Republic of the Philippines Department of Health REGIONAL OFFICE __ ASSESSMENT TOOL FOR LICENSING A BIRTHING HOME |. FACILITY INFORMATION Name of Facility Complete Address No. & Street Barangay City/Municipality Province Contact Number E-mail Address: Name of Owner Name of Head of the Facility: Latest DOH License Number (if renewal): Authorized Bed Capacity: Classification According to Ownership: Government Private Institutional Character: Free-standing Institution-Based UN, TECHNICAL REQUIREMENTS Instruction: In the appropriate box, place a check mark (1) ifthe birthing home is compliant or x mark (X) if it is not compliant. vali licensing requirements. Every birth must be attended by skiled birth attendants. 4, Physician a,_ Valid PRC license . Certificate of Completed Training from an institution with an Accredited Residency Program (for Obstetrician and Gynecologist, and Pediatrician) . Avvalid certificate of Good Standing from the Accredited Professional Organization (APO) of Physicians of PRC and/or any DOH recognized association of physicians (for Family Medicine Physicians, Municipal Health Officers and General Practitioners) <@._ Certificate of Training on BEmONC (for Family Medicine Physicians, Municipal Health Officers and General Practitioners) @. Notarized Contract of Employment/Appointment/Designation (for employees) 2. Nurs a. Valid PRC License b._ Certificate of good standing from the Accredited Professional Organization (APO) of Nurses of PRC and/or any DOH recognized association of nurses. ©. Notarized Contract of Employment (for employees) DOHSHLTOAT Revision) | enao18 | Page 10f10 |SS NO CONN EE Valid PRC License Valid Cerificate of Good Standing from the Accredited Professional Organization (APO) of Midwives of PRC ‘and/or any DOH recognized association of midwives ©. Certificate of Training on BEONC (not required for those who finished the four (4) year Midwifery Course) a Certificate of Training in Basic Life Support Notarized Contract of Employment (for employees) a ‘Administrator Notarized Contract of Employment (for employees) Clerk Notarized Contract of Employment (for employees) Utility Worker (1/5 beds/shift) Notarized Contract of Employment (for employees) 7 Driver (on call 24/7) or MOA with a transport provider a Notarized Contract of Employment (for employees) equipment and PHYSICAL FACILITY Every health facility shall have physical facility with adequate B. EQUIPMENT, INSTRUMENTS/SUPPLIES, BASIC MEDICINES (Refer to List Instruments/Supplies, Basic Medicines) Every health facility shall struments consistent with the services it shall provide, ‘of Equipment, have available medicines and operational efficiently provide health services to patients. areas in order to safely, effectively, and 1. DOH Approved Permit to Construct (PTC) DOH Approved Floor Plan Business Permit 2, 3 a Posted in conspicuous area ‘a,_License to Operate (for renewal) B._Local Permits ._ Vision and Mission ‘d_ Organizational Chart Signages Information Direction Prohibition and Warning No Smoking Sign Evacuation Plan slolale|s|s Process Flow of Clinical Services DOWBHLTOAT | Revision st0a2016 Pape 201 10Il, FACILITY OPERATIONS ‘A. MANUAL OF Seen GNSS ANDSRD ‘OPERATING PROCEDURES: 4._ Vision and Mission 2. Organizational Chart 3. Documented policies and procedures on provision of clinical services in the facili ‘a. Antepartum Care ». Spontaneous vaginal delivery including essential intrapartum care ‘. Postpertum Care . Newborn Care <4 Essential Newborn Care based on AO. No. 2009-0025 1.4 Time Bound interventions ‘4.1.2, Non time bound interventions including ] birth doses of recommended vaccines (BCG and first dose Hepa B) 41.2.1 Routine newborn care 4.4.2.2 Postnatal care ‘Detection of high risk pregnancies and early referral £. Family Planning £1 Natural Family Planning Methods pursuant to AO. No. 132 s. 2004 72 Arificial Family Planning Methods ‘g. Health Education ‘9:1 Birth Planning and Preparedness ‘9.2 Matemal and Newborn Care (Unang Yakap) 93 Infant and Young Child Feeding and Lactation Management (Breastfeeding TSek) 0-4 Hygiene 4, Documented Policies and