PH Health Ref

DC 2018-0131: Revised Licensing Assessment Tools for Hospitals

In this document:

  • •DOH STANDARDS (Indicators) for HOSPITALS Instructions: PART I HOSPITAL MEDICAL SERVICES 0 In the appropriate box, place a check mark (\I) ifthe hospital is compliant or X-mark if not compliant.
  • •PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS outbreaks of ofhospital associated infection control healthcare infections such as use of associated PPEs, isolation infections. precautions and Presence of a hand washing. coordinated system-wide procedure for asepsis. INTERVIEW Ask staff in ER and wards the procedures on isolation (Isolation - physical isolation ofa patient with infection and reverse isolation). Ask staff from ER, wards and laboratory about the approaches for asepsis during diagnostic and treatment procedures 30. There are Presence ofprogram on DOCUMENT ER programs for prevention of REVIEW Wards the prevention transmission of airborne o Policies and Isolation of transmission infections and risks from procedures on room of airborne patients with signs and isolation. Laboratory infections, and symptoms suggestive of 0 Occupational risks from tuberculosis or other Health and patients with communicable diseases Safety signs and Program for symptoms employees suggestive of tuberculosis or other communicable diseases are managed according to established protocols
  • •DOH STANDARDS (Indicators) for HOSPITALS Instructions: PART III HOSPITAL PHYSICAL PLANT
  • •In the appropriatebox, place a check mark (\l) ifthe hospital is compliant or X-mark ifnot compliant. 0 Interview at least 10 patients and 10 hospital staff members. 0 Conduct documentreview of at least 10 sample documents. needs (e.g. ramps) are available, clearly and prominently marked and free of any types of structure passagewaysfor patients with special needs. 0 They are prominently Other areas CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS I. PATIENT CARE A. ACCESS 1.A multi-levelramp Presence of ramp or OBSERVE shall have a minimum elevator clear width of 1.22 meters in one direction and slope is 1:12; an elevator which can accommodate at least a patient bed, provided if there is no ramp; Ramp is provided at the entrance if it is not at the same level with the inside 2. Entrances and exits Presence of entrances OBSERVE ER are clearly and and exits that are readily

~14k words

Document Info

Category
policies
Year
2018
Status
current
Hospital Levels
L1L2L3
Issuing Body
Department of Health
Extracted
2026-04-23

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY April 11, 2018 DEPARTMENTCIRCULAR No. 2018- QM] FOR : ALL DOH REGIONALDIRECTORS, HEALTH FACILITIES AND SERVICES REGULATORY BUREAU (HFSRB) DIVISION CHIEFS, REGULATORY LICENSING AND ENFORCEMENT DIVISION CHIEFS (RLED), HFSRB AND RLED REGULATORY OFFICERS, CHIEFS OF HOSPITALS AND HOSPITAL MEDICAL DIRECTORS SUBJECT : Revised LicensingAssessment Tools for Hospitals Based from the review of the draft hospital assessment tools and discussions during Technical Working Group meetings, Bimonthly Regulatory Licensing and Enforcement Division Chiefs Meetings, National Dialogue, and consultative meetings with HFSRB technical staff and specialty societies, the assessment tools for licensing of hospitals and infirmaries have been revised. The licensing standards and requirements are aligned with the provisions of Administrative Order No. 2012-0012 and its amendments. The following are the major changes in the Assessment Tools: 1. The Assessment Tools for licensing a Hospital are divided into parts: a. Part I: Standards for Medical Services b. Part 11: Standards for Nursing Service 0. Part III: Standards for Physical Plant d. Part IV for Level 1 Hospital i. Attachment 1.A. — Personnel ii. Attachment 1.B. — Physical Plant iii. Attachment l.C. — Equipment/Instruments iv. Attachment 1.D. — Emergency Cart Contents for Level 1 Hospitals v. Attachment 1.E — Add-on Services e. Part IV for Level 2 Hospital i. Attachment 2.A. — Personnel ii. Attachment 2.B. —— Physical Plant iii. Attachment 2.C. — Equipment/Instruments iv. Attachment 3.D — Emergency Cart Contents for Level 2 Hospitals f. Part IV for Level 3 Hospital i. Attachment 3.A. — Personnel ii. Attachment 3.B. — Physical Plant i. Attachment 3.C. — Equipment/Instruments ii. Attachment 3.D — Emergency Cart Contents for Level 3 Hospitals Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila 0 Trunk Line 651-7800 local 1108, 1111, 1112, 1113 Direct Line: 711-9502; 711-9503 Fax: 743-1829 0 URL: http://www.doh.gov.ph; e-mail: fiduque@doh.gov.ph

The HFSRB-approved floor plan shall be the basis for assessing compliance to the licensing standards for physical plant during inspection or monitoring. 3. The required quantity for each emergency medicine has been removed from the Assessment Tool. Hence, the hospitals and infirmaries have the sole responsibility for ensuring the availability of the emergency medicines based on their clinical practice guidelines or protocol and frequency ofusage. 4. Additional licensing requirements include compliance to: a. Implementation ofthe Electronic Medical Records b. Implementation of the Antimicrobial Stewardship c. National laws and DOH issuances: 1. ii. iii. iv. vi. RA. No. 10932: Anti-Hospital Deposit Law EC No. 26 s. 2017: “Providing for the Establishment of Smoke-Free Environments in Public and Enclosed Places” A.O. No. 2007-0041: “Guidelines on the Mandatory Allocation of a Certain Percentage ofthe Authorized Bed Capacity as Charity Beds in Private Hospitals” RA. No. 9439: “An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses” R.A. 10173: “An Act Protecting Individual Personal Information in Information and Communications Systems in the Government and the Private Sector, Creating for this Purpose a National Privacy Commission, and for Other Purposes” Act No. 3753: “Law on Registry of Civil Status” and Presidential Decree No. 766: Amending Sections 2 and 5 of Presidential Decree No. 651, entitled “Requiring the Registration of Births and Deaths in the Philippines which occurred from January 1, 1974 and thereafter” and extending the Period ofRegistration up to December 31, 1975. The revised Assessment Tools for hospitals to be used for both inspection and monitoring shall be effective starting April 23, 2018. Thank you. By Authority ofthe Secretary ofHealth: «44 , ROLAND E RIQUE D. DO INGO, MD, MSc U dersecretary ofHealth Health Regulations Cluster

Republic of the Philippines Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU HOSPITAL ASSESSMENT TOOL 1. HEALTH FACILITY INFORMATION Name of Facility: Address: Email Address: Tel. / Fax Nos.: Name of Owner: Tel. / Fax Nos.: Hosp. Administrator: Tel. / Fax Nos.: Chiefof Hospital/Med. Director: Tel. / Fax Nos.: License To Operate: Authorized Bed Capacity: Classification: General Level 1 I: Level 2 |:] Level 3 El Specialty El Government: [1 Private: I:I National |:| Single Proprietorship CI Local |:| Corporation ]:| Others: (specify) Others: (specify) Type of application: New |:] Renewal I:I Others:E (specify) DOH-HOS-LTO-ATPI Revisionz01 04/23/2018 Page 1 of 23

DOH STANDARDS (Indicators) for HOSPITALS Instructions: PART I HOSPITAL MEDICAL SERVICES 0 In the appropriate box, place a check mark (\I) ifthe hospital is compliant or X-mark if not compliant.

Interview at least 10 patients and 10 hospital staff members. 0 Conduct document review of at least 10 sample documents. CRITERIA INDICATOR EVIDENCE AREAS , COMPLIED REMARKS I. PATIENTRIGHTS AND ORGANIZATIONALETHICS Standard: Organizational policies and procedures respect and support patients' rights to quality care and their responsibilities in that care. l. Informed consent is All patient charts DOCUMENT Wards obtained from patients have signed consent. REVIEW prior to initiation of Patients charts care. Note: Informed consent - INTERVIEW includes a patient-doctor Patients discussion ofthe nature of the deczszon or the . ASkpatient/family from procedure; alternatives [0 the wards/ICU ifthey proposed intervention; the were appropriately r[Sks’ benefits, and informed by authorized uncertainties related to each personnel (doctor or alternative; assessment to nurse) about their patient understanding; and disease, condition or patientIS““9”“ or disability, its severity, refusal ofthe intervention. prognosis, benefits and possible adverse effects oftreatment options and the likely cost of treatment. 2. Policies and Presence of policies DOCUMENT Wards procedures which and procedures to REVIEW identify and address patients’ rights and responsibilities are documented and monitored. identify and address patients' rights (Refer to DOH Department Memorandum No. 2017-0061) Policies and procedures on patients' rights. INTERVIEW Staff Patient OBSERVE Posted patients’ rights in conspicuous places. II. PATIENTCARE A. ACCESS Standard: The organization informs the communityabout the services it provides and the hours of their availability. 3. Clinical services are appropriate to patients' needs and the former's availability is consistent with the organization’sservice capability and role in the community. Presence of facilities consistent with clinical service capability. DOCUMENT REVIEW

  1. List of services with indicated time of availability
  2. DOH LTO (updated, valid and original). ER OPD OR/RR DOH-HOS-LTO—ATPI Revisionzo1 04/23/2018 Page 2 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS 'COMPLIED REMARKS 3. PNRI certification (when applicable) OBSERVE The facilities, and structure. Check if the service capability ofthe hospital is in accordance with the health facility level ACCORDINGTO CLASSIFICATIONOF HOSPITAL(Place a check on the corresponding column, if complied) CRITERIA LEVEL 1 I LEVEL 2 LEVEL3 A. Clinical services at least for:

