SUMMARY OF FINDINGS

INFIRMARY
P. Gonzales Memorial Hospital, Inc.
582 J. P. Rizal, Lamuan, Malanday, Marikina City

Date of Monitoring: February 15, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 15, 2018

FINDINGS:
 Submit policy addressing patient’s rights (#1,3,5,6,7)
 Proof of discharge plan
 Photo of updated organizational chart
 Proof of Administrative Policies, Nursing Procedure Manuals
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Membership Minutes of meeting
Credentialing and Privileging
Waste Management
Patient Safety
Infection Control
Emergency and Disaster Preparedness
CQI
Grievance
Selections and Promotions

 Copy of hospital accomplishment report

 Policies for Dietary , Linen and Laundry, Security, Waste Disposal, and Maintenance
 Copy of memorandum of agreement for ambulance service provider

I. Human Resource Management

1. Copy of annual plan on training activities
2. Proof of orientation conducted

II. Information Management

1. Copy of policy on record storage, safekeeping and maintenance, retention and disposal
2. Copy of policy on filing and retrieval of charts
3. Copy of policy on records management to maintain confidentiality/privacy, accuracy and prevention of loss and
destruction, tampering and unauthorized access.

III. Copy of management plan for security and disposal of hazardous & biologic waste
1. Proof of implementation of preventive maintenance of equipment
2. Notarized designation for the person in-charge of security
3. Copy of sentinel event logbook
4. Copy of certification from the service provider that they conduct preventive maintenance of equipment
5. Copy of designation for the doctor & nurse-in-charge of infection control
6. Policy for needle stick injuries & safe disposal of needles
7. Policy on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies
8. Policy in reporting notifiable diseases
9. Copy of policy on waste disposal
10. Copy of memorandum of agreement for waste management service
IV. Improving performance
1. Copy of policy for quality improvement program
2. Proof of better patient outcome as a result of CQI
3. Copy of policy for anti-smoking
4. Policy on generic prescribing
5. Copy of designation of hems coordinator
6. Proof of conduct of drill exercises
7. Copy of response & recovery plan
8. Copy of logbook for newborn tested for hearing
9. Copy of logbook for FP acceptors
10. Copy of logbook for TB referral
11. Copy of the following:
- Chief of hospital/medical director - PRC license, certificate of trainings attended, proof of
employment/Appointment
- Administrative officer/personnel officer – Bachelor’s degree, proof of employment/Appointment
- Accountant or accountant clerk – Diploma(if applicable), certificate of trainings attended, proof of
employment/Appointment
- Medical records officer - proof of employment/Appointment
- Building maintenance/Utility worker - proof of employment/Appointment
- Driver - proof of employment/Appointment, Professional driver’s license if applicable
- Security guard (Utility) - proof of employment/Appointment with additional designation as security
- Dr. Edwin dela Peña - proof of employment/Appointment
- Nurses – atleast 1 Nurse with 9 units of Master’s Degree in Nursing ACLS training
- -All Hired nurses - PRC license, certificate of trainings attended, proof of employment/Appointment
- TO HIRE ADDITIONAL 4 NURSES- currently employed nurses 8
- Nursing attendant - proof of employment/Appointment, relevant training(may be in house training), PRC
license if midwife
12. Copy of letter of intent for accreditation of mother baby friendly (MBFH) facility and workplace received by the
DOH MBFH

PHYSICAL PLANT REQUIREMENT

1. Provision of PWD toilet
2. Provision of cadaver holding area
3. Provision of toilet for patients and companion with easy access/adjacent to emergency room/OPD
4. Provision of toilet within labor room at delivery service
5. 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:
1. Food conveyor or equivalent
2. Food scale
3. Utility cart
4. Garbage receptacle with cover – color coded
5. Defibrillator
6. Metzenbaum scissors straight
7. Gooseneck lamp – 2 pcs (see assessment tool)
8. Pediatric cuff
 9. Oxygen tank unit with tank holder
10. Adult cuff for labor room
11. Adult stethoscope
12. Thermometer – oral and rectal
13. Rechargeable emergency light
14. EENT Diagnostic set
15. 5 caloric agent
16. Anti-rabies vaccine (passive)
17. Digoxin 0.5mg/ampule
18. Dobutamine 250mg/20ml vial
19. Dopamine 20mg/vial
20. Haloperidol 50mg/ampule
21. Magnesium sulphate 1g/ampule
22. Methylprednisolone 4mg/tablet
23. Morphine sulphate 10mg/ampule
24. Nitroglycerine spray or isosorbide dinitrate 5mg tablet/ampule
25. Noradrenaline 2mg/ampule
26. Phenobarbital 30mg/ml IV or 30mg tablet
27. Potassium chloride 40mEq/vial
28. Sodium bicarbonate 50 mEq/ampule
29. Tramadol 50mg/capsule
30. Verapamil 5mg/2ml ampule
31. Airway / intubation kit
32. Aseptic bulb syringe
33. Cervical collars (different sizes)
34. Protective face shield or mask
35. Waterproof aprons

Monitored by: Signature

1. Dr. Alberto Ponce Belarmino MO III ________________________

2. Arch. Oliver Santos LO III ________________________
3. Cynthia Caroll De Veyra, LLB, MPA LO III ________________________
4. Carol Anne Casihan, RN ADAS III ________________________
5. Ronaldp F. Santos MT II ________________________