SUMMARY OF FINDINGS

INFIRMARY
O.C.W. GENERAL HOSPITAL
39 Tandang Sora Ave., Culiat, Quezon City 1128

Date of Monitoring: June 21, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 20, 2018

FINDINGS:
 Photo of updated organizational chart with lines of authority
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging   x
Waste Management   x
Patient Safety   x
Infection Control   x
Emergency and Disaster Preparedness   
CQI  x x
Grievance  x 
Selections and Promotions   x
 Proof of Annual accomplishment report
 Policies for Dietary
 Presence of annual plan for training activities
 Proof of orientation conducted to new personnel
 Proof of Job descriptions with conforme
 Presence of Annual Statistical Reports
 Policy on retention of records
 Policy of retrieval of charts
 Contract or Appointment of person in charge of security.
 Presence of sentinel event reporting system
 Certificate of Training (in-house) or MOA of personnel in-charge of maintenance of equipment
 Proof of designation of Infection Control Physician and Infection Control Nurse
 Presence of policies in reporting of notifiable diseases
 Presence of Quality Improvement Program and proof of implementation
 Presence of Customer Satisfaction Survey and analysis
PROGRAMS
 Mother-Baby Friendly Accreditation or received copy of letter of intent
 Immunization logbook
 Policy on generic prescribing
 Designation of HEMS Coordinator
 Newborn Screening for Hearing logbook
 TB Referral logbook
PERSONNEL
 Copy of the following:
- Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
- Medical records officer – Contract, trainings, ICD-10 trainings and Records Management Training
- Billing/Cashier – Contract, trainings
- Clerk - Contract, trainings
- Building maintenance/Utility worker - Contract, trainings
- Security guard – contract or MOA
 - Nurse Supervisor – Diploma, valid PRC license, contract, Master’s Degree in Nursing or at least 9 units.
- PHYSICIANS NURSES – to hire 6 full time nurses (plus 3 reliever-optional)
Doctor’s Name Diploma Valid PRC Contract/ Nurse’s Name Diploma Valid PRC Contract/MOA
MOA
Dr. De Jesus x x 
Dr. Cruz x x 
Dr. Oaperina x  
Dr. Guingon x  
Dr. Hadap x  

PHYSICAL PLANT REQUIREMENT

 Provision of PWD toilet

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

E-CART CONTENTS BASIC ER SUPPLIES

 Anti-rabies vaccine – active  protective face shield or mask
 Anti-rabies vaccine – passive  Pulmonary Function Test
 Dobutamine
 Haloperidol 50mg/ampule
 Morphine SO4 10mg/ampule

MONITORED BY:

Dr. Dindo
Oliver
Abby
Carol
Lito
Aldo