Ao2022 0012

Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
MAY 18 2022
ADMINISTRATIVE ORDER
No. 2022 - O012
SUBJECT: Rulesand Regulations Governing the Licensure of Cancer Treatment
Facilities in the Philippines
RATIONALE
The 2020 World Health Organization (WHO) data from the International Agency
for the Research on Cancer (IARC) showed that global burden of cancer rose to 19.3 million
new cases with an estimated 10 million cancer deaths, making it the second leading cause of
death globally. The most common types of cancers are of the breast, lung, colorectum,
prostate, and stomach, liver and cervix uteri; while the most common cause of cancer
deaths are from cancers of the female breast, lung, colorectal, prostate and stomach.
In the Philippines, despite cancer awareness and prevention campaigns, there were
153,751 new cases in 2020. The leading causes of new cancer cases are from the
following: breast 17.7%; lung 12.5%; colorectum 11.3%; prostate 5.4 %, liver 6.9%; and
other cancers 46.3 %. There were 92,606 reported deaths and 354,398 prevalent cases
(Globocan 2020). Among these new cancer cases in the country, 3,514 cases or 2.29% were
from the 0-14 age group (WHO 2020).
Early detection and treatment are still the best strategies to reduce cancer mortality,
with surgery, and/or systemic therapy and/or radiation therapy as the accepted modalities of
treatment. For low and middle income families, a diagnosis of cancer poses challenges, not
only in the access to a health care provider and facility, but also in the resulting emotional
and economic impact on the patient and his/her family. Factors such as (a) lack of access, (b)
incorrect, delayed or poor quality of treatment (due to distance, long queues and waiting
time), and (c) expensive therapies, may result in premature death or unnecessary illness and
disability resulting in increased cost of treatment to patients, affecting not only their
families but the health care system and society as well.
Section 11 of Republic Act No. (R.A.) No. 11215, titled “An Act Institutionalizing
a National Integrated Cancer Control Program and Appropriating Funds Therefor”,
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o-7 otherwise known as the National Integrated Cancer Control Act (NICCA), states that in
accordance with Section 33 of this Act, the DOH, in the implementing rules and
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>>) regulations of this Act, shall provide for the minimum required diagnostic, therapeutic,
Eom research capacities and facilities, technical, operational and personnel standards of these
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procedure for licensing in a timely manner.”
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Hence, this Administrative Order (A.O.) regulating cancer treatment facilities is

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issued for a more patient-centered health system and to improve responsiveness to the
needs of cancer patients, making quality and safe health care accessible and affordable,
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in alignment with the goals of R.A. No. 11223 or the Universal Health Care
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FOURmula One Plus and the provisions of R.A. No. 11215.
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Trunk Line 651-7800 local 1108, 1111, 1112, 1113
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Direct Line: 711-9502; 711-9503 Fax: 743-1829 ® URL: http://www.doh.gov.ph; e-mail: fiduque@doh.gov.ph
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II. OBJECTIVE
To provide guidelines in the licensing of cancer treatment facilities, to ensure

effective and efficient delivery of easily accessible, affordable, quality, safe and patient-
centered health care to cancer patients, especially in underserved and far flung areas.
IIL. SCOPE
This Order shall apply to all private and government cancer treatment facilities,
whether hospital-based or non-hospital-based.
This Order shall not apply to treatment facilities offering human stem cell, and cell-
based or cellular therapies, based on A.O. No. 2013-0012, known as “Rules and
Regulations Governing the Accreditation of Health Facilities Engaging in Human Stem
Cell and Cell-Based or Cellular Therapies in the Philippines.”
IV. DEFINITION OF TERMS
A. Applicant - refers to any natural or juridical person, government

instrumentalities/agencies, partnership, corporation or agency seeking a DOH-
License to Operate of a hospital or any other health facility.
B. Allied Health Care Professionals - refer to trained non-cancer health professionals

such as physicians, social workers, nurses, occupational therapists, recreational
therapists, dietitians, among others.
C. Cancer -also known as malignant tumors or neoplasms, refers to a generic term for
a large group of diseases that can affect any part of the body. One defining feature
of cancer is the rapid creation of abnormal cells that grow beyond their usual
boundaries, and which then can invade adjoining parts of the body and spread to
other organs.
D. Cancer Diagnosis - refers to the various techniques, procedures, diagnostics and

new and emerging technologies used to detect or confirm the presence, classification
and stage of cancer.
E. Cancer Registry - refers to a database that contains information about people

diagnosed and confirmed with various types of cancer. The registry shall require
systematic collection, storage, analysis, interpretation and reporting of data on
subjects with cancer.
F. Cancer Survivorship - refers to the period starting at the time of disease diagnosis
and continuous throughout the rest of the patient’s life. Family, careers and friends
are also considered survivors. Survivorship care has three (3) distinct phases: living
through, with, and beyond cancer.
G. Cancer Rehabilitation - refers to a program that helps cancer patients, persons

living with cancer and cancer survivors maintain and restore physical and emotional
well-being. Cancer rehabilitation is available before, during and after cancer
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Cancer Treatment - refers to the series of evidence-based multidisciplinary
interventions that are: (1) aimed at curing and controlling the progression of cancer
such as surgery, radiotherapy, radioisotope therapy, and drug therapy, including
chemotherapy, hormonotherapy, biotherapeutics, immunotherapy, gene therapy, and
other interventions; (2) aimed at improving the patient’s quality of life, such as
supportive- palliative care, pain control, psychosocial, nutritional, and hospice care.
Comprehensive Care - consists of services ranging from cancer prevention,

diagnosis, treatment and supportive care, as well as promoting research and
education.
Comprehensive Cancer Care Center - refers to a care center that is

multidisciplinary and integrates clinical care, education and research to accelerate
the control and cure of cancer.
. Certificate of Compliance (COC) - a form of authorization/permission granted by

the Food and Drug Administration (FDA) which serves as proof of the facility’s
compliance to the set technical requirements. It is a prerequisite for the issuance of
the DOH-License to Operate.
. Department of Health-License to Operate (DOH-LTO) - a formal authority

issued by the DOH to an individual, agency, partnership or corporation to operate a
hospital or other health facility. It is a prerequisite for accreditation of a health
facility by any accrediting body recognized by DOH.
. Department of Health-Permit to Construct (DOH-PTC) - a permit issued by

DOH through HFSRB to an applicant who will establish and operate a hospital or
other health facility, upon compliance with required documents set forth in this
Order prior to the actual construction of the said facility. A DOH-PTC is also
required for hospitals and other health facilities with substantial alteration,
expansion, renovation, increase in the number of beds or for additional services (add-
ons) beyond their service capability. It is a prerequisite for License to Operate.
. FDA-CDRR - refers to the Center for Drug Regulation and Research of the FDA.
. FDA-CDRRHR - refers to the Center for Device Regulation, Radiation Health and
Research of the FDA.
. Health Facility - refers to facility or institution, whether stationary or mobile, land

based or otherwise, that provides any of the following services: diagnostics,
therapeutic, rehabilitative, and other health care services except medical radiation
facilities and hospital-based or stand-alone pharmacies.
. Hospital - a place devoted primarily to the maintenance and operation of health

facilities for the diagnosis, treatment and care of individuals suffering from illness,
disease, injury or deformity or in need of obstetrical or other surgical, medical and
nursing care.
. Multidisciplinary Patient Care - refers to an integrated approach to cancer care in

which medical and allied health care professionals consider all relevant evidence-
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based treatment options and develop collaboratively an individual treatment plan for
each patient.
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S. National Integrated Cancer Control Council (NICCC) - a multi-sectoral group,
attached to the DOH, which shall act as the policy making, planning and coordinating
body on cancer control, pursuant to Section 5 of the R.A. No. 11215 or the NICCA.
T. Oncologist - a physician who has special training in diagnosing and treating cancer,
such as, but not limited to: medical oncologist, radiation oncologist, surgical
oncologist, gynecologic oncologist, pediatric oncologist, hematologic oncologist,
and other subspecialists in cancer.
U. Palliative Care - refers to a systematic and organized approach to care that improves
the quality of life of patients and their families facing problems associated with life-
threatening or life-limiting illness, through anticipation, prevention and relief of
suffering by means of early identification and impeccable assessment and treatment
of pain and other problems throughout the continuum of illness which involves
addressing physical, intellectual, emotional, social, spiritual needs and access to
information.
V. Patient Navigation - refers to individualized assistance provided at the community

or in the hospital, through all the phases of cancer experience, offered to cancer
patients, persons living with cancer, cancer survivors, families and cares to help
overcome health care system barriers and facilitate timely access to qualify medical
and psychosocial care and practical support beginning from pre-diagnosis and
extending throughout the continuum of care.
W. Philippine Nuclear and Research Institute (PNRI) - an agency under the

Department of Science and Technology (DOST) mandated to undertake research and
development activities in the peaceful uses of nuclear energy, to institute regulations
on the said uses and to carry out the enforcement of said regulations to protect the
health and safety of radiation workers and the general public pursuant to R.A. No.
5207 (Atomic Energy Regulatory and Liability Act of 1968).
X. Psychosocial Service (support program) - refers to practical support consisting of

needs-based assistance on non-medical costs such as financial assistance for
diagnosis, treatment, survivorship follow-up care; funeral assistance; education
assistance; transient housing or home support for the family/other siblings;
transportation, food and nutrition; emotional support initiatives for cancer patients,
persons living with cancer, cancer survivors and their families to reduce emotional
distress and improve well-being.
Y. Tumor Board - is a group of doctors and allied health care providers with different
specialties providing cancer care that meets regularly to discuss cancer cases with
the aim of providing best possible treatment plan for a particular cancer patient. It
also serves to share knowledge and formulate institutional policies improve quality
and standards or cancer care.
. GENERAL GUIDELINES
A. Cancer Treatment Facilities (CTFs) shall apply for a DOH-LTO and must be fully
compliant to the licensing standards of the Health Facilities and Services Regulatory
Bureau (HFSRB), Food and Drug Administration (FDA) and Philippine Nuclear
Research Institute (PNRI).
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. CTFs shall be licensed according to its function as Cancer Specialty Hospitals,
Cancer Specialty Centers in a General Hospital, and Cancer Treatment Units in a
General Hospital, Cancer Treatment Satellites or Cancer Treatment Clinics.
. Cancer Specialty Hospitals shall have a minimum authorized bed capacity (ABC) of
one hundred (100) beds, and Cancer Specialty Center in a General Hospital shall
have a minimum ABC of seventy-five (75) beds. At least ten percent (10%) of which
shall be allocated to pediatric patients and the ABC shall be indicated in the DOH-
LTO.
. CTFs shall follow the guidelines for the One-Stop Shop Licensing System
(OSSOLS) based on A.O. No. 2018-0016 titled “Revised Guidelines in the
Implementation of the One-Stop Shop Licensing System.”
. The DOH-LTO of a Cancer Specialty Center in a General Hospital or a Cancer

Treatment Unit in a General Hospital shall be subsumed in the DOH-LTO of the
general hospital as an add-on service.
. Add-on services shall be indicated in the DOH-LTO of the CTF.
. Cancer Treatment Satellites shall be issued separate licenses from its affiliated
Cancer Specialty Hospital/Cancer Specialty Center in a General Hospital.
. Cancer treatment shall only be done in DOH-licensed cancer treatment facilities.
The facility
shall be headed by a Medical Doctor, with qualifications set by the DOH,
and shall be manned by competent and well-trained staff.
CTFs shall have a Manual of Operations, which shall include, but are not limited to:
Standard Operating Procedures (SOPs) being implemented in the facility, the
standard policies issued by NICCC, the protocols for each type of cancer they cater
to and the accepted treatment regimen, policy and procedures for preparation,
administration, and transportation of cytotoxic drugs, disposal of toxic and
hazardous wastes; Policies and procedures for Infection Prevention and Control
(IPC); a Cancer Registry; DOH approved Clinical Practice Guidelines (CPGs)
;
Radiation Protection and Safety Program (if applicable) and copies of relevant laws
and DOH issuances.
. CTFs shall adhere and ensure strict compliance to IPC standards.
. CTFs shall adhere to the accepted standard treatment protocols, as prescribed in the
DOH-approved CPGs.
M. All hospital-based cancer treatment facilities shall create a Tumor Board to

determine the best possible cancer treatment and individualized care plan for
patients.
. CTFs shall use only FDA-registered drugs and/or devices and PNRI-licensed
radioactive materials.
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. CTFs shall have support services such as, but not limited to: administration and
management, human resource management, information technology and
management, equipment and physical facilities management, finance, dietary
services (for in-patients), and security services.
. CTFs shall have its own Cancer Registry and shall submit data to the Philippine
Cancer Center.
. CTFs shall use Electronic Medical Records System (EMRS) validated by DOH.
R. CTFs shall make the prices of services and goods readily available to clients, either
in printed or digital format, with updating done regularly, in accordance with DOH
guidelines.
. CTFs shall be part of a functional cancer referral network based on the guidelines
approved by the NICCC.
. CTFs shall follow the standards, criteria and requirements prescribed in the Annex
A - Assessment Tool for Licensing a CTF for hospital-based , Annex B - Assessment
Tool for Licensing a CTF for non-hospital based, Annex C - Planning and Design
Guidelines for CTFs, Annex D1 - Checklist for Review of Floor Plans for Cancer
Specialty Hospital and Cancer Specialty Center in a General Hospital, Annex D2 -
Checklist for Review of Floor Plans for Cancer Treatment Unit/Satellite/Clinic,
Annex El and E2 - Sample Floor Plans, DOH issuances, all existing relevant rules
and regulations of FDA and PNRI, and all existing relevant laws.
. In the advent of new technologies or practice protocols acceptable to DOH,

appropriate policies shall be issued as needed, to supplement this Order.
VIL. SPECIFIC GUIDELINES
A. Classification of Cancer Treatment Facilities
1. According to Ownership
a. Government - created by law. A government facility may be under the
national government (DOH), local government unit (LGU), Department of
National Defense (DND), Philippine National Police (PNP), Department of
Justice (DOJ), State Universities and Colleges (SUCs), Government Owned
and Controlled Corporations (GOCCs) and others.
b. Private - owned, established and operated with funds through donation,
principal, investment or other means by any individual corporation,
association or organization. A private health facility may be a single
proprietorship, partnership, corporation, cooperative, foundation, religious,
non-government organization and others.
2. According to Institutional Character

CTFs shall be classified as follows:
a. Hospital Based
i. Cancer Specialty Hospital
ii. Cancer Specialty Center in a General Hospital
iii. Cancer Treatment Unit in a General Hospital
b. Non-hospital based
i. Cancer Treatment Satellite
ii. Cancer Treatment Clinic
3. According to Function
a. Comprehensive Care
i. Cancer Specialty Hospital - a specialty hospital providing comprehensive
cancer care services, utilizing the multidisciplinary team approach in the
management of cancer patients, and offering the highest level of care and
a complete range of services and treatments to one or more types or
subspecialties of cancer, particularly rare cancers, complicated cancer
cases; cancer-related transplants; and molecular and genetic oncology. It
is a teaching and training facility for cancer, with research capabilities.
ii. Cancer Specialty Center in a General Hospital — cancer facility in a level
3 general hospital providing comprehensive cancer care services utilizing
the multidisciplinary team approach in the management of cancer
patients, and offering the highest level of care and a complete range of
services and treatments to one or more types or subspecialties of cancer.
It is a teaching and training facility for cancer, with research capabilities.
b. Limited Care
i. Cancer Treatment Unit in a General Hospital — is a unit within a general
hospital providing limited scope of services and treatment to one or more
types or subspecialties of cancer, utilizing the multidisciplinary team
approach in the management of cancer patients.
ii. Cancer Treatment Satellite — a non-hospital based ambulatory cancer
treatment facility, providing limited scope of services, such as systemic
therapy/radiation therapy/nuclear therapy; affiliated with any cancer
specialty hospital or cancer specialty center in a general hospital.
iii. Cancer Treatment Clinic — a non-hospital based ambulatory cancer
treatment facility, providing limited scope of services, such as systemic
therapy/radiation therapy/nuclear therapy; not affiliated with any cancer
specialty hospital or cancer specialty center in a general hospital.
B. Standards
CTFs shall be organized to provide safe, quality, effective and efficient services for
patients.
1. Personnel
a. CTFs shall have adequate, competent and appropriately-trained staff, with
continuing professional education and regular performance evaluations.
(Annex A - Assessment Tool for Licensing a CTF for hospital-based, Annex
B - Assessment Tool for Licensing a CTF for non-hospital based)
b. The multi-disciplinary team approach in providing patient care must be
utilized at all times. It is composed of, but not limited to, radiologist, cancer
surgeon, medical oncologist, radiation oncologist, pediatric oncologist, HM
gynecologic oncologist, pathologist, palliative care provider, and other
support staff.
2. Physical Facilities
CTFs shall have adequate and appropriate areas to safely, efficiently and
effectively provide health services, to patients and the general public. (Refer to
Annex C - Planning and Design Guidelines for CTFs, Annex D1 - Checklist for
Review of Floor Plans for Cancer Specialty Hospital and Cancer Specialty
Center in a General Hospital, Annex D2 - Checklist for Review of Floor Plans
for Cancer Treatment Unit/Satellite/Clinic, Annex E1 and E2 - Sample Floor
Plans)
3. Equipment and Instruments

CTFs shall have available and operational equipment and instruments
appropriate and consistent to the services offered. (Refer to Annex A -
Assessment Tool for Licensing a CTF for hospital-based, Annex B - Assessment
Tool for Licensing a CTF for non-hospital based)
4. Service Capability
CTFs shall ensure that the services delivered to patients comply with the
standards in the Assessment Tool for Licensing of Cancer Treatment Facilities,
and other relevant issuances. (Refer to Annex A - Assessment Tool for Licensing
a CTF for hospital-based, Annex B - Assessment Tool for Licensing a CTF for
non-hospital based). CTFs, in accordance with the type of the facility, shall have
the following:
a. Manual of Operations
b. Clinical Practice Guidelines
¢. Survivorship Program
d. Patient Navigation and Referral System
e. Basic Services in accordance with the type of facility, shall consist of the
following, but not limited to:
i. Consulting Services:
a) Internal Medicine
b) Pediatrics
¢) Obstetrics and Gynecology
d) Surgery
ii. Emergency Services
iii. Outpatient Services
iv. Isolation Facility
v. Surgical Facility
vi. Intensive Care Unit
vii. Respiratory Unit
f. CTFs, in accordance with the type of facility, shall consist of the following,
but not limited to:
i. Surgery
ii. Systemic Therapy
iii. Radiotherapy
iv. Therapeutic Nuclear Medicine
v. Adjunct Services for Cancer Treatment
a) Pain and Palliative Care
b) Clinical Nutrition for Cancer
¢) Cancer Rehabilitation
d) Psycho-social Service (specific for the life stage being catered to)
g. Ancillary services, in accordance with the type of the facility, shall consist
of the following, but not limited to:
i. Diagnostic Clinical Laboratory
ii. Diagnostic Imaging Facility
iii. Diagnostic Nuclear Medicine
iv. Pharmacy
v. Blood Service Facility
vi. Ambulance Service
h. Support Services, in accordance with the type of the facility, shall consist
of the following, but not limited to:
i. Administration Services
ii. Human Resource Management
iii. Information Management
iv. Equipment and Physical Facilities Maintenance
v. Finance
vi. Dietary Services (for in-patients)
vii. Security Services
i. Teaching and training capability with accreditation on residency and/or
fellowship training program for physicians in any cancer specialty and/or
subspecialty
j. Cancer-related Research
5. Quality Improvement Activities

CTFs shall establish and maintain a system for continuous quality improvement
activities, and be able to:
a. Identify the many potential risks in themultiple treatment paths and multiple
treatment providers and commit to a quality and safety agenda.
b. Monitor and assess the indicators for quality and effectiveness of their
structures, processes and outcomes as part of the ongoing performance
improvement.
6. Information Management
Every CTF shall maintain a system of communication, recording and reporting of
the patient’s condition as well as the results of examinations which may include
electronic communications, or otherwise, allowed under Republic Act (R.A.) No.
8792, otherwise known as the “Electronic Commerce Act of 2000,” and its
Implementing Rules and Regulations. Moreover, management of data or
"information should be in adherence to R.A. No. 10173 also known as the “Data
Privacy Act of 2012,” and its Implementing Rules and Regulations.
a. Contents of Medical Records (Refer to Annex A - Assessment Tool for
Licensing a CTF for hospital-based, Annex B - Assessment Tool for Licensing
a CTF for non-hospital based)
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. Individualized Clinical Management Plan
6 . Cancer Registry of the CTF
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. Proof of submission of data to the Philippine Cancer Center
0 . Validated Electronic Medical Records System (EMRS)
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Proof of submission of data to the National Health Workforce Registry
through the National Database of Human Resources for Health Information
System (NDHRHIS)
g. Logbooks or records of:
i. sentinel/adverse events
ii. preventive and corrective maintenance of equipment; and,
iii. maintenance and monitoring of health facility
h. Logistics Management in terms of availability of medicines and access to
medicines, supplies, among others.
7. Environmental Management
CTFs shall ensure that the environment is safe for their patients and staff,
including the general public. (Refer to Annex A - Assessment Tool for Licensing
a CTF for hospital-based, Annex B - Assessment Tool for Licensing a CTF for
non-hospital based)
a. There shall be a written plan and program of proper disinfection and
preventive maintenance of the facility.
b. The use of Personal Protective Equipment (PPE) and adherence to IPC
policies shall be strictly observed.
c¢. There shall be procedures for the proper disposal of infectious wastes and
toxic and hazardous substances in accordance with R.A. No. 6969 known as
“Toxic and Hazardous Substances and Nuclear Wastes Act” and other related
policy guidelines and/or issuance (e.g. DOH Healthcare Waste Management
Manual).
d. “No Smoking” signages posted in a conspicuous space, in accordance with to
R.A. No. 9211, E.O. No. 26 s. 2017, “Providing for the Establishment of
Smoke-Free Environments in Public and Enclosed Places.”
VII. PROCEDURAL GUIDELINES

A. Licensing Process
1. DOH-Permit to Construct
a. Online application for DOH-Permit to Construct (DOH-PTC) shall be
submitted to the Online Licensing and Regulatory System (OLRS) for both
hospital and non-hospital-based cancer treatment facilities. Manual
submission shall be accepted in the interim that the system is not yet fully
operational.
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b. The application process shall be in accordance with A.O. No. 2016-0042,
known as “Guidelines in the Application of Department of Health Permit to
Construct (DOH-PTC),” and the timeline shall be in compliance with the
Citizen's Charter.
c. A pre-operational permit from CDRRHR and/or radioactive material license
from PNRI, when applicable, must also be secured by the applicant.
d. The inspection team shall be composed of, but not limited to, the following
regulatory officers:
i. Team Leader: Physician
ii. Members: Nurse, Architect or Engineer, Medical Technologist
2. DOH-License to Operate (LTO)

a. CTFs shall follow the One-Stop Shop (OSS) licensing system for hospitals
and other health facilities based on A.O. No. 2018-0016 “Revised Guidelines
in the Implementation of the One-Stop Shop Licensing System,” when
applicable.
b. Manual application for PNRI LTO shall be submitted to PNRI, and payment
made directly to their Cashier, until arrangements for integration in the online
one stop-shop licensing system has been finalized, when applicable.
c. Process for inspection (initial or renewal) and monitoring shall follow AO No.
2018-0016 known as “Revised Guidelines in the Implementation of the One-
Stop Shop Licensing System” and the timeline shall be based on Citizen's
Charter Timeline and the Quality Management System (QMS) guidelines of
the Bureau.
d. Validity of the DOH-LTO
i. The DOH-LTO for the hospital-based CTFs shall be valid for one (1)
year.
ii. The DOH-LTO for non-hospital based CTFs shall be valid for three (3)
years.
e. Fees
i. The DOH-LTO fee shall follow the schedule of fees currently prescribed
by the DOH, FDA and PNRIL
ii. The applicant, upon filing the application, shall pay the corresponding
fee to the following: DOH Cashier/Center for Health Development
(CHD) Cashier; FDA Cashier or any authorized banks; and PNRI
Cashier.
VIII. VIOLATIONS, SANCTIONS AND APPEAL
Pursuant to Section 3 of E.O. No. 102 5.1999 titled ‘Redirecting the Functions and
Operations of the Department of Health,” the DOH shall “formulate national policies
and standards for health.”
A. A CTF shall be sanctioned and penalized by the HFSRB/CHD-Regulation,

Licensing and Enforcement Division (RLED) upon violation of any of the provisions
of these guidelines and its assessment tool or upon commission/omission of any
prohibited acts of related laws/issuances by persons who own and/or operate the
CTF, and/or the persons under their authority.
B. A CTF operating without an approved DOH-LTO and DOH-PTC shall be issued a
Cease and Desist Order.
C. A CTF shall be issued Preventive Suspension of not more than sixty (60) days in the
following instances:
1. Manned by unqualified/unauthorized personnel
2. Absence of required personnel
3. Absence of proper functioning equipment and/or instruments
4. Unsafe practices that will harm the patients, healthcare workers and/or the general
public
D. The following are the penalties and sanctions that shall be imposed for the
commission of any of the violations in this Order and other relevant issuances:
1. 1% offense: Thirty thousand pesos (Php 30,000.00)
2. 2offense: Fifty thousand (Php 50,000.00) and/or suspension of DOH-LTO for

15 days
3. 3" offense: One Hundred Thousand (P100,000) and/or suspension of DOH-LTO

for 30 days
4. 4" offense: Revocation of License

The applicant may re-apply for initial DOH-LTO one (1) year after revocation.
E. Upon receipt of the complaint by the HFSRB/CHD-RLED against a CTF, an

investigation shall be conducted and the appropriate sanctions be meted for its
violation/s, if warranted.
F. Any CTF or any of its

personnel not satisfied with the decision of the HFSRB/CHD-
RLED may, within ten (10) days after the receipt of the decision, file a notice of
appeal to the Head of the Health Regulation Team (HRT). All pertinent documents
and records of the appellant shall then be elevated by HFSRB/CHD-RLED to the
HRT. The decision of the Head of the HRT, if
still contested may be brought on final
appeal to
the Secretary of Health within ten (10) days after the receipt of the decision.
The decision of the Secretary of Health shall be final and executory.
IX. TRANSITORY PROVISIONS
A. The requirement for the DOH-PTC shall be waived for existing hospitals operating
a CTF prior to the effectivity of this Order. In lieu of this requirement, an as-built
plan shall be submitted to the HFSRB/CHD-RLED. However, if
there will be an
increase in the number of bed, major renovations/alterations, expansion or transfer
of location, the facility shall now apply for DOH-PTC.
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B! Cancer Specialty Hospitals and Cancer Specialty Centers in a General Hospital
shall be given five (5)-year grace period from the date of issuance of the DOH-
LTO of the CTF to fully comply with the following licensing requirements:
1. Teaching and training with accreditation of residency/fellowship training

program for physicians in a least one (1) cancer specialty and/or subspecialty;
and,
2. Cancer-related research
C. The Philippine Cancer Center, a cancer specialty hospital and the designated apex
hospital for cancer, shall be licensed in accordance with the phases of the transitory
arrangement provided by the DOH.
D. Cancer Specialty Center in a General Hospital shall be licensed as such, wherein

the authorized bed capacity may be the total of beds allotted for cancer patients
distributed in the different departments. However, such arrangement shall ensure
that the beds for the cancer patients shall have its own designated area in the
department.
E. All patient beds in a Cancer Specialty Center in a General Hospital or Cancer

Treatment Unit in a General Hospital shall be housed in the designated area for
cancer patients within five (5) years from the date of issuance of the DOH-LTO.
F. Cancer-related transplants and molecular and genetic oncology shall be required
in a Cancer Specialty Hospital only after the DOH-approved guidelines have been
developed.
X. SEPARABILITY CLAUSE
If any clause, sentence or provision of this Order shall be declared invalid or

unconstitutional, the other provisions not affected thereby shall remain valid and
effective.
XI. REPEALING CLAUSE
Any orders, issuances, rules and regulations inconsistent with or contrary to this
AO shall be repealed, amended or modified accordingly.
XII. EFFECTIVITY
This Order shall take effect fifteen (15) days after its publication in newspaper of
general circulation and upon filing three (3) copies to the University of the Philippines
Law Center.
SCO T. DUQUE III, MD, MSc

