Rencana Tindakan Perbaikan/Corrective Action Plan (“CAP”)
Unimedika Sepatan Mulia Tangerang (UMST) – PT Hero Yoyo Sudarsa (HYS)
Signing: 11 October 2021
No
Finding Description
.
1 Public disclosure of the company's activities,
impacts, and developments is one of the
prerequisites for IIF financing. UMST is expected to
produce a letter or statement of approval enabling
IIF to upload the Environmental Permit and
Assessment Document (i.e., UKL-UPL) and other
related S&E documents on the IIF website prior to
signing the facility agreement.
2 Based on SEDD, in terms of managing S&E aspects,
several components of the Social and
Environmental Management System (SEMS) are
already available or developed by UMST (eg S&E
policy, an organizational structure with specialized
personnel, etc.). After the SEDD process is
complete, UMST notifies that they have prepared
the SEMS document (which was not previously
provided during the SEDD process). Based on the
review of the IIF S&E team, the document can still
be further developed to complement the SEMS in
accordance with the first IIF Social and
Environmental Principles (SEP 1).
3 Stakeholder Engagement Plan
The available SEMS documents have included
general descriptions/guidelines related to
engagement with multiple stakeholders. However,
the explanation does not include a detailed plan or
Output Parameter Status
1. A letter of approval from UMST signed by COMPLETED
the Director or Hospital Manager allowing
IIF to upload UKL-UPL documents on the
IIF website during the period of the IIF
financing facility.
2. Copy of UKL-UPL document uploaded on
IIF website.
1. The UMST SEMS document that has been 1. Completed
reviewed and updated (which includes a Unimedika has submitted the SEMS
compilation of all requested components) Document. The document is considered
has been signed by the Director or adequate.
Hospital Leader.
2. COMPLETED
2. Documentation/proof of The SEMS dissemination was conducted
dissemination/socialization of SEMS to all through an email to all employees and a
workers, which can be in the form of direct approach to workers. It is evident
attendance lists, photos, emails, etc. through photos and a list of participants
who receive the dissemination.
1. Stakeholder Engagement Plan Document 1. ATTENTION REQUIRED
which includes stakeholder mapping, The document has been submitted on 15
plans, and programs to manage and November 2022. However, the submitted
maintain relationships with relevant document covering implementation of its
No
Finding Description Output Parameter Status
.
strategy regarding the form of engagement that will stakeholders. SEP. the SEP itself not found in the
be carried out with the identified stakeholders, submitted document. SED write a review
including communities potentially affected by the on the document for UMST references/
project. guidances in revising the document.

2. Annually

2. Documentation of the implementation of

stakeholder engagement (in the form of a
report).
4 Grievance Mechanism
In terms of employment, UMST does not yet have a 1. Worker grievance mechanism for UMST 1. ATTENTION REQUIRED
formal procedure for handling worker complaints. employees
Complaints are usually submitted directly to the
worker's supervisor without any documentation or
reports of complaints handling actions and the 2. Records of patient, community, and
status of their resolution. worker complaints with completion
status.
Note: For workers' complaint records, UMST
only needs to convey the type of complaint
and the status of the settlement, without the informs coordination meetings related to
need to disclose confidential data from
workers.
The document submitted by Unimedika
only contains grievance procedures for
the community and patient, while it
should also include the grievance
mechanism for their own workers. A
document was submitted on 31 August
2022, but it does not reflect a procedure
related to the grievance mechanism for
UMST employees. The document only
grievances, issues, and communication
related to Hospital operations. UMST
may refer to UMSB procedure for the
workers grievance mechanism.
Therefore, UMST is still required to
submit the Grievance Mechanism for
workers. By email, UMST confirmed that
will submit the document on Dec 2022
No
Finding Description
.
5 Management Program
During the construction phase, UMST shall identify
and develop the S&E risk management measures
that the contractor will require, which can be done
by developing a “Contractor Management Plan”
(CMP) or “Contractor S&E Requirements”. The CMP
should describe the various S&E considerations and
mitigations, controls, and commitments associated
with the contractor's main activities and clearly
define responsibilities, performance measurements,
and reporting requirements. Based on the document
review, UMST already has safety procedures during
renovation and construction (SPO/UMST/FMS-
K3RS/001). However, we note that these
procedures are general requirements and can be
updated or improved in accordance with IIF
standards.
During the operations phase, UMSTs need to
identify and develop programs related to the S&E
aspects they will implement, which may include
programs, performance indicators, targets,
evidence, resource estimates, etc.
Output Parameter
1. Updated Contractor Management Plan or
SOP regarding safety procedures during
renovation and construction that is
acceptable to IIF
2. The Construction Monitoring Report is
accompanied by evidence or
documentation of the implementation of
S&E management during construction
(e.g., provision of traffic safety signs in
the project area, sanitation area,
hazardous materials management, etc.)
Status
2. Annually
1. COMPLETED
UMST has prepared a document
consisting of direction for the contractor
to conduct the construction phase. It
includes contractor’s responsibility to
provide reporting to UMST, proper
facility to conduct the work, regular
coordination meeting with UMST, work
permit, dedicated OHS personnel,
availability and diligence to use PPE,
coordination with UMST regarding
mobility of construction material,
workers medical check-up, and
continuous coordination and
socialization with community or related
stakeholders prior and during the
construction activities. The document
has been agreed and signed by the
Contractor (i.e. PT Cipta Dimensi Baja
Nusantara).
2. ATTENTION REQUIRED
HYS submitted several documents in
order to comply with CAP 5.2
requirements:
 Pengarahan tim proyek UMST
terkait SOP Pelaksanaan Proyek
signed by Contractor and HYS;
 HSE Report Feb 2022;
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Finding Description Output Parameter Status
.
 Elemen 2: Manajemen Program;
 Standar Pelaksanaan K3 PT Cipta
Dimensi Baja Nusantara.
SED has reviewed all above documents
and did not find monitoring report that
covers provision of traffic safety signs,
3. S&E Management Program during the
sanitation area, hazardous material, and
operational phase
hazardous waste management.
Mohon dapat mengirimkan dokumen
HSE Report Q1-Q3 (Januari – September
2022)