procedures on transferireferral system to a health facility of higher capability 5. Documented policies and procedures on administration of life-saving medications such as magnesium suiphate, oxytocin, steroids, and oral antibiotics pursuant to A.O. No. 2010-0014. %, Documented policies and procedures on Infection Control 7. Healthcare Waste Management Documented policy and procedures on proper collection, ‘segregation, treatment and disposal of generated waste. ‘a. Written policy and procedures on waste Management b.Proper collection, segregation, coding, storage and disposal of wastes (for both solid and liquid wastes) c.Use of protective equipment and clothing appropriate for handling, storage, and disposal of wastes. & Wastes are properly segregated, coded and labelled as follows: 1 General’Non-infectious/Dry — Black <2 General’Nor-infectious/Wet ~ Green DOHBHATOAT Revision) Gereaaote Page 30110 |6.3 Infectious/Pathological - Yellow ‘G4 Sharps — Sharps container 8, Preventive maintenance program for equipment. ‘a. Plan for essential equipment replacement in case of breakdown b._Record of equipment ©. Operational _manuals of all equipment and instruments , Documented policies and procedure for handling ‘complaints, reporting and analysis of incidents, adverse events, etc. 10. Pest and vermin control program: ‘a: Documented policies for pest and vermin control Program 77. Medical Records ‘a, Confidentiality of patient information . Policy and procedures for retention and disposal of ‘medical records in accordance with Department Circular No. 70 S. 1996 B, RECORDS/FILES Each patient record shall be kept confidential and shall contain sufficient informal justify the diagnosis and treatment. tion to identify the patient and to 1. Patient's Clinical Record ‘a. Maternal Clinical Charts with duly accomplished Partograph Contents of Maternal Clinical Chart: ‘at Identification Data ‘a.2 History of Present Condition ‘a.3 Physical Examination a4 Admitting Diagnosis ‘a.5 Physician's Order Sheet (if seen by a physician) ‘26 Clinical Laboratory Report and results of other diagnostic procedures done, if any a7 Consultation/Referral Notes ‘a.8 Medication/Treatment Record ‘2.9 Postpartum Monitoring ‘2.10 Informed Consent ‘a.11 Final Diagnosis, if seen by a physician Bb, Newborn Clinical Chart 1 Identification data b.2 APGAR Scoring/Ballard’s Maturational Score 7. Logbooks for Consultations, Admissions, Discharges, Deliveries and Sentinel Events (For sentinel events, include correction, corrective and preventive actions done) 3. Copies of Birth/Death Certificates (including Fetal Deaths) submitted to local civil registrar ‘4. Copies of Annual Birthing Home Stalistical Report received by the regional office 5, Records of transter/referral of patient to another heaith facility DonaHATOAT soa2016 Page 4of 10,6. Certificate (from UPNIH) as a Newborn Screening Facility pursuant to RA No. 9288 and AO No, 2008- 0026 7. Assurance and notarized certification (from a Notary Public) that the birthing facility does not perform Dilatation and Curettage. %, Assurance and notarized certification (from a Notary Public) that the birthing facility does not perform permanent sterilization procedures such as Bilateral Tubal Ligation (BTL) and vasectomy. 9. Notarized Memorandum of Agreements for outsourced services: ‘a._Patient Transport service provider (if outsourced) b._ Waste management service (f outsourced) ._Pest and vermin control service (if outsourced) 10. Notarized Memorandum of Agreement if birthing home is manned by: d.1. Obstetrician - MOA with Pediatrician or Medical practitioners and/or local government physicians trained on BEmONC. <2 Pediatrician - MOA with Obstetrician or Medical practitioners andlor local government physicians trained on BEMONC ‘4.3 Nurse —MOA with Obstetrician and Pediatrician or a General Physician with a Certificate of Completion of a training on BEmONC ‘d.4 Midwife — MOA with Obstetrician and Pediatrician cor a General Physician with Certificate of Completion Training on BEMONC DOHBHATOAT Revilon3 8032018 Page Sof 10Checklist of Requirements on Equipment, Instruments/Sup| for