clinical areas.

Environmental cleaning protocols must detail the products, methods, and frequencies for cleaning all areas of the facility, with enhanced procedures for high-touch surfaces and clinical areas. These protocols must specify different levels of cleaning based on the risk of contamination, with more intensive procedures for surgical areas, isolation rooms, and spaces where immunocompromised patients receive care. Documentation of cleaning activities must be maintained through logs that identify the areas cleaned, person performing the cleaning, date, time, and supervisor verification.

Sterilization of reusable medical equipment must follow manufacturer guidelines and evidence-based practices. Facilities performing on-site sterilization must have designated clean and dirty areas with unidirectional workflow. Biological indicators must be used at least weekly to verify sterilization effectiveness, with results documented and maintained for three years. Chemical indicators must be used with each load, and sterilizer maintenance must be performed according to manufacturer recommendations with documentation maintained on site.

All clinical staff must complete annual training on infection control practices, with additional training provided whenever significant changes to protocols occur or when compliance issues are identified. This training must be documented in personnel records and must include hands-on demonstration of competency in proper hand hygiene, personal protective equipment use, and equipment disinfection appropriate to job responsibilities.

5.3 Medication Safety

Facilities that store or administer medications must maintain secure storage areas with access limited to authorized personnel. Controlled substances require additional security measures including double-locked storage and perpetual inventory management. Electronic or biometric access controls are recommended for medication storage areas, with documentation of all access events. The security systems must include provisions for emergency access should electronic systems fail.

Temperature-sensitive medications require continuous monitoring systems with alarm capabilities to alert staff when temperatures exceed acceptable ranges. Refrigerators used for medication storage must maintain temperatures between 36°F and 46°F (2°C and 8°C), while freezers must maintain temperatures according to specific medication requirements. Temperature logs must be maintained with twice-daily manual checks in addition to continuous monitoring systems. All refrigerators used for medication storage must be dedicated solely to that purpose, with no food or specimens stored in these units.

Adult and pediatric medications must be stored separately to prevent dosing errors, with clear labeling systems to differentiate between concentrations and formulations intended for different age groups. High-alert medications as defined by the Institute for Safe Medication Practices must be identified with special labeling and may require additional verification steps before administration.

Inventory management systems must include regular checks of all medication areas to identify and remove expired products. These checks must be performed monthly at minimum, with documentation maintained for three years. The system must include protocols for proper disposal of expired or damaged medications in accordance with DEA and EPA regulations.

When medications are subject to manufacturer or FDA recalls, a formal protocol must be implemented to identify affected lot numbers, remove these products from use, notify any patients who may have received affected medications, and document all actions taken in response to the recall. This protocol must designate responsibility for monitoring recall notices and coordinating response activities.

Documentation of medication administration must be maintained in the patient’s medical record, including the medication name, dose, route, time of administration, and administering provider. For medications prepared on site, such as vaccines drawn from multi-dose vials, documentation must include lot numbers, expiration dates, and time of preparation when stability is time-limited.

Controlled substance handling must comply with both DEA requirements and DHCS protocols, including perpetual inventory management, documentation of waste, regular reconciliation of counts, and investigation of any discrepancies. Audits of controlled substance handling must be conducted monthly by supervisory personnel not routinely involved in medication management, with documentation of these audits maintained for five years.

6.1 Credentialing Requirements

Each healthcare provider delivering services to PHG members must maintain a current and unrestricted professional license appropriate to their scope of practice as issued by the relevant California licensing board. Primary source verification of licensure must be performed at initial credentialing and not less than every three years thereafter, with ongoing monitoring between verification cycles to identify any adverse actions. Providers must be contractually obligated to notify PHG within five business days of any change in licensure status.

Providers authorized to prescribe controlled substances must maintain current Drug Enforcement Administration (DEA) certification. Verification of DEA status must include confirmation of correct address of practice and authorized schedules. For providers who prescribe controlled substances only in inpatient settings, institutional DEA numbers may be accepted if properly documented. Providers must immediately notify PHG of any change in DEA status.

Board certification in the provider’s specialty area must be verified through primary sources including the American Board of Medical Specialties, American Osteopathic Association, or other recognized specialty boards. For providers not board certified, documentation of board eligibility status must be maintained, including verification of completion of accredited residency programs appropriate to the specialty. If a provider loses board certification status, they must notify PHG within 10 business days, and a determination regarding continued participation will be made based on network needs and alternative qualifications.

Clinical providers with direct patient contact responsibilities must maintain current cardiopulmonary resuscitation (CPR) certification appropriate to their practice setting. Providers serving pediatric populations must have Pediatric Advanced Life Support (PALS) certification in addition to basic CPR. Documentation of certification must include verification of both didactic and skills components of the training.

Professional liability insurance coverage must meet PHG minimum requirements of $1 million per occurrence and $3 million aggregate for physicians, with appropriate levels established for other provider types based on risk categorization. Evidence of coverage must be obtained annually, with provisions for notification to PHG if policies are canceled or materially modified. Gap coverage must be documented if providers change insurance carriers.

All providers must maintain an active National Provider Identifier (NPI) registered with the National Plan and Provider Enumeration System (NPPES) with current practice information. Type 1 NPIs are required for individual providers, while organizational providers must maintain both Type 1 and Type 2 NPIs as appropriate. Changes to practice address, specialty, or other information registered with NPPES must be reported to PHG within 30 days.

Providers must be enrolled in the DHCS Provider Application and Validation for Enrollment (PAVE) system with active status. The enrollment must reflect all practice locations where services are provided to Medi-Cal beneficiaries, and any limitations on enrollment must be disclosed to PHG during the credentialing process. Providers not eligible for enrollment will not be accepted into the PHG network regardless of other qualifications.

Current Medicaid enrollment verification must be performed through the DHCS verification system to confirm the provider is not excluded from participation and has no restrictions on their providing services to Medi-Cal beneficiaries. This verification must be performed prior to initial credentialing, upon recredentialing, and monthly throughout the contract period as part of ongoing monitoring for adverse actions.

6.2 Training Requirements

All providers new to the PHG network must complete a comprehensive orientation to PHG policies and procedures within 30 days of contract execution. This orientation must include coverage of accessibility requirements, member rights and responsibilities, cultural competency expectations, referral procedures, prior authorization requirements, and quality improvement programs. Documentation of orientation completion must be maintained in the provider’s credentialing file.

Annual compliance training is required for all network providers and must include content addressing fraud, waste and abuse prevention; privacy and security requirements under HIPAA; proper documentation practices; accessibility standards; and ethical business conduct. This training may be provided through in-person sessions, webinars, or approved online modules. Evidence of completion must be submitted to PHG annually.

Cultural competency training meeting DHCS requirements must be completed by all providers and clinical staff. This training must address the cultural and linguistic characteristics of PHG’s member population, health disparities affecting diverse communities, strategies for effective cross-cultural communication, and use of interpretation services. The curriculum must be updated annually to reflect changing demographics and emerging cultural competency standards.

Disability sensitivity and accessibility training must be provided to all clinical and non-clinical staff to ensure appropriate interactions with individuals with various disabilities. This training must address communication techniques for individuals with hearing, speech, or cognitive impairments; proper use of auxiliary aids and services; accessible examination techniques; and legal requirements regarding accommodations. Staff directly involved in facility design or modification must receive additional training on physical accessibility standards.

Language access training must include proper protocols for working with interpreters, including positioning, speaking patterns, and documentation requirements. Staff must be trained on accessing PHG’s language line services, scheduling in-person interpreters when needed, and maintaining privacy during interpreted sessions. The training must emphasize the prohibition against using family members, particularly minors, as interpreters except in emergency situations or when specifically requested by the member after being offered professional services.

Emergency preparedness training appropriate to the facility type must be provided annually, with additional drills conducted quarterly. This training must address facility-specific emergency plans, evacuation procedures, roles and responsibilities during various emergency scenarios, and special considerations for assisting individuals with disabilities during emergencies. Documentation must include attendance records and evaluation of performance during drills.