3. COMPLETED
4. S&E Management Program The company had submitted S&E
Implementation Report management programs, which are part
of their SEMS

4. Annually

6 Emergency Preparedness and Response Plan

An internal Emergency Preparedness and Response 1. The updated Emergency Response 1. ATTENTION REQUIRED
Plan (ERP) document has been developed for the Procedure includes the items mentioned in HYS has submitted several documents
operations phase. However, the aspects covered in the corrective action plan column. related to ERP:
the emergency response plan are only limited to the  Laporan Training K3 RS;
fire evacuation plan. In-house training on this  Training K3 RS on earthquake
subject has been conducted annually. In addition, simulation;
UMST does not yet have/include emergency  Prosedur Penanggulanan
response procedures for affected communities. Bencana Kebakaran di Dalam
Rumah Sakit
In 2019 UMST received a letter of recommendation
(36/SPO/K3/RSIASM/XII/20).
from the Regional Disaster Management Agency
To fulfill CAP 6.1 requirement, HYS
(BPBD) regarding technical plans for existing
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Finding Description
.
buildings and expansion buildings. The
recommendation letter states that BPBD will visit
UMST to check the compliance stated in the letter
related to fire safety requirements, once
construction is complete.
7 Company regulations and standard operating
procedures owned by UMST do not include the
freedom to form or join workers' organizations and
the statement that there is no forced labor.
8 Based on the UKL-UPL Implementation and
Monitoring report, UMST has conducted a monthly
program for monitoring wastewater. Referring to
2019 (Semester 1 and 2) and 2020 (Semester 1)
reports, several wastewater parameters are above
the quality standard (e.g., Total Coliform, TSS,
Ammonia, BOD, and COD, Nitrate, Detergents such
as MBAS, Fluoride, and Nickel).
Recommendations for technical assessment
requirements from the Tangerang Environmental
Agency No. 658.31/04-DLHK (January 2020) have
provided several requirements for UMST to treat
wastewater (page 5). In accordance with the
Output Parameter Status
shall establish SOP related to
earthquake and flood.
2. BPBD Visit Report and Fire Protection
System Feasibility Certificate 2. COMPLETED
The BPBD visit has been conducted and
the Fire Protection System Eligibility
Certificate has been received
A statement or policy regarding the COMPLETED
freedom of workers to form or join workers' UMST has submitted the statement letter
organizations and no forced labor is signed signed by the CEO of Unimedika Hospital
by the Director or Hospital Management. Group on 31 August 2022 stating that the
Statement Letter is applicable to all hospital
under Unimedika Group. The document is
considered adequate and fulfill the CAP.
1. SOP or program for monitoring and 1. COMPLETED
evaluating the performance of Unimedika has submitted the
wastewater treatment plants (WWTP). Wastewater Management Procedure,
also Emergency Response Procedure
for WTP. The document is considered
complied.
2. WWTP Performance Evaluation Report
2. COMPLETED
WTP evaluation report for the 2021
period has been submitted. The report
3. A copy of the application for a is considered adequate.
wastewater disposal permit (IPLC) after 3. COMPLETED
the expansion of the WWTP, which is Unimedika has been obtained Technical
accompanied by the design of the Recommendation (Pertek) for
No
Finding Description Output Parameter Status
.
requirements, UMST must develop a formalized expansion WWTP. Wastewater Discharge to Waterbody.
wastewater monitoring program in the form of a
document. 4. Renewed wastewater disposal permits 4. COMPLETED
and include recommendations for Surat Kelayakan Operasional No:
However, we also received information that UMST technical assessment requirements 658.31/05-DLHK dated 23 June 2022.
plans to expand and/or increase its WWTP capacity. from the Environment Agency.
Thus, UMST needs to request a renewal of the
wastewater disposal permit in accordance with the
increase in capacity.
9 Hazardous and Domestic Waste
Improvements to facilities and specifications for 1. Updated B3 waste management 1. COMPLETED
Temporary Storage Places (TPS) for hazardous procedures, especially regarding labeling The procedure for hazardous waste
waste at UMST locations are still needed to meet management has been submitted and
the criteria of Government Regulation no. 14 of 2. Procedures for managing domestic waste is considered adequate.
2014. (non-hazardous and/or non-infectious
waste) during the construction and 2. COMPLETED
As for domestic waste, based on the SEDD report, operational stages. The procedure for domestic waste has
domestic waste is only categorized as non- been submitted and is considered
infectious waste. To achieve better environmental 3. Documentation of the implementation of adequate.
sustainability, it is necessary to carry out additional the household waste management plan,
management of domestic waste. including the amount of recycled and non- 3. BI-annually
recyclable waste collected and/or photo Documentation of hazardous waste
documentation. This can be included as management
part of the UKL-UPL implementation report
during the construction and operational
stages or submitted to IIF as a separate
document.
10 Hazardous Material
Based on SEDD, it was found that several gas 1. Updated hazardous materials 1. COMPLETED
cylinders in the gas chamber were placed unbound. management procedures, to include Unimedika has submitted the procedure
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Finding Description Output Parameter Status
.
High-pressure gas cylinders must be strapped to operating safety associated with placing for hazardous material management
prevent them from falling and exploding. compressed gas cylinders in storage procedure. The document is considered
rooms or during use to comply with IIF requirements.

2. COMPLETED
The evidence (photograph) has been
submitted to IIF.
2. Evidence of improved hazardous
materials management (can be provided
in the form of photos)

11 Based on UKL-UPL, UMST is required to measure Measurements of air quality and noise levels COMPLETED
ambient air quality and noise once during the within hospitals, construction areas, and Unimedika has conducted monitoring for
construction phase. Bore pile or foundation work sensitive receptor areas (i.e., community ambient air quality and noise level at the
has been carried out since the end of 2020. settlements) have been included as part of the construction area and community
However, based on the latest UKL-UPL UKL-UPL implementation report during the
settlement. No parameters exceed the
implementation report in July-September 2020, construction and operational stages or
threshold value.
there is no information regarding the noise level. Air submitted to IIF as a separate document.
quality measurements were carried out in July 2020
in the Nurse Station and the operating room, but
these areas do not reflect the air quality in the
construction area. In accordance with IIF standards,
UMST should also consider air quality and noise
measurements in sensitive receptor areas, such as
residential areas of communities adjacent to
construction areas.
12 Based on flood and technical recommendations Documentation or evidence of the COMPLETED
issued by the Department of Highways and Water construction of drainage canals and infiltration Unimedika has constructed the drainage as
Resources of Tangerang No. wells at the UMST location a recommendation from the Department of
614/191/DBMSDA/2020 (January 2020), UMST is Highways and Water Resources Tangerang.
required to provide ponds or infiltration wells to
The infiltrations well also have been
avoid runoff/discharge of rainwater directly into
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Finding Description Output Parameter Status
.
surface water. UMST is also required to provide a constructed in the hospital area.
study or analysis of the drainage system. However,
based on the SEDD report, drainage channels
equipped with infiltration wells are not yet available
at the UMST location.
13 UMST does not yet have a Security Management Security Management Plan COMPLETED
Plan. The security management plan aims to ensure Unimedika has submitted the Security
that the safeguarding of personnel and property is Management Plan and the content is
carried out in accordance with relevant human considered adequate.
rights principles and in a manner or practice that
avoids or minimizes risks to society.
14 In 2020, two out of three incidents were related to 1. Updated Work Incident Reporting 1. COMPLETED
needle sticks. The incident report does not explain Unimedika has submitted the updated
the root cause and corrective action is limited to procedure and is considered adequate.
consulting a doctor and undergoing certain
laboratory tests. There is no detailed preventive 2. Investigation report (two reports) 2. COMPLETED
action to prevent and minimize the incident from HYS submitted below documents to SED:
recurring. It is very important for UMST to prevent  Formulir Laporan Insiden Klinis
nosocomial infections through needle stick No: LIK/UMST/QR/002;
puncture.  Penanganan Tertusuk Jarum dan
Terpapar Cairan Tubuh Pasien
No: SPO/UMST/PPI/020 dated 4
December 2021;
 Laporan Pajanan 23 Januari
2021;
Above submitted documents
considered adequate.

