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    Summary of Findings John Paul Hospital: Infirmary

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    Karenina Victoria
    The document summarizes findings from a monitoring visit to the John Paul Hospital infirmary on July 12, 2018. It notes violations in compliance with administrative orders and inadequate nursing personnel. It provides a checklist of documentation required to assess compliance with policies, personnel qualifications, programs, physical plant requirements, and medical equipment. Submission of additional documents and hiring more nurses is required to achieve full compliance. The monitor identified areas of non-compliance and documentation needed to evaluate protocols, staffing, facilities, and equipment.

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    Summary of Findings John Paul Hospital: Infirmary

    Uploaded by

    Karenina Victoria
    36 views3 pages
    The document summarizes findings from a monitoring visit to the John Paul Hospital infirmary on July 12, 2018. It notes violations in compliance with administrative orders and inadequate nursing personnel. It provides a checklist of documentation required to assess compliance with policies, personnel qualifications, programs, physical plant requirements, and medical equipment. Submission of additional documents and hiring more nurses is required to achieve full compliance. The monitor identified areas of non-compliance and documentation needed to evaluate protocols, staffing, facilities, and equipment.

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    The document summarizes findings from a monitoring visit to the John Paul Hospital infirmary on July 12, 2018. It notes violations in compliance with administrative orders and inadequate nursing personnel. It provides a checklist of documentation required to assess compliance with policies, personnel qualifications, programs, physical plant requirements, and medical equipment. Submission of additional documents and hiring more nurses is required to achieve full compliance. The monitor identified areas of non-compliance and documentation needed to evaluate protocols, staffing, facilities, and equipment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views3 pages

    Summary of Findings John Paul Hospital: Infirmary

    Uploaded by

    Karenina Victoria
    The document summarizes findings from a monitoring visit to the John Paul Hospital infirmary on July 12, 2018. It notes violations in compliance with administrative orders and inadequate nursing personnel. It provides a checklist of documentation required to assess compliance with policies, personnel qualifications, programs, physical plant requirements, and medical equipment. Submission of additional documents and hiring more nurses is required to achieve full compliance. The monitor identified areas of non-compliance and documentation needed to evaluate protocols, staffing, facilities, and equipment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    SUMMARY OF FINDINGS

    INFIRMARY
    JOHN PAUL HOSPITAL
    26 Mariano Ponce St., cor Tirad Pas St., Caloocan City

    Date of Monitoring: July 12, 2018 FULL COMPLIANCE DATE: _____________________


    Date Prepared: August 17, 2018

    Noted Violations: 1. Non-compliance to AO 2012-0012


    2. Inadequate personnel complement in nursing service
    3. Unauthorized person performing extraction of blood for send out lab (Nurses)
    FINDINGS:
     Submit copy of Partograph
     Proof of Creation, Membership, and Minutes of Meeting for the following committees:
    Committee Creation/Order Policy Minutes of meeting
    Credentialing and Privileging X X X
    Waste Management X X X
    Patient Safety / / X
    Infection Control / / X
    Emergency and Disaster Preparedness / / X
    CQI / / X
    Grievance X X X
    Selections and Promotions X X X
     Proof of Annual accomplishment report
     Policies for Dietary, Linen/Laundry, security of patients, visitors and hospital staff
     Presence of annual plan for training activities
     Proof of orientation conducted to new personnel
     Proof of Job descriptions with conforme
     Presence of Annual Statistical Reports
     Policy on record storage, safekeeping, maintenance, retention and disposal
     Policy for security
     Presence of sentinel event reporting system
     Proof of water analysis results (last 6 months)
     Certificate of Training (in-house) or MOA of personnel in-charge of maintenance of equipment
     Presence of policies in reporting of notifiable diseases
     Presence of Quality Improvement Program and proof of implementation
     Presence of Customer Satisfaction Survey analysis
     Submit MOA for Dietary/ food supplier for patients
    PROGRAMS
     Mother-Baby Friendly Accreditation or received copy of letter of intent
     Policy on generic prescribing
     Proof of Family Planning acceptors or logbook
     TB Referral logbook
    PERSONNEL
     Copy of the following:
    - Chief of hospital/medical director - PRC license, certificate of trainings attended, COE or Appointment
    - Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
    - Medical records officer – Contract, trainings, ICD-10 trainings and Records Management Training
    - Supply Officer/Storekeeper - Contract, trainings
    - Laundry Worker – contract
    - Driver – driver’s license, contract
    - PHYSICIANS NURSES = Total of 6 full time nurses
    Doctor’s Name Diploma Valid PRC Contract/ Nurse’s Name Diploma Valid PRC Contract/MOA
    MOA
    Dr. Hilario / / / Preciosa / / /
    Dr. Pontinoza / X / Irhys / / /
    Dr. Tan / / / Vanessa / / /
    Dr.Bautista / / X Carmina / / /
    Jovie / / /
    Sherly / / /
    1. TO HIRE ADDITIONAL 3 FULL TIME
    2. NURSES
    3.

    PHYSICAL PLANT REQUIREMENT


     Provision of equipment and supply storage
     Provision of kitchen or MOA if outsorced

    EQUIPMENT/INSTRUMENT
    Submit photo and official receipt of the following:

    ADMINISTRATIVE SERVICE
     Ambulance - MOA
     Emergency light – stairways, wards and private
    rooms
    EMERGENCY ROOM Cont. EMERGENCY ROOM
     Examining table with stirrups
     Gooseneck lamp - Mayo scissors straight
     Instrument table - Metzenbaum scissors straight
     Laryngoscope with different sizes - Mosquito forceps straight
     Minor set - Scalpel handle #3
    - Kelly hemostatic forceps straight - Skin retractor
    - Kelly hemostatic forceps curved - Tissue forceps
     Sphygmomanometer – adult cuff and pedia cuff
     Suturing set
     Thermometer – rectal
    OUT-PATIENT DEPARTMENT DELIVERY ROOM
     Gooseneck lamp  Sphygmomanometer, non-mercurial
     Skin retractor  Stethoscope
     Sphygmomanometer –pedia cuff  Suction apparatus
     Thermometer – rectal  Thermometer, non-mercurial
    LABOR ROOM CADAVER HOLDING AREA
     Thermometer –rectal  Bed or stretcher for cadaver
    NURSING UNIT/WARD KITCHEN
     Clinical height scale  Provide MOA if outsorced, if owned, submit
     Emergency light the necessary requirement for Kitchen
     Thermometer –rectal Submit proof of the following:
     Exhaust fan
     Food conveyor
     Food scale
     Stove
     Refrigerator
     Utility cart
     Garbage receptacle with cover and color-
    coded
    E-CART CONTENTS BASIC ER SUPPLIES
     D50W 50mg/vial  Oropharyngeal and nasopharyngeal airways
     Activated charcoal  Intubation kit
     Anti-rabies vaccine – active  Arm sling
     Anti-rabies vaccine –  Cervical collars
    passiveBenzodiazepine(diazepam)  Sharps container
     Calcium gluconate  Pulmonary Function Test
     Dobutamine
     Morphine SO4 10mg/ampule
     Noradrenaline 2mg/ampule

    Monitored by:
    1. Dr. Karenina Victoria
    2. Carol Anne Casihan, RN
    3. Ronaldo F. Santos, RMT
    4. Engr. Joselito Enriquez

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