SUMMARY OF FINDINGS

INFIRMARY
Dr. Montano G. Ramos Hospital
141 Mindanao Ave., Bahay Toro, Proj. 8, Quezon City

Date of Monitoring: May 23, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 22, 2018

FINDINGS:
 Submit policy addressing patient’s rights
 Proof of discharge plan
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging / X X
Waste Management / / X
Patient Safety / X X
Infection Control / / X
Emergency and Disaster Preparedness / / X
CQI / / X
Grievance / X X
Selections and Promotions X X X
 Proof of Annual accomplishment report
 Valid Memorandum of Agreement with Waste Management Service, Ambulance, Security
 Presence of annual plan for training activities
 Proof of Job descriptions with conforme
 Presence of Annual Statistical Reports
 Policy of filing and retrieval of charts
 Policy to protect records and charts against loss, destruction, tampering and unauthorized used.
 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
 Present copy of manuals of equipment
 Policy for cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments, supplies
 Presence of policies in reporting of notifiable diseases (reporting for PIDSR policy)
 Submit copy of updated sanitary permit
 Presence of Quality Improvement Program and proof of implementation
 Presence of Customer Satisfaction Survey and analysis
PROGRAMS
 Mother-Baby Friendly Accreditation or received copy of letter of intent
 Immunization logbook
 Designation of HEMS Coordinator
 Newborn Screening for Hearing logbook

PERSONNEL
 Copy of the following:
- Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
- Billing/Cashier – Contract, trainings
- Clerk - Contract, trainings
- Supply Officer/Storekeeper - Contract, trainings
- Laundry Worker – contract
 - Cook - contract
- Security guard – contract or MOA
- Nurse Supervisor – Diploma, valid PRC license, contract, Master’s Degree in Nursing or at least 9 units.
- NURSES to hire additional 8 nurses– submit contract and PRC ID

PHYSICAL PLANT REQUIREMENT

 Provision of PWD toilet
 Provision of supply/linen room
 Provision of laundry area if not outsourced
 Provision of janitor’s closet
 Provision of kitchen area if not outsourced
 Provision of dishwashing area, dining area and garbage area
 Provision of hand washing or hand disinfection within the examination and treatment area
 Provision of equipment and supply storage area
 Provision of separate toilet for male, female and staff
 Delivery room currently under construction ( should be functional, submit proof of compliance)
 Provision of toilet for patients and companion with easy access/adjacent to emergency room/OPD
 Provision of toilet within labor room at delivery service
 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:

ADMINISTRATIVE SERVICE KITCHEN

 Ambulance  Exhaust fan
 Typewriter/computer  Food conveyor
 Emergency light  Food scale
 Fire extinguisher  Stove
 Generator set  Refrigerator
 Utility cart
 Garbage receptacle with cover and color-
coded
EMERGENCY ROOM Cont. EMERGENCY ROOM
 Bag valve mask unit – adult and pediatric
 Calculator - Mayo scissors straight
 Clinical weighing scale - Metzenbaum scissors straight
 Defibrillator - Mosquito forceps curved
 Delivery set (2sets) - primigravid - Mosquito forceps straight
- Metzenbaum scissors straight - Needle holder
- Mayo scissors straight - Scalpel handle #3
- Kelly hemostatic forceps - Scalpel handle #4
- Needle holder - Skin retractor
- Tissue forceps - Tissue forceps
 Delivery set (2sets) – primigravid - Thumb forceps
- Mayo scissors straight  Nebulizer
- Kelly hemostatic forceps  O2 Unit
 EENT Diagnostic set  Pulse oximeter
 Emergency cart  Sphygmomanometer – adult cuff and pedia
 Examining table cuff
 Examining table with stirrups  Stethoscope
 Gooseneck lamp  Suction apparatus
 Instrument table  Suturing set
 Laryngoscope with different sizes  Thermometer – oral and rectal
 Minor set  Wheelchair\Wheeled stretcher with side
- Kelly hemostatic forceps straight rails
- Kelly hemostatic forceps curved

OUT-PATIENT DEPARTMENT DELIVERY ROOM

 Clinical Height And Weight Scale  Air-condition unit
 Gooseneck lamp  Bag valve mask – adult and pediatric
 Instrument table  D & C set
 Minor set - Hysterometer
- Kelly hemostatic forceps straight - Uterine forceps
- Kelly hemostatic forceps curved - Dull uterine forceps
- Mayo scissors straight - Sharp uterine forceps
- Metzenbaum scissors straight - Vaginal retractor
- Mosquito forceps curved - Vaginal speculum
- Mosquito forceps straight - Ovum forceps
- Needle holder - Hegars dilator
- Scalpel handle #3 - Sponge forceps
- Scalpel handle #4  Delivery set (2sets) - primigravid
- Skin retractor - Metzenbaum scissors straight
- Tissue forceps - Mayo scissors straight
- Thumb forceps - Kelly hemostatic forceps
- Neurologic hammer - Needle holder
- Tissue forceps
 Sphygmomanometer – adult cuff and pedia cuff  Delivery set (2sets) – primigravid
 Stethoscope - Mayo scissors straight
Thermometer – oral and rectal - Kelly hemostatic forceps
 DR Light
 DR table
 Clinical infant weighing scale
 Instrument table
 Kelly pad
 Oxygen tank
 Emergency light
 Sphygmomanometer, non-mercurial
 Stethoscope
 Suction apparatus
 Thermometer, non-mercurial
 Wheeled stretcher
LABOR ROOM CSSR
 Oxygen unit  Autoclave
 Patient bed CADAVER HOLDING AREA
 Sphygmomanometer – adult cuff and pedia cuff  Bed or stretcher for cadaver
 Stethoscope
 Thermometer – oral and rectal
NURSING UNIT/WARD
 Bag valve mask unit – adult and pediatric
 Clinical height and weight scale
 Emergency light
 Patient bed with locked
 Bedside table
 Nebulizer
 Neurologic hammer
 O2 tank
 Sphygmomanometer adult cuff and pedia cuff
 Stethoscope
 Suction apparatus
 Thermometer – oral and rectal
E-CART CONTENTS BASIC ER SUPPLIES
 Salbutamol  Oropharyngeal and nasopharyngeal airways
 D50W 50mg/vial  Intubation kit
 Activated charcoal  Alcohol disinfectant
 Anti-rabies vaccine – active  Arm sling
 Anti-rabies vaccine – passive  Aseptic bulb syringe
 Amiodarone  Biomedical refrigerator
 Anti-tetanus serum  Calculator
 Aspirin USP grade 325mg/tablet  Cardiac board
 Atropine  Cardiac/EKG Leads
 Benzodiazepine(diazepam)  Cervical collars
 Calcium gluconate  Sharps container
 D5 0.3 NaCl 500ml/bottle  Elastic bandages (diff sizes)
 D5 LR 1L/bottle  Flash light/penlight
 D5 NSS 1L/bottle  Emergency light
 Digoxin 0.5mg/ampule  Sphygmomanometer, non-mercurial
 Diphenhydramine 250mg/ampule  Stethoscope
 Dobutamine  Suction apparatus
 Dopamine  Thermometer, non-mercurial
 Epinephrine  Wheeled stretcher
 Furosemide 20mg/2ml ampule  Gloves
 Haloperidol 50mg/ampule  Hydrogen peroxide
 Hydrocortisone 250mg/vial  Nasal cannula
 Hyoscine N-butyl-bromide 20mg/vial  Povidone iodine
 Lidocaine 5% solution cial 1g/50ml  protective face shield or mask
 MgSO4  Pulmonary Function Test
 Mannitol  Spine board with straps
 Mefenamic acid 500mg/tablet  Splinting devices
 Methylprednisolone 4mg/tablet  Face mask (standard)
 Metoclopramide 10mg/ampule  Sterile gauze
 Morphine SO4 10mg/ampule  Sutures
 Nitroglycerine spray or isosorbide dinitrate 5mg  Syringes
tablet5/ampule  Urethral catheter
 Noradrenaline 2mg/ampule  Urine collection bag
 ORS sachet  Waterproof aprons
 Paracetamol 300mg/ampule (IV prep)  X-ray reading lamp o negatoscope
 Phenobarbital 30mg/ml IV or 30mg tablet
 Plain LRS 1L
 Plain NSS 1L
 Potassium Chloride 20mEq/vial
 Pyridoxine 1g/ampule
 Sodium bicarbonate 50mEq/ampule
 Tetanus toxoid 0.5ml/vial
 Thiamine
 Tramadol
 Verapamil
MONITORED BY: