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Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179 URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : :

1. GENERAL INFORMATION Owner Chief of Hospital/Medical Director Classification : : : General Special Government [ [ ] ]

Private

[ ] National Local Others, please specify [ ] Single Proprietorship Partnership Corporation Civic Organization Religious Foundation Others, please specify

[ [

] ]

[ [ [ [ [ [

] ] ] ] ] ]

Chairman of the Board (If Corporation) Authorized Bed Capacity Implementing Bed Capacity

:

: :

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Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179 URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : :

2. SERVICE CAPABILITY 2.1. Service Capability of a Level 2 Hospital: 2.1.1. Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care Clinical services provided in the Level 1 Hospital, as well as specialty clinical care Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) Nursing care provided in the Level 1 Hospital, as well as total and intensive skilled care

2.1.2. 2.1.3. 2.1.4.

2.2.

The hospital shall render quality health services appropriate to the level of care being provided:
Manual of Operations/ Written Policies and Procedures Duties and Responsibilities Master Staffing Plan Organizational Chart Written Vision and Mission

SERVICE

AVAILABILITY
( if Available)

REMARKS

Administrative Service Personnel Accounting − Bookkeeping − Cashiering − Billing − Collection Medical Records Supply Housekeeping (May be contracted out) Laundry and Linen (Laundry service may be contracted out but is subject to infection control mechanisms.)
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provided that a contract of service or memorandum of agreement with a secondary clinical laboratory located within the locality must be secured. the patient can feed. bathe. but requires some assistance from the nursing staff for special treatment of certain aspects of personal care. moderate or partial care category.Form HOS-LTO-IT/L2-2007 Manual of Operations/ Written Policies and Procedures Duties and Responsibilities Master Staffing Plan Organizational Chart Written Vision and Mission SERVICE AVAILABILITY ( if Available) REMARKS Maintenance (May be contracted out) Patient Transport Service ((May be contracted out. Page 3 of 22 . 1994). SERVICE Ancillary Service Secondary Clinical Laboratory Radiology – 2nd Level Pharmacy AVAILABILITY ( if Available) LICENSE NUMBER DATE ISSUED VALIDITY REMARKS A primary clinical laboratory may be considered. May be contracted out but located within the premises of the hospital. please specify As defined in the Hospital Nursing Service Administration Manual (DOH. available for 24 hours) Security (May be contracted out) Dietary (May be contracted out) Social Service Clinical Service General Clinical Care − Medicine − Pediatrics − Obstetrics and Gynecology − Surgery and Anesthesia Emergency Service Outpatient Service Nursing Service Intermediate Care and Management Health Education and Counseling Others. under the intermediate. and results for emergency cases must be transmitted within one hour. dress and go to the toilet by himself without help.

5. [ ] Yes [ ] No 2. Medical Records Medical records contain patient information that is uniquely identifiable. [ ] Yes [ ] No Page 4 of 22 . Nursing Procedure Manual [ ] Yes [ ] No Properly Utilized Kardex [ ] Yes [ ] No The delivery of nursing care utilizes the nursing process. Emergency Room Personnel to deliver emergency care are available for 24 hours. [ ] Yes [ ] No An exit interview is conducted for personnel who resign or retire from the service.3. Administrative Service The performance of each personnel is monitored and evaluated. [ ] Yes [ ] No A Nursing Procedure Manual and a properly utilized Kardex are available in all patient care units.4.2. current. confidential and accessible when required.3.3.Form HOS-LTO-IT/L2-2007 2. Nursing Service Nursing care is provided at all times. Hospital Operations 2. [ ] Yes [ ] No 2. [ ] Yes [ ] No Written policies for all nursing service areas within the hospital are available and reviewed annually. [ ] Yes [ ] No 2. medicines and supplies necessary to provide emergency care are available.3. [ ] Yes [ ] No 2. accurately recorded. [ ] Yes [ ] No All equipment.3.3.1. Obstetrical Service Proper identification of newborns is ensured before they leave the delivery room and until discharge. [ ] Yes [ ] No New personnel receive an orientation program that covers the essential components of the service being provided.3.

[ ] Yes [ ] No Birth certificate forms are properly and completely filled up. procedures and/or operations performed on patients are recorded using ICD – 10.Form HOS-LTO-IT/L2-2007 Medical diagnoses. [ ] Yes [ ] No The Medical Records Officer is trained in ICD – 10. [ ] Yes [ ] No Records of medico – legal cases are properly and completely filled up. [ ] Yes [ ] No A Patient Logbook is properly filled up in the following areas: Admitting Office [ ] Yes [ ] No Emergency Room [ ] Yes [ ] No Outpatient Department [ ] Yes [ ] No Operating Room [ ] Yes [ ] No Delivery Room [ ] Yes [ ] No Patient Charts are properly and completely filled up and contain up-to-date information on the following: In-Patient Out-Patient Contents of Medical Chart ( if ( if available) Available) Identification Data Chief Complaint History of Present Illness Physical Examination Diagnosis/Admitting Diagnosis Admitting/Attending Physician Clinical Laboratory Report X-ray Report Consultation/Referral Notes Medication/Treatment Progress Notes Final Diagnosis Nursing Record Discharge Summary Obstetrical Record (if applicable) Consent Doctor’s Order Sheet Records of newborns are properly and completely filled up. [ ] Yes [ ] No Death certificate forms are properly and completely filled up. [ ] Yes [ ] No Page 5 of 22 . [ ] Yes [ ] No ICD – 10 reference books are available.

7719 National Blood Services Act of 1994 and Its Implementing Rules and Regulations). 7719 National Blood Services Act of 1994 and Its Implementing Rules and Regulations). [ ] Yes [ ] No The hospital obtains blood and blood products collected from healthy voluntary blood donors only (as required by R. Health Promotion and Disease Prevention The hospital has a health promotion and disease prevention program that shall include the following: Breastfeeding (as required by R.4. Human Resource Development The hospital implements a human resource development program that identifies.A. [ ] Yes [ ] No 2.A. [ ] Yes [ ] No 2.3. [ ] Yes [ ] No 2. Programs 2.4.6.A. 9288 Newborn Screening Act of 2004 and Its Implementing Rules and Regulations) [ ] Yes [ ] No Rooming-In (as required by R.3. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] No Family Planning [ ] Yes [ ] No Immunization [ ] Yes [ ] No Newborn Screening (as required by R. [ ] Yes [ ] No Page 6 of 22 . [ ] Yes [ ] No An appraisal system identifies and reviews the effectiveness and appropriateness of the training provided.4.A.2. facilitate and record training and education for all personnel. plan. Blood Services The hospital ensures that its supply of blood and blood products is safe.1. Disaster Management The hospital has a documented emergency and disaster management plan.Form HOS-LTO-IT/L2-2007 Confidentiality of patient information is maintained at all times.A. [ ] Yes [ ] No The hospital obtains blood and blood products only from blood service facilities licensed/authorized by the Department of Health (as required by R. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] No 2.4.

near misses. or untoward events such as: Accidents. investigation. incidents. objectives and scope.5. quality responsibility. please specify Page 7 of 22 . authority and resources. Hospital Committees Availability of Documentation on Committee Membership ( if Available) Availability of Written Policies and Procedures ( if Available) Committee Availability of Minutes of Meetings ( if Available) Availability of Monitoring and Evaluation Reports ( if Available) Blood Transfusion Credentials Fire Safety HIV/AIDS (as required by R. and quality activities and review processes. 8504 Philippine AIDS Prevention and Control Act of 1998) Infection Control Medical Audit Quality Assurance Therapeutics Waste Management Others. reporting.Form HOS-LTO-IT/L2-2007 2. Quality Management The hospital has an established.A. corrective action and review process for adverse.4. unplanned. and adverse clinical events [ ] Yes [ ] No Complaints and suggestions [ ] Yes [ ] No Infectious / Notifiable diseases [ ] Yes [ ] No Service shortfalls [ ] Yes [ ] No 2. analysis.4. documented and maintained quality management program that reflects continuous quality improvement principles. [ ] Yes [ ] No The program identifies the organization’s quality goals. [ ] Yes [ ] No There is an exception reporting system that includes the recording.

PERSONNEL 3.1. prior to employment. 1003 Manila Trunk Line: 743-83-01. including evidence of professional registration/license. [ ] Yes [ ] No 3.gov. Cruz.1. Direct Line: 711-6982.1. skilled and/or experienced to provide the service and meet patient needs.ph/ INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : : 3.2. 3. The health facility appoints and allocates personnel who are suitably qualified.3.1. POSITION Administrative Service Chief of Hospital / Administrative Officer Clerk (Pool) Clerk (Accounting. accountability and functions of the position. designation can be flexible as long as function is present) Medical Records Clerk Storekeeper/Linen Custodian Utility Worker (May be contracted out) Driver (May be contracted out) REQUIREMENT COMPLIANCE ( if Compliant) STATUS (FT if Full Time) (PT if Part Time) REMARKS 1 1:50 beds 1 1:50 beds 1 1/shift 1 Page 8 of 22 . skilled and/or experienced to assume the responsibilities.doh. San Lazaro Compound. where applicable. [ ] Yes [ ] No An organized medical and nursing staff shall be responsible for the quality of patient care and for the ethical conduct and professional practices of its members.Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES Building 15.1. [ ] Yes [ ] No Professional qualifications are validated. Fax: 781-4179 URL: http://www. 3. Each personnel is qualified. authority. Sta. Rizal Avenue.

patients may be referred to the Municipal/City/Provincial Social Worker.) Cook/Food Service Worker Medical Social Worker REQUIREMENT 1 COMPLIANCE ( if Compliant) STATUS (FT if Full Time) (PT if Part Time) REMARKS 1 1 In the absence of a Medical Social Worker. there must be one (1) reliever. For every three (3) Nurses. For every three (3) Nurses or Nursing Attendants/Midwives. there must be one (1) reliever. nutritionist/dietitian should be residing within the locality. Otherwise. Page 9 of 22 . The number of beds used in the ratio is the actual number of occupied Critical Care Unit beds at the time of inspection. Critical Care Units include all Intensive Care Units (ICUs) and Post-Anesthesia Care Unit (PACU)/Recovery Room (RR). Nursing Service Chief Nurse / Supervising Nurse + Staff Nurse Nursing Attendant/Midwife Others. Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four (24) beds. please specify 1 1:12 beds at any time 1:24 beds at any time + The number of registered nurses supervised should not exceed fifteen (15). Plantilla items are not required. Clinical Service Physician 1:20 beds at any time plus one (1) reliever 1 Physician (On call) The physician must not go on continuous duty for more than forty-eight (48) hours. there must be one (1) reliever. If the ABC is 24 beds and above. provided there is a Memorandum of Agreement between the hospital and the local government. For every three (3) Nursing Attendants/Midwives. the ratio will apply. In case of shared service.Form HOS-LTO-IT/L2-2007 POSITION Nutritionist/Dietitian (May be contracted out. one (1) Chief Nurse and one (1) Supervising Nurse are required.

Form HOS-LTO-IT/L2-2007 3. [ ] Yes [ ] No AND At least two (2) years of experience in a nursing supervisory/managerial position. Administrative Service The Chief of Hospital has: Completed at least twenty (20) units towards a master’s degree in hospital administration or related course. [ ] Yes [ ] No Page 10 of 22 . [ ] Yes [ ] No 3.2. Hospital Organization 3. [ ] Yes [ ] No OR At least three (3) years of experience in a supervisory/managerial position.2. [ ] Yes [ ] No OR At least three (3) years of experience in a supervisory/managerial position.2. [ ] Yes [ ] No The Administrative Officer has: Completed at least twenty (20) units towards a master’s degree in hospital administration or related course.2. Nursing Service The Chief Nurse has: Completed at least nine (9) units towards a master’s degree in nursing service administration or related course .1.

Records of equipment are maintained and updated regularly.1. All equipment and instruments necessary for the safe and effective provision of services are available and are properly maintained. ITEM Administrative Service − − − − Computer/Typewriter Fire Extinguisher Standby Generator Food Conveyor (closed type) − Refrigerator/Freezer − Stove − Transport Vehicle (Available for 24 hours) REQUIREMENT COMPLIANCE ( if Compliant) ( CONDITION if Serviceable) REMARKS 1 2 1 1 1 1 1 Page 11 of 22 . EQUIPMENT/INSTRUMENT 4.1.1. 1003 Manila Trunk Line: 743-83-01.1. [ ] Yes [ ] No 4.2.1.1. 4.3.Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES Building 15. [ ] Yes [ ] No Personnel are competent when using equipment in line with manufacturer’s instruction/operational manual. 4. Sta. 4. Fax: 781-4179 URL: http://www. [ ] Yes [ ] No There is a plan in place for essential equipment replacement. Direct Line: 711-6982. [ ] Yes [ ] No Operational manuals of all equipment and instruments are available for reference and guidance. San Lazaro Compound. Cruz.1.ph/ INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : : 4.5.doh.4. Rizal Avenue. 4. [ ] Yes [ ] No A preventive maintenance program ensures that all equipment are maintained and/or calibrated to an appropriate standard or specification.gov.