Birthing Home ’s, and Basic Medicines 1. Bench ‘COMPLIANT 7. ie Extinguisher iN REQT. COMPLIANT ‘terization Area 2.Cabinet 1 8. Open She 1 9. Sandy Generator or (alley operaled pce, ' rechargeable emergency itt) ‘ = 40. Transpor vetcl or MOA wih @ service 40h Ata ee 1 5 Desk ‘stat 11. TypewrteriComputer 1 2 Rafigrator coca (or Breast mik, 6 lectic Fan 1 ‘medicatons and vaccines such as Hepatitis 1 B and BCG) MINIMUM MINIMUM REQT. | COMPLIANT REQT. | COMPLIANT 1. AutoclaveSteam steiizroris equivalent 2, Soaking o decontaminaing solution Treatment Room (same 2s Outpatient Area) 1. Cnical weighing scale (adit) 1 5, Slehoscope 1 2. Examining table 1 6, Tape measure 1 3. Foot too! 1 7. Vaginal speculum 2 4, Gooseneck examining ight Ward (includes Labor Room and Recovery Room) 1. Lubricant (water-based) 5, Thermometer (non-morcuta) 2 Sphygmomanometer(nor-ercura) 6, Wal clock with second hand 1 3. State gloves 2 7. Bed wth guard all 1 | Depends on 4, Stethoscope 1 8, Bod sheets the number of beds DOHaH-LTOAT Revieond ier Page 6 010‘MINIMUM | ‘MINIMUM REQT. COMPLIANT REQT. COMPLIANT ‘rang Room 1 Darya ie? 6 smo a 1 a straight ran 2 7. Instrument cabinet 1 Kony a 1 avert 1 Wend eta 1 Kay pat {ote PO gen co rand is Se Sere ee ‘ requiator, min. § Ibs.) u Binds 1 11 Pal 1 ‘ano foc 1 12 Sea 1 13, Suction apparatus (not for routine 6. Tome fea th wat) 1 Sinn, may ba nents 1 ose aun may bla) 'h. Sterile plastic umbibcal cord clamp(s) 14, Pairs) of sippers (exclusive for birthing or fies. 4 ‘room use) Spee ‘15. Room thermometer (non-mercurial), Ube ot ators 1 rani om enperae aween 25.28 |} Soyet Cassa yw aH 7 provision for semi-upright postion ofthe 1 16. Gowns or patents’ gown renee Beng mae a 2. erin gh aight 1 17 Andros ‘ped ‘Fok 5 18 Sere dapen ‘ported 5. Gomera rang ane 1 19 Seu ‘pers [ conshiroar | Mats el Page 7! 10,‘Newbom Resuscitation Area NIM REaT. | COMPLIANT MINIM REQT. ‘COMPLIANT 1 Emergency Kit or car Portable itor ‘role (should conan the basic medicines, <4. Thermometer (nor-mercura) «2. Weighing scale fornewbom equipment and supplies listed) ‘Basic Medicines Basic Supplies: a | Seneca EET 'b BCG vaccines (stored inside ref at poe abe oe 1 0.70% py te ‘te ‘6. Betamethasone (Diprospan)7mg per ‘xpi plore) Drones ' Depew (1.36, 805.10 | yay (Scancottin) Smgiml per ampule (aiternative) 4. Calcium gluconate 10 mgiampule 1 -d.1V tubings (macro and micro-drip sets) Teach ¢. Diphenhydramine 50 mg/ampule 1 -@. Nasal cannulas or plastic fave masks: f {Epinephrine 1 maim ampule 1 1. Plaster is g. Erythromycin ophthalmic ointment 0.5% or fc | Sayeuacycine cota orient 1 49, Povidone-iogine solution 1 botte +h. Hepalitis B vaccines (stored inside ret at aaa 1 1 Ste ral nies 1 ‘IV fluids (stand by) such as: NDStRocPan Ri Lpertote | ates 1 St ato tek "Plann grt 2oates “val | Aca esti a Liane 2 Nie ete cals | Sin tn plas ‘pack ees i Nes Stange 1 i Sees ‘eee |. Oxytocin 10 units per ampule or Oxytocin gree, ge se nnreat 2 1 ages tee fesion Ton cig vanes 2 mn Siged ae Toe ‘Tieuerone se rp 1 1. Sel ats on oan Kamp 2 Shap cone 1 Basic Equipment eee ‘per bed a. Self inflating bag-valve-mask devices (one ‘rad enter nenbon) omental |, _and masks for the newborn (one size 1 for iSmandene snes) Tas — ae ‘¢. Sphygmomanomeler (non-mercurial) with 1 sae od eaName of Health Faci Date of Inspection: RECOMMENDATIONS: ‘A. For Inspection Process: I] _ Forissuance of License as Birthing Home, Validity from to [ ] Issuance depends upon compliance to the recommendations given and submission of the following within days from the date of inspection: 1] Non-tssuance: Specify reasonis. Inspected by: Printed Name Signature Position/Designation Received by: Signature Printed Name Position/Designation. Date DoHBHLTOAT | Revison3 039097018 Page 9 of 10,Name of Health Facility: Date of Monitoring: RECOMMENDATIONS: ‘A. For Monitoring Process: [ ] Issuance of Notice of Violation [1 Non-issuance of Notice of Violation [1 Others (Specify) Monitored by: Printed Name Signature Position/Designation Received by: Signature Printed Name Position/Designation Date “powsnetoat | Revisor3 osrs218 | Page 100! 10 |