  • Medicine
  • Pediatrics — Obstetrics and Gynecology — Surgery
  • Anesthesia
  • Others (please specify) DOCUMENT REVIEW Policies and procedures B. Departmentalized clinical services at least for:
  • Medicine — Pediatrics
  • Obstetrics and Gynecology
  • Surgery
  • Anesthesia
  • Others (please specify) DOCUMENT REVIEW 0 Policies and procedures for each department 0 Separate recording of patients per department OBSERVE 0 Physical separation of wards 0 Department head offices 0 Different clinical areas C. Dental Clinic DOCUMENT REVIEW Policies and procedures including referral system DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 3 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA D. High Risk Pregnancy Care DOCUMENT REVIEW Policies and procedures E. Neonatal Intensive Care Unit DOCUMENT REVIEW Policies and procedures F. Intensive Care Unit DOCUMENT REVIEW Policies and procedures G. Respiratory Unit DOCUMENT REVIEW Policies and procedures H. Physical Medicine and Rehabilitation Unit DOCUMENT REVIEW Policies and procedures I. Ambulatory Surgical Clinic (ASC) (Refer to Assessment Tool for Ambulatory Surgical Clinic) Note: Levels 1 and 2 may opt to have an ASC LEVEL 1 ' ‘ LEVEL 2 LEVEL 3 REMARKS J. Dialysis Clinic (Refer to Assessment Tool for Dialysis Clinic) Note: Levels 1 and 2 may opt to have a Dialysis Clinic K. Teaching and Training Hospital DOCUMENT REVIEW 0 Policies and procedures 0 Certificate of accreditation of residency training (Must have at least two accredited residency trainings) CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS 4. All patients are correctly identified by their patient charts, including newborn The contents of patient‘scharts are the following:

  1. Summary or face sheet
  2. Informed Consent DOCUMENT REVIEW Patient charts from ER, ward, and OPD INTERVIEW Patients ER OPD Wards DOH-HOS-LTO-ATPI Revisionzo1 O4/23I2018 Page 4 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS ' COMPLIED REMARKS 3. History and Physical Examination . Doctor's order . Nurses Notes . TPR Sheet . Laboratory report . Imaging reports . Maternal Record with Partograph (if warranted) 10. Newborn record and maturity rating (if warranted) 11. Medication and/or treatment record 12. Operative and anesthesia record (if warranted) Record of interdepartmental referral/consultati on to other physicians, including notes 14. Record of referral or transfer of patient to other facility/service/do ctor including notes 15. Discharge summary 16. Clinical abstract 17. Advance directive, whenever applicable 000“me 13. Standard: The care plan addressespatient's relevant clinical, social, emotional and religious needs. The plan of care, aside from delineating responsibilities, includes goals to be achieved, services to be provided, patient education strategies to be implemented, time frames to be met, and resources to be used. Presence of adopted/developed protocols, CPGs or pathways containing goals to be achieved, services to be provided, patient education strategies to be implemented, time frames to be met and resources to be used DOCUMENT REVIEW Adopted/ developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education. OBSERVE Check if medicines and treatment prescribed are in Wards ER OPD ICU accordance with DOH-HOS-LTO-ATPI Revisionzo1 04/23/2016 Page 5 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS adopted CPGs/protocols Standard: Each patient's physical, psychological and social status is assessed. An appropriate comprehensive history and physical examination is performed on every patient within 48 hours from admission. The history includes present illness, past medical, family, social and personal history. All patients have comprehensive history and PE within 48 hours from admission. DOCUMENT REVIEW Patient chart from wards or Medical Records have complete history and RE. Wards Medical Records Office Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessaryrepetition. Previously obtained information is reviewed at every stage of the assessment to guide future assessments All patient charts have progress notes by doctors and other health professionals. DOCUMENT REVIEW Patient chart from medical records/wards. Medical records room Wards Standard: Assessments are performed regularly and are determined by patients’ evolving responseto care. Qualified personnel All patients for DOCUMENT Surgical / give patients for surgery have REVIEW OB-Gync surgery pre- undergone pre- Patients’ charts of Wards operative physical operative physical surgery / OB- and pre-anesthetic and pre-anesthetic Gyne patients assessment assessment who have underwent surgery and presently admitted. IMPLEMENTATIONOF CARE Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate to the provider organization’sservice capabilityand usual case mix are availableand are performed by qualifiedpersonnel Policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations There is Quality control on diagnostic examinations including film reject analysis, etc. and calibration of diagnostic equipment DOCUMENT REVIEW Proof of monitoring of implementation of the policies and procedures on quality control of diagnostic examinations Laboratory X-ray CSSR DOH-HOS-LTO-ATPI Revision101 04/23/2018 Page 6 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED ' REMARKS C. EVALUATION OF CARE Standard: The dischargeplan is part of the patient's care plan and is documentedin the patients’ chart. 10. Discharge plans for All charts have patients to ensure discharge plans. continuity of care. DOCUMENT REVIEW Patients' charts from medical records, look at the discharge orders. It should contain all of the following: 0 May go home order 0 Home medications (if applicable) 0 Follow up visits/schedule 0 Home care/advise Medical records room wards III. LEADERSHIPAND MANAGEMENT A. MANAGEMENT REVIEW Standard: The provider organization's managementteam providesleadership, acts according to the organization's policies and has overall responsibilityfor the organization'soperation, and the quality of its services and its resources 11. Organizational Presence of OBSERVE Lobby Structure/Chart organizational structure Organizational structure/chart is posted in a conspicuous area 12. The organization Presence of written DOCUMENT Medical, and its services vision, mission, and REVIEW Nursing develop their goals of the hospital Written vision, and vision, mission and and all mission and goals Adminis- corporate goals services/departments trative based on agreed- OBSERVE Services upon values Posted vision and Laboratory mission in a conspicuous area 13. The organization Written policies and DOCUMENT Medical, and its services procedures manual REVIEW Nursing develop their for all and policies and services/departments/ 0 Written Policies Adminis- procedures. units 0 Procedure trative manual Services 14. Committees within Proof of the creation DOCUMENT Adminis- the organization of all committees REVIEW trative which includes the within the Proof ofthe office terms of reference organization which creation of all for membership includes the terms of committees, reference for written policies membership. and procedures, minutes of The following are the meetings committees required: DOH-HOS-LTO-ATPI Revisionzo1 04/23/2018 Page 7 of 23

PART I HOSPITALMEDICAL SERVICES CRITERIA INDICATOR EVIDENCE VVAREAS COMPLIED REMARKS

  1. Credentialing and privileging
  2. Blood 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. Pharmacologic and Therapeutic
  8. Emergency and Disaster Preparedness
  9. CQI
  10. Grievance 1 1.Information and Communication Technology INTERVIEW Committee members
  11. Evaluation and monitoring activities to assess management and organizational performance Presence of evaluation and monitoring activities to assess management and organizational performance DOCUMENT REVIEW Accomplishment reports or other annual reports as applicable Adminis- trative Office ANCILLARYSERVICES(Place a check on the corresponding column, if complied) REQUIREMENTS Level 1 Level 2 Level 3 REMARKS A. CLINICALLABORATORY (Refer to assessment tool for Clinical Laboratory) Notes: Level 1 and 2 Hospitals may opt for laboratory service capability higher than Secondary Clinical Laboratory and Tertiary Clinical Laboratory, respectively.
  12. Secondary Clinical Laboratory
  13. Tertiary Clinical Laboratory
  14. Tertiary Clinical Laboratory with Histopathology B. IMAGINGFACILITY DOCUMENT REVIEW 0 For waived inspection of Center for Device Regulation Radiation Health and Research (CDRRHR): Recommendation Letter 0 For inspected facilities by CDRRHR: Certificate of Compliance of Diagnostic X-ray facilities, interventional and specialized X- ray facilities DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 8 of 23

PART I HOSPITAL MEDICAL SERVICES REQUIREMENTS Level 1 Level 2 ~ Level 3 REMARKS Note: Level 1 and 2 Hospitals may opt for imaging facility service capability higher than Level 1 Imaging Facility and Level 2 Imaging Facility, respectively.

  1. Level 1 Imaging Facility
  2. Level 2 Imaging Facility
  3. Level 3 Imaging Facility C. PHARMACY Open 24/7, providing safe, affordable and efficacious medicines DOCUMENT REVIEW 0 Recommendation Letter from Center for Drug Regulation and Research (CDRR) for initial LTO for waived inspection. 0 Inspection Report from CDRR D. BLOOD SERVICE FACILITY (Refer to assessment tool for blood service facility) There shall be 24 hours / 7 days a week provision of safe blood. Note: Levels 1 and 2 may opt to have a higher a blood service facility higher than a Blood Station. Level 1 Level 2 Level 3 REMARKS
  4. Blood Station _
  5. Blood Bank
  6. Blood Bank with Additional Functions E. AMBULANCE SERVICE (Refer to assessment tool for ambulance service) The ambulance vehicle should be physically present in the hospital. It shall be available 24 hours/7 days a week. Level 1 Level 2 Level 3 REMARKS

Type 1 — Basic Life Support (BLS) 2. Type 2 — Advance Life Support (ALS) CRITERIA INDICATOR EVIDENCE AREAS , COMPLIED REMARKS IV. HUMAN RESOURCEMANAGEMENT A. HUMAN RESOURCESPLANNING Standard: Workload is monitored and appropriate guidelines consultedto ensure that appropriate staff numbers and skill mix are availableto achieve desired patient and organizational outcomes. DOH-HOS-LTO-ATPI Revision101 04/23/2018 Page 9 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS 16. The Presence ofpolicies and DOCUMENT Personnel organization procedures for hiring, REVIEW /Adminis- documents and credentialing and trative follows policies privileging of staff Policies and office and procedures procedures for for hiring, hiring, credentialing, credentialing and and privileging privileging of of its staff. staff INTERVIEW Human Resources Management Officer/Personnel Officer 17. Staff numbers Staff to bed ratio for DOCUMENT Personnel/ and skill mix licensed doctors, REVIEW Adminis- are based on registered nurses and trative actual clinical midwives/nursing aides 0 List of licensed office needs. follows the DOH doctors and prescribed ratio. (Refer nurses based on Wards (Trainees, except physicians undergoing residency training and volunteers not included) to Attachment of Assessment Tool for Personnel) HR records 0 Payroll 0 Schedule of duties for the previous and current month 0 Number ofbeds authorized by DOH and actual beds being used 0 201 files of employees B. STAFF RECRUITMENT,SELECTION,APPOINTMENTAND RESPONSIBILITIES Standard: There are relevant orientation, training and development programs to meet the educationalneeds of managementand staff. 18. Professional Presence of Qualification DOCUMENT Personnel/ qualifications Standards REVIEW Adminis- are validated, Check trative including Qualification office evidence of Standards; professional procedures in registration hiring. /license where applicable, prior OBSERVE to employment Check PRC License of some MDs, Nurses, Pharmacists 19. The staff are Staff provided withjob DOCUMENT Personnel/ provided with a description outlining REVIEW Adminis- documentedjob their accountabilities and Written job trative description responsibilities descriptions with office outlining conforrne accountabilities DOH-HOS-LTO—ATPI Revision201 04/23/2018 Page 10 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS and responsibilities C. STAFF TRAININGAND DEVELOPMENT Standard: There are relevant orientation, training and development programs to meet the educational needs of management and staff. 20. New personnel, Proof that new personnel DOCUMENT Personnel/ new graduates are adequately oriented REVIEW Adminis- and external and supervised Documentation of trative contractors- are orientation office adequately conducted supervised by qualified staff INTERVIEW Ask new personnel about the lines of authority and supervision and if the supervision is adequate OBSERVE 21. Annual plan on Presence of annual plan DOCUMENT Personnel/ training on training activities REVIEW Adminis- activities trative Annual plan office (including resource/ budgetary allocation) on training activities V. INFORMATIONMANAGEMENT A. DATA COLLECTIONAND AGGREGATION Standard: Relevant,accurate, quantitative and qualitativedata are collected and used in a timely and efficient manner for delivery ofpatient care and managementof services 22. Records are Policies and procedures DOCUMENT Medical stored, retained on record storage, REVIEW records and disposed of retention and disposal. Logbooks on room in accordance record storage, with the retention and guidelines set disposal by National Archives of the OBSERVE Philippines Proper storage of (NAP) records 23. The Presence of annual DOCUMENT Medical organization statistical reports and REVIEW records defines data other additional hospital 0 Policies and room sets, data statistics as determined procedures on generation, by the management record storage, collection and (Refer to National safekeeping and aggregation Archives of the maintenance, methods and the Philippines [NAP] per retention and qualified staff DC No. 70 s. 1996) disposal. DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 11 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS who are 0 Proof of involved in each participation or stage submission in the OHFSRS (Online Health Facility Statistical Reporting System) B. RECORDS MANAGEMENT Standard: Clinical records are readily accessible to facilitatepatient care, are kept confidentialand safe, and comply with all relevant statutory requirements and codes ofpractice. 24. When patients Presence ofpolicies and OBSERVE Medical are admitted or procedures on filing and Patient charts are Records are seen for retrieval of charts easily retrievable Room/ ambulatory or within 10-15 Office emergency care, minutes patient charts documenting any previous care can be quickly retrieved for review, updating and concurrent use. 25. The Presence ofpolicies and DOCUMENT Medical organization has procedures on protection REVIEW Records policies and ofrecords and patient Logbooks for Room/ procedures, and charts against loss, borrowing and Office devotes destruction, tampering retrieval of charts Wards resources, and unauthorized access including or use, and in OBSERVE infrastructure, maintaining Access to records to protect confidentiality/ privacy. and patient charts records and patient charts against loss, destruction, tampering and unauthorized access or use. Only authorized individuals make entries in the patient chart. 26. Electronic All general and specialty OBSERVE Medical Medical hospitals are mandated to Records Records comply with the EMR EMR Room/ implementation starting implementation Office October 2018. includes, but is Wards not limited to, 6- claims, primary care benefits, maternal and neonatal deaths, DOH-HOS-LTO-ATPI Revision101 04/23/2018 Page 12 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS injury, and confirmed cases of diagnosis (e.g. cancer, diabetes mellitus, cerebrovascular accident) VI. SAFE PRACTICE AND ENVIRONMENT A. INFECTIONCONTROL Standard: All interdisciplinary infection control program ensuresthe prevention and control of infection in all services. 27. Infection Presence of an Infection DOCUMENT Infection Prevention and Prevention and Control REVIEW Control Control Committee (IPCC) with o IPCC Committee Committee defined roles and composition Office responsibilities 0 Full time Infection Control Nurse (1: 100 beds) 0 IPCC functions and activities 0 Minutes of meetings 28. Infection Presence of an infection DOCUMENT Nurse Prevention and control program ensuring REVIEW Super— Control prevention and control of 0 IPC Manual. Visor’s Program infections on all services. c Policies on Office rational antimicrobial use based on the hospital antibiogram and surveillance of AMR 0 Reports of infection control activities e.g. surveillance, training, outbreak investigation, etc. o Policies and procedures on disposition of dead bodies with dangerous communicable disease. Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcare— associated infections. 29. Organization takes steps to prevent and control Presence of a coordinated system-Wide procedure for prevention DOCUMENT REVIEW Validate hospital policies on ER Wards Laboratory DOH-HOS-LTO-ATPI Revisionzo1 04/23/2018 Page 13 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS outbreaks of ofhospital associated infection control healthcare infections such as use of associated PPEs, isolation infections. precautions and Presence of a hand washing. coordinated system-wide procedure for asepsis. INTERVIEW Ask staff in ER and wards the procedures on isolation (Isolation - physical isolation ofa patient with infection and reverse isolation). Ask staff from ER, wards and laboratory about the approaches for asepsis during diagnostic and treatment procedures 30. There are Presence ofprogram on DOCUMENT ER programs for prevention of REVIEW Wards the prevention transmission of airborne o Policies and Isolation of transmission infections and risks from procedures on room of airborne patients with signs and isolation. Laboratory infections, and symptoms suggestive of 0 Occupational risks from tuberculosis or other Health and patients with communicable diseases Safety signs and Program for symptoms employees suggestive of tuberculosis or other communicable diseases are managed according to established protocols

Policies on timely referral and case reporting of highly transmissible and notifiable infectious disease e.g. meningoco- ccemia, SARS, avian flu, etc. 0 Procedures on recycling & reuse OBSERVE 0 Use of gloves, surgical masks 0 Lavatories or designated areas for hand DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 14 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS washing or dispenser for hand sanitizers 0 Separate holding room for highly infectious cases. 0 Ask a staff to demonstrate hand washing technique Standard: When needed, the organization agencies. reports information about infections to personneland public health 31. Policies and Presence ofpolicies and DOCUMENT procedures in procedures in reporting REVIEW reporting notifiable diseases Copy of reports notifiable submitted to diseases (Refer Philippine to A0 No. Integrated Disease 2008—0009). Surveillance and Response (PIDSR) B. PATIENTAND STAFF SAFETY Standard: The organization plans a safe and effective environmentof care consistent with its mission, services, and with laws and regulations. 32. An incident reporting system identifies potential harms, evaluates causal and contributing factors for the necessary corrective and preventive action Presence of incident reporting system/sentinel event monitoring system (which may include hospital associated infections, unexpected deaths, adverse drug reactions, blood transfusion reactions, falls, etc.) DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/order s or proceedings on sentinel events INTERVIEW Ask at random any staff from wards and ER: 0 How the incident reporting system works 0 Correction, corrective and preventive actions taken Infection Control Committee office CQI Office Wards ER ICU OR VII. IMPROVINGPERFORMANCE Standard: The organization has a planned systematic organization-wide approach to process design and performance measurement, assessment and improvement. 33. Continuous Quality Improvement Program Presence of Quality Improvement Program DOCUMENT REVIEW CQI plan and proofof implementation Adminis- trative Office DOH-HOS-LTO-ATPI Revision201 04/23/2018 Page 15 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED "REMARKS Standard: Management is primarily responsible for developing, communicating,and implementinga comprehensive quality improvementprogram throughout the organization and delegating responsibilitiesto appropriate personnel for its day-to-dayimplementation 34. Comprehensive quality improvement program throughout the organization and delegating responsibilities to appropriate personnel for its day-to-day implementation Proof that the management is primarily responsible for developing, communicating and implementing a comprehensive quality improvement program implementation DOCUMENT REVIEW 0 Memoranda/or ders creating the Q1 team/Quality circle 0 Minutes of meetings/ extracts of minutes relating to concerned topic, documentation of activities 0 Monitoring reports on CPG use or similar QI activities 0 Designation of a point person for the CQI INTERVIEW Validate the activities by asking the management team or officer involved in CQI program Adminis- trative Office Standard: The organization providesbetter care service as a result of continuousquality improvement activities 35. Customer Presence of customer DOCUMENT Adminis- satisfaction satisfaction survey REVIEW trative survey Accomplished Office client satisfaction survey forms with monthly analysis; actions taken 36. Better patient Proof of better patient DOCUMENT Adminis- outcome. outcomes REVIEW trative Documentation of Office better outcomes for patients as a result of CQI activities (Correction, corrective and preventive actions ofproblems identified) DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 16 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS , VIII. NATIONAL LAWS AND DOH ISSUANCES INIPLEMENTED IN HOSPITALSAND OTHER HEALTH FACILITIES 37. Newborn Proof of implementation DOCUMENT OB Ward Screening — in ofNewborn Screening REVIEW (Rooming compliance to o Policies and 111) RA 9288 and procedures on its IRR Universal Newborn Screening 0 Logbook of Newborns who were tested and copies of waiver for those who were not screened 0 Availability of filter paper 38. Universal Proof of implementation DOCUMENT Newborn Newborn ofNewborn Hearing REVIEW hearing Hearing Screening 0 Logbook of screening Screening — in Newborns who room compliance to were tested on RA 9709 hearing (Universal 0 Proof ofreferral Newborn if service is not Hearing available Screening Act) 39. Mother- Baby Proofof implementation DOCUMENT OB Ward Friendly of Rooming—in and REVIEW Hospital Breastfeeding MBFHI Initiative — in Certificates: compliance to o MBF Hospital RA 7600 and o MBF Workplace RA 10028 and its IR, and (MOU for those Executive who are not Order No. 51 certified yet). (Milk Code) OBSERVE