Pediatric Cuff Set − Stethoscope − Suction Apparatus − Suturing Set − Vaginal Speculum Set − Wheelchair − Wheeled Stretcher Surgical Service – Obstetrical Service − Air-conditioning Unit − Anesthesia Machine − Bassinet − C/S Set − D/C Set − Delivery Set − DR Light − DR Table with Stirrup − Infant Weighing Scale − Instrument Table − Kelly Pad − Laparotomy Set REQUIREMENT COMPLIANCE ( if Compliant) ( CONDITION if Serviceable) REMARKS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Page 12 of 22 .Form HOS-LTO-IT/L2-2007 ITEM Clinical Service Emergency Room – Outpatient Department − Ambu Bag .Adult Cuff .Adult .Pediatric − Clinical Weighing Scale − EENT Diagnostic Set (or its equivalent) − Emergency Cart (or its equivalent) − Examining Table − Gooseneck Lamp / Examining Light − Instrument Table − Medicine Cabinet − Minor Surgery Instrument Set − Nebulizer − Neurological Hammer − Oxygen Unit − Sphygmomanometer .

Adult Cuff .Adult Pediatric REQUIREMENT 1 1 1 1 1 1 1 1 1 1 1 1 COMPLIANCE ( if Compliant) ( CONDITION if Serviceable) REMARKS − Bedside Table − Clinical Weighing Scale − Emergency Cart (or its equivalent) − Patient Bed − Nebulizer − Oxygen Unit 1/Nursing Unit (in Adult Units) 1/Nursing Unit (in Pediatric Units) Depends on ABC* 1/Nursing Unit 1/Nursing Unit Depends on ABC* 1/Nursing Unit 1/Nursing Unit plus one (1) standby oxygen unit 1/Nursing Unit 1/Nursing Unit (in Adult Units) 1/Nursing Unit (in Pediatric Units) 1/Nursing Unit 1/Nursing Unit − Sphygmomanometer .Pediatric Cuff Set − Spinal Set − Stethoscope − Suction Apparatus − Wheeled Stretcher Nursing Unit − Ambu Bag .Adult Cuff Pediatric Cuff Set − Stethoscope − Suction Apparatus * Authorized Bed Capacity Central Sterilizing and Supply Room − Autoclave 1 Page 13 of 22 .Form HOS-LTO-IT/L2-2007 ITEM − Laryngoscope with Blades − Major Surgical Instrument Set − OR Light − OR Table − Oxygen Unit − Sphygmomanometer .

please specify Page 14 of 22 .Form HOS-LTO-IT/L2-2007 ITEM REQUIREMENT COMPLIANCE ( if Compliant) ( CONDITION if Serviceable) REMARKS Others.

AREA Administrative Service Lobby − Waiting Area − Information and Reception Area − Toilet Business Office Medical Records Room Office of the Chief of Hospital/Administrative Officer Laundry and Linen Area Maintenance and Housekeeping Area Parking Area for Transport Vehicle Supply Room Waste Holding Room Dietary − Dietitian Area − Supply Receiving Area − Cold and Dry Storage Area − Food Preparation Area − Cooking and Baking Area Page 15 of 22 COMPLIANCE ( if Compliant) ( LIGHTING if Adequate) VENTILATION ( if Adequate) REMARKS . Sta. 1003 Manila Trunk Line: 743-83-01.ph/ INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : : 5.gov. PHYSICAL PLANT 5. Direct Line: 711-6982.1. San Lazaro Compound. Cruz. Fax: 781-4179 URL: http://www. All physical facilities and utility systems necessary for the safe and effective provision of services are available and are properly maintained.doh. Rizal Avenue.Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES Building 15.