HIPAA and data security training must be provided to all staff with access to protected health information, regardless of clinical role. This training must address permissible uses and disclosures, minimum necessary standards, security practices for electronic protected health information, breach notification procedures, and consequences of non-compliance. Staff with access to electronic health records or other sensitive systems must receive additional training on password management, phishing prevention, and workstation security.

6.3 Documentation Requirements

All providers must maintain a current signed DHCS provider agreement reflecting their participation in Medi-Cal managed care programs. This agreement must be executed prior to providing services to PHG members and must be updated whenever DHCS issues revised agreement templates. The agreement must accurately reflect all practice locations and services provided to beneficiaries.

Disclosure of ownership and control must be updated annually using DHCS-approved forms. These disclosures must identify all individuals and entities with ownership or control interest as defined by federal regulations, including information about related entities and any history of adverse actions. Changes in ownership or control must be reported to PHG within 35 days of the change.

Documentation of all required training must be maintained in a centralized system accessible during site reviews and audits. This documentation must include the training topic, date, duration, content summary, trainer qualifications, and verification of the provider’s or staff member’s attendance and comprehension. For online training modules, electronic verification of completion including time spent on the module must be maintained.

Current professional liability insurance certificates must be maintained on file and updated prior to expiration of previous coverage. These certificates must identify PHG as a certificate holder entitled to notification of any changes in coverage status. Where tail coverage is necessary due to claims-made policies, evidence of this extended coverage must be documented.

Evidence of continuing education compliance appropriate to the provider’s licensure requirements must be maintained and made available upon request during credentialing activities. For specialties requiring Maintenance of Certification programs, evidence of current participation in these programs should be documented.

Quality metrics reporting as required by the DHCS contract must be submitted according to established timelines using approved formats. This includes HEDIS measures, population health metrics, and specialized reporting for vulnerable populations. Providers must maintain systems capable of generating these reports and must validate data accuracy prior to submission.

Updated facility site review documentation must be maintained on site and available for inspection by PHG representatives or regulatory agencies. This includes evidence of completed corrective actions for any previously identified deficiencies, ongoing monitoring of accessibility features, and regular self-assessment using PHG-provided tools.

7.1 Initial Assessment

PHG will conduct comprehensive accessibility assessments for all new facilities prior to their utilization for patient care services. These assessments must be completed and any critical deficiencies remediated before the first patient encounter. The assessment will evaluate all aspects of accessibility including approach and entry, interior circulation, program accessibility, and communication features. A passing score as defined by current DHCS standards must be achieved before the facility can be added to the provider directory.

Newly contracted provider locations must undergo a complete accessibility assessment within 60 days of contract execution. During this interim period, the provider may be listed in the directory with appropriate notation regarding pending accessibility verification. The assessment will utilize the standardized tools described in section 7.3, with results documented in the provider’s file and summary results available to members upon request.

Facilities undergoing significant renovation or remodeling that affects accessibility features must suspend services in the affected areas until a focused reassessment confirms compliance with accessibility standards. The scope of this reassessment will be determined based on the nature of the renovation but must at minimum include evaluation of all modified elements and their integration with existing accessibility features.

Facilities changing service types or patient populations must undergo reassessment focused on accessibility features relevant to the new service configuration. For example, a facility transitioning from adult-only services to include pediatric care would require assessment of features specific to serving children with disabilities, including appropriately sized accessible equipment and communication supports suitable for younger patients.

All initial assessments will be conducted by staff trained in applying the DHCS Facility Site Review and Medical Record Review Survey Tools as updated in APL 22-018. These assessors must complete DHCS-approved training and demonstrate competency in applying the tools consistently across various facility types. Assessment teams should include at least one member with expertise in physical accessibility standards and one with clinical background appropriate to the facility type.

7.2 Periodic Reassessment

PHG will conduct periodic reassessments of high-volume providers, defined as those serving more than 200 unique PHG members annually, every 3 years in accordance with DHCS requirements. These comprehensive reassessments will include all elements of the initial assessment to ensure ongoing compliance with evolving standards. The reassessment schedule will be maintained centrally to ensure timely completion and appropriate resource allocation.

