January 2022 to June 2022 (Cavite)

Departmen NC Issue Root Corrected Plan Status Outcome

t Cause Action
Nursing Observation Vaccines/vials were being
stored with reagents and
DT specimens
Radiology Negative Releasing logbook updated
yet should be done per
month not alphabetically
for easy documentation
Radiology Negative No code-keyboard/mouse
both computer 1 & 2
Radiology Threat Although there are 2 waste
basin,One must be labeled
in yellow as infectious
waste
To ensure proper waste
segregation
Rehab/ PT Threat Water leakage; Possible
accident if left unnoticed
Rehab/ PT Negative Need repaint/Scrubbing of
sink area although auditee
claimed it can’t be remove
Cashiering Opportunity New employee should be
oriented on clinic process

January 2022 to June 2022 (Makati)

Departmen NC Issue Root Corrected Plan Status Outcome
t Cause Action
Nursing Negative Organizational Chart not
updated on manual
Nursing Negative Monitoring of temperature
of refrigerator not updated
Nursing Negative Queuing monitor not
functioning - 3rd floor
Nursing Threat Lack of manpower
Laboratory Negative No Permit to Transport
Laboratory Threat Lack of manpower (2
RMT, 2 Lab assist)
Radiology Negative Organizational chart not
updated on manual
Cardiology Opportunity New portable 2D Echo
machine
Psychology Negative Manuals not updated
(organizational chart/ List
of equipment: Asus
notebook - for Cavite)
Records Negative Inaccuracy of color coding
and identification of
tracking record
Cashier Negative Logbook (Discount Card)
not indicated in manual
and has no control number
Cashier Negative Currency detector not
functioning

January 2022 to June 2022 (Other Department)

Department NC Issue Root Corrected Plan Status Outcome
Cause Action
Top Threat Time period set for
Management expansion is not yet
determined
Top Threat Cost of expenses are fast
Management growing than the revenue
Marketing Negative Marketing Manual is not
updated with its
organizational chart
Marketing Negative Lack of manpower
HRD Threat Difficulty in hiring of staff
(competition on other
companies - higher
salaries, work from home
set-up, arrangements)
IT Negative Records of maintenance
and update of each
computer was not
presented. (Suggested to
have semi-annual
maintenance/ cleaning of
the computers to endure
the efficacy of each
computer.
IT Negative Suggested to have a spare
CPU that is readily
available whenever there is
a computer error.