all the areas specified under OPD are required. The rest of the areas under OPD are not required.Form HOS-LTO-IT/L2-2007 AREA − Serving and Food Assembly Area − Washing Area − Garbage Disposal Area − Dining Area − Toilet Cadaver Holding Room COMPLIANCE ( if Compliant) ( LIGHTING if Adequate) VENTILATION ( if Adequate) REMARKS Not required if the service is contracted out. Clinical Service Emergency Room − Waiting Area − Toilet (adjacent or within ER) − Nurse Station − Examination and Treatment Area with Lavatory/Sink − Observation Area − Equipment and Supply Storage Area − Wheeled Stretcher Area Outpatient Department − Waiting Area − Toilet (accessible) − Admitting and Records Area − Consultation Area − Examination and Treatment Area with Lavatory/Sink OPD and ER departments may be combined in one complex. Surgical and Obstetrical Service − Major Operating Room − Delivery Room − Sub-sterilizing Area / Work Area Page 16 of 22 . If OPD and ER are combined in one complex. If OPD and ER are separate. only this area under OPD is required.

[ ] Yes [ ] No Not located adjacent to railroads.2. Environment The hospital is: Readily accessible to the community. [ ] Yes [ ] No Free from undue noise. flood. industrial plants. and waste disposal plants. freight yards. airports. − Janitor’s Closet Nursing Unit − Patient Room (Male and Female) − Toilet (Male and Female) − Isolation Room with Toilet − Nurse Station − Treatment and Medication Area with Lavatory/Sink Central Sterilizing and Supply Room − Receiving and Releasing Area − Work Area − Sterilizing Area − Sterile Supply Storage Area Nursing Service Office of the Chief Nurse COMPLIANCE ( if Compliant) ( LIGHTING if Adequate) VENTILATION ( if Adequate) REMARKS 5. foul odor. smoke. dust.Form HOS-LTO-IT/L2-2007 AREA − Sterile Instrument. children’s playgrounds. Supply and Storage Area − Scrub-up Area − Clean-up Area − Dressing Room − Toilet − Nurse Station / Work Area − Wheeled Stretcher Area. [ ] Yes [ ] No Page 17 of 22 .

3. [ ] Yes [ ] No Exits terminate directly at an open space to the outside of the building. attached equipment and any escorts of patients who require to be transported or transferred between rooms or services in their beds.8. [ ] Yes [ ] No Smoking is absolutely prohibited throughout the hospital in accordance with R. [ ] Yes [ ] No 5. Lighting and Ventilation Areas used by patients and personnel are adequately lighted and ventilated. Occupancy The location of the hospital complies with all local zoning ordinances. [ ] Yes [ ] No 5. corridors. remote from each other. personnel and public. Safety The hospital provides and maintains a safe environment for patients.A. and exterior stair.7. are provided for each floor of the building. interior stair. Patient Movement Adequate space is provided to allow patients and personnel to move safely around patient bed areas. [ ] Yes [ ] No A minimum of two (2) exits. [ ] Yes [ ] No Page 18 of 22 .5. [ ] Yes [ ] No 5. [ ] Yes [ ] No Exits are restricted to the following types: door leading directly outside the building. [ ] Yes [ ] No 5.4. [ ] Yes [ ] No Buildings pose no hazards to the life and safety of patients.6. Exposure to Environmental Tobacco Smoke Patients and personnel are not put at risk by exposure to environmental tobacco smoke. Security The hospital ensures the security of person and property within the facility. elevators and turning areas readily accommodate the bed. personnel and public. ramp. 9211 Tobacco Regulation Act of 2003.Form HOS-LTO-IT/L2-2007 5. [ ] Yes [ ] No 5. [ ] Yes [ ] No Patients who use mobility aids are able to safely maneuver with the assistance of their aid within their bed area. [ ] Yes [ ] No Doorways.

