Republic of the Philippines

DEPARTMENT OF HEALTH
CENTER FOR HEALTH
DEVELOPMENT
Cordillera Administrative Region
Baguio City
AO 2020-0047 “Rules and Regulations Governing the Licensure of Primary Care Facilities in the Philippines”

COORDINATION MEETING WITH CALANASAN

RHU – PRIMARY CARE FACILITY
Jefferson D. Tamondong, Licensing Officer II
 CALANASAN RHU – PCF Good practices
1. Licensed PCF and a Konsulta Package provider
2. Attendance to virtual orientations on PCF conducted by RLED and PhilHealth
3. Close coordination with personnel of DOH CAR and PhilHealth CAR and
actual visits to the regional offices were essential to fulfill the needed and essential
requirements
4. Dedicated and committed colleagues of Calanasan RHU from accomplishing
the baseline assessment, to facilitating the signing of the MOA with other health
facilities, to crafting and printing the needed policies and documentations up to the
appraisal, checking and submission if documents - acted as a team
 CALANASAN RHU – PCF Good practices
5. Technical assistance provided by the Apayao Provincial Health Office and Provincial DOH of
Apayao have been of great help, too
6. Though they have been performing already some of the minimum standards, there are more
things to be done, if they are to realize Universal Health Care
7. To sustain the delivery of safe and quality health services, the standards and requirements for a
PCF have been included in their Local Investment Plan for Health
8. As a licensed PCF, they are guided by the principle that health is a basic human right, they
shall continue their health programs and ensure that the people, especially the poor, are protected
from high cost of health care for a medical financial assistance program, attain the best possible
health outcomes with no disparity through quality, responsive and people centered health system
9. As a regulated PCF of DOH, they ensure that only safe and quality health services are
delivered to the people
 TIMELINES
DATE Activities
March 30, 2023 Monitoring visit
Post-Monitoring Letter
April 28, 2023 Submission of the facility of partial compliance
May 8, 2023 Communication letter was drafted for the partial compliance received by the LO
-Submission of complete proofs of rectification was on May 16, 2023 as stated in
the letter

May 15, 2023 Request letter for extension was sent by the facility
May 17, 2023 Response letter for extension was drafted and granted by the LO-in-charge
-May 29, 2023 was stated as the due date for the requested extension

May 29, 2023 Acknowledgement letter for the proofs of compliance submitted by the facility on
May 19, 25 and 26, 2023 and for meeting the due date for the requested extension
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY RECOMMENDATIONS PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED

2. Patients’ rights No posted patients’ rights To provide photo of posted Posted patients’ rights April 28, 2023
patients’ rights

4. Population- No documentation presented To provide documentation of After Activity Report/TB/ Proper April 28, 2023
based Primary on activities conducted activities washing / IEC materials
Care Services
(HEALTH
PROMOTION)

10. CPGs No proof of implementation To provide adopted CPGs After Activity Report/TB CPG April 28, 2023
of adopted protocols and
DOH approved CPGs
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY
17. Physician No PCW certification
(Full time) (Dr. Melchor B. Patal-e )
18. Nurse (Full • Expired PRC ID
time) • No PCW Certificate
• No Proof of relevant
training (Ms. Rhodora
Isabelle Balalio)
19. Midwife (Full • Expired PRC ID
Time) • No PCW certificate
• No Proof of relevant
training (Ms. Florie Joy
L. Allag)
20. Dentist Expired PRC ID of Dr. Ma.
Consuelo A. Bunot
RECOMMENDATIONS
To provide PCW certificate
To provide:
Updated PRC ID
PCW Certificate
Proof of relevant trainings
To provide:
Updated PRC ID
PCW Certificate
Proof of relevant trainings
To provide updated PRC ID
PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED
Primary Care Worker Certificate of
Dr. Patal-e = Moratorium until
December 2023
Updated PRC ID (10/21/24) April 28, 2023
PCW Certificate – Dec 2023
Proof of relevant trainings
Updated PRC ID (10/21/24) April 28, 2023
PCW Certificate – Dec 2023
Proof of relevant trainings
PRC ID (2/5/27/2025) April 28, 2023
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY RECOMMENDATIONS PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED
21. Sanitation No PRC ID or Career To provide PRC ID/ Career PRC ID May 19, 2023
Inspector Service Eligibility of the Service Eligibility
Sanitation Inspector

22. Information No Resume (Ms. Jehnalie A. To provide resume PDS May 19, 2023
Technology Bunot)
Officer

23. Records  No Resume To provide proof of  Resume May 19, 2023

Officer  No Medical Records employment • Proof of employment
Management Training
• Request letter for:
Certificate
• No ICD-10 Training Certificate *Medical Records Management
• No proof of employment Training
*ICD-10 Training
30. Validated No proof of functional EMR To provide proof of functional Screenshot of functional iClinicSys April 28, 2023
Electronic (iClinicSys) EMR (iClinicSys)
Medical Records
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY RECOMMENDATIONS PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED
31. NDHRHIS No proof of submission of To provide proof of Proof of submission of data to May 19, 2023
data to NDHRHIS submission of data to NDHRHIS
NDHRHIS