Medium-volume providers, serving between 50 and 200 unique PHG members annually, will also undergo full reassessment every 3 years using the same comprehensive tools applied to high-volume providers. This consistent approach ensures all members have access to facilities meeting the same accessibility standards regardless of provider size.

Low-volume providers, serving fewer than 50 unique PHG members annually, will be reassessed every 3 years or upon DHCS request, whichever occurs first. While the assessment interval matches that of higher volume providers, PHG may prioritize scheduling of these assessments based on risk factors such as previous deficiencies, member complaints, or changes in facility conditions identified through other monitoring activities.

Following significant facility modifications, a focused reassessment must be conducted within 30 days of completion to verify that the modifications meet accessibility requirements and do not adversely affect other accessibility features. The scope of this reassessment will be tailored to the specific modifications but must include evaluation of integration with existing accessibility features and any impact on overall accessibility.

When accessibility complaints are received from members, staff, or other stakeholders, a focused assessment of the specific issue must be conducted within 14 days of the complaint. This assessment will be limited to the issues identified in the complaint plus any related features that may contribute to the reported problem. If the focused assessment reveals broader concerns, a full reassessment may be triggered regardless of the usual reassessment schedule.

7.3 Assessment Tools

The DHCS Facility Site Review tool in its most current version serves as the primary instrument for evaluating general facility compliance. This standardized tool addresses physical accessibility, safety features, infection control practices, and administrative systems. The scoring methodology established by DHCS determines whether a facility meets minimum requirements, with critical elements requiring 100% compliance and non-critical elements requiring an overall score of 80% or higher.

The Physical Accessibility Review Survey (PARS) tool provides detailed evaluation of accessibility features specific to individuals with disabilities. This tool examines exterior routes, building access, interior circulation, restroom accessibility, examination room features, medical equipment, and communication aids. The PARS results are used to classify facilities according to their level of accessibility for inclusion in the provider directory with appropriate symbols indicating accessibility status.

The PHG Supplemental Environmental Safety Checklist extends beyond DHCS requirements to address additional safety concerns identified through risk management activities. This checklist includes evaluation of slip/fall prevention measures, ergonomic factors for both patients and staff, emergency response capabilities specific to individuals with disabilities, and environmental factors that may affect individuals with sensory sensitivities or environmental illness.

Provider qualification verification is conducted using a standardized checklist that confirms appropriate licensure, certification, training completion, and malpractice coverage. This verification process includes primary source confirmation of credentials and regular monitoring for adverse actions against providers that might affect their eligibility to serve PHG members.

Medical equipment accessibility is evaluated using a specialized tool that examines adjustability, transfer supports, weight capacity, and control accessibility. This evaluation considers the needs of individuals with various disabilities including mobility impairments, visual impairments, and dexterity limitations. Equipment must meet both technical standards and usability criteria as determined through consultation with disability advocates and clinical experts.

8.1 Deficiency Classification

Identified deficiencies will be classified according to their potential impact on patient safety and accessibility. Critical deficiencies are those posing immediate risk to patient safety or creating significant barriers to access for individuals with disabilities. Examples include non-functioning emergency equipment, blocked emergency exits, completely inaccessible entrances, or absence of required infection control practices. These critical deficiencies require immediate corrective action, with timeframes ranging from immediate correction for severe safety issues to 24-48 hours for other critical concerns.

Significant deficiencies substantially impact accessibility or compliance but do not pose immediate dangers or complete barriers to access. Examples include examination tables that are not height-adjustable, restrooms lacking some required accessibility features but remaining basically functional, or incomplete documentation of required safety checks. These significant deficiencies must be remediated within 30 days, with a corrective action plan submitted within 7 days of identification detailing the specific steps that will be taken to achieve compliance.

Minor deficiencies have minimal impact on accessibility or compliance and typically represent opportunities for improvement rather than significant problems. Examples include signage that meets technical requirements but could be improved for better visibility, environmental features that meet minimum standards but fall short of best practices, or administrative processes that are compliant but could be more efficient. These minor deficiencies must be remediated within 90 days, with documentation of corrective