SUMMARY OF FINDINGS

INFIRMARY
P. Gonzales Memorial Hospital, Inc.
582 J. P. Rizal, Lamuan, Malanday, Marikina City

Date of Monitoring: February 15, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 15, 2018

FINDINGS:
 Submit policy addressing patient’s rights
 Proof of directional signages, unobstructed passageways, ramps.
 Proof of completely accomplished patient’s chart (with Partograph and Newborn record if applicable)
 Proof of Clinical Practice Guidelines (CPG) (Top 5 cases of Admissions/Consultations)
 Proof of discharge plan
 Photo of updated organizational chart
 Proof of Administrative Policies, Nursing Procedure Manuals
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging
Waste Management
Patient Safety
Infection Control
Emergency and Disaster Preparedness
CQI
Grievance
Selections and Promotions
 Proof of Annual accomplishment report
 Policies for Dietary, Linen/Laundry, Security of Patients.
 Valid Memorandum of Agreement with Waste Management Service, Ambulance, Security
 Policy for hiring, credentialing, and privileging of staff
 Presence of annual plan for training activities
 Proof of orientation conducted to new personnel
 Proof of Job descriptions with conforme
 Presence of Annual Statistical Reports
 Policy on record storage, safekeeping, maintenance, retention and disposal
 Policy of filing and retrieval of charts
 Policy to protect records and charts against loss, destruction, tampering and unauthorized used.
 Management plans addressing:
a. Safety
b. Security
c. Disposal and Control of Hazardous Wastes
d. Emergency and Disaster Preparedness
 Proof of preventive maintenance of equipment, presence of operating manuals of medical equipment
 Contract or Appointment of person in charge of security.
 Presence of sentinel event reporting system
 Proof of water analysis results (last 6 months)
 Certificate of Training (in-house) or MOA of personnel in-charge of maintenance of equipment
 Proof of designation of Infection Control Physician and Infection Control Nurse
 Policy for the prevention of hospital associated infections (use of PPEs, isolation precautions, and hand washing)
 Policy for prevention and treatment of needle-stick injuries
 Policy for cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments, supplies
  Presence of policies in reporting of notifiable diseases
 Policies and procedures for Waste Disposal
 Presence of Quality Improvement Program and proof of implementation
 Presence of Customer Satisfaction Survey and analysis
PROGRAMS
 Newborn Screening logbook
 Mother-Baby Friendly Accreditation or received copy of letter of intent
 Immunization logbook
 Policy on Anti-smoking and “No Smoking Signage”
 Policy on generic prescribing
 Designation of HEMS Coordinator
 Newborn Screening for Hearing logbook
 Proof of Family Planning acceptors or logbook
 TB Referral logbook
PERSONNEL
 Copy of the following:
- Chief of hospital/medical director - PRC license, certificate of trainings attended, COE or Appointment
- Administrative officer/personnel officer – Diploma , Contract
- Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
- Medical records officer – Contract, trainings, ICD-10 trainings and Records Management Training
- Billing/Cashier – Contract, trainings
- Clerk - Contract, trainings
- Supply Officer/Storekeeper - Contract, trainings
- Building maintenance/Utility worker - Contract, trainings
- Laundry Worker – contract
- Driver – driver’s license, contract
- Cook - contract
- Security guard – contract or MOA
- Nurse Supervisor – Diploma, valid PRC license, contract, Master’s Degree in Nursing or at least 9 units.
- PHYSICIANS NURSES
Doctor’s Name Diploma Valid PRC Contract/ Nurse’s Name Diploma Valid PRC Contract/MOA
MOA
PHYSICAL PLANT REQUIREMENT
 Provision of PWD toilet
 Provision of cadaver holding area
 Provision of toilet for patients and companion with easy access/adjacent to emergency room/OPD
 Provision of toilet within labor room at delivery service
 No ramp/elevator as access to upper level floor – construct ramp/elevator as mean of access for patient and
disabled persons to enhance mobility.

Recommendation for physical plant: - required to apply for upgrading in function of the facilities to meet the
minimum requirement governing the new classification of hospitals as per AO 2012-0012
-Secure approved permit to construct prior to all major addition, alteration
and upgrading as an infirmary level from DOH0NCRO before proceeding with its construction.

EQUIPMENT/INSTRUMENT
Submit photo and official receipt of the following:

ADMINISTRATIVE SERVICE KITCHEN

 Ambulance  Exhaust fan
 Typewriter/computer  Food conveyor
 Emergency light  Food scale
 Fire extinguisher  Stove
 Generator set  Refrigerator
 Utility cart
 Garbage receptacle with cover and color-
coded
EMERGENCY ROOM Cont. EMERGENCY ROOM
 Bag valve mask unit – adult and pediatric
 Calculator - Mayo scissors straight
 Clinical weighing scale - Metzenbaum scissors straight
 Defibrillator - Mosquito forceps curved
 Delivery set (2sets) - primigravid - Mosquito forceps straight
- Metzenbaum scissors straight - Needle holder
- Mayo scissors straight - Scalpel handle #3
- Kelly hemostatic forceps - Scalpel handle #4
- Needle holder - Skin retractor
- Tissue forceps - Tissue forceps
 Delivery set (2sets) – primigravid - Thumb forceps
- Mayo scissors straight  Nebulizer
- Kelly hemostatic forceps  O2 Unit
 EENT Diagnostic set  Pulse oximeter
 Emergency cart  Sphygmomanometer – adult cuff and pedia
 Examining table cuff
 Examining table with stirrups  Stethoscope
 Gooseneck lamp  Suction apparatus
 Instrument table  Suturing set
 Laryngoscope with different sizes  Thermometer – oral and rectal
 Minor set  Vaginal speculum
- Kelly hemostatic forceps straight  Wheelchair\Wheeled stretcher with side
- Kelly hemostatic forceps curved rails
 OUT-PATIENT DEPARTMENT DELIVERY ROOM
 Clinical Height And Weight Scale  Air-condition unit
 EENT Diagnostic set with ophthalmoscope & otoscope  Bag valve mask – adult and pediatric
 Gooseneck lamp  D & C set
 Instrument table - Hysterometer
 Minor set - Uterine forceps
- Kelly hemostatic forceps straight - Dull uterine forceps
- Kelly hemostatic forceps curved - Sharp uterine forceps
- Mayo scissors straight - Vaginal retractor
- Metzenbaum scissors straight - Vaginal speculum
- Mosquito forceps curved - Ovum forceps
- Mosquito forceps straight - Hegars dilator
- Needle holder - Sponge forceps
- Scalpel handle #3  Delivery set (2sets) - primigravid
- Scalpel handle #4 - Metzenbaum scissors straight
- Skin retractor - Mayo scissors straight
- Tissue forceps - Kelly hemostatic forceps
- Thumb forceps - Needle holder
- Neurologic hammer - Tissue forceps
 Delivery set (2sets) – primigravid
 Sphygmomanometer – adult cuff and pedia cuff - Mayo scissors straight
 Stethoscope - Kelly hemostatic forceps
Thermometer – oral and rectal  DR Light
 DR table
 Clinical infant weighing scale
 Instrument table
 Kelly pad
 Oxygen tank
 Emergency light
 Sphygmomanometer, non-mercurial
 Stethoscope
 Suction apparatus
 Thermometer, non-mercurial
 Wheeled stretcher
LABOR ROOM CSSR
 Oxygen unit  Autoclave
 Patient bed CADAVER HOLDING AREA
 Sphygmomanometer – adult cuff and pedia cuff  Bed or stretcher for cadaver
 Stethoscope
 Thermometer – oral and rectal
NURSING UNIT/WARD
 Bag valve mask unit – adult and pediatric
 Clinical height and weight scale
 Emergency light
 Patient bed with locked
 Bedside table
 Nebulizer
 Neurologic hammer
 O2 tank
 Sphygmomanometer adult cuff and pedia cuff
 Stethoscope
 Suction apparatus
 Thermometer – oral and rectal
 E-CART CONTENTS BASIC ER SUPPLIES
 Salbutamol  Oropharyngeal and nasopharyngeal airways
 D50W 50mg/vial  Intubation kit
 Activated charcoal  Alcohol disinfectant
 Anti-rabies vaccine – active  Arm sling
 Anti-rabies vaccine – passive  Aseptic bulb syringe
 Amiodarone  Biomedical refrigerator
 Anti-tetanus serum  Calculator
 Aspirin USP grade 325mg/tablet  Cardiac board
 Atropine  Cardiac/EKG Leads
 Benzodiazepine(diazepam)  Cervical collars
 Calcium gluconate  Sharps container
 D5 0.3 NaCl 500ml/bottle  Elastic bandages (diff sizes)
 D5 LR 1L/bottle  Flash light/penlight
 D5 NSS 1L/bottle  Emergency light
 Digoxin 0.5mg/ampule  Sphygmomanometer, non-mercurial
 Diphenhydramine 250mg/ampule  Stethoscope
 Dobutamine  Suction apparatus
 Dopamine  Thermometer, non-mercurial
 Epinephrine  Wheeled stretcher
 Furosemide 20mg/2ml ampule  Gloves
 Haloperidol 50mg/ampule  Hydrogen peroxide
 Hydrocortisone 250mg/vial  Nasal cannula
 Hyoscine N-butyl-bromide 20mg/vial  Povidone iodine
 Lidocaine 5% solution cial 1g/50ml  protective face shield or mask
 MgSO4  Pulmonary Function Test
 Mannitol  Spine board with straps
 Mefenamic acid 500mg/tablet  Splinting devices
 Methylprednisolone 4mg/tablet  Face mask (standard)
 Metoclopramide 10mg/ampule  Sterile gauze
 Morphine SO4 10mg/ampule  Sutures
 Nitroglycerine spray or isosorbide dinitrate 5mg  Syringes
tablet5/ampule  Urethral catheter
 Noradrenaline 2mg/ampule  Urine collection bag
 ORS sachet  Waterproof aprons
 Paracetamol 300mg/ampule (IV prep)  X-ray reading lamp o negatoscope
 Phenobarbital 30mg/ml IV or 30mg tablet
 Plain LRS 1L
 Plain NSS 1L
 Potassium Chloride 20mEq/vial
 Pyridoxine 1g/ampule
 Sodium bicarbonate 50mEq/ampule
 Tetanus toxoid 0.5ml/vial
 Thiamine
 Tramadol
 Verapamil
MONITORED BY: