A.O. No.

2020 - 0047
ANNEX B

Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

ASSESSMENT TOOL FOR LICENSING A PRIMARY CARE FACILITY

INSTRUCTIONS:
I. To properly fill-out this tool, the Licensing Officer shall make use of: INTERVIEWS, REVIEW OF
DOCUMENTS, OBSERVATIONS and VALIDATION of findings.
2. If the corresponding items are present, available or adequate, place (/) on each of the appropriate spaces
under the FINDINGS column or space provided alongside each corresponding item. If not, put an (X)
instead.
The REMARKS column shall document relevant observations.
to
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vee Make sure fill-in the blanks with the needed information. Do not leave any items blank.
The Team Leader shall ensure that all team members write down their printed names, designation and
affix their signatures and indicate the date of inspection/monitoring, all at the last page of the tool.
The Team Leader shall make sure that the Head of the facility or, when not available, the next most senior
or responsible officer likewise affix his/her signature on the same aforementioned pages, to signify that
the inspection/monitoring results were discussed during the exit conference and a duplicate copy also
received.

GENERAL INFORMATION:

Name of Primary Care Facility:

Address:
(Number and Street) (Barangay/District) (Municipality/City)

(Province/Region)

Telephone/Fax No. E-mail Address:

Initial: Renewal:

Existing License No: Date Issued: Expiry Date:

Name of Owner or Governing Body (if corporation):

Name
of Head of Primary Care Facility:
Classification:

Ownership: Government Private

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8
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PART I. SERVICE CAPABILITY, PERSONNEL AND PHYSICAL PLANT

L PATIENT
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1.
RIGHTS AND ORGANIZATION ETHICS —

quality care and their responsibilities in that care.

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Informed consent Document Review

ee
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2 Standard: Organizational Policies and procedures which respect and‘support patients’ rights to

is obtained from e All patient charts have signed

patients prior to consent for procedures
procedures. (example: minor surgery,
immunization).
2. Policies which Observe
identify and e Posted patients’ rights in
address patients’ conspicuous places.
rights and
responsibilities are
documented.
TL. PATIENT CARE | 5

Pos Standard: ‘The organization iinforms the s

community about the services.sitit providesand the hours
_ of their availability.

3. Clinical
_
Observe
services :

are appropriate to e List of services and schedule

patients' needs and of operation posted in a
the former's conspicuous area.
availability is e DOHLTO (updated, valid
consistent with the and original) posted in a
organization's conspicuous area.
service capability
and role in the
community.
4. Population-based Document Review
Primary Care - Written policies and procedures
Services based on DOH issued
(Government PCFs guidelines:
only) e Health promotion
Epidemiologic surveillance
Health protection (vector
control, environmental
health, occupational safety,
and food safety measures)
e Emergency preparedness and
response
5. Individual-based Document Review
Primary Care - Written policies and procedures
Services based on DOH guidelines and
Manual of Procedures:
Maternal and Newborn Care
Family Planning Services
Nutrition Services
Dental Services (may be
outsourced and/or located Ly

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__
outside PCF through a valid
MOA. Outsourced dental
services shall comply with
the licensing standards
Assessment Tool)
in this

Referral services* to:

—_
o Community-based
Rehabilitation Services
(example: physical therapy,
occupational therapy,
speech therapy)
o Developmental and mental
health evaluation
o Substance abuse services
*May be provided by PCF
6. Minor Surgeries Document Review
Written policies and procedures in
conducting minor surgical procedures:
Suturing of superficial
lacerations
e Circumcision
e Incision and Drainage
e Debridement
e Excision of small cysts
7. Administrative Document Review
Services Written policies and procedures on:
Issuance of certificates
(Government PCFs (medical certification, death
only) certification, and medico-
legal certification)
Sanitation inspection and
issuance of sanitary permit
8. Supervisory Document Review
Services Written policies and procedures on:
Patient navigation in its
primary care provider
network
Supervision of barangay
health stations (Government
PCFs only)
Supervision of health
workers (Government PCFs
only)

each patient that is readily accessible to authorized personnel. _

9. Ail patients are Document Review
—
t

ne r
Standard: Theorganization uniquely identifies all patients and creates a specific patient record for
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correctly The contents of patient's records are

identified by their the following:
patient records. Doctor's order
An appropriate

Det
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__
history and Informed Consent, if
physical applicable
examination _is e Complete history and physical
performed on examination (may use SOAP
every patient. The method for follow-up check-
history includes ups)
present illness, e Medication and/or treatment
past medical, record
family, social and e Dental records (May be stored
personal history. separately if dental facility is
outsourced and located outside
the PCF)
e Laboratory and X-ray reports,
if any
e Record of referral or transfer of
patient to other
facility/service/doctor
including notes
__ Standard: The
care plan addresses patient's relevant clinical needs.
10. Coordinated plan Document Review
of care with goals. e Proof of implementation of
adopted/developed protocols,
and DOH approved CPGs,

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once available.
TL. LEADERSHIP AND MANAGEMENT
:
1 |
vs - | : :

Standard: The PCF’s management team provides leadership, acts according to the organization’ Ss.

ee ee
~ policies and has
for the organization’ s Operation, and the quality of its services |
overall responsibilityfo
11.
‘and its resources
Organizational
~

Observe
28 . ©
ee

ee ees

oe
Be oe

Structure/Chart e Observe
ifthe organizational
structure/chart is posted in
conspicuous area.
12.The organization Document Review
and its services e® Written vision and mission
develop their
vision and Observe
mission. Posted vision and mission in
e
a conspicuous area
14.Evaluation and Document Review
monitoring e Accomplishment reports or
activities to assess other annual reports, as
management and applicable.
organizational
performance
(Required for
government-
owned PCFs.
Recommended
only for privately-
owned PCFEs.)

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: Iv. HUMAN RESOURCE MANAGEMENT
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c
Standard: Workload is monitored and appropriate guidelines consulted to ensure that |

appropriate staffnumbersand skill mix areavailable to achieve desired patient and organizational
- outcomes.
_

15. The organization Document Review

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documents and e Policies and procedures for

follows policies and hiring and credentialing of

§=6
procedures for hiring staff
and credentialing of
its staff. Interview
e Administrative Officer or
Head of PCF

Standard: There are relevant activities related to orientation of new ersonnel.

16. New personnel, Document Review
new graduates and e Documentation of
external contractors- orientation conducted
are adequately
supervised by
qualibed
staff
Standard: Thereshall be an adequate numberof qualified, trained and competent staff to ensure
“efficient and effective delivery of quality primarycare services. es
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The staff ‘composition and number/ratio shall depend on the workload. and services being provided, -
_ adjusted based on applicable workload assessment tools set by DOH.
__

17.Physician Document Review

(Full time) e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings
o Proof of
Employment/Appointment
18. Nurse (Full Time) Document Review
e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings
o Proof of
Employment/Appointment
19. Midwife Document Review
(Full Time) e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings

We
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o Proof of
Employment/Appointment
20. Dentist Document Review
e Proof of qualifications
o Resume
oPRC ID and Certificate
o Proof of
Employment/Appointment,
if applicable
o Valid Memorandum of
Agreement (MOA),
outsourced
if
21. Sanitation Document Review
Inspector e §=Proof of qualifications

(Government PCFs o Resume

only) OPRC ID and Certificate
o Proof of
Employment/Appointment
22. Information Document Review
Technology Officer e Proof of qualifications
o Resume
*may be allowed to o Proof of
handle two Employment/Appointment
administrative roles
at a time
23. Records Officer Document Review
e of qualifications
§=©Proof

*may be allowed to o Resume

handle two Medical Records
oO

administrative roles Management Training

at a time Certificate
oICD-10 Training
Certificate
o Proof of
Employment/Appointment
24. Administrative Document Review
Officer e Proof of qualifications
o Resume
*may be allowed to o Proof of
handle two Employment/Appointment
administrative roles
at a time

25. Utility Worker Document Review

e Proof of qualifications
o Resume
o Proof of
Employment/Appointment
V. INFORMATION MANAGEMENT 2
¢

i
-

Standard: Relevant, accurate, quantitative and qualitative data are collected and used inatimely

fu
and efficient manner for delivery of patient care and management of services _f f£

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26. Records are Document Review
stored, retained and
disposed of in
¢ Logbooks on record storage,
retention and disposal
accordance with the
guidelines set by Observe
National Archives of e Proper storage of records
the Philippines
(NAP)
27. The organization Document Review
defines data sets, data e Policies and procedures on
generation, collection record storage, safekeeping
and aggregation and maintenance, retention
methods and the and disposal.
qualified staff who
are involved in each
stage.
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential
and safe, and comply with all relevant statutory requirements and codes of practice. ~
28. Patient records Observe
documenting any e Patient records are easily
previous care can be retrievable within 10-15
quickly retrieved for minutes
review, updating and
concurrent use.
29.The organization Document Review
has policies and e Logbooks for borrowing and
procedures, and retrieval of records
devotes resources,
including Observe
infrastructure, to e Access to records
protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access
or use. Only
authorized
individuals make
entries in the patient
records
30. Validated Observe
Electronic Medical e EMR implementation
Records includes, but is not limited
to, primary care benefits,
maternal and neonatal
deaths, injury, and confirmed
cases of diagnosis
31. National Document Review
Database of Human e Proof of submission of data
Resources for Health to NDHRHIS
He
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 )

‘Information System
(NDHRHIS)
VIL SAFE PRACTICE AND ENVIRONMENT
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Standard: The organization plans a safe aca effectiveenvironment ofcare consistent with its
_mission, services, and with laws and regulations ~ t

32. An incident Document Review

reporting system e Record of incident reports
identifies potential
harms, evaluates
causal and
contributing factors
for the necessary
corrective and
reventive action
33. Presence of a Document Review
management plan, e Management plan, policies
policies and and procedures on safety
procedures e Proof of implementation of
addressing safety the following:
e Fire drill conducted in the
past 12 months
e Earthquake drill
conducted in the past 12
months
34. Building Document Review
Maintenance e Routine program of work for
Program is in place preventive maintenance and
ensuring facilities are record of corrective
in state of good repair maintenance are
available
35. Policies and Document Review
procedures for the e Presence of operating
safe and efficient use manuals of the medical
of medical equipment equipment
according to e Preventive and corrective
specifications are maintenance logbook and
documented and plan for replacement
implemented.
37. A coordinated Document Review
security arrangement e Designation of person in
in the organization charge of security.
assures protection of
patients and staff
Interview
e Ask the personnel in charge
of security what the policies
on security are.

Observe

ee
e Security measures

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 su a
Standard: ‘Emergency light and/or power supply, water and ventilation systems are provided for, irin
_keeping with relevant statutory requirements and codes of practice. _
38. Generator, Document Review:
emergency light, e Bacterial water analysis done
water system, every 6 months.
adequate ventilation e Proof of corrective measures
or air conditioning done for failed bacterial
water analysis.
e Preventive and corrective
maintenance logbooks of
generator, emergency light,
ventilation and conditioning

Observe:
e Test if faucets and water
closets are working
e Functional emergency lights
and generators
39, Non-medical Document Review:
equipment are e Records of preventive and
regularly maintained corrective maintenance and
with plan for plan for replacement
replacement
according to expected
life span or when no
longer serviceable
40. Operating Document Review:
manuals of non- e Operating manuals of
medical equipment equipment, generators, air
conditioners and other non-
medical equipment
Standard: The
~ handling, | collection
= requirements and code of practice and disposal, of waste conform with relevant statutory
41. Policies and Document Review:
procedures on Waste e Issuances — laws, memos,
Disposal guidelines on waste
Management segregation, collection,
treatment and disposal
e Contracts with service
providers, waste handlers or
(if
disposal contractors
applicable)

Observe:
e Location of waste holding
area
e Segregation of waste (use of

fl
color coded garbage plastic
and/or bins)
AAT

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 Proper labelling of waste
receptacles
Proper management of
temporary storage areas prior
to hauling for disposal
Standard: An interdisciplinary infection, control program ensures the Prevention and control of
¢
_
infection in allservices. oe Coa See ee
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ir |
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42. Infection Document Review

Prevention and e IPC Manual
Control (IPC)
Program
43. Policies and Document Review
procedures on e Policies and procedures on
cleaning, cleaning, disinfecting,
disinfecting, drying, drying, packaging and
packaging and sterilizing of equipment,
sterilizing of instruments and supplies
equipment,
instruments and
supplies.
Standard: The organization uses
‘healthcare- associated infections.
44. “Organization Document Review
a
| t
a coordinated system-wide approach to reduce therisks of BS

takes steps to prevent Validate PCF policies on

and control outbreaks
of healthcare
associated infections.
infection control such as use
of PPEs, isolation
precautions and hand
washing.
Written policies and
procedures in
accordance
with DOH issuances.

Observe
Use of gloves, surgical
masks, etc., as needed
Sinks or lavatories or
designated areas for hand
washing or dispenser for
sanitizers
Ask a PCF staff to
demonstrate hand washing.
45. There are Document Review
programs for Reports of needle stick
prevention and injuries
treatment of needle
stick injuries, and Interview
policies and staff their policies on
Ask
procedures for the needle stick injury
safe disposal of used
needles are Observe 4
AEE
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documented and e Use of PPEs in doing minor
monitored surgeries, handling patients
with infectious diseases etc.

