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SUMMARY OF FINDINGS

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

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


Date Prepared: August 17, 2018

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


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

PHYSICAL PLANT REQUIREMENT


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

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

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

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

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