Secretary of Health
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ANNEX A
A.O. No. 2022-0012
ASSESSMENT TOOL FOR LICENSING A CANCER TREATMENT FACILITY
INSTRUCTIONS:
1. To properly fill-out this tool, the Licensing Officer shall make use of: INTERVIEWS, REVIEW OF
DOCUMENTS, OBSERVATIONS and VALIDATION of findings.
e Interview at least ten (10) patients and ten (10) hospital staff members
e Conduct document review of at least ten (10) sample documents
If the corresponding items are present, available or adequate, place (/) on each of the appropriate
spaces under the FINDINGS column or space provided alongside each corresponding item. If not,
put an (X) instead.
The REMARKS column shall document relevant observations.
Make sure to fill-in the blanks with the needed information. Do not leave any items blank.
The Team Leader shall ensure that all team members write down their printed names, designation
and affix their signatures and indicate the date of inspection/monitoring, all at the last page of the
tool.
The Team Leader shall make sure that the Head of the facility or, when not available, the next most
senior or responsible officer likewise affix his/her signature on the same aforementioned pages, to
signify that the inspection/monitoring results were discussed during the exit conference and a
AN
duplicate copy also received.
4
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[|
PART I - MEDICAL SERVICES
Hospital-Based Cancer Treatment Facility
1
HEALTH FACILITY INFORMATION
Name of Facility:
Address:
~~
Email Address: Tel. / Fax Nos.:
Name of Owner: Tel. / Fax Nos.:
Hosp. Administrator:
Tel. / Fax Nos.:
Chief of Hospital/Med. Director: Tel. / Fax Nos.:
Existing License No.: Authorized Bed Capacity(if applicable):
Classification According to Function:
[1 cancer Specialty Hospital

[] Cancer Specialty Center in a General Hospital
Od Cancer Treatment Unit in a General Hospital
Classification According to Ownership:
Government Private
[1 National [1] Single Proprietorship
[1] Local Corporation
[1 others: (specify) Others: (specify)
Type
Activity:
of application:
[] Inspection
| Initial
C1]
[_] Renewal
Monitoring [1
[_]Others: (specify)
surveillance Cothers: (specify)

f
“ol
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.
\
|
)
CRITERIA EVIDENCE
INDICATOR AREAS COMPLIED REMARKS
(if applicable) (if applicable)
:
I. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS

Standard: Organizational policies and procedures respect and support patients’ rights to quality care and their
responsibilities in that care.
1. Informed consent is obtained « All patient DOCUMENT Admitting Area/
from patients prior to initiation charts have REVIEW Treatment Area
of care. signed « Patients charts
Note: Informed consent - consent.
includes a patient-doctor INTERVIEW
discussion of the nature of the « Patients
decision or the procedure; Ask patient/family
alternatives to proposed if they were
intervention; the risks, benefits, appropriately
and uncertainties related to informed by
each alternative; assessment to authorized
patient understanding; and personnel (doctor
patient's acceptance or refusal or nurse) about
of the intervention. their disease,
condition or
disability, its
severity,
Prognosis,
benefits and
possible adverse
effects of
treatment options
and the likely cost
of treatment.
2. Policies and procedures « Presence of DOCUMENT Wards/
which identify and address policies and REVIEW Treatment Area
patients’ rights and procedures to « Policies and
responsibilities are identity and procedures on
documented and address patients' rights.
monitored. patients' rights
(Refer to DOH INTERVIEW
Department « Staff Patient
Memorandum
No. 2017-0061 OBSERVE
and « Posted patients’
Department rights in
Memorandum conspicuous
No. 2017- places (e.g.
0223) admitting area,
lobby or
reception area,
treatment area)
II. PATIENT CARE
A. ACCESS
Standard: The organization informs the community about the services it provides and the hours of their availability.
. Clinical services are . Presence of DOCUMENT Lobby/
appropriate to patients’ needs facilities REVIEW Reception Area
and the former's availability is consistent with * List of services
consistent with the clinical service available,
organization's service capability. schedule of
capability and role in the operating hours
community. and
corresponding
prices and fees
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* DOH LTO
(updated, valid
and original).
OBSERVE
« The facility and
structure.
o Check if the
service capability
the
of facility is
in accordance
with its
classification.
« Posted list of
services and
schedule of
operating hours.
+ Available list of
prices and fees.
ACCORDING TO CLASSIFICATION OF HOSPITAL-BASED CANCER TREATMENT FACILITY

Place a check in the corresponding column, if complied
A.Basic Services
1 Consulting Services at least
for:
a. Internal Medicine
b. Pediatrics
c. Obstetrics and
Gynecology
d. Surgery
DOCUMENT REVIEW
Policies and procedures on how to
access such services
2. Emergency Services Note: Access to
3. Outpatient Services ICU and
4. Isolation Facility respiratory unit,
5. Surgical Facility if not available
6. Intensive Care Unit in the cancer
7. Respiratory Unit treatment
Jacility
DOCUMENT REVIEW
* Policies and procedures
* Memorandum of Agreement
with a Higher Level of
Hospital (for a Level 1
Hospital without ICU and
Respiratory unit as an
additional service/s)
LEGEND:
A 2 TU
Co-Shared with the General Hospital

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B.Cancer Treatment Services

(All items (all items are (Items No. 2, 3 or
are required) required) 4, and 5 are
required)
Surgery
Systemic Therapy
DE
Radiotherapy
Therapeutic Nuclear Medicine
Adjunct services for cancer
treatment
a. Pain and Palliative Care
b. Clinical Nutrition for
Cancer
Cancer Education
lale
Spiritual Care
Cancer Rehabilitation
mle
Psycho-social Service
(specific for the life stage
being catered to)
DOCUMENT REVIEW
* Policies and procedures for each
service
OBSERVE
* Different clinical areas (if
applicable)
C. Teaching and training

capability
Note: With accredited
residency/fellowship training
program for physicians in any
cancer specialty and/or
subspecialty
DOCUMENT REVIEW
* Policies and procedures
* Certificate of accreditation of
residency/fellowship training
LEGEND:
HA q
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D. Cancer-related Research
DOCUMENT REVIEW
* Presence of Level Ill PHREB-
accredited Ethics Review
Board/Committee/Institutional
Ethics Review Board or MOA
with Level III PHREB-
accredited ERC
* Certificate of accreditation as
Level III PHREB-accredited
ERB/ERC
* Researches approved by
PHREB or ERB/ERC of the
CTF
4. All patients are correctly « The contents of DOCUMENT ER

identified by their patient patient's REVIEW OPD
charts. charts/records are the « Patient Wards
following: charts/records Treatment
1. Summary or face from ER : Area
sheet Wards, OPD and
2: Informed Consent Treatment Area
History and
Physical INTERVIEW
Examination « Patients
Clinical
Management Plan
Doctor's order
Nurses Notes
TPR Sheet
Nutrition Notes
Laboratory and X-
ray reports, if any
. Imaging reports
. Medication and/or
treatment record
. Operative and
anesthesia record
(if applicable)
. Record of referral/
consultation to
other physicians,
including notes
LEGEND:

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21
TH
CRITERIA INDICATOR
EVIDENCE AREAS
COMPLIED REMARKS
14. Record of referral
or transfer of
patient to other
facility/service/
doctor (if
applicable)
15. Discharge
summary
16. Clinical abstract
17. Individual Care
Plan
18. Advance
Directives (if any)
Standard: The care plan addresses patient's relevant clinical, social, emotional and religious needs.
5. The Clinical Management e Presence of Clinical DOCUMENT Wards
Plan, developed by the Management Plan REVIEW Treatment Area
multidisciplinary team, « Adopted/developed * Clinical ER
aside from delineating protocols, DOH- Management OPD
responsibilities, includes approved CPGs or Plan ICU
goals to be achieved, pathways containing Copy of
services to be provided, goals to be achieved, protocols, DOH-
patient education services to be provided, approved CPGs
strategies to be implemented, patient education or pathways
time frames to be met, and strategies to be
resources to be used. implemented, time OBSERVE
frames to be met and « Check if
resources to be used medicines and
treatment
prescribed are in
accordance with
adopted DOH-
approved
CPGs/protocols
INTERVIEW
« Patients/family,
regarding the
involvement in
the development
ofthe plan
Standard: Each patient's physical, psychological and social status is assessed.

6. An appropriate « All patients have DOCUMENT Wards
comprehensive history and comprehensive REVIEW Treatment
physical examination is history and PE. If « Patient chart from Area
performed on every patient. admitted in hospital, wards or Medical Medical
The history includes present within 48 hours from Records Office Records
illness, past medical, family, admission. have complete Office
social and personal history. history and P.E.
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EVIDENCE AREAS
CRITERIA INDICATOR COMPLIED REMARKS
(if applicable) {if applicable)
Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and
unnecessary repetition.
7. Qualified personnel give « All patients for DOCUMENT Wards
patients for surgery surgery have REVIEW Treatment Area
preoperative physical and undergone « Patients’ charts of
pre-anesthetic assessment preoperative physical surgery patients
and pre-anesthetic who have
OR assessment underwent
surgery and
Pre-treatment, physical « All patients undergo presently
evaluation prior to systemic pre-treatment, admitted.
and/or radiotherapy. physical evaluation
to
prior therapy.
B. IMPLEMENTATION OF CARE
Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate to
the provider organization’s service capability and are performed by qualified personnel
8. Policies and procedures on « Presence of policies DOCUMENT Pharmacy
medication management and and procedures on REVIEW Treatment Area
use medication Ask the staff on the
management and use folowing:
* Dispensing of
medicines
* Verification of
doctor’s orders
* Identification of
patient’s prior to
administration
* Documentation
and reporting of
adverse drug
events
9. Policies and procedures for « There is quality control DOCUMENT Laboratory

the standard performance, on diagnostic REVIEW X-ray
monitoring and quality examinations e Proof of
control of diagnostic including image reject monitoring of
examination analysis, etc. and implementation
calibration of ofthe policies
diagnostic equipment and procedures on
quality control of
diagnostic
examinations
C. EVALUATION OF CARE
Standard: The discharge plan or home instructions is part of the patient's care plan and is documented in the patients’ chart/record.
10. Discharge plans/home « All charts/records have DOCUMENT Medical Records

instructions for patients to discharge plans/home REVIEW Office
ensure continuity ofcare. instructions. « Patients’ charts Wards
from medical Treatment Area
records
room/area, look
for proof of
discharge
teaching
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RR CRITERIA INDICATOR
EVIDENCE
(if applicable)
AREAS
(if applicable)
COMPLIED| REMARKS
plan explained
with the patient
and
family/guardian
and properly
signed by the
patient. It should
contain all ofthe
followingbut not
limited to:
1. Home
medications (if
applicable)
2. Follow up
visits/schedule
3. Home care/
advise
III. LEADERSHIP AND MANAGEMENT
A. MANAGEMENT REVIEW
Standard: The provider organization's management team provides leadership, acts according to the organization's
policies and has overall responsibility for the organization's operation, and the quality of its services and its resources
11. Organizational « Presence of OBSERVE Lobby/
Structure/Chart organizational structure ¢ Organizational Reception Area
structure/chart is
posted in a
conspicuous area
12. The organization and its « Presence of written DOCUMENT Lobby/

services develop their vision, mission, and REVIEW Reception Area
vision, mission and goals of the cancer « Written vision, Medical,
corporate goals based on treatment facility mission and goals Nursing and
agreed upon values Administrative
Office
OBSERVE
« Posted vision and
mission in a
conspicuous area
13. The organization and « Presence of written DOCUMENT Medical,

its services develop policies and procedures REVIEW Nursing and
their policies and manual for all services * Written Policies Administrative
procedures. * Manual of Office
Procedures Treatment Area
* Documentation of
orientation on
policies and
procedures
conducted
14. The organization shall * Creation of the Tumor DOCUMENT Administrative

create a Tumor Board Board which includes REVIEW Office
appointment of * Proof of creation
members ofthe Tumor
Board, including
appointment of
members
* Written Policies
and procedures
* Minutes ofthe
Meeting
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=
CRITERIA FYIDENC AREAS

INDICATOR |cOMPLIED REMARKS
* Members of the
Tumor Board,but
not limited to:
Surgical
Oncologist,
Medical
Oncologist,
Pediatric
Oncologist,
Radiation
Oncologist,
Gynecologic
Oncologists
(especially for
female patients),
Pathologist, Pain
and Palliative Care
Provider, Clinical
Psychologist or
Psychiatrist
15. Committees within the « Creation of all DOCUMENT Administrative

organization which committees within the REVIEW Office
includes the terms of organization which e Proof of the
reference for includes the terms of creation of all
membership reference for committees,
membership written policies
and procedures,
The following are minutes of
the committees meetings
required:
1. Credentialing INTERVIEW
and Privileging « Committee
2. Blood members
Transfusion
3. Healthcare Waste
Management
4. Patient Safety
5. Infection
Prevention and
Control
6. Antimicrobial
Stewardship
(functional in Level
3 Hospitals by
2019, Level 2 by
2020, and all levels
by 2022)
7. Pharmacy and
Therapeutics
8. Emergency and
Disaster
Preparedness
9. CQI
10. Grievance
11. Information and
Communication
Technology
12. Level 111 PHREB-
Accredited Ethics
Review Board/
Committee
&
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CRITERIA
IV. HUMAN RESOURCE MANAGEMENT

A. HUMAN RESOURCES PLANNING
INDICATOR
en
(if applicable) i
AREAS
;
af
applicable)
|
COMPLIED
J
J
REMARKS
Standard: Workload is monitored and appropriate guidelines consulted to ensure that appropriate staff numbers and
skill mix are available to achieve desired patient and organizational outcomes.
17. The organization » Presence of policies and DOCUMENT Personnel/
documents and follows procedures for hiring, REVIEW Administrative
policies and credentialing and « Policies and Office
procedures for hiring, privileging of staff procedures for hiring,
credentialing, and credentialing and
privileging ofits staff. privileging of staff
INTERVIEW
+ Human Resources
Management
Officer/Personnel
Officer
18. Staff numbers and « Staff to bed ratio for DOCUMENT Personnel/
skill mix are based licensed doctors, REVIEW Administrative
on actual clinical registered nurses and * List of licensed doctors Office
needs. nursing aides and and nurses and other Wards
other personnel personnel based on HR Treatment Area
(Trainees, except follows the DOH records
physicians undergoing prescribed ratio. * Payroll
residency (Refer to Attachment * Schedule ofduties for
training and volunteers of Assessment Tool the previous and
not included) for Personnel)
current month
* Number ofbeds
authorized by DOH
and actual beds being
used
* 201 files of employees
B. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES
Standard: Recruitment, selection and appointment procedures ensure appropriate competence, training and experience
of all hired staff.
19.Professional » Presence of Qualification DOCUMENT Personnel/
qualifications are Standards REVIEW Administrative
validated, including o Check Qualification Office
evidence of Standards; procedures
professional in hiring.
registration /license OBSERVE
where applicable, o Check PRC ID
prior to employment of some MDs, Nurses,
Pharmacists, Rad
Tech, etc.
20. The staff are provided « Staff provided with job DOCUMENT Personnel/
with a documented description outlining REVIEW Administrative
job description their accountabilities and « Written job Office
outlining responsibilities descriptions with
accountabilities and conforme
responsibilities
IC.STAFF TRAINING AND DEVELOPMENT
Standard: There are relevant orientation, training and development programs to meet the educational needs of
management and staff.
R1.New personnel, new o Proof that new DOCUMENT Personnel/
graduates and personnel are REVIEW Administrative
external contractors adequately oriented and « Documentation of Office
are adequately supervised orientation conducted
supervised by INTERVIEW
qualified staff « Ask new personnel
about the lines of
authority and
supervision and ifthe
supervision is
adequate
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:
EVIDENCE AREAS
22.Annual plan on e Presence of annual plan DOCUMENT Personnel/
training activities on training activities REVIEW Administrative
e Annual plan Office
(including resource/
budgetary allocation)
on training activities
V. INFORMATION MANAGEMENT
A. DATA COLLECTION AND AGGREGATION
Standard: Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for
delivery of patient care and management of services
23. Records are stored, Policies and procedures
eo DOCUMENT Medical Records
retained and on record storage, REVIEW Office
disposed of in retention and disposal. e Logbooks on record
accordance with (Refer to National storage, retention and
the guidelines set Archives ofthe disposal
by the DOH and Philippines [NAP] and
National Archives DC No. 2021-0226- OBSERVE
ofthe Philippines Dissemination ofthe e Proper storage of
(NAP) Approved Records records
Disposition Schedule)
24. The organization defines| e Presence of annual DOCUMENT Medical Records
data sets, data statistical reports and REVIEW Office
generation, collection other additional hospital e Policies and
and aggregation methods statistics as determined by procedures on record
and the qualified staff the DOH storage, safekeeping
who are involved in each and maintenance,
stage retention and disposal.
25. Cancer Registry e Policies and procedures e Presence of Cancer Medical Records
on record, safekeeping Registry in the facility; Office
and maintenance ofcancer Proof of submission of
registry data to the Philippine
Cancer Center
B. RECORDS MANAGEMENT
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and comply
with all relevant statutory requirements and codes of practice.
26. When patients are » Presence of policies and OBSERVE Medical Office
admitted or are seen procedures on filing, « Patient charts are
for ambulatory or retrieval of charts and easily retrievable
emergency care, request for clinical within 10-15 minutes
patient charts records/abstracts
documenting any « Proper filing of patient
previous care can be records/charts
quickly retrieved for
review, updating and
concurrent use.
27.The organization has » Presence of policies and DOCUMENT Medical Records

policies and procedures on protection REVIEW Office
procedures, and of records and patient » Logbooks for Wards
devotes resources, charts against loss, borrowing and Treatment Area
including destruction, tampering retrieval of charts
infrastructure, to and unauthorized access
protect records and or use, and in maintaining OBSERVE
patient charts against confidentiality/privacy. o Access to records and
loss, destruction, patient charts
tampering and
unauthorized access or
use. Only authorized
individuals make entries
in the patient chart.
A
A
\
]
Ly
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ie
ah JE
: ;
:
EVIDENCE AREAS hE
28. Validated + Presence of DOH-

|
DOCUMENT
Gfapplicable). it applicante)
Medical Records
SOMELIED
|
REMARKS
Electronic Health/ validated EMRS/ EHRS REVIEW Office

Medical Record « DOH Certificate on
System (EMRS/ EMRS/ EHRS
EHRS) Validation
OBSERVE
+ EMR implementation
include, butis not
limited to, e-claims,
primary care benefits,
maternal and neonatal
deaths, injury, and
confirmed cases of
diagnosis
29. Inventory of » Policies and Procedures DOCUMENT Medical Records

medicines, supplies, on Conduct and REVIEW Office
among others Frequency of Inventory « Logbooks/ Records Pharmacy
and stock taking Presence CSSR
of inventory of Stock Room
medicines,supplies, among
others
30. National Health Presence of human DOCUMENT Medical Records

Workforce Registry resource data REVIEW Office
thru the National o Proofof submission of
Database of Human data to NDHRHIS
Resources for
Health Information
System )
(NDHRHIS)
VI. SAFE PRACTICE AND ENVIRONMENT

A. PATIENT AND STAFF SAFETY
Standard: The organization plans a safe and effective environment of care consistent with its mission, services, and
with laws and regulations
B1. An incident reporting « Presence of incident DOCUMENT Administrative
system identifies reporting system/sentinel REVIEW Office
potential harms, event monitoring system + Record of sentinel
evaluates causal and (which may include health events
contributing factors for care associated infections,
the necessary unexpected deaths,
corrective and adverse drug reactions,
preventive action falls, etc.)
32. Infection Prevention Presence of an Infection DOCUMENT Administrative

and Control Prevention and Control REVIEW Office
Committee Committee (IPCC) with * [PCC composition
defined roles and *
Appointment letter
responsibilities
a
(notarized) of full-
time IPC Nurse(1:100
beds) for specialty
hospitals)
* IPCC functions and
activities
®
Minutes of Meetings
iE DOH-HFSRB-QOPO1-CTF-AT
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21
'
CRITERIA INDICATOR SYIDENGE AREAS COMPLIED COMMENTS
33. Infection Prevention Presence of an infection DOCUMENT Administrative
and Control Program control program ensuring REVIEW Office
prevention and control of ¢ [PC Manual
infections on all services. * Policies on rational
antimicrobial use
based on the hospital
antibiogram and
surveillance of AMR
* Reports of infection
control activities e.g.
training, outbreak
investigation, etc.
* Policies and
procedures on
disposition of dead
bodies
Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcare- associated
infections.
34. Organization Presence of a coordinated DOCUMENT All Clinical
takes steps to system-wide procedure for REVIEW Areas
prevent and prevention of hospital « Validate hospital
control associated infections policies on infection
outbreaks of Presence of a control such as use of
healthcare coordinated system-wide PPEs, isolation
associated procedure for asepsis. precautions and hand
infections. washing.
OBSERVE
* Lavatories or
designated areas for
hand washing or
dispenser for hand
sanitizers
* Ask astaff to
demonstrate hand
washing technique
B35. There are Presence of program on DOCUMENT Isolation

programs for the prevention of REVIEW Room
prevention of transmission of airborne * Policies and
transmission of infections and risks from procedures on
airborne patients with signs and isolation.
infections, and symptoms suggestive of *
Occupational Health
risks from tuberculosis or other and Safety Program
patients with communicable diseases for employees Policies
signs and on timely referral and
symptoms case reporting of
suggestive of highly transmissible
tuberculosis or and notifiable
other infectious disease €.g.
communicable
diseases are
meningococcemia,
managed
SARS, avian flu,
etc.
according to
established
protocols OBSERVE
* Use of gloves,
surgical masks,
gowns, goggles,
caps, splash-proof
apron
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3
AREAS
CRITERIA INDICATOR eVID ENCH (if COMPLIED COMMENTS
(if applicable) es
|
INTERVIEW
applicable) :
gis : ;
o Ask staff in ER
and wards for
hospitals or
treatment area in
the procedures on
isolation
(Isolation - physical
isolation of a patient
with infection and
reverse isolation).
« Ask staff from ER,
wards and treatment
area about the
approaches for asepsis
during diagnostic and
treatment procedures
B. PATIENT AND STAFF SAFETY

Standard: The organization plans a safe and effective environment of care consistent with its mission, services, and with
laws and regulations.
36. An incident reporting « Presence of incident DOCUMENT
system identifies reporting system/sentinel REVIEW
potential harms, event monitoring system « Incident/sentinel
evaluates causal and (which may include event reports or
contributing hospital associated communications/
factors for the infections, unexpected memoranda/order s
necessary corrective deaths, adverse drug or proceedings on
and preventive reactions, blood sentinel events
action transfusion reactions, INTERVIEW
falls, etc.) and the e Ask at random any staff
indicated corrective from wards and ER:
actions. 1. How the
incident
reporting
system works
2. Correction,
corrective and
preventive
actions taken
VII. IMPROVING PERFORMANCE
Standard: The organization has a planned systematic organization- wide approach to process design and performance
measurement, assessment and improvement.
37. Continuous Quality « Presence of Continuous DOCUMENT Administrative
Improvement Program Quality Improvement REVIEW Office
(CQI) Program « CQI plan and proof of
implementation
B8.Comprehensive o Proof that the DOCUMENT Administrative
quality improvement management is primarily REVIEW Office
program throughout responsible for * Memoranda/orders
the organization and developing, creating the QI
delegating communicating and team/Quality circle
responsibilities to implementing a * Minutes of
appropriate personnel comprehensive quality meetings/ extracts of
for its day-to-day improvement program minutes relating to
implementation implementation concerned topic,
documentation
of activities
* Monitoring reports
on CPG use or
similar QI activities
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3 EVIDENCE AREAS
CRITERIA INDICATOR COMPLIED COMMENTS
*
Designation of a point
person for the CQI
INTERVIEW
+ Validate the activities
by asking the
management team or
officer involved in CQI
program
Standard: The organization provides better care service as a result of continuous quality im rovement activities
39. Customer » Presence of customer DOCUMENT Administrative
satisfaction survey satisfaction survey, REVIEW Office
analysis and actions taken « Accomplished client
satisfaction survey
forms with monthly
analysis; actions
taken
40. Better patient « Proof of better patient DOCUMENT Administrative
outcome. outcomes REVIEW Office
+ Documentation of
better outcomes for
patients as a result of
CQI activities
(Correction,
corrective and
preventive actions of
problems identified)
VIII. NATIONAL LAWS AND DOH ISSUANCES IMPLEMENTED IN HOSPITALS AND OTHER HEALTH
FACILITIES
41. Anti-smoking — in « Presence of policies and DOCUMENT Hallways
compliance to R.A. procedures on REVIEW Toilets
9211 EO No. 26 s. antismoking « Policies and Wards
2017, “Providing for procedures on anti- Offices
the Establishment of smoking OPD
Smoke-Free « Proof of Treatment Area
Environments in implementation
Public and Enclosed OBSERVE
Places” e “No Smoking”
signages posted in a
conspicuous spaces
42.Generic e Presence of policies and DOCUMENT Pharmacy
Prescribing — in procedures on generic REVIEW Wards
compliance to prescribing * Policies and Treatment Area
R.A. 6675 procedures on generic
(Generics Act of prescribing
1988) * Prescriptions filled in
the Pharmacy
* Physicians’ orders
in patients’ charts
* Documentation of
nurses on medicines.
43. Health Emergency e Presence of policies and DOCUMENT ER
Management procedures on Handling REVIEW Wards
Services (HEMS) — in emergencies e Hospital Emergency Offices
compliance to AO No. o Self-assessment for Management Plan Treatment Area
2004-0168 "National disaster readiness using (e.g. fire drill,
Policy on Health the “Safe Hospital earthquake drill, etc.)
Emergencies and Checklist” available at e Proof of
Disasters" the HEMB website. implementation
e Result of self-
assessment and how
gaps were resolved
OBSERVE
o Exit and Evacuation
plans posted in all
hallways and rooms
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ats td in
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{i
i EVIDENCE AREAS
:
ADORE COMPLIED COMMENTS

|
Gf applicable) | (if applicable)

44. R.A. No. 9439: “An e Presence of policies and DOCUMENT Administrative
Act Prohibiting the procedures on handling REVIEW Office
Detention of Patients cases of patients for e Policies and ER
in Hospitals and discharge but with unpaid procedures on Admitting
Medical Clinics on hospital bills are aligned handling cases of Section
Grounds of Non- with the provisions in patients for discharge
payment of Hospital R.A. No. 9439. but with unpaid
Bills or Medical hospital bills
Expenses” o Proofof
implementation
OBSERVE:
of the R.A.
e A copy
No. 9439 and its
Implementing Rules
and Regulations are
posted in a
conspicuous space.
45. R.A. No. 10932: Anti- e Presence of policies and DOCUMENT Administrative
Hospital Deposit Law procedures on the REVIEW Office
implementation of R.A. e Policies and ER
No. 10932 procedures on the Admitting
implementation of RA Section
10932 rendering
emergency care and
admission to poor
indigent and
marginalized patients.
OBSERVE:
of the R.A.
e A copy
No. 10932 and its
Implementing Rules
and Regulations are
posted in a
conspicuous space.
#6. R.A. No. 10173: Data e Presence of policies and DOCUMENT Administrative
Privacy Act of 2012 procedures on the REVIEW Office
implementation of R.A. ¢ Policies and Medical Records
No. 10173 procedures on the Office
implementation of RA
No. 10173
e Designated Data
Privacy Officer Proof
of Appointment with
Specific Roles and
Functions
47. R.A. No. 11036: ¢ Presence of policies and DOCUMENT Administrative

Mental Health Act procedures on the REVIEW Office
implementation of R.A. o Policies and
No. 11036 procedures on the
implementation of RA
No. 11036
OBSERVE
o Availability of mental
health services in
accordance with DOH
guidelines
LY
DOH-HFSRB-QOP01-CTF-AT :
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Rs
Berg EVIDENCE AREAS
Tihlep Ln (if applicable) (if applicable)
COMPLIED COMMENTS
48. A.O. No. 2021-0008 e Presence of policies and DOCUMENT Administrative
Guidelines in the procedures on the REVIEW Office
Public Access to implementation of AO eo Policies and Lobby
Price Information of No. 2021-0008 procedures on the Clinical
All Health Services implementation of AO Laboratory
and Goods in Health No. 2021-0008 X-ray
Facilities in the OBSERVE Admitting Office
Philippines e Availability and Treatment Area
accessibility of the
updated price list of all
health services and
goods to public and
patients may be
presented in any form,
but not limited to, the
following:
1. Printed handout
2. Menu booklet
3. Interactive digital
form (e.g. use of
tablets and
computers)
Posters and
tarpaulins
#49. Implementing Rules » Presence of policies and DOCUMENT Administrative

and Regulations of procedures on the REVIEW Office
R.A. No. 11223 implementation of Section e Policies and
Universal Health 29.6 to 29.7 of the UHC procedures in the
Care Act IRR (mandatory basic bed implementation of
allocation) Section 29.6 to 29.7 of
the UHC IRR
o Patient Census
OBSERVE
e Bed distribution
according to DOH
Guidelines
¢ Presence of policies and DOCUMENT Administrative

procedures on the REVIEW Office
implementation of Section |e Policies and Human Resource
17.4 of the UHC IRR on Procedures in the Department
the creation of the public implementation of
health unit Section 17.4
Appointment letter of
designated personnel
for the public health
unit
OBSERVE
¢ Presence of public
health unit area
44
vo iA
7
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Page 21
19 of

HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Name of Health Facility:

Date of Inspection:
RECOMMENDATIONS:
A. For Licensing Process
[ ] For Issuance of License To Operate as
Validity from to
[ 1 Issuance depends upon compliance to the recommendations given and submission of the
following within days from the date of inspection
[ 1 Non-issuance. Specify reason/s:
Inspected by:
Printed name Signature Position/Designation
Received by:
Signature:
Printed Name:
Position/Designation:
Date:
A DOH-HFSRB-QOP01-CTF-AT
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00
|
Page 20 of 21
- A Department of Health
</ HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Date of Monitoring:
RECOMMENDATIONS:
B. For Monitoring Process
[ 1 Issuance of Notice of Violation
[ 1 Non-issuance of Notice of Violation
[ ] Others. Specify:
Monitored by:
Received by:
Signature:
Printed Name:
Date:
A) DOH-HFSRB-QOPO01-CTF-AT
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PART II - NURSING SERVICE
ANNEX A
A.O. No. 2022- (012
Instruction:
In the appropriate box, place a check mark (V) if the cancer treatment facility is compliant or X-mark if not compliant.
CANCER CANCER
i ;
CANCER SPECIALTY TREATMENT

EVIDENCE AREAS oppciaLTy REMARKS
CRITERIA INDICATOR CENTERINA UNITINA
(if applicable) (if HOSPITAL GENERAL GENERAL
applicable) HOSPITAL HOSPITAL
I
I. PATIENT CARE
A. ACCESS
Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.
1. Nurses are « Licensed and DOCUMENT Wards

competent and appropriately trained REVIEW Treatment
appropriately- nursing personnel « Valid PRC ID Area
trained. « Active affiliation ER
membership from OPD
the Accredited
Professional
Organization
(APO) for Nurses
recognized by PRC
« Certificate of
relevant trainings
- Fundamental
concepts in
Oncology
- Chemotherapy
Infusion and
safety program
for nurses (for
systemic therapy)
2. Nurses make use of « Charts have nurses’ CHART REVIEW Wards

Nursing Process in notes and shall use * Patients’ charts Treatment
the care of patients the DOH-prescribed from medical Area
form of charting records/area, wards Medical
or treatment area Records
« Presence of Nursing have nurses’ notes Office
manual and properly
utilized Kardex * DOCUMENTS
Patients’ charts
Kardex
Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate to the provider
organization’s service capability are available and are performed by qualified personnel
3. Medicines are o All medicines are CHART REVIEW ER

administered in administered « Check patients Wards
a timely, safe, observing patient’s charts for the Treatment
appropriate and rights stated in the accuracy of Area
controlled Department medicine
manner. Memorandum No. administration.
2017-0061 (English
version) and
Department
Memorandum No.
2017-0223 (Tagalog
version).
J DOH-HFSRB-QOP01-CTF-AT
Revision: 00
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Pace 1 of 4
4. Doctors’ order « Presence of policies DOCUMENT Clinical

are verified and and procedures on REVIEW Nursing
patients are verification of « Policies and Areas
properly doctor’s medication procedures on
identified before order verification of
medications are doctor’s medication
administered. order
INTERVIEW
o Ask staff how they
verify the
medicine with the
doctor’s
medication order
prior to
administration of
medicines.
OBSERVE
«How staff verifies
the medicine with
the doctor’s
medication order
prior to
administration of
medicines.
5. Patients are properly « Presence of DOCUMENT Clinical

identified before policies and REVIEW Nursing
medicines are procedures on « Policies and Areas
administered. medication procedures on
administration medication
administration
INTERVIEW
« Verify from patients
if they were
correctly identified
prior to drug
administration.
OBSERVE
* Patient should be
the one to state
his/her name
or
Staff asked the
relatives
accompanying the
patients, to verify
his/her identity if
patient was unable
to give key
information or
Check the patient’s
identification band
if no relatives are
a9
present
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Pace 2 of 4
|
CANCER CANCER
CRITERIA INDICATOR
EVIDENCE AREAS gprciaity CENTERINA UNITINA REMARKS
(if applicable) Gf HOSPITAL GENERAL GENERAL
6. Medicine o All charts have propery CHART REVIEW Medical
administration is documentation of o Medication sheet [Records
properly medicine in patient chart Office/
documented in the administration. from medical |Area,
patient chart. records/area, Wards,
wards or treatment [Treatment
area. Area
II. SAFE PRACTICE AND ENVIRONMENT
A. INFECTION CONTROL
infections.
7. There are programs Presence of policies DOCUMENT Wards
for prevention and and procedures on the REVIEW [Treatment
treatment of needle prevention and « Policies and Area
stick injuries, and treatment of needle procedures on the ER
policies and stick injuries and safe prevention and
procedures for the disposal of needles treatment of needle
safe disposal of used stick injuries and
needles are safe disposal of
documented and needles
monitored. INTERVIEW
o Ask staff their
policies on needle
stick injury
OBSERVE
oUse of PPEs in
doing systemic
therapy and/or
radiotherapy, IV
insertions, etc.
8. Ensure safe Presence of policies DOCUMENT Treatment
compliance to safe and procedures on REVIEW Area
handling practices of safe handling of « Policies and
hazardous and non- hazardous and non- procedures on safe
hazardous drugs and hazardous drugs, handling of
spill management. including spill hazardous and non-
management hazardous drugs,
including spill
management
INTERVIEW
o Ask staff their
policies and
procedures
OBSERVE
« Safe handling
practices
Standard: Cleaning, disinfecting, drying, packaging and sterilizing of equipment, an d maintenance of associated environment, conform to
relevant statutory requirements and codes of prac tice.
9. Policies and * Presence of policies DOCUMENT CSSR/
procedures on cleaning, and procedures on REVIEW Sterilization,
disinfecting, drying, cleaning, disinfecting, * Policies and Area
packaging and drying, packaging and procedures
sterilizing of equipment, sterilizing of *
Logbooks on
instruments and equipment, packaging and
supplies. instruments and sterilizing of
supplies equipment,
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Pace 3 of 4
CANCER CANCER
CRITERIA INDICATOR EVIDENCE AREAS GpECIALTY CENTERINA UNITINA REMARKS
(if applicable) (if HOSPITAL GENERAL GENERAL
instruments and
supplies
OBSERVE
« Designated areas
for receiving,
cleaning,
disinfecting,
drying packaging,
sterilizing and
releasing of
sterilized
equipment,
instruments and
supplies.
SQ —
Revision: 00
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Pace 4 of 4
PART III PHYSICAL PLANT
—-
ANNEX A
A.O. No. 2022-_(pi2
Instruction:
In the appropriate box, place a check mark (V) if the hospital is compliant or X-mark if not compliant.
CANCER CANCER
CRITERIA
I. PATIENT CARE
INDICATOR
(f applicable)
c
-
AREAS
plicable)
Rk
SPECIALTY
HOSPITAL
_
CENTERINA
GENERAL
HOSPITAL
UNITINA
GENERAL
HOSPITAL |
| REMARKS
A. ACCESS
. A multi-level ramp « Presence of OBSERVE Entrance
shall have a minimum ramp/s + Presence of Multi-level
clear width of 1.22 multi-level ramp ramp
meters in one direction and ramp at the (if any)
and slope is 1:12; it
entrance if is
Ramp is provided at not at the same
the entrance if it is not level with the
at the same level with inside
the inside.
2. Entrances and exits are « Presence of OBSERVE Entrance and

clearly and prominently entrances and * With entrance Exits
marked. exits that are and exit signs. ER
readily Check ER, OPD OPD
accessible. (Ref and wards Wards
erence: RA * Entrances and Treatment
6541 Building exits are Area
Code of the accessible and OR/RR/DR
Philippines) free from any Imaging
obstruction.
. Directional signs are « Presence of OBSERVE All Areas

prominently posted to directional « Signages are
help locate service signage to prominently
areas within the identify and posted.
organization. locate service Signage is easily
areas. seen along
corners,
corridors, lobby.
4. Alternative « Alternative OBSERVE Entrance and

passageways for passageways Check: Exits
patients with special (e.g. ramps) * Alternative ER
needs (e.g. ramps) are are provided, passageways for OPD
available, clearly and as required in patients with Wards
prominently marked Accessibility special needs. Treatment
and free of any Law for all eiDircotional Area
obstruction. types of Signage for Other Areas
structure. alternative
passageways are
prominently
posted.
* Alternative
passageways are
A
free from
obstruction.
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Page 1 of 10
PART III - PHYSICAL PLANT
5. Corridors conform « Corridors used OBSERVE Corridors

with standard as access for * Corridors 2.44
measurement. patients using meters wide can
bed or accommodate 2
stretcher are at wheeled
least 2.44 stretchers
meters while in alongside each
areas not other.
commonly * Wheeled
used for bed or stretcher can
stretcher are at have a 360
least 1.83 degree turning
meters. radius.
B. SERVICES THAT MAY BE OUTSOURCED
6. Outsourced services are « Presence of all DOCUMENT Administrative/
within the facility. outsourced REVIEW Business
services within Office
« Contracts/MOA
the hospital for outsourced
services
« Valid licenses of
all providers
« Check contracts /
job orders
a. ADMINISTRATIVE SERVICES
i. Dietary « Presence of DOCUMENT
Policies and REVIEW/
Procedures on INTERVIEW
safe and « Policies and
nutritious foods Procedures on
to patients safe and
nutritious foods to
« Diet patients
prescription or « Monthly menu for
diet counselling patients
is provided to Individual Meal Office
patients plan
Nutrition Notes:
« Useof (Standardized
Nutrition Care form of charting
Process in the to emphasize 5
planning of domains of Administrative/Business
individual meal nutrition care)

plan of patients
ii. Linen/Laundry If not DOCUMENT
contracted out, REVIEW/
there shall be: INTERVIEW
«+
Sorting of « Check policies
soiled and and procedures
contaminated on how soiled
linens in linens are
designated collected
areas disinfected and
« Systematic washed.
washing of
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Page 2 of 10
laundry with
safeguard
against spread
of infection
Disinfection of
laundry.
iii. Security Presence of DOCUMENT

policies and REVIEW
procedures on « Policies and
security of procedures on
patients, security of
visitors and patients, visitors
hospital staff and hospital staff
OBSERVE
« Security check for
internal and
external
customers
including use of
visitor’s pass
iv. Housekeeping/ Presence of DOCUMENT

Janitorial policies and REVIEW
the provision procedures on
and housekeeping
maintenance OBSERVE
of clean, safe « Cleaning
and sanitary practices of the
facilities and Janitorial staff
environment
for hospital
personnel,
patients and
clients
v. Maintenance Presence of DOCUMENT Lobby

(Equipment and policies and REVIEW ER
Building) procedures on « Policies and OPD
maintenance procedures on Wards
maintenance Other Areas
Schedule of
Maintenance
#1)
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CANCER CANCER
CRITERIA INDICATOR EVIDENCE REMARKS
:
AREAS SPECIALTY CENTER IN A UNIT IN A

(if applicable) HOSPITAL GENERAL GENERAL
(if applicable)
HOSPITAL HOSPITAL _

laws and regulations
7. CTF has a valid DOH- « Presence of DOCUMENT Administrative
License to operate valid DOH- REVIEW Office
(LTO). LTO + Updated DOH- Lobby
LTO with add-on
services
indicated, if any.
OBSERVE
« DOH-LTO is
posted in a
conspicuous area.
8. Building Maintenance « Presence of DOCUMENT Administrative

Program is in place Policies and REVIEW Office
ensuring facilities are procedures on « Written policy Maintenance
in stateof good repair building and procedures Office
maintenance and routine
program for the
proper preventive
and corrective
maintenance and
monitoring of
physical plant and
facilities.
« Proposed
schedule for
preventive
maintenance
« Updated records
of corrective
maintenance
OBSERVE
«Updated proof of
actual
implementation
of maintenance as
to structure,
ventilation,
lighting and water
supply
9. The management shall « Presence of a DOCUMENT Administrative

have a plan addressing management REVIEW Office
safety of patients, plan, policies + Management Maintenance
personnel and the and plan, policies and Office
general public. procedures procedures ER
addressing: « Proofof Wards
1. Safety Implementation Laboratory
2. Security Policies and Pharmacy
« Procedures on OR
protection and
safety
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. Disposal and « Check presence

control of of MSDS
hazardous (Material Safety
materials and Data Sheet)
biologic
wastes, and
radioactive INTERVIEW
waste « Ask about the
. Emergency frequency of the
and disaster following:
preparedness « Fire drill
. Radiation conducted in the
Protection and past 12 months
Safety « Earthquake drill
Program (c/o conducted in the
FDA and past 12 months
PNRI)
There shall be
a contingency
plan in case
of accidents
and
emergencies
following the
guidelines
stipulated in
DOH AO No.
2004-0168
titled
“National
Policy of
Health
Emergencies
and
Disasters”.
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—-
CANCER CANCER
EVIDENCE
|
CRITERIA INDICATOR AREAS SPECIALTY CENTERINA UNIT IN A REMARKS

:
A
(if applicable) HOSPITAL GENERAL GENERAL
(if applicable) HOSPITAL HOSPITAL
i
10. Safe and efficient use Presence of DOCUMENT ER

of medical equipment policies and REVIEW OPD
and instruments procedures for: « Presence of Wards
according to 1. Quality operating manuals| DR
specifications are Control of the medical Laboratory
properly documented 2. Corrective equipment Compounding
and implemented. and « Preventive and Area
i
Preventive corrective Maintenance

Maintenance maintenance Office
pret for
logbook Other Areas
jcc 2+l) « Quality control
tests results
and highly
p
« Schedule of
sensitive BIR 4
thatuinents calibration of
machine/equipme
nt
« Calibration
certificate of
machine/
equipment
OBSERVE
« How staff
performs
necessary
precaution or
safety procedures
such as: red light
is on while x-ray
procedure is
being done.
Note: Look into

their storage of
mercury
containing devices
which are no
longer allowed to
be used.
11. Patient areas provide « Presence of OBSERVE ER

sufficient space for adequate *
Adequate space OPD
safety, comfort and space, lighting for patients in Wards
privacy of the patient and moving around the| DR
and for emergency ventilation in bed/chair areas Treatment Area
care. compliance *
Adequate lighting
with structural (lights are
requirements working, lighting
(for patient is adequate
safety and enough for
privacy) conduct of general
activities.)
* Adequate
ventilation
* Segregation of
sexes, in wards A
AA
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CANCER CANCER
EVIDENCE REMARKS
CRITERIA INDICATOR AREAS SPECIALTY CENTERINA UNIT IN A
(f f applicable)
and clinical areas
0 plicable)
Tika
HOSPITAL GENERAL
HOSPITAL
GENERAL
HOSPITAL
(if applicable)
12. A coordinated « Presence of anf DOCUMENT Lobby

security arrangement appointed REVIEW Administrative
in the organization personnel in « Contract or Office
assures protection of charge of Appointment of
patients, staff and security person in charge
visitors. of security.
INTERVIEW
« Ask the personnel
in charge of
security what the
policies on
security are.
OBSERVE
« Security measures
CCTV is provided
B. MAINTENANCE OF THE ENVIRONMENT OF CARE

Standard: Emergency light and/or power supply, water and ventilation systems are provided for, in keeping with relevant
statutory requirements and codes of practice.
13. Generator, emergency « Presence of DOCUMENT Engineering/
light, water system, generator, REVIEW Maintenance
adequate ventilation or emergency «+
Check result of Other
air conditioning light, water water analysis for Relevant
system, the last 6 months. Areas
adequate « Preventive and
ventilation or corrective
air maintenance
conditioning. logbooks
OBSERVE
«Test if faucets
and water closets
are working
« Functional
emergency lights
and generators
14. Equipment are + Presence of DOCUMENT Engineering/

regularly maintained policies and REVIEW Maintenance
with plan for procedures on « Records of Other
replacement preventive preventive and Relevant
according to expected and corrective corrective Areas
life span or when no maintenance maintenance and
longer serviceable. and plan for
replacement
warranted
if replacement
SN
~=D
ry
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Page 7 of 10
Ak
CANCER CANCER
CRITERIA INDICATOR REMARKS
0
AREAS SPECIALTY| CENTERINA UNIT IN A
(f applicable) plicable) HOSPITAL GENERAL GENERAL
HOSPITAL HOSPITAL
15. Training of the staff « Proofof DOCUMENT Engineering/
who is in charge of training of the REVIEW Maintenance
the maintenance of the staff who is in « For in-house: Office
equipment. charge of the Certificate of Laboratory
maintenance training of Imaging
ofthe service personnel Other Areas
equipment or Certificate of
training For
outsourced
service:
MOA/Contract
INTERVIEW
« Ask about how
equipment
(generator, A/C,
Medical and
nonmedical
devices, etc.) are
maintained
Standard: Current information and scientific data from manufacturers concerning their products are available for reference
and guidance in the operation and maintenance of plant and equipment.
16. Operating manuals of « Presence of DOCUMENT Engineering/
equipment operating REVIEW Maintenance
manuals « Operating Office
equipment manual of Imaging,
Medical Laboratory
equipment,
generators, air
conditioners and
other non-
medical
equipment.
C. ENERGY AND WASTE MANAGEMENT

Standard: The handling, collection and disposal of waste conform with relevant statutory requirements and code of
practice
17. Licenses/permits/ « Presence of DOCUMENT Administrative

clearances from licenses/ REVIEW Office
pertinent permits/ « Valid
regulatory clearances licenses/permits
agencies from pertinent from regulatory
regulatory agencies (LGU,
agencies,
applicable
if «
DENR,
Proof of
etc.)
compliance i.e.,
generator permit,
elevator permit,
etc.
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Page 8 of 10
CRIA
18. Policies and Presence of DOCUMENT Hospital

procedures on Waste policies and REVIEW Surroundings
Disposal Management procedures on « Policies and Maintenance
waste procedures on Waste Holding
management proper waste Room/Area
and proper disposal.
disposal of Issuances -
general and memos,
infectious guidelines on
wastes and waste
toxic and segregation,
hazardous collection,
substances in treatment and
accordance disposal.
with R.A. No. Contracts with
6969 and service providers
other related waste handlers or
policy disposal
guidelines contractors (if
and/or applicable)
issuance (e.g. . Notarized
DOH Memorandum of
Healthcare Agreement with
Waste infectious waste,
Management toxic, and
Manual). hazardous
Radioactive substances and
waste radioactive waste
management hauler (if
for facilities applicable)
with nuclear « Record of
medicine disposal of
services radiologic wastes
(if applicable)
(c/o FDA and
PNRI)
OBSERVE
« Segregation of
waste
Proper labelling
of waste
receptacles
Recyclable waste
staging areas
« Proper
management of
temporary
storage areas
prior to hauling
for disposal.
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INTERVIEW
« Ask staff
regarding SOPs
on actual
procedure on
waste disposal
« Ask staff at
random: their
manner of waste
segregation and
disposal; safe
storage and
disposal of
reagents, and
disposal of
wastewater
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PART IV — PERSONNEL, EQUIPMENT, INTRUMENT, SUPPLIES
ANNEX A
AO No. 2022- 0012
Instruction:
In the appropriate box, place a check mark (V) if
the cancer treatment facility is compliant or X-mark if not compliant.
I. PERSONNEL
TOP MANAGEMENT (full-time)

Chief of Licensed physician| DOCUMENT
a
«
Hospital/Medical e Master’s Degree REVIEW

Director in Hospital * Diploma for
Administration Master's
or related course Degree
(MPH, MBA, ¢ Traded
Ph sician
etc.) AND at least
five (5) years
Se ID
4
hospital
®
Certificates of
experience in a Trainings
supervisory or attended
managerial * Proof of
position Employment/
Appointment
(notarized)
* Service
Record/
Certificate of
Employment
(proof of
hospital
Supervisory
/managerial
experience)
Chief of Clinics / * Licensed physician DOCUMENT
Chief Medical * Board certified by REVIEW
Professional any subspecialty * Diploma/
Services society recognized Certificate
by PRC, Oncologist from Specialty
for Cancer Specialty Society
Hospital * Updated PRC
* At least five (5) ID
years hospital * Certificates of
experience in a Trainings
clinical supervisory attended
on managerial * Proof of
Rosin Employment/
Appointment
(notarized)
Legend:
f
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Page 1 of 30
PART IV - PERSONNEL, EQUIPMENT, INTRUMENT, SUPPLIES
CANCER CANCER
NUMBER/
POSITION QUALIFICATION EVIDENCE SPECIALY CENTER IN A UNITINA REMARKS
RATIO HOSPITAL GENERAL GENERAL
:
HOSPITAL _
HOSPITAL
Chief Nurse / * Licensed nurse DOCUMENT 1
Director of Nursing REVIEW

* Master's Degree in
Nursing AND at
* Diploma
least five (5) years * Updated
of clinical PRC ID
experience in a * Certificate
supervisory or of Training
managerial position in Oncology
in nursing Nursing
(R.A. No. 9173) * Proof of
Employment
/Appointment
(notarized)
* Service
Record/
Certificate of]
Employment
(proof of
supervisory/
managerial
experience in
nursing)
Chief « Master's Degree DOCUMENT 1
Administrative in Hospital REVIEW

Officer/ Hospital Administration or « Diploma for
Administrator related course Master's
(MPH, MBA, Degree
MPA, MHSA,
«Updated
etc.) AND at least
es
PRC ID
five (5) years :
: ;
* Certificates
hospital experience ee
en Ce
in a supervisory or
managerial position
*
attended
Proof of
Employment/
Appointment
(notarized)
* Service
Record/
Certificate
of
Employment
(proofof
hospital
supervisory/
managerial
experience)
J
a
Legend:

) DOH-HFSRB-QOP01-CTF-AT
/ Revision: 00
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Page 3 of
30
PART IV —-
PERSONNEL, EQUIPMENT, INTRUMENT, SUPPLIES
CANCER CANCER
NUMBER/
POSITION QUALIFICATION EVIDENCE SPECIALY CENTER IN A UNITINA |REMARKS
HOSPITAL HOSPITAL
ADMINISTRATIVE SERVICES
Accountant * (Certified Public DOCUMENT 1
(may be outsourced) Accountant REVIEW

*
Diploma/
Certificate of
Billing Officer * With Bachelor’s units earned
Degree relevant to *
Updated PRC
the job
Book keeper ID
(if applicable)
* Certificates
Budget / Finance Officer
of Trainings
attended
Cashier
-
* Proofof 1
Employment/
Appointment
Human Resources (notarized) 1
Management
Officer / Personnel
Officer
Clerk 1:50 beds
Engineer (full-time) « Licensed DOCUMENT 1
Engineer REVIEW
*
Diploma
*
Updated PRC
ID
* Proof of
Employment/
Appointment
(notarized)
Supply « With appropriate DOCUMENT 1
Officer/Storekeeper training and REVIEW

experience * Certificates
« Atleast 2 years of Trainings
college level attended
Proof of
Employment/
Appointment
(notarized)
Laundry Worker (may « Training on safe

be outsourced) handling of
antineoplastic
contaminated
linen
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PART IV —-
CANCER CANCER
NUMBER/
POSITION QUALIFICATION EVIDENCE SPECIALY CENTER IN A UNITINA REMARKS
HOSPITAL HOSPITAL
Medical Records Officer * Bachelor's Degree DOCUMENT 1
(full-time) *
Training in ICD 10 REVIEW
*
Training in *
Diploma
Medical * Certificates of
Records relevant
Management trainings
attended
* Proof of
Employment /
Appointment
(notarized)
Data Protection Officer * Data Protection DOCUMENT 1
(may be designated) Officer Training REVIEW

* DPO/Letter of
appointment
and his/her
relevant
functions
* Contract of
employment
Medical Social Worker| e Licensed Social DOCUMENT 1
(full-time) Worker REVIEW

*
Diploma /
Certificate of
units earned
*
Updated PRC
ID (if
Patient Navigator * Training in Patient applicable) 1:30 if in
(may be dedicated or Navigation oi
@artificates active
designated) SE
oy
reve treatment,
1:70 for
ii
trainings follow-up
FERS attended
Nutritionist- *
;
Licensed 0; 1
Proof of
A
*
Dietician (full-time, Nutritionist-
preferably with training Dietician Employment/
in clinical nutrition) Appointment
(notarized)
Driver * Licensed DOCUMENT 1
(may be outsourced) professional driver REVIEW

« Proof of
Employment /
Appointment
Cook (notarized)
(may be outsourced)
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PART IV —-
Building DOCUMENT 1
per shift
Maintenance Man / REVIEW
Utility Worker * Relevant
(may be outsourced) Training
Security Guard
(may be outsourced)
* Security guard must
have a valid
* License,
applicable
if
License to Exercise * Proof of
Security Profession Employment /
from the Philippine Appointment
National Police (notarized) 1
per shift
(PNP) * Notarized
MOA if
outsourced
CLINICAL SERV ICES

Consultant Staff in: * Licensed physician DOCUMENT All
* Fellow/Diplomate REVIEW consultants
General Surgery, General * ACLS certified * Certificate must be
Medicine, General from board
Pediatrics, General Specialty certified
Obstetric and society, if
Gynecology, applicable
and General Internal (for Board
Medicine* Certified)
* Residency
*Hospital may have Training
additional consultants from Certificate
other specialties.
(for Board
Eligible)
* Certificate of
Residency
Training /
Medical
Specialists
(DOH
Medical
Specialist,
last exam was
in 1989)
»
Updated PRC
ID
* Certificates
of Trainings
attended
* Proof of
Employment/
Appointment
(notarized)
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Oncology Subspecialty * Licensed Physician DOCUMENT (Note:

Presence of
Sections/Departments * Fellow in REVIEW consultants
composed of any but not Oncology * Certificate applicable to the
limited to: Pediatric * ACLS (adult) or from Sub- service of the unit)
Oncologist, Surgical PALS (pedia) specialty
Oncologist, Medical Certified society
*
Updated PRC
Oncologist, Hematologic ID
Oncologist, Gynecologic Note: BLS certified for
Cancer Center in a General
* Certificates
Oncologist, Trophoblastic of Trainings
Hospital and Cancer
Disease Specialist, Treatment Unit, if the facility attended
Urologic Oncologist, has a Code Team * Proof of
Radiation Oncologist, Employment/
Pathologist, Radiologist, Appointment
Nuclear Medicine (notarized)
Physician, Rehabilitation
* Presence of
Code Team
Medicine Physician, Pain
- Proof of
Medicine and Palliative Appointment
Care Physician, of the
Psychiatrist Others members of
(please specify) the Code
Team (if
applicable)
- Policies and
Procedures
of the Code
Team (if
applicable)
Intensive Care Unit: * Licensed physician DOCUMENT A team Note: With access
to ICU in a Level 1
Multidisciplinary Team *
Fellow/Diplomate REVIEW composed Hospital
composed of, but not * ACLS certified « Certificate
from Specialty
at
of least 1
limited to: Board certified per

society, (for specialty
Cardiologist, Board
Certified) (may be
Pulmonologist,
¢ Updated PRC part time or
Neurologist,
ID visiting
Surgeon, * Certificates of consultants)
Anesthesiologist Trainings OR an
OR an Intensivist attended
intensivist
* Proof of
Employment/
Appointment
(notarized)
Fellows on Duty * Board DOCUMENT Wards - (Note: If with in-
REVIEW 1:20 beds patient beds)

Eligible/Certified
* Licensed * Diploma at any
physician
* Updated PRC given time
ID
ACLS or ATLS or
* Certificates of
PALS certified Trainings
attended
®
Proof of
Employment/
Appointment
(notarized)
* Schedule of
duty approved
by Medical
Director/
Chief of
Hospital
« Proof of
Employment/
Appointment
(notarized)
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PART IV —- PERSONNEL, EQUIPMENT, INTRUMENT, SUPPLIES
NURSING SERVICES
Assistant Chief Nurse * Licensed nurse DOCUMENT 1

for ABC
* At least twenty REVIEW of 100 or
(20) units towards
*
Diploma/ more
Master's Degree Certificate of
Units Earned
a . * Updated
Muse. PRC ID
Seine iu
Oncology Nursing
i
* Certificates
of Trainings
* Atleast three 3) in Oncology
years-ex perience Nursing
in supervisory/ attended
managerial * Proof of
ploy
;
position in nursing 8
Appointment
(notarized)
* Service
Record/
Certificate of
Employment
(proof of
supervisory/
managerial
experience
in nursing)
Supervising Nurse * Licensed nurse DOCUMENT 1

per
* With at least nine REVIEW Department
Et
~ Office
(9) units of * Diploma/
Master's Degree Certificate of
P
in Nursing Units Earned
* Atleast two (2) * Updated
years-experience PRC ID
in general Certificates
nursing service of Trainings
administration in Oncology
Nursing
attended
Proof of
Employment
/
Appointment
(notarized)
* Service
Record/
Certificate of
Employment
(Proof of
general
nursing
service
administration
experience)
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NURSING SERVICES
~~
Head Nurse/Senior Nurse Licensed nurse DOCUMENT [1
per shift
* With at least 2 REVIEW per clinical
years-hospital * Diploma department
experience * Updated PRC
* BLS certified ID
* Certificate of
Staff Nurse in Ward * Licensed nurse training in 1:8 beds at (Note: If with in-
Oncology lany time (1 patient beds)

*
Training in
Oncology Nursing
Nursing reliever for
attended
«ACLS certified pens
»
nurse per shift * Certificate of
gsfr i
Staff Nurse in of
pe
Licensed nurse Note: Ratio (Note:
Basic
Treatment Area * Training in Basic Radiation :
Oncology Nursing Training (if |operating {the
service of the
* ACLS certified applicable) frowrs unit)
- Systemic Therapy nurse per shift * Certificate of [1:0
i
Unit * Basic Radiation other relevant [Peds/chair
l
Safety Training (if trainings gEeye
; ;
applicable) * Proof of
1
per shift
- Radiotherapy Unit employment
1
reliever)
(notarized)
1:1
Schedule of
y/o.
*
fo
duty approved for

by Chief Nursejrachytherapy)
Staff Nurse in * Licensed nurse DOCUMENT 1:3 beds at
ICU * Training in Critical [REVIEW ny time per
Care Nursing * Diploma shift (plus 1
[feliever per
* ACLS certified * Updated PRC
3 RNs)
ID
* Certificate of
Training in
Critical
Nursing Care
(if applicable)
¢ Certificate of
other relevant
trainings
* Proof of
employment
(notarized)
* Schedule of
duty approved
by Chief Nurse
Nursing Assistant * Underboard BSN DOCUMENT (Ward (Note: Required if
REVIEW 1:24 beds with 24 in-patient
graduate/ Midwife
beds and above)
or TESDA certified at any
a
« Updated PRC
Nursing Assistant ID (if time (plus
reliever
:
Sa
Applicable)
*
Diploma,
assistants/
&
midwives
attire
7
* Proof of
Employment
( notarized )
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Specially Trained * Licensed DOCUMENT 1

per shift
Pharmacist in Oncology pharmacist REVIEW (1 reliever)
~~
training in +
Diploma
oncology +
Updated PRC
pharmacy ID
+ Certificate of
Training in
Pharmacology
Oncology
attended
+
Proof of
Employment/
Appointment
(notarized)
Radiation Oncologist * Licensed Physician DOCUMENT [1
per shift
* Diplomate/Fellow in REVIEW
Radiation Oncology « Certificate
+
certified
ACLS from Phil.
+ BLS certified for Radiation
Cancer Center in a Oncology
General Hospital and Bos iet) and
Phil. College
Cancer Treatment of Radiology
Unit, if the facility as an active
has a Code Team member (AO
No. 2013-
0031)
« Updated PRC
ID
« Certificates of
Trainings
attended
« Proof of
Employment/
Appointment
(notarized
FDA REQUIREMENTS
(Required for Cancer Specialty Hospital and Cancer Specialty Center in a General Hospital, if applicable for Cancer Treatment Unit in a General Hospital)
Note: Qualifications Standards set and already checked by FDA
In-house « Masters in Medical * Proof of 1

per shift
Radiation Oncology Physics Appointment/ (full time)
Medical Physicist (ROMP) Contract of
Employment
(notarized)
* Schedule of
Duty
Certified Medical Physicistf « Certified by the + Proof of 1

per shift
in Radiation Oncology Philippine Board of| Appointment/ {(fy]l-time or]
Contract of
Medical Physics (CMP{ Medical Physics
Employment
lo, time)
ROMP) consultant/ Section of ROMP
pele :
«
(notarized)
Schedule of
Duty
i
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AY DOH-HFSRB-QOPO01-CTF-AT
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Page 11 of 30
Radiotherapy Technologist . Licensed DOCUMENT 4
per 8-hr
RTT) Radiologic REVIEW shift + 1
Technologist +
Updated PRC (dedicated
« Completed ID for CT SIM
relevant clinical « Proof of
training in Appointment/
radiotherapy Contract of
+ Appropriate Employment
training with (notarized)
the supplier's + Schedule of
application Duty
specialist.
Radiation Protection « Radiation DOCUMENT 1

per shift
Officer (RPO) Oncology REVIEW
(may be designated) Medical « Proof
of
Physicist Appointment/
(ROMP) Contract of
Employment
(notarized)
+ Schedule of
Duty
Assistant RPO « Radiation DOCUMENT 1

per shift
(may be designated) Oncology REVIEW
Medical + Proof
of
Physicist Appointment/
(ROMP) Contract of
Employment
(notarized)
Schedule of
Duty
PNRI REQUIREMENTS
(Required for Cancer Specialty Hospital and Cancer Specialty Center in a General Hospital, if applicable for Cancer Treatment Unit in a General Hospital)
Note: Qualifications Standards set and already checked by PNRI
Radiation Protection « Licensed BS OCUMENT per
[1
Officer (RPO) Degree Holder EVIEW facility

(may be designated) + Has completed 200| « Updated PRC
hours of PNRI- ID
approved Proof of
+
classroom and Appointment/

laboratory training Contract of
for the medical use Employment
of radioactive (notarized)
materials * Schedule of
Has
at least one
(1) year of
Duty
relevant,
fulltime
experience on
radiation safety
at medical
institution under
the supervision
of RPO
CE /
A
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Page 12 of 30
PART IV —-
NCER
Assistant RPO Licensed BS DOCUMENT 1

per
(may be designated) Degree Holder REVIEW facility
Has completed 200| « Updated PRC
hours of PNRI- ID
ir it
apEtoYed
classroom and
Proof of
+
rosa
laboratory training
for the medical use hntof
wing
of radioactive ployment
materials (Hotrized)
Schedule of
H as at least one (1)
D ed
year of relevant,
fulltime experience
on radiation safety
at medical
institution under
the supervision of
RPO
Nuclear Medicine Licensed Physician DOCUMENT 1
per shift
Physician Diplomate/Fellow [REVIEW
in Nuclear Updated PRC
+
Medicine ID
BLS certified
« Proof of
Has completed 200
hours of PNRI-
A
fo dini t S
Me
=
approved classroom
and laboratory
Fe
oe
Rp cyment
(pctanzed)
ae for the
training
medical use of
+
Schedule of
D Hy
radioactive
materials
Has at least two
(2) years of
relevant, fulltime
clinical training
and work
experience under
the supervision
of an Authorized
User
Nuclear Medicine Licensed DOCUMENT 1
per shift
Technologist Radiologic REVIEW
Technologist/ + Updated PRC
Medical ID (if
Technologist/ applicable)
Nuclear Medicine « Proof of
Technologist Appointment/
Has completed 200 Contract of
hours of PNRI- Employment
approved classroom| (notarized)
and laboratory « Schedule of
training for the Duty
medical use of
radioactive
materials
mA)
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Page 13 of 30
PART IV —-
CANCER CANCER
QUALIFICATION EVIDENCE NUMBER/
POSITION SPECIALY CENTER IN A UNIT IN A REMARKS
HOSPITAL HOSPITAL
+ Has
at least six
(6)
months of relevant,
fulltime work
experience in
nuclear medicine at
a medical
institution under
the supervision by
Nuclear Medicine
Technologist
Medical Physicist « Licensed BS DOCUMENT As per
Degree Holder REVIEW agreed
« Has earned Proof of
+ schedule
graduate credit Appointment/ and/or as
units in Radiation Contract of per need
Physics, Physics of Employment basis
Nuclear Medicine, (notarized)
Radiation Schedule of
+
Protection, Duty
Radiation
Dosimetry,
Radiation Biology
in a masteral degree
program in Medical
Physics or its
equivalent
« Has completed 200
hours of PNRI-
approved classroom
and laboratory
training for the
medical use of
radioactive
materials
« Has at least one (1)
year of relevant,
fulltime training
and work
experience in
radiation protection
or related topics
and quality
assurance and
quality control, and
equipment
management, under
the supervision of a
medical physicist
Radiopharmacist/ Radiopharmacist DOCUMENT 1

per shift
Radiochemist / Radiochemist / REVIEW
or trained »
Updated PRC
Nuclear ID
Medicine * Proof of
technologist in Employment/
Radiopharmacy Appointment
(notarized)
* Schedule of
Duty
fl A0 ‘)
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Page 14 of 30 :
PART IV —-
CANCER CANCER
EVIDENCE NUMBER/
POSITION QUALIFICATION SPECIALY CENTER IN A UNIT IN A REMARKS
HOSPITAL HOSPITAL
OTHER PERSONNEL
Rehabilitation Medicine Diplomate/ DOCUMENT
Physician Fellow in REVIEW
Rehabilitation +
Diploma
Medicine *
Updated PRC
Licensed ID
Physician * Certificate
from Specialty
society, if
applicable (for
Board
Certified)
*
Residency
training
certificate for
board eligible
* Certificates of
Trainings
attended
Proof of
Employment/
Appointment
(notarized)
Physical Therapist * Licensed DOCUMENT

Physical REVIEW
Therapist +
Diploma
*
Updated PRC
ID
* Certificates of
Trainings
attended
* Proof of
Employment/
Appointment
(notarized)
Psychologist * Licensed DOCUMENT

Psychologist REVIEW
*
Diploma
¢ Updated PRC
ID
* Certificates of
Trainings
attended
* Proof of
Employment/
Appointment
(notarized)
Legend:

4
ASA + ‘)
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PART IV —-
II. PHYSICAL PLANT
1. DOH - Approved PTC
2. DOH - Approved Floor Plan
3. Checklist for Review of Floor Plans

(accomplished)
OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):
~~ DOH-HFSRB-QOP01-CTF-AT
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Page 16
00
of 30
|
:
PART IV —-
oy
IILLEQUIPMENT/INSTRUMENT/SUPPLIES
CANCER CANCER
CANCER SPECIALTY [TREATMENT
QUANTITY AREA SPECIALY CENTERINA UNITINA REMARKS
Su HOSPITAL GENERAL GENERAL
HOSPITAL HOSPITAL
ADMINISTRATIVE SERVICE
Ambulance (may be outsourced)
Te co
Note: Level
;
Parking
For
; 1
;
*
Typell access to Type 2
* Available 24/7 Ambulance
* Physically present if not being used
during time of inspection/monitoring
Computer with Internet Access 1
Administrative
Office
Emergency Light 1
per unit or lobby, hallway,
area nurses' station,
office/unit and
stairways
Fire Extinguishers 1
per unit or lobby, hallway,
area nurses' station,
office/unit and
stairways
LCD Projector 1
Conference
Room
Generator set with Automatic Transfer 1 Genset house
Switch (ATS)
KITCHEN/DIETARY
Exhaust fan 1
Food Conveyor or equivalent (closed-

I
type)
Food Scale 1
Blender/Osteorizer 1
Oven 1
Kitchen/
Stove 1 Dietary
Refrigerator/Freezer with Ref 1
Thermometer
Utility cart 1
Color-coded Trash bins with cover 1

for each
color
EMERGENCY ROOM
Bag-valve-mask Unit
- Adult 1
- Pediatric 1
Calculator for dose computation 1
Clinical Weighing scale 1
Defibrillator with paddles 1
Delivery set, primigravid 2 sets ER
Delivery set, multigravida 2 sets

ECG Machine 1
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PART IV —-
CANCER CANCER
EQUIPMENT/INSTRUMENT/ AREA SPECIALY CENTER IN A UNIT IN A REMARKS
QUANTITY
SUPPLIES HOSPITAL GENERAL GENERAL
HOSPITAL HOSPITAL
EENT Diagnostic Set with
Ophthalmoscope and Otoscope
Crash Cart (for contents, refer to
separate list)
Examining table
Examining table (with Stirrups for OB
Gyne
Gooseneck lamp/Examining Light
with bulb guard/screen
Instrument/Mayo Table
Minor Instrument Set (May be used for

Tracheostomy, Closed Tube
Thoracostomy, Cutdown, etc.) ER
Nebulizer
Negatoscope
Neurologic Hammer
OR Light (portable or equivalent)
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Pulse Oximeter
Sphygmomanometer, Non-mercurial
- Adult Cuff
- Pediatric Cuff
Stethoscope
Suction Apparatus
Suturing Set
Thermometer, non-mercurial
- Oral
- Rectal
1
for each
Vaginal Speculum, Different Sizes different
size
Wheelchair 1
Wheeled Stretcher with guard/side

rails and wheel lock or anchor
OUT- PATIENT DEPARTMENT
Clinical Height and Weight Scale

ophthalmoscope and otoscope
Gooseneck lamp/Examining Light OPD
Examining table with wheel lock or

anchor
{ )
4
Legend: 4
fA
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OUT- PATIENT DEPARTMENT

Instrument/Mayo Table 1
Minor Instrument Set 1
Neurologic Hammer 1
Oxygen Unit
Tank is anchored/chained/ strapped or 1

Peak flow meter
- Adult 1 OPD
- Pediatric 1
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1
- Oral 1
- Rectal 1
Suture Removal Set 1
Wheelchair / Wheeled Stretcher 1
OPERATING ROOM
Air conditioning Unit 1
Anesthesia Machine 1/ per OR

Cardiac Monitor with Pulse Oximeter 1 OR
Ceasarian Section Instrument 1
Defibrillator with paddles 1
Electrocautery machine 1
Crash Cart (for contents, refer to 1
separate list)
Instrument / Mayo Table 1
Laparotomy pack (Linen pack) 1

per OR
Laparotomy / Major Instrument Set 1
per OR
Laryngoscopes with different sizes of 1
blades
Operating room light 1
per OR
Operating room table 1
per OR
Orthopedic Instrument Set 1
set
[ose
Oxygen Unit
Tank is anchored/chained/ strapped or 1
per OR
oor
- Adult cuff 1
per OR
- Pediatric cuff 1
per OR
Spinal Set 2
Stethoscope 1/ OR
Suction Apparatus 1/0OR
/ /)
Legend:
R Y a
FSA
»
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06/19/2022
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CANCER CANCER
SUPPLIES QUANTITY
HOSPITAL GENERAL GENERAL
HOSPITAL HOSPITAL
DELIVERY ROOM (DR), optional
Air-conditioning Unit 1
Bag valve mask unit (Adult and 1
pediatric)
Bassinet 1
Clinical Infant Weighing Scale 1
1
(if DR is
Defibrillator with paddles

3 . separate
Bote
:
OR
Complex )
Delivery set, primigravid 1
set
Delivery set, multigravida 2 sets
Delivery room light 1
Delivery room table 1
Dilatation/Curettage set 1
set
Crash Cart (for contents, refer to 1
(if DR is
separate DR
separate list)
from
OR
Complex)
Instrument/Mayo Table 1
Kelly Pad or equivalent 1
Laryngoscope with different sizes of

blades Toei
Oxygen Unit
Rechargeable Emergency Light (In case 1
of generator malfunctions)
Sphygmomanometer —-Non-mercurial 1
Stethoscope 1
Suction Apparatus 1
Wheeled Stretcher 1
INTENSIVE CARE UNIT (ICU) — For all types of ICU (PICU, SICU, Medical ICU, etc.)
Air conditioning unit 1
Bag-valve-mask Unit
- Adult
tp
- Pediatric
Cardiac Monitor with Pulse Oximeter bt
Defibrillator with paddles pt

ICU
Crash Cart (for contents, refer to

separate list)
7)
Infusion pump
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SE
CANCER CANCER
Eo QUANTITY AREA
CANCER
SPECIALY
HOSPITAL
SPECIALTY
CENTERINA
GENERAL
|TREATMENT
UNITINA
GENERAL
REMARKS
HOSPITAL HOSPITAL
Laryngoscope with different sizes of 1 each
blades
Mechanical with guard side rails and Depending
wheel lock or anchored on the
number of
beds
declared
Mechanical Ventilator / Respirator 1
(May be outsourced)
Minor Instrument Set (May be used for 1
Tracheostomy, Closed Tube

Thoracostomy, Cutdown, etc.) ICU
Oxygen Unit 1

Sphygmomanometer, non-mercurial 1
(reserved for sudden breakdown of
cardiac monitor)
- Adult cuff for adult unit
- Pediatric cuff for pediatric unit
Stethoscope 1
Suction Apparatus 1
ONCOLOGY NURSING UN IT/WARD (ONU)

Bag-Valve-Mask Unit
- Adult
- Pediatric
Clinical Height and Weight Scale

Defibrillator with paddles
Note: Nursing units located on the same floor may share the
defibrillator and the crash cart provided that they are not more
than 50 meters away from each other.
Crash cart or equivalent (refer to 1

ONU
separate list for the contents)
Laryngoscope with different sizes of 1
each
blades
Mechanical/Patient bed With locked, if
ABC
wheeled; with guard or side rails
Bedside Table ABC
Nebulizer
Neurologic Hammer
Oxygen Unit
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial
- Adult cuff
- Pediatric cuff
Stethoscope
Suction Apparatus
- Oral
- Rectal
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05/19 12022 :
Page 22 of 30 ;
PART IV —-
CANCER CANCER
SUPPLIES QUANTITY
HOSPITAL HOSPITAL
SYSTEMIC THERAPY UNIT (STU)
Note: Required for Cancer Specialty Hospital and Cancer Specialty Center in a General Hospital
Required for Cancer Treatment Unit in a General Hospital, if applicable
Infusion Pump 1
per chair
Oxygen therapy flowmeter or Oxygen 1
tank and regulator (anchored if not

piped-in))
Pharmacy refrigerator
Pulse oximeter
Sphygmomanometer, Non- Mercurial 1 each
- Adult cuff
- Pediatric cuff
- Neonate cuff
Stand up scale with Stadiometer, infant 1 each
weighing scale
Stethoscope , adult and pediatric 1 each
MEDICAL FURNITURE
Reclining chairs (Will vary

depending on STU
the number of
infusion
treatment
stations)
Wheeled Stretcher with guard/side rails 1
and wheel lock or anchor

Wheelchair
PERSONNEL PROTECTIVE
EQUIPMENT AND CLOTHING
Gloves
Face masks
Gown
Respirator/N95 mask
(small,medium, large) with fit testing as
much as possible for compounding area
Safety googles
SINGLE USE DEVICES/DISPOSABLE /
MEDICAL SUPPLIES
Compress, gauze, sterile and non-sterile 1 each
Foley catheter (adult, pedia) 1 each
Infusion giving set, sterile, single use 1 each
(microset, macroset)
Infusion set with volumetric chamber

(soluset)
IV catheters (various sizes) 1 each
Nasogastric tubes (various sizes) 1

each
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PART IV - PERSONNEL, EQUIPMENT, INTRUMENT, SUPPLIES
CANCER CANCER
QUANTITY
HOSPITAL HOSPITAL
1
Needles, luer lock,sterile,single-use each
(various sizes)
Skin-cleaning wipe/swab-pas, alcohol
Suction catheters, sterile (various 1 each

sizes)
Suction tube, L50cm, sterile, single

use
Syringes, luer lock, sterile, single-use

(various capacities)
Tape, medical roll
Torniquet
SOLUTIONS AND REAGENTS
IV solutions (PNSS, D5Water) STU
Isopropyl Alcohol 70%
Sodium hypochlorite solution
Aqueous antibacterial
solution/aqueous cleaning and
decontaminating solution, alkaline
detergent solution
OTHERS
Designated container per area for 1

each
disposal of cytotoxic waste
Hazardous drugs spill kits
Labels for drug identification
COMPOUNDING AREA (may be located in the systemic therapy unit or in the pharmacy)
Class-II Type B biological safety

cabinet PHARMACY
or
CA
Hazardous drugs spill kits
b>
~
“~N
= ID
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PART IV —-
CANCER CANCER
EQUIPMENT/INSTRUMENT/ AREA
QUANTITY SPECIALY CENTER IN A UNIT IN A REMARKS
HOSPITAL HOSPITAL
RADIOTHERAPY UNIT (RTU), license from FDA-CDRRHR and PNRI
Pulse oximeter (portable)

- Adult cuff
- Pediatric cuff
- Neonate cuff
RTU
Stethoscope
Weighing scale
NUCLEAR THERAPY UNIT (NTU), license from PNRI

Pulse oximeter (portable) 1

- Adult cuff
- Pediatric cuff NU
- Neonate cuff
Stethoscope
Weighing scale 1
RESPIRATORY / PULMONARY UNIT (RU/PU)

ABG Machine 1
Pulmonary Function Test (PFT) or Peak 1
Expiratory Flow Rate (PEFR) Tube RU/PU

Spirometer 1
Nebulizer 1
CANCER REHABILITATION UNIT (CRU)

Note: For CTU in a Levels 1&2 Hospitals, with access to Physical Rehab Unit
Physical Medicine and Rehabilitation Unit
Bicycle Ergonometer
Cervical Traction
Cold Therapy Products
Diagonal Mirrors CRU
Dynamometer
Exercise Plight/Bed
Legend:
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CANCER CANCER
CANCER SPECIALTY [TREATMENT
EQUIPMENT/INSTRUMENT/ SUPPLIES QUANTITY AREA SPECIALY CENTERINA UNITINA REMARKS
HOSPITAL HOSPITAL
Exercise stairs with rails 1
Goniometer 1
Hot Therapy Products 1
Light Therapy 1
Lumbar Traction 1
Overhead Pulley 1
Paraffin Wax 1
Parallel Bars 1
CRU
Pedometer 1
Pulley System 1
Therapy Machine 1
Therapy Mats 1
Therapy Rolls 1
Therapy Wedges 1
Transcutaneous Electric Nerve Stimulator 1
(STENS)
CENTRAL STERILIZING & SUPPLY ROOM/AREA

Autoclave/Steam Sterilizer 1 CSSR
MORGUE
Autopsy table 1 Note: For

Levels 1&2
Autopsy instrument set
-
1
hospitals,
Cadaver freezer 1
MORGUE cadaver
holding area
Cadaver Shower 1 is required,
with access to
Morgue
Legend:
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IV. CRASH CART CONTENTS
CONTENTS QUANTITY ER ICU DR* OR ONU (indicate number of nursing units) STU* RTU*| NMU* OTHERS REMARKS
AIRWAY:
Bag-Valve-Mask Device or Resuscitator 1
each
(neonate, pedia and adult)
Endotracheal Tubes (neonate, pedia and 1
each
adult)
Intubation Kit: Laryngoscope set with blade 1
each
(0,1,2,3), with disposable stylet
(neonate,pedia and adult)
Simple rebreather facemask with reservoir 1
each
bag ( neonate, pedia and adult)
Non-rebreather facemask with reservoir 1
each
bag (neonate, pedia and adult)
Nasal cannula (neonate, pedia, adult) 2 each
CIRCULATION:
D5W 250 ml 1
Plain LRS 1L/bottle 2
Plain NSS 1L/bottle-0.9% Sodium

Chloride
Intravenous Infusion sets ( Microset, 1
each
Macroset, Blood Transfusion Set)
Infusion set with volumetric chamber 1
(Soluset)
Sterile needles of various sizes 1
each size
DRUGS:
3
Adenosine 6 mg/2mL vial
Amiodarone 150mg/3mL ampule
4
Aspirin USP grade (325 mg/tablet)
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CONTENTS QUANTITY ER ICU DR* OR RR ONU (indicate number of nursing units) STU* RTU*| NM*| OTHE! REMARKS
3
Atropine mg/ml ampule
B-adrenergic antagonists (i.e. Salbutamol 3
2mg/ml) nebule; for GIDA, may be
Metered Dose Inhaler (MDI) or in tablet
form
Benzodiazipine (Diazepam 10 mg/2ml 1
ampule and/or Midazolam) (in high alert

box)
Calcium (usually calcium gluconate 10% 1
solution in 10 mL ampule)
4
Clopidogrel 75mg tablet
!
Digoxin 0.5mg/2mL ampule
1
Diphenhydramine 50mg/mL ampule
Dobutamine 250mg/5mL ampule or pre- 1
mixed solution 250mg/250ml

Dopamine 200mg/5SmL ampule/vial or pre- 1
mixed solution 250 mg/250ml

1
D50W 50mg/vial
5
Epinephrine 1mg/ml ampule
2
Furosemide 20mg/2ml ampule
Haloperidol 50mg/mL ampule (in high 1
alert box)
l
Hydrocortisone 250mg/2mL vial
1
Lidocaine 10% in S0mL spray
3
Lidocaine 2% solution vial 1g/50ml
3
Magnesium sulfate 1g/2mL ampule
1
Mannitol 20% solution in 500ml/bottle
1
Metoclopramide 10mg/2mL ampule
Morphine sulfate 10mg/mL ampule (in 1
high alert box)
00
:
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30
CONTENTS QUANTITY ER ICU DR* OR ONU (indicate number of nursing units) STU* RTU* OTHE! REMARKS
Nitrates: 1
(Nitroglycerine),
3 (Isosorbide
Nitroglycerin 10mg/10mL ampule or dinitrate)
10mg/10mL ampule or Isosorbide dinitrate
Smg SL tablet (for GIDA)
Noradrenaline 2mg/2mL ampule or
Norepinephrine 2mg/2ml ampule
Paracetamol 300mg/ampule
Sodium bicarbonate SOmEq/50mL ampule
Verapamil 5mg/2 ml ampule
Vitamin B1/6/12 vial (1gB1, 1gB6,
0.01gB12 in 10 mL vial)
EQUIPMENT AND SUPPLIES
Alcohol disinfectant
Aseptic bulb syringe

Calculator
Cardiac Board
ECG Machine with leads
Eye protective googles or face shield
Gloves, sterile
Gloves, non-sterile
Manual Defibrillator or AED (for GIDA)
Nasogastric Tubes (different sizes: infant,
pedia and adult)
Nebulizer
Pen light
Quantitative Glucometer and Hemo Glucose
Test Strips with
5 test strips
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CONTENTS QUANTITY ER ICU DR* OR ONU (indicate number of nursing units) STU* RTU* NTU*| OTHE REMARKS
Respirator mask (N95:small,medium, large) 1

each
with fit testing as much as possible
Sterile gauze (pre-folded and individually
packed)
Surgical Set
Suturing Needles
Sutures: 1
each
Cutting/atraumatic sutures
Silk, nylon, catgut
Syringes (different volumes)
1
each
Thoracotomy Bottle
Thoracotomy Chest Tube
Waterproof Apron
V. EMERGENCY MEDICINES and SUPPLIES

CONTENTS QUANTITY ICU DR* OR ONU (indicate number of nursing units) stu* RTU* NTU* OTHERS |REMARKS
Paracetamol 500 mg tablet 1
Phenobarbital 120mg/ml ampule IV or 1
30mg tablet (in high alert box)

Phenytoin 100mg/capsule or 100 mg/2mL
ampule (in high alert box)
Potassium Chloride 40mEq/20mL vial (in
high alert box)
PPE: Protective face shield or googles,
mask, gloves, bunny suit or coverall suit
Urethral Catheter
Urine Collection bag
Notes:
ER — Emergency Room
ICU — Intensive Care Unit
STU — Systemic Therapy Unit* (if applicable)
OR — Operating Room
RR — Recovery Room
DR — Delivery Room* (if applicable)
ONU — Oncology Nursing Unit
RTU — Radiotherapy Unit*(if applicable) DOH-HFSRB-QOP01-CTF-AT
NMU — Nuclear Therapy Unit*(if applicable) Revision: 00 :
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Page 30 of
30
ANNEX B
A.O. No. 2022-_ 0/2
ASSESSMENT TOOL FOR LICENSING A CANCER TREATMENT FACILITY
INSTRUCTIONS:
| To properly fill-out this tool, the Licensing Officer shall make use of: INTERVIEWS, REVIEW OF
DOCUMENTS, OBSERVATIONS and VALIDATION of findings.
e Interview at least ten (10) patients and ten (10) hospital staff members
e Conduct document review of at least ten (10) sample documents
If the corresponding items are present, available or adequate, place (/) on each of the appropriate
spaces under the FINDINGS column or space provided alongside each corresponding item. If not,
put an (X) instead.
The REMARKS column shall document relevant observations.
ode.
Make sure to fill-in the blanks with the needed information. Do not leave any items blank.
The Team Leader shall ensure that all team members write down their printed names, designation
and affix their signatures and indicate the date of inspection/monitoring, all at the last page of the
tool.
The Team Leader shall make sure that the Head of the facility or, when not available, the next most
senior or responsible officer likewise affix his/her signature on the same aforementioned pages, to
signify that the inspection/monitoring results were discussed during the exit conference and a
duplicate copy also received.
//
ay }
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.
Non-Hospital Based Cancer Treatment Facility
HEALTH FACILITY INFORMATION
'
Name of Facility:
__
Address:
Email Address: Tel. / Fax Nos.:
Name of Owner: Tel. / Fax Nos.:
Head of Facility: Tel. / Fax Nos.:
Existing License No. (if applicable): Tel. / Fax Nos.:
Classification According to Function:
[4 Cancer Treatment Satellite

[1] Cancer Treatment Clinic
Classification According to Ownership:

Government Private
National
[1 Single Proprietorship
i] Local [] Corporation
L lothers: (specify) [1 Others: (specify)
Type of application: [_] Initial [J Renewal [_] Others: (specify)
Activity: [inspection [1 Monitoring [surveillance [] Others: (specify)

of 4]
00
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) PART I - MEDICAL SERVICES
|
EVIDENCE AREAS REMARKS
CRITERIA INDICATOR COMPLIED
I. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
Standard: Organizational policies and procedures respect and support patients' rights to quality care and their
responsibilities in that care.
1. Informed consent is obtained * All patient DOCUMENT Treatment Area
from patients prior
ofcare.
to initiation charts have REVIEW
Patient charts
signed consent. «
Note: Informed consent -

includes a patient-doctor INTERVIEW
discussion of the nature of the * Patients
decision or the procedure;
alternatives to proposed Ask patient/family
intervention; the risks, if they were
benefits, and uncertainties appropriately
related to each alternative; informed by
assessment to patient authorized
understanding; and patient's personnel (doctor
acceptance or refusal of the or nurse) about
intervention. their disease,
condition or
disability, its
severity,
prognosis,
benefits and
possible adverse
effects of
treatment options
and the likely cost
of treatment.
2. Policies and procedures * Presence of DOCUMENT Treatment Area
which identify and policies and REVIEW
address patients’ rights procedures to * Policies and
and responsibilities are identify and procedures on
documented and address patients’ rights.
monitored. patients’ rights
(Refer to DOH INTERVIEW
Department * Staff
Memorandum o Patient
No.
2017-0061 and OBSERVE
Department * Posted patients’
Memorandum rights in
No. 2017-0223) conspicuous
places (e.g.
lobby/reception
area, treatment
area)
II. PATIENT CARE
A. ACCESS
Standard: The organization informs the community about the services it provides and the hours of their availability.
3. Clinical services are * Presence of DOCUMENT Lobby/
appropriate to patients’ needs facilities REVIEW Reception Area
and the former's availability is consistent with * List of services
consistent with the clinical service available,

organization's service capability. schedule of
capability and role in the operating hours
community. and
corresponding
prices and fees
* DOH LTO
(updated, valid
i
and original).
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EVIDENCE
3
OBSERVE
*The facility
and structure.
* Check if the
service
capability of
the facility is in
accordance
with its
classification.
* Posted list of
services and
schedule of
operating
hours.
¢ Available list
of prices and
fees.
ACCORDING TO CLASSIFICATION OF NON-HOSPITAL BASED CANCER TREATMENT FACILITY
AREAS
memaks
Place a check in the corresponding column, if complied
ommemi
mwicator
comrump
CANCER TREATMENT SERVICES
lwo
Systemic Therapy
Radiotherapy
Therapeutic Nuclear Medicine
Adjunct Services for Cancer
Treatment*
Pain and Palliative Care
Clinical Nutrition
Cancer Education
Spiritual Care
Psycho-social (specific for the
life stage being catered to)
*Note: All items are required
DOCUMENT REVIEW
* Policies and
procedures for each
service
OBSERVE
Different areas
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EVIDENCE AREAS
“4. All patients are correctly * The contents off DOCUMENT Treatment
identified by their patient patient's REVIEW Area
charts records are the * Patient
following: charts/records
1. Summary or from Treatment
Face sheet Area
2. Clinical INTERVIEW
Management * Patients
Plan
3. Doctor’s Order
4. Informed
Consent Form
(updated per
cycle)
5. Laboratory and
X-ray Reports
6. Clinical
Graphic
Patient’s Vital
Signs (per visit)
7. Medication
Record
8. Nutrition
Notes-Dietary
Assessment,
Updates and
Progress Notes
9. Consultations,
Hospitalizations]
10. Nurse’s Notes
(per visit)
. Problem List
(per visit)
12. Clinical
Abstract
13. Documented
Patient
Education
14. Advance
Directives (if
any)
Standard: The care plan addresses patient's relevant clinical, social, emotional and religious needs.
5. The Clinical Management * Presence of DOCUMENT Treatment
Plan, developed by the Clinical REVIEW Area
multidisciplinary team, aside Management * Clinical
from delineating Plan Adopted/ Management
responsibilities, includes goals developed Plan
to be achieved, services to be
p rotocolsS, Copy of
ChE
provided, ea
patient education
rd
:
« DOH-
*
strategies to be implemented, protocols,: DOH-

abntovad
pp approved CPGs
time frames to be met, and
CPGs or
resourcesto be used
pathways
or pathways
containing goals
geasnvn
Vi
to be achieved, * Check if
services to be
i
provided, medicines an
patient treatment
education prescribed are in
strategies to be accordance with
& DOH-HFSRB-QOP01-CTF-AT
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00
EVIDENCE AREAS
implemented, adopted DOH-
time frames to approved
be met and CPGs/protocols
resources to be
used INTERVIEW
* Patients/
family,
regarding the
involvement in
the development
of the plan
Standard: Each patient's physical, psychological and social status is assessed.

6. An appropriate * All patients DOCUMENT Treatment
comprehensive history and have REVIEW Area
physical examination is comprehen- * Patient chart from Medical
performed on every patient. sive history Medical Records Records
The history includes and PE. Area have Area
present illness, past complete history
medical, family, social and and P.E.
personal history.
7. Qualified personnel give All patients DOCUMENT Treatment
patients undergo pre- REVIEW Area
pre-treatment and physical treatment and eo
Patients’ charts of
evaluation prior to systemic physical patients who have
and/or radiotherapy. evaluation underwent systemic
prior to and/or radiotherapy
therapy.
Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate
to the provider organization’s service capability and are performed by qualified personnel
8. Policies and procedures on * Presence of DOCUMENT Treatment
medication management policies and REVIEW Area
and use procedures Ask staff on the Pharmacy
on following: (if applicable)
medication *
Dispensing of
management medicines
and use * Verification of
doctor’s orders
* Identification of
patient’s prior to
administration
* Documentation
and reporting of
adverse drug
events
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EVIDENCE AREAS
9. Policies and procedures for * There is DOCUMENT X-ray
the standard performance, quality control REVIEW
monitoring and quality on diagnostic * Proof of
control of diagnostic examinations monitoring of

examination including implementation of
image reject the policies and
analysis, etc. procedures on
and calibration quality control of
of diagnostic diagnostic
equipment examinations
C. EVALUATION OF CARE
Standard: The discharge plan or home instructions is part of the patient's care plan and is documented in the patients’
chart/record.
10. Home instructions for * All records DOCUMENT Treatment
patients to ensure continuity have home REVIEW Area
of care. instructions. Patients' charts Medical
from medical Records Area
records area, look
for proof of
discharge/ teaching
plan explained with
the patient and
family/guardian
and properly signed
by the patient. It
should contain the
following but not
limited to:
* Home
* medications (if
applicable)
* Follow up visits/
schedule
* Home
care/advise
III. LEADERSHIP AND MANAGEMENT

A. MANAGEMENT REVIEW
Standard: The provider organization's management team provides leadership, acts according to the organization's
policies and has overall responsibility for the organization's operation, and the quality of its services and its resources
11. Organizational * Presence of OBSERVE Lobby/
Structure/Chart organizational *
Organizational Reception
structure structure/chart is Area
posted in a
conspicuous area
12. The organization and its * Presence of DOCUMENT Lobby/

services develop their written REVIEW Reception
vision, mission and vision, * Written vision, Area
corporate goals based on mission, and mission and goals
agreed upon values goals of the
hospital and OBSERVE
all services * Posted vision and
mission in a
conspicuous area
D
~
A=
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13. The organization and * Presence of DOCUMENT Administrative

its services develop written REVIEW Office
their policies and policies and
procedures. procedure * Written Policies
manual for all Procedure manual
services
* Documentation of
orientation on
policies and
procedures
conducted
14. Evaluation and * Presence of DOCUMENT Administrative

monitoring activities to evaluation and REVIEW Office
assess management and monitoring *
Accomplishment
organizational activities to reports or other
performance assess annual reports as
management applicable
and
organizational
performance
Place a check on the corresponding column, if complied
A. IMAGING FACILITY (c/o FDA), if applicable

DOCUMENT REVIEW
For inspected facilities by CDRRHR: License to Operate a Therapeutic X-ray Facility, Certificate of Compliance for Level 3
Medical X-ray Facility with CT Scan/Simulator
Level 3 Medical X-ray Facility with CT

Scan/Simulator
Note: For systemic therapy, CT scan is

optional
nv DOH-HFSRB-QOPO01-CTF-AT
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CANCER TREATMENT CANCER TREATMENT
SATELLITE CLININC
REQUIREMENT (Systemic Therapy and/or (Systemic Therapy and/or REMARKS
Radiotherapy) Radiotherapy)
B. PHARMACY for CTF dispensing cancer drugs (c/o FDA)

DOCUMENT REVIEW
The FDA - Center for Drug Regulation and Research (CDRR) shall issue:
e Recommendation Letter for waived inspection
e Certificate of Compliance (COC) or Licence to Operate (LTO) for inspected facilities
The pharmacy shall provide safe,

affordable and efficacious medicines.
C. AMBULANCE SERVICE
(Refer to Annex C of AO No. 2018-0001 - Assessment tool for licensing a land ambulance and land ambulance service provider)
The ambulance vehicle should be physically present in the hospital-based cancer treatment facility.
It shall be available 24 hours/7 days a week.
Type 2 — Advance
Life Support (ALS)
Note: Can be outsourced
SLREDAES
Do ADE EVIDENCE
(if applicable)
AREAS
(if applicable)
COMPLIED REMARKS
IV. HUMAN RESOURCE MANAGEMENT
A. HUMAN RESOURCES PLANNING
Standard: Workload is monitored and appropriate guidelines consulted to ensure that appropriate staff numbers and
skill mix are available to achieve desired patient and organizational outcomes.
15. The organization * Presence of DOCUMENT Personnel/
policies
documents and follows and procedures for REVIEW Administrative
policies and procedures hiring, credentialing * Policies and Office
for hiring, credentialing, and privileging of procedures for
and privileging of its staff. staff hiring,
credentialing
and privileging
of staff
INTERVIEW
* Human
Resources
Management
Officer/
Personnel
Officer
16. Staff numbers are * Presence of list of DOCUMENT Personnel/
based on actual CTF personnel and REVIEW Administrative
clinical needs. their schedule of * List licensed
of Office
duties doctors and Treatment
nurses and other Area
JON { h DOH-HFSRB-QOP01-CTF-AT
i
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EVIDENCE AREAS
(if applicable) (if applicable) |
*
personnel
based on HR
records
*
Payroll
* Schedule of
duties for the
previous and
current
month
* 201 files of
employees
B. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES

17. Professional * Presence of DOCUMENT Personnel/
qualifications are Qualification REVIEW Administrative
validated, including Standards * Check Office
evidence of professional Qualification
registration /license Standards;
where applicable, prior to procedures in
employment hiring.
OBSERVE
* Check PRC ID of
Physicians,
Nurses,
Pharmacists, Rad.
Tech,Medical
Physicist, etc.
18. The staff are provided with *
Staff provided with DOCUMENT Personnel/
a documented job job description REVIEW Administrative
description outlining outlining their *
Written job Office
accountabilities and accountabilities and descriptions with
responsibilities responsibilities conforme
IC.STAFF TRAINING AND DEVELOPMENT

19.New personnel, new * Proof
that new DOCUMENT Personnel/
graduates and external personnel are REVIEW Administrative
contractors are adequately adequately oriented * Documentation Office
supervised by qualified and supervised of orientation
staff conducted
INTERVIEW
* Ask new
personnel
about the lines
of authority
and
supervision
and if the
supervision is
adequate
&
A ) | DOH-HFSRB-QOP01-CTF-AT
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|
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19:
EVIDENCE AREAS
(if applicable) (if applicable) :
20.Annual plan on training * Presence of annual DOCUMENT Personnel/

activities plan on training REVIEW Administrative
activities * Annual plan Office
(including
resource/
budgetary
allocation) on
training
activities
V. INFORMATION MANAGEMENT
A. DATA COLLECTION AND AGGREGATION
Standard: Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner
for delivery of patient care and management of services
21.Records are stored, * Policies and DOCUMENT Medical
retained and disposed of procedures on record REVIEW Records Area
in accordance with the storage, retention and * Logbooks on
guidelines set by the disposal. (Refer to record storage,
DOH and National National Archives of retention and
Archives of the the Philippines disposal
Philippines (NAP) [NAP] and DC No.
2021-0226- OBSERVE
Dissemination of the « Proper storage
Approved Records of records
Disposition
Schedule)
22.Cancer Registry * Policies and * Presence of Medical
procedures on record, Cancer Registry Records Area
safekeeping and in the facility;
maintenance of Proof of
cancer registry submission of
data to the
Philippine
Cancer Center
B. RECORDS MANAGEMENT
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and comply
with all relevant statutory requirements and codes of practice.
:
* Presence of policies OBSERVE Medical
23.Patient charts documenting
;
and procedures on Patient charts Records

:
*
:
any previous care can be
filing and retrieval of
; :
Area
:
are easily
Co
:
quickly retrieved for
;
eae
charts retrievable
:
forma within 10-15

concurrent use. i
minutes
24.The organization has * Presence of policies DOCUMENT Medical
policies and procedures, and procedures on REVIEW Records
and devotes resources, protection of records ©
Logbooks for Area
including infrastructure, to and patient charts borrowing and
protect records and patient against loss, retrieval of
charts against loss, destruction, charts
destruction, tampering and tampering and
unauthorized access or use. unauthorized access OBSERVE
Only authorized individuals or use, and in *
Access to
make entries in the patient maintaining records and
chart. confidentiality/ patient charts
privacy.
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CRITERIA INDICATOR AIDE
(if applicable)
AREAS
(if applicable)
cOMPLIED REMARKS
25.Validated Electronic * Presence of DOH- DOCUMENT Medical
Medical/Health Record validated REVIEW Records
System (EMRS/EHRS) EMRS/EHRS * DOH Certificate Area
on EMRS/
EHRS
Validation
OBSERVE
>
EMR
implementation
include, butis
not limited to,
eclaims,
primary care
benefits,
maternal and
neonatal deaths,
injury, and
confirmed cases
of diagnosis
26. Inventory of * Policies and DOCUMENT Medical
medicines,supplies, Procedures on REVIEW Records Area
among others Conduct and *
Logbooks/ Pharmacy (if
Frequency of Records applicable)
Inventory and stock Stock Room
taking Presence of
inventory of
medicines,supplies,a
mong others
27.National Health * Presence of HR data DOCUMENT Medical
Workforce Registry thru REVIEW Records Area
the National Database of * Proof of
Human Resources for submission of

Health Information data to
System (NDHRHIS) NDHRHIS
VI. SAFE PRACTICE AND ENVIRONMENT

Standard: The organization plans a safe and effective environment of care consistent with its mission, services, and
with laws and regulations
28. An incident reporting * Presence of incident DOCUMENT Administrative
system identifies potential reporting system/ REVIEW Office
harms, evaluates causal and sentinel event * Record of
contributing factors for the monitoring system sentinel events

necessary corrective and (which may include
preventive action health care associated
infections, unexpected
deaths, adverse drug
reactions, falls, etc.)
29. Infection Prevention and * Presence of an DOCUMENT Administrative
Control Infection Prevention *
Designation/App Office
and Control Nurse ointment Letter
(may be designated) (notarized) of an
IPC Nurse
)
A
A)
DOH-HFSRB-QOP01-CTF-AT |
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CRITERIA INDICATOR
EVIDENCE AREAS
COMPLIED
BE
~~
(if applicable) (if applicable) |
: ’ ;
IPC Nurse
functions and
activities
infections.
30. Organization takes steps * Presence of a DOCUMENT Treatment
to prevent and control coordinated system- REVIEW Area
outbreaks of healthcare wide procedure for *
Validate policies
associated infections. prevention of on infection
healthcare associated oir,scax wn
infections
he gh
precautions and
hand washing.
OBSERVE
* Lavatories or
designated areas
for hand washing
or dispenser for
hand sanitizers
* Ask a staff to
demonstrate
hand washing
technique
31. There are programs for * Presence of program DOCUMENT Treatment
the prevention of on prevention of REVIEW Area
transmission of transmission of *
Occupational
airborne infections, airborne infections Health and
and risks from patients and risks from Safety Program
with signs and patients with signs for employees
symptoms suggestive and symptoms * Policies on
of tuberculosis or other suggestive of timely referral
communicable tuberculosis or other and case
diseases are managed communicable reporting of
according to diseases highly
established protocols transmissible and
notifiable
infectious
disease e.g.
meningococcemia
, SARS, avian
flu, etc.
OBSERVE
*Use of gloves,
surgical masks,
gowns, goggles,
caps, splash-
proof apron
INTERVIEW
* Ask staff from
treatment area
about the
approaches for
asepsis during
diagnostic and
treatment
procedures.
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19
EVIDENCE AREAS COMPLIED
CRITERIA INDICATOR REMARKS
(if applicable) _(if applicable)
|
B. PATIENT AND STAFF SAFETY

laws and regulations.
32. An incident reporting * Presence of incident DOCUMENT Treatment Area
system identifies potential reporting REVIEW
harms, evaluates causal system/sentinel event * Incident/
and contributing factors monitoring system sentinel event
for the necessary (which may include reports or
corrective and preventive healthcare associated communications
action infections, /memoranda/
unexpected deaths, order s or
adverse drug proceedings on
reactions, falls and sentinel events
the indicated
corrective actions). INTERVIEW
Ask at random
any staff from
treatment area
* How the
incident
reporting
system works
* Correction,
corrective and
preventive
actions taken
VII. IMPROVING PERFORMANCE

Standard: The organization has a planned systematic organization- wide approach to process design and performance
measurement, assessment and improvement.
33. Continuous Quality Presence of Quality
*
DOCUMENT Administrative
Improvement Program Improvement REVIEW Office
Program * CQI plan and
proof of
implementation
34.Comprehensive * Proofthat the DOCUMENT Administrative

quality improvement management is REVIEW Office
program throughout the primarily responsible * Memoranda/
organization and delegating for developing, orders
responsibilities to communicating and creating the
appropriate personnel for implementing a QI team/
its day-to-day comprehensive Quality circle
implementation quality improvement * Minutes of
program meetings/
implementation extracts of
minutes relating
to concerned
topic,
documentation of]
activities
* Monitoring
reports on
CPG use or
similar QI
activities
~~
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EVIDENCE AREAS
CRITERIA INDICATOR cOMPLIED REMARKS
* Designation of
a point person
for the CQI
INTERVIEW
* Validate the
activities by
asking the
management
team or officer
involved in CQI
program
Standard: The organization provides better care service as a result of continuous quality improvement activities
35. Customer * Presence of customer DOCUMENT Administrative
satisfaction survey satisfaction survey , REVIEW Office
analysis and actions * Accomplished
taken client
satisfaction
survey forms
with monthly
analysis; actions
taken
36.Better patient outcome. * Proof of better patient DOCUMENT Administrative

outcomes REVIEW Office
* Documentation
of better
outcomes for
patients as a
result of CQI
activities
(Correction,
corrective and
preventive
actions of
problems
identified)
VIII. NATIONAL LAWS AND DOH ISSUANCES IMPLEMENTED IN HEALTH FACILITIES
37.Anti-smoking — in « Presence of policies DOCUMENT Hallways

compliance to RA 9211 and procedures on REVIEW Toilets
a
EO No. 26 5. 2017, antismoking
* Policies and Offices
“Providing for the Dost 5
Establishment of Smoke- Proof of
Free Environments in implementation
Public and Enclosed OBSERVE
Places” * “No Smoking”
signages
posted in a
conspicuous
spaces
AN
>
[J
>
1
a
i
al
V DOH-HFSRB-QOPO01-CTF-AT
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i
|
EVIDENCE AREAS
38.Generic Prescribing — in * Presence of policies DOCUMENT Treatment
compliance to RA No. and procedures on REVIEW Area
6675 (Generics Act of generic prescribing
* Policies and Pharmacy
1988) procedures on (if applicable)
generic
prescribing
* Prescriptions
filled in the
Pharmacy
* Physicians’
orders in
patients’ charts
* Documentation
of nurses on
medicines.
39.Health Emergency * Presence of policies DOCUMENT Administrative
Management Services Policies and REVIEW Office
(HEMS) — in compliance Procedures on « Hospital Treatment
Emergency
to AO No. 2004-0168 Handling Area
Management
"National Policy on Health emergencies Plan (e.g. fire
Emergencies and * Self-assessment for drill, earthquake
Disasters" disaster readiness drill, etc.)
using the “Safe e Proof of
Hospital Checklist” implementation
o Result of self-
available at the
assessment and
HEMB website. how gaps were
resolved
OBSERVE
* Exit and
Evacuation plans
posted in all
hallways and
rooms
40.R.A. No. 10173: Data * Presence of Policies DOCUMENT Administrative

Privacy Act of 2012 and Procedures on the REVIEW Office
implementation of
* Policies and
R.A. No. 10173 procedures on the Medical
implementation of Records
RA No. 10173 Office
* Designated Data
Privacy Officer
Proof of
Appointment
with Specific
Roles and
Functions
41.R.A. No. 11036: Mental * Presence of Policies DOCUMENT Administrative

Health Act and procedures on the REVIEW Office
implementation of * Policies and
R.A. No. 11036 procedures on the
implementation
of RA No. 11036
OBSERVE
* Availability of
mental health
services in
accordance with
DOH guidelines
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’ PART I - MEDICAL SERVICES
EVIDENCE AREAS
i

(if applicable) UC appilcatie)
42.A0 No. 2021-0008 * Presence of Policies DOCUMENT Administrative
Guidelines in the Public and procedures on REVIEW Office
Access to Price the implementation * Policies and
Information of All of AO No. 2021- procedures on the
Health Services and Goods implementation
0008
in Health Facilities in the of AO No. 2021-
Philippines 0008
OBSERVE
Availability and
accessibility of
the updated price
all
list of health
services and
goods to public
and patients may
be presented in
any form, but not
limited to, the
following:
* Printed handout
*
Menu booklet
* Interactive
digital form
(e.g. use of
tablets and
computers)
* Posters and
tarpaulins
00
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Page 19
17 of
i) 3
MENT «©
Date of Inspection:
RECOMMENDATIONS:
A. For Licensing Process
[ For Issuance of License To Operate as
1]
Validity from to
Issuance depends upon compliance to the recommendations given and submission of the following
[1 within days from the date of inspection
[ 1 Non-issuance. Specify reason/s:
Inspected by:
Received by:
Signature:
Printed Name:
Date:
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Page 18 of 19

Date of Monitoring:
RECOMMENDATIONS:
B. For Monitoring Process
[1] Issuance of Notice of Violation
[1] Non-issuance of Notice of Violation
[1] Others. Specify:
Monitored by:
Received by:
Signature:
Printed Name:
Date:
[
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19
ANNEX B
A.0.No.2022-_[pl2
Instruction:
AREAS CANCER
CRITERIA INDICATOR ADEN TREATMENT
CANCER
TREATMENT REMARKS
co PP ble)
Gf
applicable) SATELLITE CLINIC
:
I. PATIENT CARE
A. ACCESS
1. Nurses are * Licensed and DOCUMENT Treatment
competent and appropriately REVIEW Area
appropriately- trained nursing * Valid PRC ID
trained personnel * Active affiliation
membership from
the Accredited
Professional
Organization
(APO) for Nurses
recognized by
PRC
* Certificate of
relevant trainings
- Fundamental
concepts in
Oncology
- Chemotherapy
Infusion and
safety program
for nurses (for
systemic
therapy)
2. Nurses make use of * Charts have CHART Medical

Nursing Process in the nurses’ notes and REVIEW Records
care of patients shall use the * Patients’ charts Area
DOH-prescribed from medical
form of charting records area, or
* Presence of treatment area
Nursing manual have nurses’ notes
and properly
utilized Kardex DOCUMENTS
* Patient charts
* Kardex
Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate to
the provider organization’s service capability are available and are performed by qualified personnel.
3. Medicines are * All medicines are CHART Treatment
administered in a administered REVIEW Area
timely, safe, observing patient’s * Check patients’
appropriate and rights stated on charts for the
Department
controlled
Memorandum No. accuracy of
manner. medicine
* 2017-0061
administration
(English version)
and Department
Memorandum No.
2017-0223
(Tagalog version)
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4. Doctors’ order are * Presence of DOCUMENT Treatment

verified and policies and REVIEW Area
patients are procedures on * Policies and
properly identified verification of procedures on
before doctor’s verification of
medications are medication order doctor’s medication
administered. order
INTERVIEW
* Ask staff how they
verify the
medicine with the
doctor’s
medication order
prior to
administration of
medicines.
(OBSERVE
* How staff verifies
the medicine with

the doctor’s
medication order
prior to
administration of
medicines.
5. Patients are properly e Presence of DOCUMENT Treatment

identified before policies and [REVIEW Area
medicines are ¢ Policies and
procedures on
administered. medication procedures on
medication
administration
administration
INTERVIEW
e Verify from
patients if they
were correctly
identified prior to
drug
administration.
(OBSERVE
* Patient should be
the one to
state
his/her name
or
Staff asked the
relatives
accompanying the
patients,to verify
his/her identity if
patient was unable
to give key
information
6. Medicine e All charts have ICHART REVIEW Medical

administration is proper * Medication Records
properly documentation sheet in patient Area
documented in the of medicine chart from Treatment
patient chart. administration. Medical Area
Records Area or
Treatment Area.
WH DOH-HFSRB-QOP01-CTF-AT
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Page 2 of 4
CANCER CANCER
CRITERIA INDICATOR
EVIDENCE
(if applicable)
AREAS
(if applicable)
ppATMENT TREATMENT REMARKS
orgyyrTE CLINIC
IL. SAFE PRACTICE AND ENVIRONMENT
A. INFECTION CONTROL
infections.
7. There are programs o Presence of DOCUMENT Treatment
for prevention and policies and REVIEW Area
treatment ofneedle procedures on the e Policies and
stick injuries, and prevention and Procedures on the
policies and treatment of needle| prevention and
procedures for the stick injuries and treatment of needle
safe disposal of used safe disposal of stick injuries and
needles are needles safe disposal of
documented and needles
monitored.
INTERVIEW
o Ask staff their
policies on needle
stick injury
(OBSERVE
o Use of PPEs in
doing systemic
therapy and/or
radiotherapy, IV
insertions, etc.
8. Ensure safe Presence of DOCUMENT Treatment

compliance to safe policies and REVIEW Area
handling practices of procedures on safe Policies and
hazardous and non- handling of procedures on
hazardous drugs and hazardous and non- safe handling of
spill management. hazardous drugs, hazardous and
including spill non-hazardous
management drugs, including
spill management
INTERVIEW
Ask staff their
policies and
procedures
(OBSERVE
Safe handling
practices
Standard: Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and maintenance of associated environment,
conform to relevant statutory requirements and codes of practice.
9. Policies and Presence of policies DOCUMENT Sterilization

procedures on cleaning, and procedures on REVIEW Area/
disinfecting, drying, cleaning, * Policies and Equipment/
packaging and disinfecting, drying, procedures Instrument
sterilizing of packaging and * Logbooks
on Storage Area
equipment, instruments sterilizing of packaging and
and supplies. equipment, sterilizing of
instruments and equipment,
supplies instruments and
supplies
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OBSERVE
*
Designated areas
for receiving,
cleaning,
disinfecting,
drying
packaging,
sterilizing and
releasing of
sterilized
equipment,
instruments and
supplies
Revision: 00
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Page 4 of 4
ANNEX B
A.O. No. 2022-_00]2
Instruction:
I. PATIENTCARE
A. ACCESS
1. A multi-level ramp « Presence of OBSERVE Entrance
shall have a ramp/s « Presence of multi- Multi-level
minimum clear level ramp (if ramp
width of 1.22 meters applicable) and ramp (if any)
in one direction and at the entrance if it
slope is 1:12, for is not at the same
CTFs that have level with the inside
clinical services
located in the upper
floors; Ramp is
provided at the
entrance if it is not
at the same level
with the inside.
2. Entrances and exits Presence of OBSERVE Entrance
are clearly and entrances and * With entrance and Exits
prominently marked. exits that are exit signs.
readily +
Entrances and exits
accessible. are accessible and
(Reference: free from any
RA 6541 obstruction.
Building Code
of the
Philippines)
3. Directional signs are Presence of OBSERVE All Areas
prominently posted to directional « Signage are
help locate service signage to prominently posted
areas within the locate service
organization. areas
4. Alternative Entrance ramp OBSERVE Entrance
passageways for is provided, as Check: Other Areas
patients with special required in * Alternative
needs (e.g. ramps) Accessibility passageways for
are available, clearly Law for all patients with special
and prominently types of needs.
marked and free of structure. *
They are
any obstruction. prominently marked.
*
They are free from
obstruction.
5. Corridors Corridors used OBSERVE Corridors
conform with as access for * Corridors sufficient
standard patients using enough to can
bed or accommodate 2
measurement.
stretcher are at
wheeled stretchers
least 2:44
meters, and at and/or 2 wheel chairs
least alongside each other
wos) DOH-HFSRB-QOPO1-CTF-AT
00
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|
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Page 10f8
1.83 meters in * Wheeled stretcher

areas not and/or wheel chairs
commonly can have a 360
used for bed or
degree turning radius
stretcher and
those serving
only
ambulatory
patients and
those in
wheelchair
are. Service
corridors may
be reduced to
at least 1.2
meters.
B. SERVICES THAT MAY BE OUTSOURCED
6. Outsourced services « Presence of all DOCUMENT Administrative/

are within the outsourced REVIEW Business Office
facility. services within * Contracts/MOA for
the facility outsourced services
* Valid licenses of all
providers
* Check contracts/ job
orders
a. ADMINISTRATIVE SERVICES
i. Linen/ «If not contracted DOCUMENT Administrative/
i
Laundry out, there shall REVIEW/ Business
INTERVIEW Office
sorting of
SHSOIHNSIO « Check policies and
soiled and
procedures on how
contaminate
dies soiled linens are
: :
in
designated collected disinfected
areas; and washed.
2. Systematic
washing of
laundry with
safeguard
against
spread of
infection;
and
3. Disinfection
of laundry.
ii. Security + Presence of DOCUMENT

policies and REVIEW
security of procedures on
patients, security of patients,
visitors and visitors and hospital
staff staff
OBSERVE
« Security check for
Ie
internal and external
customers including
use of visitor’s pass
Revision: 00
05/18 /2022
Page 20f8
iii. Housekeeping/ * Presence of DOCUMENT

Janitorial policies and REVIEW
the provision procedures on
and housekeeping
maintenance of
clean, safe and OBSERVE
sanitary « Cleaning practices of
facilities and the Janitorial staff
environment
for hospital
personnel,
patients and
clients
Standard: The organization plans a safe and effective environment of care consistent with its mission,
services, and with laws and regulations
7. CTF has a valid * Presence of DOCUMENT Lobby
DOH-License to valid DOH- REVIEW Business Office
Operate (LTO). LTO « Updated DOH-LTO
with add-on services
indicated,ifany
OBSERVE
« DOH-LTO posted in
a conspicuous area
8. Building * Policies and DOCUMENT All areas

Maintenance procedures on REVIEW Cancer
Program is in place building « Written policy and treatment
ensuring facilities maintenance routine program for facility
are in state of good the proper preventive surroundings,
repair. and corrective Maintenance
maintenance and
monitoring of
physical plant and
facilities.
« Proposed schedule
for preventive
maintenance
« Record of corrective
maintenance
available
OBSERVE
« Updated proof of
actual
implementation of
maintenance as to
structure, ventilation,
lighting & water
supply
Revision: 00
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Page 30f 8
CRITERIA
9. The management
shall have a plan
addressing safety of
patients, personnel
and the general
public.
*
INDICATOR
Presence of a
management
plan, policies
and procedures
addressing:
1. Safety
2. Security
3. Disposal and
control of
hazardous
materials
|
and biologic
wastes, and
radioactive
waste
4. Emergency
and disaster
preparedness|
5. Radiation
Protection
*
*
|
DOCUMENT
REVIEW
*
Gf
eA
EVIDENCE
licable)
Management plan,
policies and
procedures
Proof of
Implementation
Policies and
Procedures on
protection and safety
Check presence of
MSDS (Material
Safety Data Sheet)
INTERVIEW
Ask about the
frequency ofthe
following:
Fire drill conducted
in the past 12 months
BREA
any)
(if
Non-Hospital
applicable)
Administrative
Office
Laboratory (if
Pharmacy (if
any)
Based
CANCER
TREATMENT
SATELLITE
| CANCER
TREATMENT
PCLINIG
|
|
Cancer Treatment Facility
REMARKS
:
and Safety «
Earthquake drill
Program (¢/0| conducted in the
FDA and past12 months
PNRI)
* There shall be a
contingency
plan in case of
accidents and
emergencies
following the
guidelines
stipulated in
DOH AO No.
2004-0168
known as
National Policy
of Health
Emergencies
and Disasters.
10. Safe and efficient Presence of DOCUMENT Administrative
use of medical policies and REVIEW Office
equipment and procedures for: «Presence of Treatment
instruments *
Quality operating manuals Areas
according to Control of the medical Compounding
Looe
Bk
©
Specifications are equipment Area

properly * Preventive and
documented and Maintenance corrective
implemented. Program for maintenance
medical logbook
equipment *
Quality control
se
and highly tests results
«+
Record of schedule
Instruments and updated
certificate of
calibration of /
Revision: 00 :
06/19 12022
Page 4 of 8 :
machine and
equipment
OBSERVE
» How staff performs
necessary
precaution or
safety procedures
such as: red light
is on while x-ray
procedure is being
done.
Note: Look into
their storage of
mercury
containing
devices which are
no longer
allowed to be
used
11. Patient areas provide * Presence of OBSERVE Treatment Area

sufficient space for adequate space, «=
Adequate space for Other Areas
safety, comfort and lighting and patients in moving
privacy of the patient| ventilation in around the bed/chair
and for emergency compliance areas
care. with structural «
Adequate lighting
requirements (lights are working,
(for patient lighting is adequate
safety and enough for conduct of
privacy) general activities)
*
Adequate ventilation
*»
Segregation of sexes
of age groups in
treatment areas (if
applicable)
12. A coordinated * Presence of an DOCUMENT
security appointed REVIEW
arrangement in the personnel in * Contract or
organization charge of Appointment of
assures protection security. person in charge of
of patients, staff security.
and visitors.
INTERVIEW
* Ask the personnel in
charge of security
what the policies on
security are.
OBSERVE
1
«Security measures
CCTV is provided
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Page 50f8
B.
~
iPa
CRITERIA
13. Generator,
emergency light,
water system,
adequate ventilation
or air conditioning
*
INDICATOR
MAINTENANCE OF THE ENVIRONMENT OF CARE
generator,
emergency
light, water
system,
adequate
ventilation or
AlN
conditioning.
REVIEW
*
*
Wier
ie.
EVIDENCE
licable)
Check result of water

analysis for the last 6
months.
Preventive and
corrective
maintenance logbooks
OBSERVE
Test if faucets and
water closets are
working
Functional emergency
AREAS
(if
Business
Office
Other
Relevant
Areas
Non-Hospital
applicable)
Based
CANCER
TREATMENT
SATELLITE!
|
|
-
CANCER
TREATMENT
CUINIC
Standard: Emergency light and/or power supply, water and ventilation systems are provided for, in keeping with relevant
statutory requirements and codes of practice.
Presence of DOCUMENT Administrative/
|
Cancer Treatment Facility
||«i
REMARKS
lights and generators

14. Equipment are * Presence of DOCUMENT Administrative/
regularly policies and REVIEW Business Office
maintained with procedures on * Records of
plan for preventive and preventive and
replacement corrective corrective
according to maintenance maintenance and
expected life span and plan for replacement
or when no longer
serviceable.
replacement
warranted
if
15. Training of the
staff * Proof of DOCUMENT Administrative/
who
is
in charge of
the maintenance of
training of the
staff who is in
REVIEW
* For in-house:
Business
Office
the equipment charge of the Certificate of Treatment Area
maintenance training of service Imaging (if
of the personnel or applicable)
equipment Certificate of Other Areas
training
* For
outsourc
ed
service:
MOA/C
ontract
INTERVIEW
* Ask about how
equipment
(generator, A/C,
Medical and
nonmedical devices,
etc.) are maintained
Standard: Current information and scientific data from man ufacturers concerning their product s are available for reference
and guidance in the operation and mai ntenance of plant and equipment.
16. Operating manuals * Presence of DOCUMENT Administrative/
of equipment operating REVIEW Office
manuals *
Operating manual of Imaging (if
equipment Medical equipment, applicable)
generators, air Treatment Area
An
77 DOH-HFSRB-QOP01-CTF-AT
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-
conditioners and
other non-medical
equipment.
C. ENERGY AND WASTE MANAGEMENT
Standard: The handling, collection and disposal of waste conform with relevant statutory requirements and code of practice
17. Licenses/permits/ * Presence of DOCUMENT Administrative/
clearances from licenses/permit REVIEW Business Office
pertinent / clearances * Valid
regulatory from pertinent licenses/permits
agencies regulatory from regulatory
if
agencies, agencies (LGU,
applicable DENR, etc.)
* Proof of compliance
i.e., generator
permit, etc.
18. Policies and * Presence of DOCUMENT CTF
procedures on policies and REVIEW Surroundings
Waste Disposal procedures on ¢ Policies and Waste Holding
Management waste procedures on Area/s
management proper waste
and proper disposal.
disposal of * Issuances - memos,
general and guidelines on waste
infectious segregation,
wastes and collection, treatment
toxic and and disposal.
hazardous * Contracts with
substances in
service providers
accordance
waste handlers or
with R.A. No.
disposal contractors
6969 and other
related policy
(if applicable)
* Notarized
guidelines
Memorandum of
and/or issuance
Agreement with
(e.g. DOH
infectious waste,
Healthcare
toxic, and hazardous
Waste
substances and
Management
radioactive waste
Manual)
hauler (if applicable)
Radioactive
* Record of disposal
waste
of radiologic wastes
management
for facilities (c/o FDA and PNRI)
with nuclear OBSERVE
medicine * Segregation of waste
services (if * Proper labelling of
applicable) waste receptacles
* Recyclable waste
staging areas
* Proper
management
of temporary storage
areas prior to hauling
for disposal.
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:
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Page 7 of
8
INTERVIEW
* Ask staff regarding
SOPs on actual
procedure on waste
disposal
* Ask staff at random:
their manner of
waste segregation
and disposal; safe
storage and disposal
of reagents, and
disposal of
wastewater
Revision: 00
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Page 8 of 8
PART IV — PERSONNEL, EQUIPMENT, INSTRUMENT, SUPPLIES
ANNEX B
A.O. No. 2022-_00i2
Instruction: In the appropriate box, place a check mark (V) if the cancer treatment facility is compliant or X-mark if not compliant.
I. PERSONNEL
TOP MANAGEMENT (full-time)

Head of Cancer « Licensed physician DOCUMENT REVIEW
Treatment Satellite/ At least two (2) * Diploma for Master’s
Cancer Treatment years health facility Degree
Clinic experience in a *
Updated Physician
supervisory or
PRC ID
managerial position
AND/OR
* Certificates of
Trainings attended
preferably with
Master’s Degree
*
Proof of
in Administration Appointment/Contract
or Diploma/ of Employment
Certificate on (notarized)
related courses * Service
Record/ Certificate of
Employment (proof of
supervisory/
managerial experience)
Ha
Fy
Accountant DOCUMENT REVIEW 1
Certified Publ
. :
«
(may be * Diploma / Certificate
outsourced) of units earned
Billing Officer « With Bachelor’s * Updated PRC ID
1
Degree relevant to (if applicable)

pp
Book keeper
Bia 1
the job
”
* Certificates of
(may be designated)
A
Budget / Finance Trainings attended 1
Officer * Proof of Employment/

Appointment
Cashier
5
1
(notarized)
Human Resources 1
Management
Officer / Personnel
Officer
1
Clerk, pool
Engineer « Licensed Engineer DOCUMENT REVIEW 1
(part-time) * Diploma
* Updated PRC ID
* Proof of
Appointment/Contract
of Employment
(notarized)
Supply Officer/ « With appropriate DOCUMENT REVIEW 1
Storekeeper training and * Certificates of

experience Trainings attended
at least two (2) * Proof of Employment /
years college level Appointment
49
(notarized)
Revision: 00
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Page 1 of 14
CANCER CANCER
NUMBER/
POSITION QUALIFICATION EVIDENCE TREATMENT| TREATMENT REMARKS
RATIO SATELLITE CLINIC
:
* With training on safy DOCUMENT REVIEW 1
Laundry Worker handling of . * Certificate of Training

(may be antineoplastic attended
contaminated linen
i
outsourced) |, Proof of Employment /

Appointment (notarized)
Medical Records Bachelor's Degree ©
DOCUMENT 1
Officer (may be *
Training in ICD 10 REVIEW
designated) *
Training in Medical «
Diploma
* Records * Certificates of relevant
Management trainings attended
* Proof of Employment/
Medical Social « Licensed Social DOCUMENT REVIEW 1
ES
Worker (part-time) Worker (may be *
Diploma / Certificate of
outsourced)
Updated PRCID
2
Nutritionist- « Licensed
J
1
Dietician (part- Nutritionist- Certificates of Trainings

time/on-call), Dietician (may be attended
preferably with
training in clinical
nutrition
outsourced) OR
Licensed Physician
who has special
*
Proof of Employment
/
training in clinical
nutrition
Driver (may be » Licensed DOCUMENT REVIEW 1
outsourced) professional driver « Proofof Employment /

Appointment
(notarized)
Utility Worker DOCUMENT REVIEW 1
per shift
(may be * Relevant training
outsourced) * License, if applicable
Security Guard * Security guard must « Proof of Employment / 1
per shift
have a valid License Appointment
to Exercise Security (notarized)
Profession from the « Notarized MOA if
Philippine National outsourced
Police (PNP)
SYSTEMIC THERAPY UNIT (if applicable)
Consulting Licensed DOCUMENT per service 1
Oncologist Physician REVIEW

(Medical Certified Diploma
Oncologist and/or Diplomate/Fellow Certificate from
Pediatric in Oncology by Sub-specialty society
Oncologist, the accredited « Updated PRC ID
Gynecologic relevant sub- « Certificates of
Oncologist, specialty society Trainings attended
Hematologist, ACLS Certified « Proof of
Trophoblastic Employment/
Disease Specialist] Appointment
and Other Trained (notarized)
Oncologists
Physician on * Licensed DOCUMENT 1
Duty physician REVIEW

* ACLS or PALS *
Diploma
certified * Updated PRC ID
* Board eligible or « Certificate of
Board certified in Trainings attended
IM, Pedia or Gyne
Revision: 00
05/19/2022
Page 2 of 14 |
se
alli
a |
C5
ere RE
CANCER.
Elba
NTIMBERY
Te lib BER Re pio”

|
POSITION EVIDENCE
NT TE
QUALIFICATION REMARKS
|
TREATMENT
|
|
TREATMENT
* Experience in * Proof of Employment/
~~
prescribing Appointment
chemotherapy, (notarized)
ensuring safety, * Schedule ofduty
monitoring and approved by the Head
managing toxicity of the Cancer
Treatment Facility
Staff Nurse * Licensed nurse DOCUMENT
Re
* Training in REVIEW J
Oncology Nursing * Diploma

- Systemic
* ACLS certified * Updated PRC ID
Therapy Unit 1:6 beds/ chairs
(if applicable) Turse per shift * Certificate of training |]
reliever)
* Basic Radiation in Oncology Nursing
gi
TTT
AgioLIcTapy Safety Training (if attended
fr 2
Therapy Unit Radiotherapy:
I
applicable) Cod
Certificate
I
per shift (1
*
(if applicable) of other 1
relevant trainings reliever)

* Proof of Employment /
Appointment 1:1 bed/ chair
(notarized) brachytherapy)
* Schedule of duty
approved by the head
of the facility
Specially trained * Licensed DOCUMENT 1
per shift
pharmacist in pharmacist REVIEW (1 reliever)
oncology * Training in * Diploma
oncology +
Updated PRC ID
pharmacy (in- * Certificate of Training
house training)
in Pharmacology
Oncology attended
* Proof of Employment /
Appointment
(notarized)
RADIOTHERAPY UNIT (if applicable)

Note: Personnel will depend on what type of therapy (teletherapy and/or brachytherapy) CTF offers
Radiation * Licensed Physician DOCUMENT 1

per shift
Oncologist * Diplomate/Fellow REVIEW
in Radiation + Diploma
Oncology « Updated PRC ID
* ACLS certified « Certificate from Phil.
Radiation Oncology
Society and Phil.
College of Radiology
as an active member
(AO No. 2013-0031)
« Certificate of
Trainings attended
o Proof of
Employment/
Appointment
(notarized)
2/
J/ )
/
/
i’ 71
:
ih
3
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Page 3of 14 |
FDA REQUIREMENTS
Note: Qualifications Standards set and already checked by FDA
(if applicable)
In-house « Masters in Medical * Proof of Employment 1
per shift
Radiation Physics /Appointment (full time)
Oncology Medical (notarized)
Physicist (ROMP) * Schedule of Duty
Certified Medical * Certified by the * Proof of 1

per shift
Physicist in Philippine Board of Employment / full-time or
Radiation Medical Physics Appointment part-time)
Oncology Medical Section of ROMP (notarized)
Physics (CMP- * Schedule of Duty
ROMP) consultant/
part-time
Radiotherapy * Licensed DOCUMENT REVIEWH per 8-hr
Technologist Radiologic « Valid PRC ID shift + 1
(RTT) Technologist dedicated

* Proof of for CT SIM
« Completed
relevant clinical Employment /
training in Appointment
radiotherapy (notarized)
« Appropriate * Schedule of Duty
training with the
supplier's
application
specialist.
Radiation « Radiation DOCUMENT REVIEW]! per shift
Protection Officer Oncology * Proof of
(RPO) Medical Physicist
Employment /
(may be (ROMP)
Appointment
designated)
(notarized)
* Schedule of Duty
Assistant RPO « Radiation * Proof of 1
per shift
(may be Oncology Employment /
designated) Medical Physicist Appointment
(ROMP) (notarized)
¢ Schedule of Duty
PNRI REQUIREMENTS (if applicable)

Note: Qualifications Standards set and already checked by PNRI
Medical Physicist © Licensed BS Degree DOCUMENT REVIEW s per
Holder * Proof of
Employment / greed
Has earned graduate chedule
credit units in Appointment
nd/or as
Radiation Physics, (notarized)
Physics of Nuclear per need
* Schedule of Duty basis
Medicine,Radiation
Protection,
Radiation
Dosimetry,
in|
Radiation Biology
a masteral degree
program in Medical
Physics or its
0
equivalent
Has completed 200
hours of PNRI-
approved classroom
and laboratory
training for the
00
Revision:
05/1912022
Page 4 of 14 :
medical use of
radioactive material
is Has at least one (1)

year of relevant,
fulltime training and
work experience in
radiation protection
or related topics and
quality assurance
and quality control,
and equipment
management, under
the supervision of a
medical physicist
Radiation o Licensed BS Degree] DOCUMENT REVIEW]! per shift
Protection Officer Holder eProof of
(RPO) * Has completed 200
hours of PNRI- Employment /
approved classroom Appointment
ane Home (notarized)
eat
ainingfor the
Schedule of Duty
ad
N
ae
radioactive materials]
e Has at least one (1)
year of relevant,
fulltime experience
on radiation safety
at medical
institution under the
supervision of RPO
Assistant RPO * Licensed BS Degree DOCUMENT REVIEW|] per shift
Holder eProof of
a ms
* Has completed 200 Empl /
hours of PNRI-
approved classroom ppointment
and laboratory (notarized)
training for the * Schedule of Duty
medical use of
radioactive materials
®
Has at least one (1)
year of relevant,
fulltime experience
on radiation safety at
medical institution
under the
supervision of RPO
Nuclear * Licensed Physician DOCUMENT REVIEW, 1
per shift
Medicine *
Diplomate/Fellow in| * Valid PRC ID
Physician Nuclear Medicine or| « proof of
* BLS certified Employment /
* Has completed 200 Appointment
hours of PNRI- (notarized)
approved classroom * Schedule of Duty
and laboratory
training for the
medical use of
radioactive materials
®
Has at least two (2)
years of relevant,
fulltime clinical
training and work
experience under the
supervision of an
Authorized User
SE
Revision: 00 i
05/1912022
Page 5of 14:
Nuclear Medicine Licensed DOCUMENT REVIEW, 1

per shift
Technologist Radiologic ®
Valid PRC ID (if
Technologist/
Medical applicable)
technologist/
®
Proof of Employment/
Nuclear Medicine Appointment
Technologist (notarized)
Has completed 200 ®
Schedule of Duty
hours of PNRI-
approved classroom
and laboratory
training for the
medical use of
radioactive
materials
Has at least six (6)
months of relevant,
fulltime work
experience in
nuclear medicine at
a medical
institution under the
supervision by
Nuclear Medicine
Technologist
/
Radiopharmacist/ » Radiopharmacist/ DOCUMENT REVIEW, 1
per shift
Radiochemist Radiochemist/ or « proof of
trained Nuclear
Employment/
Medicine
pant Appointment (notarized)
Technologist in
Radiopharmacy
v.
SHPO
Schedule of D TY
Revision: 00
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Page 6 of 14
PART IV —- PERSONNEL, EQUIPMENT, INSTRUMENT, SUPPLIES
JL RENSICALELANT
1. DOH -Approved PTC
2. DOH -Approved Floor Plan
3. Checklist for Review of Floor Plans

(accomplished)
OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):
Revision: 00
06 /19 72022
Page 7 of 14
III. EQUIPMENT/INSTRUMENT/SUPPLIES
CANCER CANCER
EQUIPMENT/ AREA TREATMENT TREATMENT REMARKS
INSTRUMENT/SUPPLIES QUANTITY
SATTELITE CLINIC
ADMINISTRATIVE SERVICE
Ambulance (may be outsourced) Parking
* Type II Ambulance
*
Physically present if not being
used during time of
inspection/monitoring
Computer with Internet Access 1 Administrative Office
Emergency Light 1
per unit or lobby, hallway, nurses'
area station, office/unit and
stairways
Fire Extinguishers 1
per unit or lobby, hallway, nurses’
area station, office/unit and
stairways
LCD Projector Conference Room
Generator set with Automatic Genset house

Transfer Switch (ATS)
SYSTEMIC THERAPY UNIT (STU), if applicable

Infusion pump 1
per chair
Oxygen therapy flowmeter or 1
Oxygen tank and regulator

(anchored if not piped-in)
Pharmacy refrigerator
Pulse oximeter STU

Sphygmomanometer, Non-
mercurial
* Adult cuff
* Pediatric cuff
Stand up scale with Stadiometer, infant 1 each
weighing scale
Stethoscope , adult and pediatric
MEDICAL FURNITURE
Reclining chairs will vary
depending on the
STU
number of
infusion
treatment stations
Wheeled Stretcher with guard/side 1
rails and wheel lock or anchor

Wheelchair 1
PERSONNEL PROTECTIVE
EQUIPMENT AND CLOTHING
Gloves
| 1 STU
DOH-HFSRB-QOPO1-CTF-AT |
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Page 8 of 14 |
CANCER CANCER
EQUIPMENT/ INSTRUMENT/
QUANTITY AREA TREATMENT TREATMENT REMARKS
SUPPLIES
SATTELITE CLINIC
Face masks
Gown 1 STU
Respirator/N95 mask for
Compounding area
Safety goggles 1
SINGLE USE DEVICES/DISPOSABLE/MEDICAL SUPPLIES

Compress, gauze, sterile and non- 1 each
sterile
Foley catheter (adult, pedia) 1 each
Infusion giving set, sterile, single 1 each
use (microset,macroset)
Infusion set with volumetric
chamber (soluset)
IV Catheters (various sizes) 1 each
Nasogastric tubes (various sizes) 1 each
Needles , luer lock, sterile, single 1
each
use (various sizes)
Skin-cleaning wipe/swab-pas, 1
STU
alcohol
Suction catheters, sterile (various 1
each
sizes)
Suction tube, L50cm, sterile, single
use
Syringes, luer lock, sterile, single-
use (various capacities)
Tape, medical roll
Torniquet
SOLUTIONS AND REAGENTS
IV solutions (PNSS, D5Water)
Isopropyl Alcohol 70%
Sodium hypochlorite solution
STU
Aqueous antibacterial
solution/Aqueous cleaning and
decontaminating solution, alkaline
detergent solution
OTHERS
Designated containers and area for
didposal of cytotoxic waste
STU
Hazardous drugs spill kits 1
Labels for drug identification

COMPOUNDING AREA (CA), if applicable
Class II Type B biological safety 1
cabinet
Hazardous drugs spill kits 1 CA
RADIOTHERAPY UNIT (RTU), if applicable

License from FDA/PNRI
Sphygmomanometer, Non-Mercurial 1
* Adult cuff
* Pediatric cuff
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Page 90of 14 :
‘ PART IV — PERSONNEL, EQUIPMENT, INSTRUMENT, SUPPLIES
[JIPMENT
Stethoscope 1
Thermometer, non-mercurial 1
Weighing scale 1 ok
NUCLEAR THERAPY UNIT (NTU), if applicable
License from PNRI
Sphygmomanometer, Non- 1
Mercurial
* Adult cuff
* Pediatric cuff NTU

Stethoscope 1
Thermometer, non-mercurial 1
Weighing Scale 1
STERILIZATION AREA (SA)
Autoclave/Steam Sterilizer 1 SA
Revision: 00
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Page 10 of 14
IV. CRASH CART CONTENTS
CONTENTS QUANTITY REMARKS
IAIRWAY:
Bag-Valve-Mask Device or Resuscitator (pedia and adult) 1 each
Endotracheal Tubes (pedia and adult) 1 each
Intubation Kit: Laryngoscope set with blade (0,1,2,3) 1 each
with disposable stylet (pedia and adult)
Simple rebreather facemask with reservoir bag ( pedia and adult) 1 each
Non-rebreather facemask with reservoir bag (pedia and adult) 1 each
Nasal cannula (pedia, adult) 2 each
(CIRCULATION:
D5W 250 ml 1
Plain LRS 1L/bottle 2

Plain NSS 1L/bottle-0.9% Sodium Chloride 9)
Intravenous Infusion sets ( Microset, Macroset, Blood Transfusion Set) 1 each

Infusion set with volumetric chamber ( Soluset) 1
Sterile needles of various sizes 1 each size

DRUGS:
Adenosine 6 mg/2mL vial 3
Amiodarone 150mg/3mL ampule 3
Aspirin USP grade (325 mg/tablet) 4
Atropine mg/ml ampule 3
B-adrenergic agonists (i.e. Salbutamol 2mg/ml) nebule; for GIDA, may be Metered Dose Inhaler (MDI) 3
or in tablet form
1
Benzodiazipine (Diazepam 10 mg/2ml ampule and/or Midazolam) (in high alert box)
Calcium (usually calcium gluconate 10% solution in 10 mL ampule) /
St
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Page 11 of 14 :
Clopidogrel 75mg tablet

SN
=|
Digoxin 0.5mg/2mL ampule
Diphenhydramine 50mg/mL ampule
[=
Dobutamine 250mg/5SmL ampule or pre-mixed solution 250mg/250ml

em
Dopamine 200mg/5mL ampule/vial or pre-mixed solution 250 mg/250ml

bm
D50W 50mg/vial |
Epinephrine mg/ml ampule
DN
Furosemide 20mg/2ml ampule

DY)
Haloperidol 50mg/mL ampule (in high alert box)

[=
=
Hydrocortisone 250mg/2mL vial
Lidocaine 10% in 50mL spray =
Lidocaine 2% solution vial 1g/50ml I

Magnesium sulfate 1g/2mL ampule
OS
Mannitol 20% solution in 500ml/bottle

[rt
pt
Metoclopramide 10mg/2mL ampule
Morphine sulfate 10mg/mL ampule (in high alert box) bt
Nitrates: 1
(Nitroglycerine), 3
(Isosorbide dinitrate)
Nitroglycerin 10mg/10mL ampule or 10mg/10mL ampule or Isosorbide dinitrate 5Smg SL tablet (for
GIDA)
Noradrenaline 2mg/2mL ampule or Norepinephrine 2mg/2ml ampule 1
1
Paracetamol 300mg/ampule
Sodium bicarbonate 50mEq/50mL ampule 1
1
Verapamil Smg/2 ml ampule
1 each
Vitamin B1/6/12 vial (1gB1, 1gB6, 0.01gB12 in 10 mL vial)
Revision:00
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Page 12 of 14 i
EQUIPMENT AND SUPPLIES:
Alcohol disinfectant 1
Aseptic bulb syringe 1
1
Calculator
Cardiac Board 1
ECG Machine with leads 1
Eye protective googles or face shield

1
Gloves, sterile 1
Gloves, non-sterile 1
Manual Defibrillator or AED (for GIDA) 1
Nasogastric Tubes (different sizes: infant, pedia and adult) 1 each

Nebulizer 1
Neurological hammer
1
Pen light 1
1;
Quantitative Glucometer and Hemo Glucose Test Strips with 5 test strips
Respirator mask (N95:small,medium, large) 1 each
with fit testing as much as possible
Sterile gauze (pre-folded and individually packed) 1
1
Surgical Set
Suturing Needle
1
Sutures: 1 each
Cutting/atraumatic sutures
Silk, nylon, catgut
Syringes (different volumes) 1 each
Thoracotomy Bottle
1
Thoracotomy Chest Tube 1
1
Waterproof Apron
00
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Page 13 of 14 i
V. EMERGENCY MEDICINES AND SUPPLIES
Paracetamol 500mg tablet 1
Phenobarbital 120mg/ml ampule IV or 30mg tablet (in high alert box) 1
Phenytoin 100mg/capsule or 100 mg/2mL ampule (in high alert box) 1
Potassium Chloride 40mEq/20mL vial (in high alert box) 1
PPE: Protective face shield or googles, mask, gloves, bunny suit or coverall suit 1 each
Urethral Catheter 1
Urine Collection bag 1
YU
Revision: 00 :
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Page 14 of
14
ANNEX C
A.O. No. 2022-002
PLANNING AND DESIGN GUIDELINES FOR CANCER TREATMENT FACILITIES
I. GENERAL CONSIDERATIONS
1. Location. The cancer treatment facility shall be located in a highly suitable site, away
from areas that will diminish its accessibility and threaten its physical structure in times
of emergencies. Self-accomplishment of the Hospital Safety Index forms of the
Department of Health (DOH) - Safe Hospitals in Emergencies and Disasters is highly
recommended prior to the application of DOH-Permit-to-Construct (PTC). Likewise, it
shall be located in an area that is readily accessible from available means of
transportation and reasonably free from undue noise, smoke, dust, foul odor, flood, and
shall not be located adjacent to railroads, freight yards, children’s playground, industrial
plants and disposal plants.
Privacy. The design shall also provide the patient’s appropriate levels of auditory and
visual privacy and dignity throughout the care process. Careful consideration for the
privacy and confidentiality of the patients shall be considered, as well as comfort to
reduce discomfort and stress for patients.
Safety. Consideration should be given to the comfort and safety of the patients, staff,
and the general public, such that the spaces shall be planned and designed to avoid
exposing them to risks such as injury and radiation hazard.
Conformance with Building Laws. The cancer treatment facility shall be planned and
designed to observe appropriate architectural and engineering practices, to meet
prescribed functional programs, and shall be in conformity to all applicable local and
national regulation for the planning and design, construction, renovation, maintenance
its
and repair of facilities.
Environment. The design of the spaces for the patients and the public should create a
pleasant, reassuring atmosphere for patients while retaining the necessary functional
and clinical requirements. Additional design features for a user-intended designed
environment for patients (e.g. children, elderly) are recommendatory.
Ventilation. Adequate ventilation shall be provided to ensure comfort of patients,

personnel, and public. Artificial heating, ventilation and air conditioning (HVAC)
systems shall also be provided in the some spaces (e.g. treatment areas, imaging areas)
to attain required HVAC requirements for a conducive environment depending on the
needs based on its function.
Accessibility. Spaces for the patients and the public shall be planned and designed with
accessibility in mind, especially for people with specific needs (e.g. elderly, pregnant
HY
women, children and person with disabilities (PWD)).
DOH-HFSRB-QOP01-CTF-PTC-PDG
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[05/19 /2022
Page 1 of 11
8. Ergonomics. Ergonomics must be considered in the planning and design of the spaces
and its equipment and furniture for the health and safety of both the patient and staff.
Clearances and dimensions in the working areas and patient areas should allow staff
to
and patient efficiently work and move from standing and seated positions.
Segregation. Wards and treatment areas (systemic therapy), if applicable, shall observe
segregation of sexes and age groups. Separate toilets shall also be maintained for
patients and personnel (preferably segregated by gender).
10. Spaces. The cancer treatment facility shall provide adequate space or area for its
various space/room requirements in order to attain the effective and efficient operation
of its activities and functions. Adequate areas shall be provided for the procedure,
people, activity, furniture, equipment and utility within the space.
Table 1. Recommended Areas for the Space Programming of Cancer Treatment Facility
Space |
Area in m?
ADMINISTRATIVE SERVICES
Lobby
Waiting Area 0.65 / person
Information and Reception Area 4.00 - 5.02 / staff
Toilet (PWD Accessible) 3.06
Offices 4.00 - 5.02 / staff
Conference and Training Room 1.40 / person
Prayer Room 0.65 / person
Staff Toilet 1.67
Housekeeping Area 4.00 - 5.02 / staff
Laundry and Linen Area
Working Areas 5.02 / staff
Storage 4.65
Engineering Area 5.02 / staff
Working Areas 5.02 / staff
Motorpool 9.30 / garage
Mechanical Equipment Room 28.00
Property and Supply Office 4.00 - 5.02 / staff
Waste Holding Room 4.65
Dietary
Dietitian Area 4.00 - 5.02 / staff
Cold and Dry Storage Area 4.65
Food Preparation Area 4.65
Cooking and Baking Area 4.65
Serving and Food Assembly Area 4.65
Washing Area 4.65
Garbage Disposal Area 1.67
Dining Room 1.40 / person
Staff Locker Room and Toilet 2:32
Cadaver Holding Room 7.43 / bed
CLINICAL SERVICES
Clinical Consultation Room 5.02 / staff
Patient toilet (PWD Accessible) 3.06
Staff / general toilet 1.67
Isolation Room with Toilet (1 bed) 9.29
Chemotherapy Treatment Room
> /V
/ DOH-HFSRB-QOP01-CTF-PTC-PDG |
t Revision: 00 |
/ 05/19/2022
Page 2 of 11 i
Space Area in m?
Chair bay infusion units 3.00 / chair
Beds infusion units 7.43 / bed
Nurse Station 5.02 / staff
Chemotherapy drug preparation room* 5.02 / staff + area for large
equipment with appropriate
work area
Anteroom (Optional if utilizing BSC Class 2.32
111 or higher)
Procedure / treatment room 7.43 / bed

External Beam Radiation Therapy (EBRT)*
EBRT Treatment Room/bunker
Control Console Area 5.02 / staff
Dressing room (patient) 2.32
Dressing room (staff) 2.32
Brachytherapy*
Brachytherapy Treatment room™*
Procedure / Preparation room 7.43 / bed
Control Console Area 5.02 / staff
Dressing room 2.32
Recovery Room 7.43 / bed
Sterilization Room and clean up area 4.65
Storage Area 4.65
Imaging and Treatment Planning
Treatment Planning Room 5.02 / staff
Server Room 4.65
Patient Preparation/ Fitting Room (Not required if 7.43 / bed + area for storage
the fitting is done in the simulation room)
Mould Room/workshop 5.02 / staff + area for large
equipment with appropriate
work area
Medical Physicist Office 4.00 - 5.02 / staff
CT Scan / MRI Room*
Control Room 5.02 / staff
Toilet 1.67
Emergency Room
Toilet 3.06
Examination and Treatment Area with Lavatory/Sink 7.43 / bed
Observation Area 7.43 / bed
Equipment and Supply Storage Area 4.65
Wheeled Stretcher Area 1.08 / stretcher
Outpatient Department
Toilet 1.67
Admitting and Records Area 5.02 / staff
Consultation Area 5.02 / staff
Examination and Treatment Area with Lavatory/Sink 7.43 / bed
Dental Clinic 8.36 / dental chair
Surgical and Obstetrical Service
Major Operating Room 33.45
Recovery Room 9.29
Revision: 00
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Page 3 of 11
Space Area in m?
Delivery Room 33.45
Labor Room and Toilet 9.29
Sub-sterilizing Room 4.65
Sterile Instrument, Supply and Storage Area 4.65
Anesthesia Storage Area 4.65
Scrub-up Area 4.65
Clean-up Area 4.65
Male Dressing Room and Toilet 2.32
Female Dressing Room and Toilet 2:32
Wheeled Stretcher Area 1.08 / stretcher
Nursing Unit
Private Room with Toilet 9.29
Semi-private room with toilet 7.43 / bed
Female Ward with Toilet 7.43 / bed
Male Ward with Toilet 7.43 / bed
Isolation Room with Toilet 9.29
Nurse Station with Work Area and Lavatory/Sink 5.02 / staff
Treatment Room with Lavatory/Sink 7.43 / bed
Central Sterilizing and Supply Room
Receiving and Releasing Area 5.02 / staff
Work Area 5.02 / staff
Sterilizing Room 4.65
Sterile Supply Storage Area 4.65
Staff Locker Room and Toilet 2.32
ANCILLARY SERVICES
Clinical Laboratory as per AO No. 2021-0037
Radiology*
Pharmacy*
Note:* The room/s intended for these areas shall be sufficient in size, planned and designed to
accommodate the equipment manufacturer's recommendations and compliant with the licensure
requirements of FDA-CDRRHR and CDRR, and/or DOST-PNRI.
II. FUNCTIONAL AND PLANNING CONSIDERATIONS
1. Function and Zoning. The different areas of the facility shall be functionally related
with each other. The spaces/areas of the cancer treatment facility shall be zoned and
planned based on the functionality of the space, the activity workflow of the facility,
and its required levels of access to the public, patient and staff (public, private, semi-
private and service areas).
For specialty cancer hospitals and specialty cancer centers, its

areas shall be grouped
according to the zoning requirements stipulated in the Annex B — Planning and Design
Guidelines for Hospitals and Other Health Facilities in the A.O. No. 2016-0042 titled
“Guidelines in the Application for Department of Health - Permit-to-Construct.”
Access and Activity Workflow. Activity workflow ofthe patient, staff and visitors
shall be considered in planning and designing. Crossing of patients and visitors should
be avoided, if possible. Access for ambulatory, ambulatory with mobility aides, and
non-ambulatory patients shall be considered.
05/19 /2022
Patient treatment areas shall be accessible to its support-to-treatment facilities, such as
for diagnostic imaging, pharmacy and clinical laboratory services. There shall also be
access to service zones for housekeeping and transport of supplies and wastes,
preferably via a service corridor.
Public and administrative areas. The Public and Administrative area, particularly the
lobby, business office and the consultation rooms shall be located near the main
entrance of the facility. Other offices for personnel, if provided, may be located herein
or in a more private setting.
The waiting area should accommodate a range of patients and visitors with varied levels
of ability and provide clear access to conveniently located public and patient amenities,
such as toilets. Other amenities may be considered, such as parenting rooms and child
play area.
For hospital-based cancer treatment facilities, staff and support rooms may be shared
with the facility it is attached, depending on its location and accessibility to the CTF to
reduce duplication of facilities.
Consultation rooms. There shall be consultation room/s, as well as

meeting/conference room accommodating the multidisciplinary teams, for patient
consultation, follow-up and case review, as well as family counselling.
Treatment planning and diagnostic imaging areas. The treatment planning and
diagnostic imaging areas should be planned adjacent or easily accessible from the
radiation therapy rooms. The room/s intended for diagnostic imaging facilities,
treatment planning and simulation shall be sufficient in size, planned and designed to
accommodate the equipment manufacturer's recommendations and compliant with the
licensing requirements of FDA-CDRRHR and/or DOST-PNRI, depending on the
procedures and services to be rendered.
Radiotherapy treatment area. The radiotherapy treatment area placement should be

carefully planned and designed to provide good patient flow, functional program, and
radiation safety. The room/s intended for radiotherapy treatment shall be sufficient in
size, planned and designed to accommodate the equipment manufacturer's
recommendations and compliant with the licensing requirements of FDA-CDRRHR
and/or DOST-PNRI, depending on the procedures and services to be rendered.
Rooms for External beam radiation therapy (EBRT) and brachytherapy, and other
rooms housing large equipment, are preferably be located in the ground level, because
of its load requirements, shielding, and ease of installation and
maintenance/replacement. Anent thereto, there may also be a restriction on the type of
use/activity to be located above these rooms/bunkers.
Facility for mould/blockers shall be a room/space for patient preparation and fitting,
and a separate room for mould room/workshop. Ifthe fitting is done in the simulation
room, room for patient preparation and fitting is not required. These rooms shall have
adequate area for the activity and procedure to be done in the room, equipment,
furniture, and people, with adequate storage areas for devices and supplies. Adequate
J
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area for the storage and workspace with a lavatory/sink for fabrication, and with
appropriate ventilation requirements, shall be provided in the mould room/workshop.
Systemic Therapy Treatment Area. The location and layout of the systemic therapy
~~
treatment areas shall take into account the workload and patient flow within the facility,
and in case of hospitals-based CTFs, with other areas of the hospital. The treatment
areas should be readily accessible, especially for outpatients, who constitute the
majority of patients. It should be built in a way to minimize exposure of staff and
members ofthe public to risk and hazard and contamination ofthe environment (e.g.
distance, wall thickness/composition, appropriate ventilation outlets, fluid drainage,
waste management and storage).
The systemic therapy treatment area shall be planned to provide direct visualization
between staff and patients in treatment bays to enhance staff monitoring of patient
condition during treatment. The nurse station shall be strategically planned and located
in such manner that the nurses on duty shall have visual supervision/surveillance of
patients undergoing treatment. Also, the height of counter in the nurses' work area shall
be designed in such manner as to allow visual access of patients on wheelchair.
Treatment area shall allocate at least 3.0 square meters (1.5 meters by 2.0 meters) per
chemotherapy
if
infusion units, utilizing chairs, and 7.43 square meters per bed for patients receiving
infusions in a patient bed rather than chair. Provision for curtains or low
partitions between units for patient privacy is recommendatory. The treatment units and
adjacent circulation areas shall be planned in such manner as to provide easy access to
patients on wheelchair and stretcher. Furthermore, acuity, sexes, comorbidities and age
and mix of the patients should be considered in the patient placement and clustering
within the treatment area/s.
There shall also be an area for Cytotoxic Drug preparation, with anteroom with
adequate area for changing, storage for PPEs, hand washing sink and an emergency
shower and eyewash, and appropriate ventilation requirements. The compounding
room, located preferably adjacent or near the pharmacy, if any, or the treatment area
where the cytotoxic drugs are administered to the patients, shall be adequate in size and
conducive to its functional program. The room shall have adequate refrigerators and
storage for supplies, a biosafety cabinet and a designated containers and area for
disposal of cytotoxic waste and pharmacy for the storage of drugs. Requirement for
anteroom is not required if the compounding room utilizes biosafety cabinet Class III
Isolation room. Provision/Access to standard isolations rooms should be provided for

use by patients who are infectious or require reduced contact due to compromised
immune systems. These isolation rooms may be used depending on service plan
requirements.
III. SPECIFIC TECHNICAL REQUIREMENTS
I Equipment, furniture and fixtures. Equipment, furniture, fittings and the facility
itself shall be designed and constructed to be safe, robust and meet the needs of a range
of users. Large and complex equipment (e.g. linear accelerator, brachytherapy, CT
scan) should be installed based on the manufacturer’s specifications and
recommendations. The following shall also be considered:
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Weight and dimensions of the equipment;
Dimensions of doors and corridors to allow passage of equipment and furniture;
Provision for flood-free and structurally sound facility/room for equipment;
Adequate space required for maintenance;
Proper Selection, installation and placement to avoid risks and injury; and
e Mechanical, environment and electrical requirements of the equipment.
Furthermore, consideration should be given in the design and selection of furniture and
fixtures intended for children, adolescents, PWD, pregnant women and alike (e.g. beds).
Handwashing. Adequate handwashing facilities shall be provided for staff and patient
use in all patient treatment areas, isolation rooms, consultation rooms, procedure rooms,
cytotoxic drug preparation rooms, nursing units and nurse stations. Private rooms and
treatment units (if any) shall be provided with separate hand washing sink or lavatory
for exclusive usage. The number of hand washing facilities per bed/chairs shall be in
accordance with the current DOH guidelines.
Emergency shower and eyewash for quick drenching or flushing of the eyes and body
parts shall be made available and accessible for areas where cytotoxic drugs are
prepared, stored, and utilized, for immediate emergency use.
Segregation. Wards, if any, shall observe segregation of sexes and according to age
groups. It is also recommended to observe segregation of sexes and ages (children,
adolescent, and adults) in the treatment areas.
Separate toilet shall be maintained for patients and personnel, male and female,
compliant with the plumbing fixture requirements of the National Plumbing Code (e.g.
1
toilet per 8 patients and toilet per 15 personnel). Provision for toilet dedicated for
1
cancer patients undergoing radiation therapy or systemic therapy shall be established,

separate from the toilets for other patients, staff and the general public.
Environment. Natural light and views should be available from the medical oncology
treatment areas and nursing units (e.g. locating treatment bays/ rooms adjacent to a
window or locating chairs and beds to have an external view from each patient space,
use of design features such as plants, colors and pictures to distract the sight from
clinical areas).
Medical Gas. Sufficient supply for oxygen, and medical air systems (e.g. suction and
nitrous oxide), if applicable, shall be made available in patient treatment areas.
Safety and Security. Controlled access and security measures are required in all areas
restricted to authorized staff and/or patients (e.g. patient treatment rooms, diagnostic
imaging rooms, compounding room). Warning devices (e.g. lights, signages) at the
entry to the diagnostic imaging and radiotherapy treatment rooms and other
controlled/supervised areas shall be installed to prevent unintended passage during the
procedure.
Fire Safety. The facility shall conform to the applicable provisions of the 2019 Revised
Implementing Rules and Regulations (IRR) of Republic Act (RA) 9514 or the Fire Code
of the Philippines. In addition, special consideration (e.g. automatic fire suppression
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system) shall also be given in the treatment areas and rooms housing sophisticated
equipment and hazardous materials (e.g. treatment bunker).
Patient Movement. Spaces shall be wide enough for free movement of patients,
whether they are on beds, stretchers, or wheelchairs. Circulation routes for transferring
patients from one area to another shall be available and free at all times. Corridors for
access by patient using bed or stretcher and equipment shall be at least 2.44 meters (or
8 feet) in clear width. Corridors in areas not commonly used for bed, stretcher, and
equipment transport may be reduced in width to 1.83 meters (or 6 feet) in clear width.
Service and exit corridors may be reduced to 1.2 meters (or 4 feet). Internal circulation
spaces within each spaces such as those on treatment areas shall be provided
unobstructed to allow easy passage of patients on stretchers/wheelchairs and emergency
carts, equipment and alike.
Clearances. Adequate clearances intended for the activity shall be provided

Consideration shall be given for the size and type of equipment, activity involved,
ergonomics and anthropometrics of the users.
10. Electrical System. There shall be a stable and uninterrupted power supply and a back-
up power supply, to ensure continuity ofservices. Installation of uninterrupted power
systems (UPS) for essential equipment is recommended, to guarantee that ongoing
procedures can be finished in case of power failure and fluctuations.
11. Lighting. All areas shall be well-lighted by providing appropriate general and task
lighting to ensure comfort of the patients and staff alike so that tasks can be safely
achieved. Exposed or dangling electrical wires and unwanted glare for lighting fixtures
shall be avoided (preferably color corrected). A means for dimming the room lights in
radiotherapy treatment and imaging rooms should be considered.
. Information and communications technology (ICT). Provision for ICT and

communication system between staff and patients are recommended for efficient
operation ofthe facility.
18%
Ceiling Height. The floor-to-ceiling height of rooms shall be compliant with the
provisions on ceiling height stated in the Rule VIII ofthe Presidential Decree (PD) 1096
or the National Building Code ofthe Philippines, that is, there shall be a floor-to-ceiling
height ofat least 2.4 m for artificially ventilated rooms and 2.7 m for natural ventilated
rooms. Furthermore, higher ceiling heights shall be considered for rooms having ceiling
mounted and tall and large equipment.
14. Plumbing. Continuous and sufficient supply of potable water shall be made available
at all times. Piping systems shall be kept concealed as possible yet should be located
where they will be easily accessible for service and repairs with a minimum of
disruption ofthe facility operations.
. Ventilation. Adequate ventilation shall be provided to ensure comfort of patients,

personnel, and public. Special consideration should be given on ventilation, air
//
conditioning, proper humidity and temperature control requirements depending on the
equipment and systems and the activity involved (e.g. treatment rooms, imaging).
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Provision for ventilation and air conditioning requirements to create a protective and
conducive environment for the patients (immunocompromised) should be considered.
Exhaust shall be provided in the mould room/workshop, cytotoxic preparation room,

clinical laboratory (if any), and in other areas where appropriate air exchange is
essential.
16. Material Specification. Floors, walls and ceilings shall be of sturdy materials that shall
allow durability, acoustic properties, fire rating, ease of cleaning, compliant with
infection control standards, and radiation shielding, if applicable.
a. Walls and partition. All walls ofthe cancer treatment facility in general shall be
structurally sound, safe, and sturdy with minimum fire resistant rating as prescribed
by the Fire Code ofthe Philippines for this type of occupancy. Wall finish shall be
with impervious, smooth, with less terminations, washable and easy to clean.
Flooring. Floors in general shall be made of durable materials and shall be readily
cleanable and wear-resistant. Floors subject to traffic while wet (i.e. entrance porch,
toilet facilities) shall have a non-slip surface. Special consideration shall also be
givento the weight of the equipment, level of cleanliness required, and the activity
involved and function of the space.
Appropriate floor finishes, for constant staff movement to/ from and between
patients during treatments, are recommended. Seamless floor finish in the patient
treatment areas is recommended and self-coving to a height of 6 inches (152.4
millimeters) towards the wall.
Fenestration. Windows and openings shall be in compliance with the requirements

of Rule VIII of the National Building Code of the Philippines. Provision of windows
to allow external views in patient areas (systemic therapy treatment areas and
patient rooms and wards) is recommended. Other rooms may have specific
requirements for openings (e.g. anthropod-proof screens, no openings) because of
functional requirements of the room and required level ofsterility (i.e. diagnostic
imaging facilities, radiotherapy treatment rooms, operating rooms).
Doors. Doors shall be compliant with the provisions ofthe implementing Rules and
Regulations ofthe National Building Code and Fire Code ofthe Philippines. Doors
that can be used for emergency exits must always lead directly outside of the
building to an open area such as court, yard, street or alley, interior stair, ramp, and
exterior stair. Proper signage for identification and direction shall be provided.
Entry points, doors requiring bed/trolley access and doors of rooms housing large
equipment shall be wide enough to accommodate required clearance for such
use/equipment without posing hazard to patient and staff and risk of damage to
equipment.
An electrically-operated door interlock must be provided in the radiation therapy
treatment areas.
17. Acoustics. Acoustic treatment will be required for all examination, consult and
treatment rooms and offices to ensure privacy for patients, families and staff as well as
for the control of undue noise such as those associated with machinery and equipment.
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18. Infection control. Consideration in planning and design shall be given for patients
whom are at increased risk of infection due to immunosuppression and frequent
exposure to healthcare settings. Flooring, walls, furniture and fittings should be
carefully selected to ensure effective infection control measures. The facility shall be
planned and designed in accordance with the provisions of the latest edition of the DOH
Manual on Infection Prevention and Control and other relevant statutory requirements
and code ofpractice.
19. Waste management. There shall be facilities for the efficient handling, storage and
management of wastes, including infectious and radiologic wastes, in accordance with
the provisions ofthe latest edition of the DOH Health Care Waste Management Manual,
Republic Act (RA) 6969, and other relevant statutory requirements and code of
practice.
As such, there shall be separate storage for both cytotoxic waste and radioactive wastes.
Methods of storage, treatment and disposal of radioactive waste shall conform to the
requirements and guidelines of the PNRI.
20. Additional Requirements. The design of the pharmacy, , diagnostic imaging facilities,
radiation therapy treatment areas, and nuclear medicine facilities, if any, shall comply
with the requirements for infrastructure, equipment and radiation protection of the
FDA-CDRRHR, FDA-CDRR and/or DOST-PNRI,
procedures and services the facility will render.
if
applicable, depending on the
IV. REFERENCES
Relevant Laws and Standards
Batas Pambansa Blg. 344. An Act to Enhance the Mobility of Disabled Persons by Requiring Certain
Buildings, Institutions, Establishments, and Public Utilities to Install Facilities and Other Devices.
(February 25, 1983).
R.A. No. 1378. Revised National Plumbing Code of the Philippines. (December 21, 1999).
R.A. No. 9514. Revised Implementing Rules and Regulations ofthe Fire Code of the Philippines.
(August 7, 2019).
P.D. No. 856. Code on Sanitation ofthe Philippines. (December 23, 1975).
P.D. No. 1096. Revised Implementing Rules and Regulations ofthe National Building Code. (2005).
Code of PNRI Regulations Part 03. Standards for Protection against Radiation. (September 6, 2004).
Code of PNRI Regulations Part 12. Licenses for Medical Use of Radioactive Sources in Teletherapy.
(October 20, 2008).
Code of PNRI Regulations Part 13. Licenses for Medical Use of Unsealed Radioactive Material. (March
24,2014).
wl
Code of PNRI Regulations Part 14. Licenses for Medical Use of Radioactive Sources in Brachytherapy.
(January 4, 2010).
bP
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DOH Issuances and Manuals
Department of Health. (1994). A.O. No. 35 s. 1994. Requirements for the Control of Radiation Hazards
from Clinical Diagnostic X-ray Facilities.
Department of Health.(2004). AO No. 2004-0168. National Policy on Health Emergencies and

Disasters.
Department of Health. (2011). Department Order No. 2021-0001.Annex H- Resource Stratified

Framework for Cancer Centers.
Department of Health. (2011).Safe Hospitals in Emergencies and Disasters: Philippine Indicators for
Level to 4 Hospitals.
1
Department of Health. (2013). A.O. No. 2013-0031. Requirements for the Operation of a Therapeutic
X-ray Facility Utilizing Medical Linear Accelerators.
Department of Health. (2016). A.O. No. 2016-0042. Guidelines in the Application for Department of
Health-Permit to Construct (PTC).
Department of Health. (2020). Manual on Healthcare Waste Management. 4" Edition.
International Guidelines
American Institute of Architects. (2001).Guidelines for Design and Construction of Hospital and Health
Care Facilities. Washington, D.C.: AIA
International Atomic Energy Agency. (2004). Radiotherapy Facilities: Master Planning and Concept
Design Considerations. Vienna: IAEA
International Atomic Energy Agency. (1999). Mouldroom Techniques for Teletherapy. Vienna: IAEA.
World Health Organization. (2017). List of Priority Medical Devices for Cancer Management. 48-149.
Geneva: WHO.
Books and Publications
De Chiara, Joseph. (2001). Time-Saver Standards for Building Types (4th edition). New York:
McGraw-Hill Book Company.
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of the Philippines
Republic
ANNEX D1
A.O. No. 2022- 0012
CHECKLIST FOR REVIEW OF FLOOR PLANS

CANCER SPECIALTY HOSPITAL AND CANCER SPECIALTY CENTER IN
A GENERAL HOSPITAL

Address:
Date: Review: 1% ond 3nd
1. PHYSICAL PLANT
1.1. Administrative Service
UL. Lobby
1.1.1.1. Waiting Area
1.1.1.2.
_
Information, Reception and Communication Area
1.1.1.3. Public Toilet (Male/Female/PWD)
1.1.2. Admitting and Social Service Office!
1.1.3. Business Office
Lad 3d Billing!
10153120 Cashier!
1.1.3.3. Budget and Finance'
1
4. Public Health Unit !
1
.5. Medical Records Office
.1.6. Personnel Office/s
1
1
7. Office of the Head of the Facility
él .8. Prayer Room’
1
.9. Play Area (optional)
1
.10. Family Counselling / Conference and Training Room
.1.11. Library (optional)
1
*
1
.12. Laundry*' and Linen Office!
__1.1.12.1. Sorting and Washing Area*’
1.1.12.2. Pressing and Ironing Area*!
1.1.12.3. Storage Area’
1.1.13. Engineering Office*!
CocJETS Werk Apeat
___1.1.13.2. Housekeeping Area*
_1.1.13.3. Motorpool* and Ambulance Parking Area
1.1.14. Property and Supply Office’
1.1.15. Waste Holding Room
1.1.16. Dietary*!
~___1.1.16.1. Nutritionist-Dietician Office
____1.1.16.2. Supply Receiving Area*
____1.1.16.3. Cold and Dry Storage Area*
.1.16.4. Food Preparation Area*
1.16.5. Cooking and Baking Area*
_1.1.16.6. Special Diet Preparation Area?
1.16.7. Service and Food Assembly Area’
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_1.1.16.8. Washing Area’
__1.1.16.9. Garbage Disposal Area’
___1.1.16.10. Dining Area’
____1.1.16.11. Toilet!
LT, 17. Staff Pantry
1.1. 18. Morgue (for Cancer Specialty Hospital? and Cancer Specialty Center in
a Level 3 General Hospital®); or Cadaver Holding Area (for Cancer
Specialty Center in a Level 1 and 2 General Hospital")
1.2. Clinical Service
1.2.1. Radiation Oncology Department
_____
1.2.1.1. Clinical Consultation Room with hand washing sink
1.2.1.2. External Beam Radiation Therapy (EBRT)
_1.2.1.2.1. EBRT Treatment Room
_1.2.1.2.2. Control Console Area
_1.2.1.2.3. Dressing Areas (separate for staff and
patient)
1.2.1.3. Brachytherapy
1.2.1.3.1. Brachytherapy treatment room
1.2.1.3.2. Procedure / Preparation Room
1.2.1.3.4. Dressing Room with lockers
_1.2.1.3.5. Recovery Room
_1.2.1.3.6. Sterilization Room with clean up area for
used instruments
_1.2.1.3.7. Storage Area
1.2.1.4. Imaging and Treatment Planning
_1.2.1.4.1. Treatment Planning Room
__1.2.1.4.2. Server Room
_1.2.1.4.3. Patient Preparation/ Fitting Room (optional
if the fitting is done in the simulation room)
1.2.1.4.4. Mould Room/Workshop (with exhaust fan)
___1.2.1.4.5. Medical Physicist Room
_1.2.1.4.6. CT Scan/Simulator and/or MRI Room’
_1.2.1.4.6.1. Control Room
_1.2.1.4.6.2. Toilet
1.2.1.5. Patient Toilet
1.2.2. ne 12.1.6. Staff Toilet

Systemic Therapy (Chemotherapy) Department
1.2.2.1. Clinical Consultation Room with hand washing sink
1.2.2.2. Chemotherapy Treatment Room
_1.2.2.2.1. Patient Bed / Chair Bays
1.2.2.2.2. Nurse’s Station
1.2.2.3. Support Area
_1.2.2.3.1. Chemotherapy drug preparation room with
Ante room having a changing area, shelves
for PPE’s, sink, shower and eye wash (with
exhaust fan); (Anteroom is not required if
utilizing BSC Type III or higher)
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A
~1.2.2.3.2. Procedure/treatment room (If doing catheter
insertion, lumbar puncture and intrathecal
chemotherapy)
1.2.2.3.3. Supplies and Equipment Storage Room
1.2.24. Patient Toilet
1222. 5¢ Staff Toilet
ed
i
1.2.3. Emergency Room!
Waiting Area
CLA 1239, Toilet
TTio8s, Nurse’s Station with Work Area with lavatory/sink
ieee
2B,
Triage Area' / Room?
BE
TRL Observation Area
Examination and Treatment Area with Lavatory/Sink
Pee; Minor Operation Room/Area
39;
Decontamination Room with Shower/Dressing Room?
Isolation room with Toilet and Ante Room with PPE Rack,
sink or Lavatory
1.2.3.10. Equipment and Supply Storage Area
1.2.3.11. Wheeled Stretcher Area
1.2.3.12. Doctor-On-Duty Room?
1.2.4. Outpatient Department '
Sie orn Waiting Area
1.2.4.2 Toilet (Male/Female/PWD)
TEs
ah LB
Admitting and Records Area
Consultation Area/s
eas Respiratory Unit ?
Te A,
Wy
iRl
2a,
OPD Nurse’s Station with work area with lavatory/sink
Examination and treatment Area/s with lavatory/sink
le2 448: Office of the Department Heads"
1.2.5. Surgical Service !
al DEST Major Operating Room
I
L125,
hs
Minor Operating Room?
Recovery Room with Nurses” Work Area
Sub-sterilizing area/Work Area
Sterile Equipment, Supply and Storage Area
a.
JRE
2546:
igs
Scrub-up Area
Clean-up Area
Male Dressing Room and Toilet
1.2.5.9. Female Dressing Room and Toilet
1.2.5.10. Nurses’ Station/Work Area
1.2.5.11. Wheeled Stretcher Area
1.2.5.12.Janitor’s Closet with mop sink
1.2.6. Obstetrical Service (Optional)
alge 1 Delivery Room
les
anl2 69! Labor Room with toilet
Sub-sterilizing area/ Work Area
Ji? ote Sterile Equipment, Supply and Storage Area

alles,
T1066.
Scrub-up Area
Clean-up Area
Lali
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1.2.6.7. Male Dressing Room and Toilet
1.2.6.8. Female Dressing Room and Toilet
1.2.6.9. Nurses’ Station/Work Area
_1.2.6.10. Wheeled Stretcher Area
___1.2.6.11.Janitor’s Closet with mop sink
1.2.7. Intensive Care Unit!
1.2.7.1. Nurses’ Station with Work Area with lavatory/sink
1.2.7.2. Medication Preparation Area
Gis203 Toilet
1.2.7.4. Patient Area
1.2.7.5. Dressing Area
1.2.7.6. Equipment Supply and Storage
1.2.8. Neonatal Intensive Care Unit (NICU) (optional)
1.2.8.1. Nurses’ Station/ Work Area with sink
1.2.8.2. Newborn Care Area
1.2.8.3. Breastfeeding Area with lavatory
1.2.8.4. Treatment Area
1.2.8.5. Viewing Area
1.2.9. Nursing Unit
1.2.9.1. Patient Room with toilet (Separate for male and female,
child and adolescent)
1.2.9.2. Isolation Room with Toilet and Ante Room with PPE rack,
sink/lavatory and hamper
1.2.9.3. Nurses’ Station
_1.2.9.3.1. Utility Area
__1.29.3.2. Linen Area
_1.2.9.3.3. Toilet
_1.2.9.3.4. Equipment and Supply Area?
1.2.9.4. Treatment and Medication Area with lavatory/sink
1.2.9.5. Doctor-On-Duty Room?
1.2.9.6. Garbage Bin room?
1.2.9.7. Janitor’s Closet?
1.2.10. Central Sterilizing and Supply Room!
_1.2.10.1. Receiving and Cleaning Area
_1.2.10.2. Inspection and Packing Area
_1.2.10.3. Sterilizing Room
1.2.10.4. Storage and Releasing Area
1.2.11.
LZ Tails
Rehabilitation Room !
1.2.11.2. Treatment area

1.2.11.3. Therapy Area
1.3. Ancillary Service
1.3.1. Clinical Laboratory (tertiary level) with Anatomic Pathology '
1.3.1.1. Clinical Work Area with Lavatory/Sink
1.3.1.2. Microbiology Section
_1.3.1.2.1. Culture and Sensitivity Room / Processing
Room
_1.3.1.2.2. Media Preparation room (optional if using
commercially prepared media)
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_1.3.1.2.3.
Decontamination Room
1.3.1.2.4. Sterilization Room/Unit
1.3.1.3.
Anatomic Pathology Section (room type)
1.3.1.4.
Pathologist Office
1.3.1.5.
Collection Area (separate from the Clinical Working Area)
_1.3.1.5.1. Extraction Area
1.3.1.5.2. Specimen Collection toilet
1.3.2. Radiology (3" Level)
*
1.3.2.1.X-ray Room with Control Booth, Dressing Area and Toilet

1.3.2.2.Dark Room / Image Processing Area
1.3.2.3.Film File and Storage Area
1.3.2.4. Radiologist Area
1.3.3. Pharmacy with work counter and sink '
___
1.3.3.1.Chemotherapy drug preparation room with Ante room
having a changing area, shelves for PPE’s, sink, shower and
eye wash (if compounding is done in the pharmacy)
Notes:
1.3.4. Blood Bank “
* _ When the services are outsourced and/or located outside the premises of the Cancer Specialty Hospital / Cancer
Specialty Center, these areas are not required. However, a contract of service or Memorandum of Agreement
(MOA) with a service provider should be secured as a prerequisite for the DOH- License to Operate (LTO),
'- For hospital-based cancer specialty centers, spaces/services may be co-shared with the General Hospital.
2- For hospital-based cancer specialty centers, these facilities shall have access tothis services if not available within the
general hospital.
- Required for cancer specialty hospital only.
*
2. PLANNING AND DESIGN

2.1. Floor plantomustthe beapplicable
properly identified and completely labeled.
2.2. 2.2.1. Exits restricted tocodesthe following
Conforms part of normal professional practice.
as
types: door leading directly outside ofthe
_2.2.4.
building, interior stair, ramp, and exterior stair.
Minimum oftwo (2) exits as remote as possible from each other.
2.2.2.
2.2.3. Exits terminate directly at an open space to the outside ofthe building.
Patient corridors for ingress and egress shall be at least 2.44 meters in clear
_2.2.6.
and unobstructed width.
2.2.5. Minimum ofone (1) toilet on each floor accessible to the disabled.
There shall be a separate toilet dedicated for the use of patients undergoing
cancer treatment.
2.3. Meets prescribed functional programs.
2.3.1. Main entrance ofthe hospital directly accessible from public road.
____
2.3.2. Business Office located near the main entrance of the hospital.
2.3.3. Ramp or elevator for clinical, nursing, and ancillary services located on
upper floors.
Appropriate waiting areas are provided and found commensurate to the
2.3.4.
number of companions/ relatives ofpatients (provide at least 0.65 m/
person).
2.4. 2.4.1. Emergency Room
Located in the ground floor to ensure easy access.
2.4.2. Separate entrance to the emergency.
2.4.3. Ramp for wheelchair access (BP 344 compliant).
Revision: 00
08/19 572022
Page of 8
2.44. Easily accessible to the clinical and ancillary services (laboratory,
radiology, pharmacy, operating room)
2.4.5. Nurses’ station located to permit observation of patient and control of
access to entrance, waiting area and treatment area.
2.5. Outpatient Department
2.8: Located near main entrance of the hospital to ensure easy access for
patients.
2.52. Separate toilets for patients and staff.
2.6. Surgical Service
2.6.1. Located and arranged to prevent non-related traffic through the suite.
216.2. Operating room located as remote as practicable from the entrance to the
suite to provide greater asepsis.
2.6.3. Dressing room arranged to avoid exposure to dirty areas after changing to
surgical garments.
2.6.4. Nurses’ station located to permit visual observation of patient and
movement into the suite.
2.6.5. Scrub-up area recessed into an alcove or other open space out of the main
traffic.
2.66. Sub-sterilizing area shall be provided and accessible from the operating
room.
2.6.7. Recovery room located within the suite in an area near the entrance to the
suite.
2: Nursing Service
2901: Nurses’ station located and designed to allow visual observation of patient
and movement into the nursing unit.
ZT2. Nurses’ station provided in all nursing units of the hospital with a ratio of
at least one (1) nurses’ station for every thirty-five (35) beds.
2.7.3. Toilet immediately accessible from each room in a nursing unit.
2.7.4. Separate toilets and rooms for male and female patients, and preferably
children and adolescent.
2.8. Medical Oncology Service
2.8:1. The treatment room is planned in an enclosed environment with
appropriate control door/s for entry and exit of patients and staff in order
to attain/maintain patient safety, comfort and privacy, and promote
infection control.
2.8.2, Nurses’ Station is located and designed to allow adequate surveillance of
patients undergoing treatment. The station shall be near the entrance door
to control the access to the treatment room.
2:83. All other support areas/rooms such as chemotherapy drug preparation
room, offices, staff pantry, storage room, consultation rooms and meeting
rooms, including toilets are properly planned and located outside or zoned
from the treatment room.
2.8.4. Chemotherapy drug preparation room may located within or adjacent to
the treatment area or in the pharmacy.
285, The procedure/treatment room for catheter insertion. Lumbar puncture and
intrathecal chemotherapy should have access to a dedicated lockable
refrigerator for storage of intrathecal chemotherapy for short periods prior
to administration.
Revision: 00
08/19 /2022
Page 6 of 8
2.9. 2.9.1.
Radiation Oncology Service
Mould room/workshop shall have adequate area for the storage and
workspace with lavatory/sink for fabrication, and with appropriate
a
ventilation requirements.
2.9.2. Ifthe fitting is done in the simulation room, room for patient preparation
and fitting is NOT required.
2.9.3. If providing image-guided brachytherapy, CT Scan/Simulator and/or MRI
Room should be adjacent or near the brachytherapy suite.
Dietary, engineering and other non-patient contact services located in an areas away
___ 2.10. from normal traffic within the hospital, or located in separate buildings within the
hospital premises.
2.11. The dietary service shall be away from the morgue with at least twenty-five (25) meter
distance.
COMMENTS:
Revision: 00
08/19 12022
Page 7 of 8

Address:
Date:
COMMENTS:
HEALTH FACILITIES EVALUATION AND REVIEW COMMITTEE (HFERC)

| Approved
|] [ | Disapproved
Chairperson, HFERC
Vice-Chairperson, HFERC
Member Member Member
Revision:
0S /19 12022
00:
Page 8 of8 :
ANNEX D2
A.O. No. 2022- 0012
CHECKLIST FOR REVIEW OF FLOOR PLANS

CANCER TREATMENT UNIT / SATELLITE / CLINIC
Address:
Date: Review: 1% ond 3d
1. PHYSICAL PLANT
1.1. Administrative Service
LEE Eobby
1.1.1.1. Waiting Area
1.1.1.2. Information and Reception Area
1.1.1.3. Toilet (provide with urinal if common for male and
female, PWD-accessible) '
1s Business Office and Cashier '
1: Medical Records Area!
bh:
Personnel Office/s
1. Family Counselling / Conference Room '
1. Waste Holding Area '
1.
ees Staff Pantry (optional for hospital-based)
I Patient Toilet
Ii Staff Toilet*
1.2. Clinical
c ervice
BRicY Radiation Oncology Department
1.2.1.1. Clinical Consultation Room with hand washing sink*
1.2.1.2. External Beam Radiation Therapy (EBRT)
_1.2.1.2.1. EBRT Treatment Room
_1.2.1.2.3. Dressing Areas (separate for staff and
patient)
1.2.1.3. Brachytherapy
__1.2.1.3.1. Brachytherapy treatment room
Procedure / Preparation Room
1.2.1.3.2.
_1.2.1.3.4. Dressing Room with lockers
_1.2.1.3.5. Recovery Room
_1.2.1.3.6. Sterilization Room with clean up area for
used instruments
_1.2.1.3.7. Storage Area
Tha GL,
Imaging and Treatment Planning
_1.2.1.4.1. Treatment Planning Room
____1.2.1.42. Server Room
__1.2.1.4.3. Patient Preparation/ Fitting Room
(optional if the fitting is done in the
simulation room)
Jee] DOH-HFSRB-QOP01-CTF-PTC-CR
Revision: 00
08/19 12022
Page 1 of 4
_1.2.1.4.4. Mould Room/Workshop (with exhaust
fan)
_1.2.1.4.5. Medical Physicist Room
~_1.2.1.4.6. CT Scan/Simulator and/or MRI Room’
~__1.2.1.4.6.1. Control Room
_1.2.1.4.6.2. Toilet
1.2.2. Systemic Therapy (Chemotherapy) Department
1.2.2.1. Clinical Consultation Room with hand washing sink*
1.2.2.2. Chemotherapy Treatment Room
1.2.2.2.1. Patient Bed / Chair Bays
_1.2.2.2.2. Nurse’s Station
1.2.23. Support Area
_1.2.2.3.1. Chemotherapy drug preparation room
with Ante room having a changing area,
shelves for PPE’s,sink, shower and eye
wash (with exhaust fan); (Anteroom is not
required if utilizing BSC Type or II
higher)
_1.2.2.3.2. Procedure/treatment room (If doing
catheter insertion, lumbar puncture and
intrathecal chemotherapy)
_1.2.2.3.3. Supplies and Equipment Storage Room
_1.2.2.3.4. Pharmacy (required if the CTF will
dispense drugs) '
Notes:
'
- For Hospital-based cancer treatment units, spaces/services may be co-shared with the General Hospital.
* - If providing both systemic therapy and radiotherapy, these spaces/services may be co-shared.
2. PLANNING AND DESIGN
2.1. Floor plan must be properly identified and completely labeled.
___ 2.2. Minimum of two (2) exits as remote as possible from each other.
__
2.3. Appropriate waiting area is provided and found commensurate to the number of
companions/ relatives of patients (provide at least 0.65 m/ person).
2.4. Rooms used for treatment, consultation, and isolation (if any) shall have wall partitions
from floor to ceiling.
2.5. There shall be a separate toilet dedicated for the use of patients undergoing treatment.
For Medical Oncology:

2.6. The treatment room is planned in an enclosed environment with appropriate control
door/s for entry and exit ofpatients and staff in order to attain/maintain patient safety,
comfort and privacy, and promote infection control.
2.7. Nurses’ Station is located and designed to allow adequate surveillance of patients
undergoing treatment. The station shall be near the entrance door to control the access
to the treatment room.
2.8. All other support areas/rooms such as chemotherapy drug preparation room, offices,
staff pantry, storage room, consultation rooms and meeting rooms, including toilets are
properly planned and located outside or zoned from the treatment room.
2.9. Chemotherapy drug preparation room may located within or adjacent to the treatment
area or in the pharmacy.
2.10. The procedure/treatment room for catheter insertion. Lumbar puncture and intrathecal
chemotherapy should have access to a dedicated lockable refrigerator for storage of
intrathecal chemotherapy for short periods prior to administration.
{
) DOH-HFSRB-QOP01-CTF-PTC-CR
Revision: 00
i
06 /19 2/2022
Page of 4
For Radiation Oncology:
__2.1. Mould room/workshop shall have adequate area for the storage and workspace with a
lavatory/sink for fabrication, and with appropriate ventilation requirements.
__ 2.2. Ifthe fitting is done in the simulation room, room for patient preparation and fitting is
NOT required.
__ 2.3. If providing image-guided brachytherapy, CT Scan/Simulator and/or MRI Room
should be adjacent or near the brachytherapy suite.
COMMENTS:
/ 1
Revision: 00
08/19 12022
Page 3 of 4

Address:
Date:
COMMENTS:
HEALTH FACILITIES EVALUATION AND REVIEW COMMITTEE (HFERC)

[
Approved
|] [ Disapproved |]
Chairperson, HFERC
Vice-Chairperson, HFERC
«lf :
Revision: 00
05/19 /2022
Page 4 of 4
) ANNEX Ef
ee
A.O. No. 2022- pole
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WAITING AREA
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J
MAIN ENTRANCE
SAMPLE FLOOR PLAN

SCALE 1:100 m
aAS0
—
ZA
&)
Nl
'
es
DEPARTMENT OF
HEALTH
CENTRAL OFFICE
Son Lzaro Compound, Rial Avenue,
St. Cuz, Menke Cty
TITLE / SHEET CONTENT:
SAMPLE FLOOR PLAN FOR

CANCER TREATMENT FACILITY
SYSTEMIC THERAPY (CHEMOTHERAPY)
APPROVED BY:
ATTY. NICOLAS
HEALTH FACILITIES AND
a
vB ;
Ss -UTERO
SERVICES REGULATORY
/ &
BUREAU, DOH
Ill, CESO Ill
SHEET
A52
PREPARED
NO.
SDD & RCED

1 OF
BY:
1
ANNEX E2
A.O. No. 2022- 00 12
PROPOSED
EXPANSION
EBRT
EXTERNAL BEAM
RADIOTHERAPY
TREATMENT ROOM
(LINEAR ACCELERATOR)
BRACHYTHERAPY
TREATMENT ROOM
(58m?)
PROPOSED
EXPANSION
(BRACHYTHERAPY)
C.T.SCAN/
SIMULATION ROOM
(36 m?)
2
LOBBY
MEDICAL BUSINESS CASHIER
RECORDS OFFICE
MAIN ENTRANCE
SAMPLE FLOOR PLAN

NOTE:
ae
THE BUNKER/ROOM INTENDED FOR
RADIOTHERAPY TREATMENT AND DIAGNOSTIC
IMAGING AND SIMULATION SHALL IN
SCALE 1:150 m AND DESIGNED BA ED ON THE
SIZE,
PLANNED
EQUIPMENT MANUFACTURER S SPEC CATIONS
2 a 8 12 LICENSING REQUIREMENTS
AND THE
FDA-CDRRHR AND DOST-PNRI,3 OF
APPUCABLE.
i
a
TITLE / SHEET CONTENT: APPROVED BY: SHEET NO. 1 OF 1
epic of he Philos
4) \/
:
ar
& HEALTH ENTOF
/ Bo
<5)
|
SAMPLE FLOOR PLAN FOR
CREE TENET FACET
ATTY, NicolasBI LuT
ROI, CESO Il A ON
CENTRAL OFFICE
Comput as Ss, Bi: Ch; Menke Oy RADIOTHERAPY SERVICES REGULATORY
HEALTH FACILITIES AND BUREAU, DOH HFSRB-SDD
V
ANNEX F
A.O. No. 2022-_(DI2
REFERENCES
Relevant Laws
Batas Pambansa Blg. 344. An Act to Enhance the Mobility of Disabled Persons by Requiring Certain Buildings,
Institutions, Establishments, and Public Utilities to Install Facilities and Other Devices. (February 25, 1983).
E.O. No. 26 s. 2017. Providing for the Establishment of Smoke Free Environments in Public and Enclosed Places.
(May 16, 2017).
P.D. No. 856. Code on Sanitation of the Philippines. (December 23, 1975).
P.D. No. 1096. Revised Implementing Rules and Regulations of the National Building Code. (2005)
R.A. No. 10173. Data Privacy Act of 2012. (August 15, 2012).
R.A. No. 10932. An Act Strengthening the Anti-Hospital Deposit Law by Increasing the Penalties for the Refusal
of Hospitals and Medical Clinics to Administer Appropriate Initial Medical Treatment and Support in
Emergency or Serious Cases, Amending for the Purpose Batas Pambansa Bilang 702, Otherwise Known as
"An Act Prohibiting the Demand of Deposits or Advance Payments for the Confinement or Treatment of
Patients in Hospitals and Medical Clinics in Certain Cases", As Amended by Republic Act No. 8344, and for
Other Purposes Anti-Hospital Deposit Law. (August 3, 2017).
R.A. No. 11036. An Act Establishing a National Mental Health Policy for the Purpose of Enhancing the Delivery
of Integrated Mental Health Services, Promoting and Protecting the Rights of Persons Utilizing Psychosocial
Health Services, Appropriating Funds Therefor and Other Purposes. (June 20, 2018).
R.A. No. 11215. An Act Institutionalizing A National Integrated Cancer Program And Appropriating Funds
Therefor. (February 14, 2019).
R.A. No. 11215. Implementing Rules and Regulations of the National Integrated Cancer Control Act. (August 9,
2019).
R.A. No. 11223.Implementing Rules and Regulations of the Universal Health Care Act. (February 20, 2019).
R.A. No. 4226. An Act Requiring the Licensure of All Hospitals in the Philippines and Authorizing the Bureau
of Medical Services
to Serve as the Licensing Agency. (June 19, 1965).
R.A. No. 6675. An Act to Promote, Require and Ensure the Production of an Adequate Supply, Distribution, Use
and Acceptance of Drugs and Medicines Identified by their Generic Names. (September 13, 1988).
R.A. No. 9439. An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Non-
payment of Hospital Bills or Medical Expenses. (April 27, 2007).
RA No. 9514 Revised Implementing Rules and Regulations of the Fire Code of the Philippines. (August 7, 2019).
Issuances and Manuals

Department of Health. (1994). A.O. No. 35 s. 1994. Requirements for the Control of Radiation Hazards from
Clinical Diagnostic X-ray Facilities.
Department of Health.(2004).A.0. No. 2004-0168. National Policy on Health Emergencies and Disasters.
ge 1
Page 1
of 2
Department of Health. (2011).Safe Hospitals in Emergencies and Disasters: Philippine Indicators for Level 1
to 4
Hospitals.
Department of Health.(2012).A.0. No. 2012-0012. Rules and Regulations Governing the Classification of
Hospital and Other Health Facilities.
Department of Health. (2013). A.O. No. 2013-0031. Requirements for the Operation of a Therapeutic X-ray Facility
Utilizing Medical Linear Accelerators.
Department of Health. (2016). A.O. No. 2016-0042. Guidelines in the Application for Department of Health-
Permit to Construct (PTC).
Department of Health. (2018). A.O. 2018-0016. Revised Guidelines in the Implementation of the One-Stop Shop
Licensing System.
Department of Health. (2020). Manual on Healthcare Waste Management. 4" Edition.
Department of Health. (2021). A.O. No. 2021-0008. Guidelines in the Public Access to Price Information ofAll
Health Services and Goods in Health Facilities in the Philippines.
Department of Health. (2021). Department Order No. 2021-0001.Annex H- Resource Stratified Framework for
Cancer Centers.
International Guidelines
American Institute of Architects. (2001).Guidelines for Design and Construction of Hospital and Health Care
Facilities. Washington, D.C.: AIA
International Atomic Energy Agency. (2004). Radiotherapy Facilities: Master Planning and Concept Design
Considerations. Vienna: IAEA
International Atomic Energy Agency. (1999).Mouldroom Techniques for Teletherapy. Vienna: IAEA.
World Health Organization. (2017). List of Priority Medical Devices for Cancer Management. 48-149. Geneva:
WHO.
Books and Publications
De Chiara, Joseph. (2001). Time-Saver Standards for Building Types (4th edition). New York: McGraw-Hill
Book Company.
Electronic Sources
International Agency for Research on Cancer.(2021).Retrieved from https:/gco.iarc.fr/today/

onlineanalysispie?v=2020&mode=cancer&mode_population=continents&population=900&populations=900
&key=total&sex=0&cancer=39&type=0&statistic=5&prevalence=0&population _group=0&ages_group%5B
%5D=0&ages_group%5B%5D=17&nb_items=7&group cancer=1&include nmsc=1&include nmsc_other=
1
&half pie=0&donut=0.
World Health Organization. (2020). Retrieved from https://cdn.who.int/media/docs/default-source/country-

profiles/cancer/phl 2020.pdf?sfvrsn=d800b438 2&download=true
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Republic of the Philippines

Hence, this Administrative Order (A.O.) regulating cancer treatment facilities is

1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e

To provide guidelines in the licensing of cancer treatment facilities, to ensure

IV. DEFINITION OF TERMS

A. Applicant - refers to any natural or juridical person, government

B. Allied Health Care Professionals - refer to trained non-cancer health professionals

D. Cancer Diagnosis - refers to the various techniques, procedures, diagnostics and

E. Cancer Registry - refers to a database that contains information about people

G. Cancer Rehabilitation - refers to a program that helps cancer patients, persons

Comprehensive Care - consists of services ranging from cancer prevention,

Comprehensive Cancer Care Center - refers to a care center that is

. Certificate of Compliance (COC) - a form of authorization/permission granted by

. Department of Health-License to Operate (DOH-LTO) - a formal authority

. Department of Health-Permit to Construct (DOH-PTC) - a permit issued by

. Health Facility - refers to facility or institution, whether stationary or mobile, land

. Hospital - a place devoted primarily to the maintenance and operation of health

. Multidisciplinary Patient Care - refers to an integrated approach to cancer care in

V. Patient Navigation - refers to individualized assistance provided at the community

W. Philippine Nuclear and Research Institute (PNRI) - an agency under the

X. Psychosocial Service (support program) - refers to practical support consisting of

. The DOH-LTO of a Cancer Specialty Center in a General Hospital or a Cancer

. Add-on services shall be indicated in the DOH-LTO of the CTF.

. Cancer treatment shall only be done in DOH-licensed cancer treatment facilities.

. CTFs shall adhere and ensure strict compliance to IPC standards.

M. All hospital-based cancer treatment facilities shall create a Tumor Board to

. In the advent of new technologies or practice protocols acceptable to DOH,

VIL. SPECIFIC GUIDELINES

A. Classification of Cancer Treatment Facilities

2. According to Institutional Character

3. Equipment and Instruments

5. Quality Improvement Activities

VII. PROCEDURAL GUIDELINES

2. DOH-License to Operate (LTO)

VIII. VIOLATIONS, SANCTIONS AND APPEAL

A. A CTF shall be sanctioned and penalized by the HFSRB/CHD-Regulation,

1. Manned by unqualified/unauthorized personnel

2. Absence of required personnel

3. Absence of proper functioning equipment and/or instruments

1. 1% offense: Thirty thousand pesos (Php 30,000.00)

2. 2offense: Fifty thousand (Php 50,000.00) and/or suspension of DOH-LTO for

3. 3" offense: One Hundred Thousand (P100,000) and/or suspension of DOH-LTO

4. 4" offense: Revocation of License

E. Upon receipt of the complaint by the HFSRB/CHD-RLED against a CTF, an

F. Any CTF or any of its

IX. TRANSITORY PROVISIONS

1. Teaching and training with accreditation of residency/fellowship training

D. Cancer Specialty Center in a General Hospital shall be licensed as such, wherein

E. All patient beds in a Cancer Specialty Center in a General Hospital or Cancer

If any clause, sentence or provision of this Order shall be declared invalid or

XI. REPEALING CLAUSE

SCO T. DUQUE III, MD, MSc

ASSESSMENT TOOL FOR LICENSING A CANCER TREATMENT FACILITY

The REMARKS column shall document relevant observations.

HEALTH FACILITY INFORMATION

Name of Owner: Tel. / Fax Nos.:

Chief of Hospital/Med. Director: Tel. / Fax Nos.:

Existing License No.: Authorized Bed Capacity(if applicable):