15 The lowest salary level at UMST is for cleaning A sample copy of salary/pay slip (cleaning COMPLETED
services which are known to be below the minimum service) Unimedika has submitted the payslip for one
wage regulated in Tangerang Regency. This of their cleaning services.
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Finding Description Output Parameter Status
.
cleaning service is rented directly by UMST.
However, the Human Resources (HR) department
has proposed a wage adjustment that refers to the
Tangerang regional regulation and the adjustment
was approved by the President Director of
Unimedika in March 2021.
 Persyaratan Pelaporan Reguler (Bagian dari Rencana Tindakan Perbaikan)

No Laporan Reguler Status

Laporan Pelaksanaan UKL-UPL, meliputi pengukuran dan evaluasi air limbah, udara ambien, dan kebisingan.
1 UMST has submitted RKL-RPL for Semester 2 2021 period
Laporan Implementasi RKL-RPL diserahkan kepada IIF maksimal 6 bulan setelah periode pelaporan.
ATTENTION REQUIRED
Similar to CAP No 5.2 above, HYS submitted several
documents in order to comply with CAP 5.2
requirements:
 Pengarahan tim proyek UMST terkait SOP
Pelaksanaan Proyek signed by Contractor and
HYS;
 HSE Report Feb 2022;
Pemantauan HSE dan Sosial Selama Tahap Konstruksi dan Operasional (Laporan Pelaksanaan K3RS)  Elemen 2: Manajemen Program;
 Standar Pelaksanaan K3 PT Cipta Dimensi Baja
2
Nusantara.
Laporan diserahkan kepada IIF maksimal 3 bulan setelah periode pelaporan
SED has reviewed all above documents and did not find
monitoring report that covers provision of traffic safety
signs, sanitation area, hazardous material, and hazardous
waste management

Mohon dapat mengirimkan dokumen HSE Report Q1-Q3

(Januari – September 2022)

3 Laporan Tahunan Perlindungan Sosial dan Pemantauan Lingkungan yang terdiri dari, namun tidak terbatas December 2022
pada:
a. Implementasi program pengelolaan Sosial dan Lingkungan
b. Pencatatan dan pelaporan keluhan masyarakat, pasien, dan karyawan, dilengkapi dengan status
penyelesaiannya;
c. Dokumentasi rencana pelibatan pemangku kepentingan;
No Laporan Reguler Status
d. Dokumentasi pelatihan tanggap darurat dan pelaksanaan simulasi (drill);
e. Pelaksanaan rencana pelatihan pekerja;
f. Pengelolaan (atau manifes) Limbah B3 dan Non B3 termasuk catatan kuantitasnya;
g. Dokumentasi pengelolaan bahan berbahaya dan beracun (misalnya MSDS, daftar bahan, dll);
h. Catatan/laporan pengukuran kinerja K3;
i. Laporan atau dokumentasi dari setiap inspeksi atau kunjungan HSE & Sosial yang dilakukan oleh otoritas
lokal; dan
j. Laporan Monitoring dan Evaluasi IPAL

Laporan tahunan diserahkan kepada IIF maksimal pada tanggal 31 Desember setiap tahun, dimulai satu tahun
setelah penandatanganan Facility Agreement. Template pelaporan akan disediakan oleh IIF
Apabila terjadi kecelakaan yang mengakibatkan korban jiwa dan/atau kecelakaan lain yang bersifat material
4 (berdampak pada aspek sosial dan lingkungan), UMST harus segera memberitahukan kepada IIF dalam waktu No report
1x24 jam, dan dilanjutkan dengan penyampaian laporan detail hasil investigasi paling lama 3 (tiga) bulan.
Jika ada pergantian personel yang bertanggung jawab dalam mengelola aspek S&E, UMST harus
5 None
menginformasikan kepada IIF dalam waktu seminggu untuk memudahkan proses komunikasi (pelaporan).