] Standard:
ee ee
Whenneeded, the organization reportsinformation
about infections to personnel and
public health agencies. ee |

46. Policies and Document Review

procedures in e Copies of reports submitted
reporting notifiable to PIDSR and other
diseases (Refer to AO applicable DOH recording
No. 2008-0009 and and notification systems.
AO No. 2020-0013). |

ho oo
as
VIL. IMPROVING PERFORMANCE. # Be
:

has. planned systematic organization- wide approach,to process:

“e__ Standard: The organization
- a
design and performance measurement, assessment and improvement. e
:
a7.Continuous Document Review
Quality Improvement e CQI plan and proof of
(CQIT) Program implementation

Interview
e Ask about their activities on
CQI.

48. Customer
The.
- Standard:
“@improvement

satisfaction survey
activities
Document Review
e
EUS; E

See
Domains of the survey form
used.
:
a
organization. Brovides better. care service as result. of continuous quality:
fe cos

e Survey results and how

complaints/comments are
acted upon.

VII PHYSICAL
and
49. Entrances
PLANT.
Observe
sy
exits are clearly and e Posted entrance and exit
prominently marked, signs.
free of any e Entrances and exits are
obstruction and accessible and free from any
readily accessible. obstruction

Note: Exit signs should be luminous

or illuminated and prominently
marked. There should be exit signs in
major areas of the hospital and all
doors leading to the
outside. (Reference: RA 6541 Building
Code of the Philippines)
50. Directional signs Observe
are prominently e Directional signs are
posted to help locate prominently posted.
service areas within
the organization.

. Ate
Nn

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51. Ramps for Observe
patients with special @
Ramps for patients with
needs are available, special needs.
clearly and © Prominently marked
prominently marked o Free from obstruction
and free of any
obstruction.

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PART IT. EQUIPMENT AND INSTRUMENTS

_
nctional
MEDICAL EQUIPMENT AND INSTRUMENTS INPCF
Autoclave, 20 L
BP apparatus, non-mercurial, with adult and pediatric cuffs
Cervical Inspection Set/Vaginal Speculum Set
Small size
Medium size
Large size
Dressing set (minor surgical set)
Surgical scissors straight
Surgical scissors curved
Bandage scissors
Pick up (ovum) forceps
Mosquito forceps
Tissue forceps with teeth
Tissue forceps without teeth
Suture removal scissors
EENT Diagnostic Set
Ophthalmoscope
Otoscope
Emergency light
Examining light
Examining table
Foot stool
Instrument table
IV stand
Nebulizer
Neurohammer
Non-mercurial thermometer
Salter scale
Safety/Sharps collector box
Snellen’s Chart, Visual Acuity Chart

et
Stethoscope Z

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 Weighing scale with height measuring stick, adult
Weighing scale, infant
Wheelchair
Wheeled stretcher
Vaccine carrier with cold dog
Vaccine carrier thermometer
Vaccine refri gerator

‘(OutsourcedHoxial se
- DENTAL EQUIPMENT AND INSTRUMENTS ~
complywith thefollowing
service.locatedoutside PCF shall still be Inspectedand
licensing requirements) pe

Autoclave, 20 L
Dental Unit and chair with compressor and complete
accessories, with high and low speed hand pieces
Dental prophylaxis instrument set:
Universal scaler, non-magnetic hollow handle
Peri Curette, non-magnetic hollow handle
Periodontal probe
Gracey curette, set of 6 different tips, non-magnetic
hollow handle
Dental instruments: mouth mirror, cotton plier, explorer,
spoon excavator (1 set)
Basic Dental Surgery Set
Extraction forcep, #16 with cross serration (for
better grip)
Ergonomic for better comfort designed instrument
Extraction forcep, #17
Extraction forcep, #18L
Extraction forcep, #18R
Extraction forcep, #44
Extraction forcep, #69
Extraction forcep, #150
Extraction forcep, #151
Pedo forcep, #150
Pedo forcep, #151
Pedo forcep, #17S
Pedo forcep, #16S
Pedo forcep, #18R
Pedo forcep, #18L
Aspirating syringe (2), stainless steel, with locking
mechanism

Aa
LA

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q¢

Minnesota retractor, stainless steel

Bone file, stainless steel
Dental instrument cabinet
Instrument table
Sterilizing unit, table top
unit
Sharp waste disposal
e
“NON-MEDICAL EQUIPMENT AND INSTRUMENTS ——™”
Computer/laptop with internet connection
(mobile data, Ethernet)
Printer
Mobile phone/cellphone
Fire extinguisher
Standby generator set

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