33. Presence of a No management plan, To provide management plan, Management plan, policies and May 25, 2023
management plan, policies and procedures on policies and procedures on procedures on safety submitted
policies and safety safety
procedures
addressing safety

34. Building No preventive and corrective To provide preventive Preventive corrective maintenance May 25, 2023
Maintenance maintenance record/logbook and corrective maintenance record/logbook and plan of
plan of replacement
Program is in record/logbook and plan of replacement
place ensuring replacement
facilities are in
state of good
repair
35. Operating No file of operating manuals To file of operating manuals Operating manuals of medical April 28, 2023
manuals of medical of the medical equipment of the medical equipment equipment
equipment and
Records of preventive
and corrective
maintenance and plan
for replacement
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY RECOMMENDATIONS PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED
38. Bacterial water No bacterial water analysis To provide bacterial water Negative Bacterial water analysis May 19, 2023
analysis (proof of done (No proof of negative analysis report for the past 6 result
payment or lab report
bacterial water analysis) months from DOH accredited
of the past 6 months;
timeline within 15 lab
working days)
38. Proof of No preventive and corrective To provide logbook Updated logbook May 19, 2023
corrective report, maintenance logbooks of
preventive and
generator, emergency light,
corrective
maintenance logbook ventilation and air-
for Generator, conditioning
emergency light,
water system,
adequate ventilation
or air conditioning
40. Operating No operating manuals of non- To provide operating manuals Operating manuals of non-medical May 19, 2023
manuals of non- medical equipment of non-medical equipment equipment
medical
equipment
 CALANASAN RHU – PCF Monitoring Findings
CRITERIA DEFICIENCY RECOMMENDATIONS PROOF OF COMPLIANCE DATE SUBMITTED
SUBMITTED
41. Contracts with No contract with an To provide contract with an MOU submitted May 24, 2023
service providers, accredited waste hauler accredited waste hauler *Contract with an accredited waste
waste handlers or
hauler
disposal contractors
45. Needle stick No logbook for needle stick To provide logbook for needle Updated logbook for needle stick May 19, 2023
injury injury stick injury injury
46. PIDSR No updated copies of PIDSR To provide updated copies of PIDSR reports May 19, 2023
reports PIDSR reports

47. CQI Plan No proof of implementation of To provide proof of Proof of implementation of CQI plan May 19, 2023
CQI plan on file implementation of CQI plan

52. Availability of No Pricelist posted in a Pricelist to be posted in a Pricelist posted in a conspicuous area April 28, 2023
pricelist in a conspicuous area (should indicate conspicuous area (should indicate
conspicuous area whether free of charge) whether free of charge)

53. Pricelist shall be No Pricelist itemized
itemized comprehensively (medical and
comprehensively surgical procedures, price of lab
tests, price of drugs/medicines,
include outsourced services)
Updated Pricelist should be Updated Pricelist itemized April 28, 2023
itemized comprehensively (medical comprehensively
and surgical procedures, price of
lab tests, price of drugs/medicines,
include outsourced services)

54. Pricelist to be No Pricelist uploaded/posted on To post Pricelist on the official FB Screenshot of price list posted on the April 28, 2023
available on health the official FB page page official FB page
facility's official
website
RLED ADVISORY
 IMPORTANT
1. Update all logbooks
 Medical/ Death and Medico-legal certification
 Sanitary permit
 Referral – Record of referral or transfer of patient to other facility/ service/ doctor
 Record storage, retention and disposal
 Borrowing and retrieval of records
 Record of incident reports (H.E.A.R.S)
 Preventive and corrective maintenance logbook for building
 Preventive and corrective maintenance logbook for medical and non-medical equipment
2. Proof of implementation – Population-based services (Training design/ syllabus, Attendance, After
Activity Report, photo documentations)
3. Proof of implementation – Individual-based services
1. Updated Referral Logbook
2. Maternal and Newborn Care
2.1. Updated recording forms for IMCI
2.2. Fully accomplished Family Health Diary to be backed up with ITR (Individual Treatment Record)
2.3. Logbook for Newborn Screening and Hearing
2.4. Mother and Newborn Chart
2.5. Family Planning Logbook
4. Documentation of orientations conducted to new personnel
5. All 201 files of personnel should be updated and intact
6. Updated proof of submission of data to NDHRHIS
7. Proof of implementation for Fire and Earthquake drill in the past 12 months
8. Bacterial water analysis every 6 months
9. Contract with service providers, waste handlers or disposal contractors
10. Proof of implementation of CQI plan
Thank you!