SUMMARY OF FINDINGS

INFIRMARY
NEOPOLITAN MEDICAL MATERNITY CHILDRENS & LYING-IN CLINIC, INC.
KM. 23 Flordeliza Bldg. Quirino Highway, Lagro, Novaliches, Quezon City

Date of Monitoring: August 14, 2018 FULL COMPLIANCE DATE: _____________________

Evaluated by: _______________________________
Date Prepared: August 20, 2018

VIOLATIONS: 1. Physical facilities not compliant to AO 2012-0012

2. Inadequate personnel complement in the nursing service
FINDINGS:
 Submit policy addressing patient’s rights
 Proof of Clinical Practice Guidelines (CPG) (Top 5 cases of Admissions/Consultations)
 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 x x x
Waste Management x x x
Patient Safety x x x
Infection Control x  x
Emergency and Disaster Preparedness x  x
CQI x x x
Grievance x x x
Selections and Promotions x x x
 Proof of Annual accomplishment report
 Valid Memorandum of Agreement with Waste Management Service, Ambulance, Security
 Policy for credentialing, and privileging of staff
 Presence of annual plan for training activities
 Proof of orientation conducted to new personnel
 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. Security
b. Disposal and Control of Hazardous Wastes
 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
 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
PROGRAMS
 Policy on Anti-smoking
 Policy on generic prescribing
 Designation of HEMS Coordinator, proof of drills/exercises, response or recovery plan
 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
- Building maintenance/Utility worker - Contract, trainings
- Driver – driver’s license, 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 – to hire 1 fulltime nurse (plus 3 reliever-optional)
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
 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:
KITCHEN OUT-PATIENT DEPARTMENT
 Food conveyor  Gooseneck lamp
 Food scale
 Utility cart
Garbage receptacle with cover and color-coded
EMERGENCY ROOM DELIVERY ROOM
 Defibrillator – out of service  Emergency light
 Delivery set (2sets) - primigravid
- Metzenbaum scissors straight
 Gooseneck lamp
 Sphygmomanometer –pedia cuff
 LABOR ROOM CADAVER HOLDING AREA
 Oxygen unit (anchored)  Bed or stretcher for cadaver
 Sphygmomanometer – adult cuff and pedia cuff
 Stethoscope
 Thermometer – oral and rectal
NURSING UNIT/WARD
 EENT Diagnostic Set
E-CART CONTENTS BASIC ER SUPPLIES
 D50W 50mg/vial  Intubation kit
 Anti-rabies vaccine – passive  Aseptic bulb syringe
 Digoxin 0.5mg/ampule  Cervical collars
 Dobutamine  protective face shield or mask
 Dopamine  Waterproof aprons
 Haloperidol 50mg/ampule
 MgSO4
 Methylprednisolone 4mg/tablet
 Morphine SO4 10mg/ampule
 Nitroglycerine spray or isosorbide dinitrate 5mg
tablet5/ampule
 Noradrenaline 2mg/ampule
 Phenobarbital 30mg/ml IV or 30mg tablet
 Potassium Chloride 20mEq/vial
 Sodium bicarbonate 50mEq/ampule
 Tramadol
 Verapamil
MONITORED BY:

Dr. Dindo
Oliver
Cynthia
Carol
Aldo