. examination..10.... [ ] Yes [ ] No A ramp or elevator is provided for ancillary......... and/or procedure are conducted in a manner or environment where these cannot be observed or the risk of being overheard by others is minimized.. The water tank/water reservoir is flushed regularly. The hospital has a waste management program... [ ] Yes [ ] No Corridors in areas not commonly used for bed....11... Water Supply The hospital has an approved water supply system.83 Meters in width. [ ] Yes [ ] No Page 19 of 22 ....... [ ] Yes 5..1............ clinical and nursing services located on the upper floor... Auditory and Visual Privacy Adequate privacy for patients is provided such that sensitive or private discussion... [ [ ] No ] Yes [ ] No The hospital has available water supply that is potable and safe for drinking......... [ ] Yes [ ] No A ramp is provided as access to the entrance of the hospital or health facility that is not on the same level of the site. [ ] Yes [ ] No DOH licensed facilities shall be given until end of 2010 to comply. Power Supply The hospital has an approved power supply system. 5...12.....9. [ ] Yes [ ] No Records of water analysis (bacteriological examination) are available and updated regularly (at least annually).12....Form HOS-LTO-IT/L2-2007 Corridors and ramps for access by patient and equipment are at least 2. 5.. [ ] Yes [ ] No 5.......... Waste Management 5.......... [ ] Yes [ ] No Frequency ............. [ ] Yes [ ] No Frequency .... stretcher and equipment transport are at least 1..... [ ] Yes [ ] No Panel boards and feeders are properly coded and labeled.....44 Meters in width...

...... [ ] Yes [ ] No 5. Ward [ ] Yes [ Dietary Service [ ] Yes [ ] No ] No Page 20 of 22 ..................... [ ] Yes [ ] No Frequency ...13.. Liquid Waste Liquid waste is discharged into a multi-chamber septic tank.. storage..................... Memorandum of Agreement is available and updated. and disposal of wastes are provided to and used by personnel...................... [ ] Yes [ ] No 5............ Solid Waste Solid waste is collected.............. [ ] Yes [ ] No OR Liquid waste is discharged into municipal/city sewers that are connected to a sewage treatment plant...... Black Trash Bag (General – Non-Infectious – Dry) [ ] Yes [ ] No Green Trash Bag (General – Non-Infectious – Wet) [ ] Yes [ ] No Yellow Trash Bag (Infectious – Pathological) [ ] Yes [ ] No Sharp Container (Sharps) [ ] Yes [ ] No Logbook Available and Updated [ ] Yes [ ] No Frequency ........12......... Records are available and updated.......... coding and labeling of waste......... Sanitation The hospital observes pest and vermin control: In-House [ ] Yes [ ] No Contractor [ ] Yes [ ] No Company Name ....12... 2004. There are screen wires on doors............. and other openings......3...... [ ] Yes [ ] No Frequency ... treated and disposed of in accordance with the Health Care Waste Management Manual of the Department of Health. windows........ [ ] Yes [ ] No The hospital observes segregation...Form HOS-LTO-IT/L2-2007 5.. Protective equipment and clothing appropriate to the risks associated with the handling.........................2..............

......... ease of cleaning and fire resistance........18.. Maintenance A building maintenance program is in place to ensure that all buildings/facilities are kept in a state of good repair...... [ ] Yes [ ] No [ ] Yes [ ] No Separate toilets are available for patients and personnel. 5. [ ] Yes [ ] No 5..Form HOS-LTO-IT/L2-2007 5. Segregation Wards observe segregation of sexes. Material Specification Floors. Signage There are visual aids and devices for: Information and Orientation Direction Identification Prohibition and Warning Official Notice 5.....17. male and female.. walls and ceiling are made of sturdy materials that allow durability.. Permits A Permit to Construct is available for: Construction of New Hospital (if applicable) [ ] Yes [ ] No Alteration/Expansion/Renovation of Existing Hospital (if applicable) [ ] Yes [ ] No Change in Classification (if applicable) [ ] Yes [ ] No Increase in Bed Capacity (if applicable) [ ] Yes [ ] No [ [ [ [ [ ] Yes ] Yes ] Yes ] Yes ] Yes [ [ [ [ [ ] No ] No ] No ] No ] No Page 21 of 22 .15....16. [ ] Yes [ ] No 5...14........... [ ] Yes [ ] No Frequency . [ ] Yes [ ] No A building/facility inventory is maintained and updated regularly..... Written policies and procedures are available.....

Form HOS-LTO-IT/L2-2007 Republic of the Philippines Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES Building 15. Direct Line: 711-6982. Rizal Avenue. San Lazaro Compound.doh. Fax: 781-4179 URL: http://www. 1003 Manila Trunk Line: 743-83-01. Cruz. Sta.ph/ INSPECTION TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : : PERSONS INTERVIEWED: Printed Name and Signature Position SURVEYED BY: Printed Name and Signature Position DATE ___________________________ TIME ___________________________ Page 22 of 22 .gov.