Use this SOP to maintain current credentials, required personnel records, staff identification, role-specific agreements, and documented training for CalOptima and DHCS Facility Site Review readiness.

📚 Resources Needed

  • Current California professional licenses and certifications

  • Personnel credential files and education or training records

  • Staff identification badges or tags showing each person's name and title

  • NP and CNM Standardized Procedures, PA Practice Agreements, and Supervisory Guidelines

  • Pediatric training records when the facility serves patients under 21 years old

✅ Before You Start

  • Confirm the current staff roster and each person's licensed or non-licensed role.

  • Identify whether personnel documents are maintained onsite or by a centralized personnel department.

  • Confirm all role-specific procedures, agreements, supervision terms, signatures, and review schedules are current.

🚀 Tips & Tricks

  • Organize personnel files by staff member and role so requested credentials and training records can be produced promptly.

  • Track license, certification, training, agreement, and review dates before they expire or require revision.

📘 Instructions

Step 1: Verify Professional Licenses And Certifications

  • Confirm every medical professional license and certification is current, issued by the appropriate agency for California practice, and available onsite.

  • A site with a centralized personnel department is not required to keep the documents or copies onsite; however, copies for currently certified or credentialed personnel must be readily available when reviewers request them.

Step 2: Provide Required Professional Licensing Notification

  • Notify each member that MDs, DOs, NPs, and PAs are licensed and regulated by their respective boards.

Step 3: Maintain Personnel Identification

  • Health care personnel must wear identification badges or tags printed with their name and title.

  • If patients are not being seen at the time of the audit, the badges or tags must be readily available when requested by the reviewer.

Step 4: Maintain Education And Training Records

  • Maintain onsite documentation of education and training for all non-licensed medical personnel.

  • When the facility serves pediatric patients under 21 years old, retain evidence of completed training that is valid for four years in audiometric screening; vision screening; anthropometric measurements, including obtaining body mass index percentile; and dental screening and fluoride varnish application.

Step 5: Maintain NP And CNM Standardized Procedures

  • CNMs and NPs must operate under written Standardized Procedures collaboratively developed and approved by the supervising physician, the NP, and administration within the organized health care facility or system where the procedures will be used.

  • Keep the Standardized Procedures readily available for NPs and CNMs.

  • Clearly define the scope of practice for NPs and CNMs, including delegation of MA supervision when the supervising physician is off premises.

Step 6: Maintain PA Practice Agreements

  • The Practice Agreement must define the specific procedures identified in practice protocols or specifically authorized by the supervising physician.

  • The supervising physician and PA must date and sign the Practice Agreement, which must address delegation of MA supervision when the supervising physician is off premises.

  • An original or copy must be readily accessible at every practice site where the PA works.

Step 7: Document PA Supervision And Emergency Backup

  • The supervising physician's responsibility for supervising the PA must define the supervision responsibilities and methods required by Title 16, section 1399.545 of the Physician Assistant Regulations, and the physician must sign it.

  • Identify emergency patient transport and backup procedures for times when the supervising physician is not onsite, including authorization to call 911 and the name of the hospital to which the patient will be transported.

  • Update any Delegation of Services Agreement (DSA) in effect before Jan 1, 2020 to meet current requirements.

Step 8: Review Procedures Agreements And Guidelines

  • Periodically review Standardized Procedures, Practice Agreements, and Supervisory Guidelines.

  • At every change in scope of work, the supervising physician and NPMP must complete signed and dated revisions.

  • Specify in writing how frequently reviews will occur to identify changes in the scope of service.

🛠 Troubleshooting

A License Certification Or Training Record Is Missing

Obtain the current document from the appropriate agency or personnel department and make it readily available before marking the file complete.

A Scope Of Work Changes

Review the applicable Standardized Procedure, Practice Agreement, and Supervisory Guideline. Complete all required signed and dated revisions before the changed work continues.

The Supervising Physician Is Off Premises

Follow the written delegation and emergency backup provisions, including MA supervision, calling 911 when authorized, and transport to the hospital named in the Practice Agreement.

✅ Completion Check

•  All medical professional licenses and certifications are current, California-appropriate, and available onsite or readily available from the centralized personnel department.

•  Each member received the required licensing and board-regulation notification for MDs, DOs, NPs, and PAs.

•  Personnel identification and all required non-licensed staff training records are available, including valid four-year pediatric training evidence when applicable.

•  NP and CNM Standardized Procedures are approved, available, and define scope of practice and MA supervision when the supervising physician is off premises.

•  Each PA Practice Agreement is signed and dated, accessible at every practice site, and includes procedures, supervision, MA delegation, emergency transport, 911 backup, and the transport hospital.

•  Pre-2020 DSAs are updated, periodic reviews occur, scope changes receive signed and dated revisions, and the review frequency is specified in writing.

References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Personnel, page 39

Source Protocol Created: Apr 29, 2026

Internal readiness SOP only; the full CalOptima, DHCS, licensing-board, professional-practice, and personnel requirements control.