  • Breastfeeding area should be provided at the NICU 0 There shall be no nursery for normal newborns
  1. Family Presence of Family DOCUMENT OPD planning — in planning services REVIEW OB wards compliance to 0 List ofFF RA 10354 acceptors (Responsible 0 Evidence as Parenthood conscientious and objector if FP Reproductive DOH-HOS-LTO-ATPI Revision101 04/23/2018 Page 17 of 23

PART I HOSPITAL MEDICAL SERVICES ' CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS Health Act of services are not 2012) provided 0 Referral Logbook if conscientious objector. 41. Immunization Proof that newborn DOCUMENT OB Ward — in babies given BCG and REVIEW compliance to first dose Hepatitis B Records of RA No. 306 vaccine Newborns given BCG and first dose Hepa—B vaccine OBSERVE INTERVIEW STAFF 42. Anti-smoking — Proof of implementation DOCUMENT Hallways in compliance ofpolicies and REVIEW Toilets to RA 9211 procedures on anti- Policies and Wards smoking procedures on Offices EC No. 26 s. 2017, anti-smoking OPD “Providing for the Establishment of OBSERVE Smoke-Free “No Smoking” Environmentsin signages posted in Public and a conspicuous Enclosed Places” spaces 43. Generic Proof of implementation DOCUMENT Pharmacy Prescribing — ofpolicies and REVIEW Wards in compliance procedures on generic o Prescriptions to RA 6675 prescribing filled in the (Generics Act Pharmacy Of 1983) 0 Physicians’ orders in patients’ charts 0 Documentation of nurses on medicines. 44. Health Proof of implementation DOCUMENT ER Emergency of the Hospital REVIEW Wards Management Emergency Management 0 Self-assessment Offices Services Plan (e.g. fire drill, for disaster (HEMS) — in earthquake drill, etc.) readiness using compliance to A0 2004-0168 "National Policy on Health Emergencies and Disasters" the “Safe Hospital Checklist” available at the HEMB website. 0 Result of self- assessment and how gaps were resolved DOH-HOS-LTO-ATPI Revision201 04/23/2018 Page 18 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS OBSERVE Exit plans posted in all hallways and rooms 45. National Proof of implementation DOCUMENT OPD Tuberculosis ofNational TB Program REVIEW Wards Program 0 Presence of Hospital TB NTP — in compliance Referral with RA 10767 Logbook (ComprehensiveTB 0 List of EliminationPlan Act) Diagnosed TB Cases Notified (with received remarks by DOH— Regional Office) 46. AD. No. 2007- Proof of implementation DOCUMENT Wards 0041: of allocation of charity REVIEW “Guidelines on beds to indigent patients Policies and the Mandatory in private hospitals procedures on the Allocation of a allocation of Certain charity beds for Percentage of confinement of the Authorized indigent patients Bed Capacity or patients as Charity classified as Class Beds in Private C or D patients as Hospitals” defined in AD. No. 51-A s. 2000: “Implementing Guidelines on Classification of Patients and on Availment of Medical Social Services in Government Hospitals.” OBSERVE At least ten percent (10%) of authorized bed capacity of private hospital is allocated as charity beds. 47. R.A. 9439: “An Proofof implementation DOCUMENT Adminis— Act of R.A. 9439 REVIEW trative Prohibiting the Office Detention of Patients in Hospitals and Medical Policies and procedures on handling cases of patients for DOH-HOS-LTO-ATPI Revision201 04/23/2018 Page 19 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE T AREAS COMPLIED REMARKS Clinics on discharge but with Grounds of unpaid hospital Nonpaymentof bills are aligned Hospital Bills with the or Medical provisions in R.A. Expenses” No. 9439. 48. R.A. 10932: Proof of implementation DOCUMENT Adminis- Anti-Hospital of R.A. 10932 REVIEW trative Deposit Law Policies and Office procedures on the implementation of ER RA 10932 rendering emergency care and admission to poor indigent and marginalized patients. OBSERVE: A copy of the R.A. 10932 and its Implementing Rules and Regulations are posted in a conspicuous space. 49. R.A. 10173: Proofof implementation DOCUMENT Adminis- Data Privacy ofR.A. 10173 REVIEW trative Act Policies and Office procedures on the implementation of Medical RA 10173 Records Office 50. Act No. 3753: Proof of implementation DOCUMENT “Law on ofAct No. 3753 and REVIEW Registry of Presidential Decree No. a Birth Civil Status” 766 certificates and and death Presidential certificates Decree No. properly filled 766: Amending out and filed Sections 2 and o Logbooks 5 0f showing proof Presidential of submission Decree No. of 651, entitled accomplished “Requiring the birth and death Registration of certificates to Births and local civil Deaths in the registry Philippines 0 Properly filed WhiCh and signed occurred from waivers by January 13 families or 1974 and relatives if they DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 20 of 23

PART I HOSPITAL MEDICAL SERVICES CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS thereafter” opt to file the and extending births/deaths the Period of personally at Registration the local civil up to registry. December 31, 1975. DOH-HOS-LTO-ATPI Revision:01 04/23/2018 Page 21 of 23

Republic of the Philippines Department of Health 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 HOSPITAL Validity from to [ ] Issuance depends upon compliance to the recommendations given and submission of the following within days from the date of inspection [ ] Non-issuance. Specify reason/s: Inspected by: Printed name Signature Position/Designation Received by: Signature: Printed Name: Position/Designation: Date: DOH-HOS-LTO-ATPI Revision201 04/23/2018 Page 22 of 23

Republic of the Philippines Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU Name of Health Facility: Date of Monitoring: RECOMMENDATIONS: B. For Monitoring Process [ ] Issuance ofNotice of Violation [ ] Non-issuance of Notice of Violation [ ] Others. Specify: Monitored by: Printed name Signature Position/Designation Received by: Signature: Printed Name: Position/Designation: Date: DOH-HOS-LTO-ATPI Revisionzo1 04/23/2018 Page 23 of 23

PART II HOSPITAL NURSING SERVICE DOH STANDARDS (Indicators) for HOSPITALS Instructions: 0 In the appropriate box, place a check mark (\l) ifthe hospital is compliant or X-mark if not compliant. 0 Interview at least 10 patients and 10 hospital staff members. 0 Conduct document review of at least 10 sample documents. CRITERIA INDICATOR EVIDENCE AREAS COMPLIEVD’ I. PATIENTCARE A. ACCESS Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessaryrepetition.

  1. NURSING Licensed and DOCUMENT Wards, SERVICES appropriately trained REVIEW ER, OPD Moderate Nursing Care nursing personnel PRC Valid license and Management assigned in special and Certificate of relevant critical areas training
  2. Nurses make use of Charts have nurses’ CHART REVIEW Wards Nursing Process in notes Patients’ charts from the care ofpatients medical records or wards Medical Presence ofNursing have nurses’ notes Records manual and properly Office utilized Kardex DOCUMENTS Patients’ charts Kardex B. IMPLEMENTATIONOF CARE ' Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations appropriate to the provider organization’sservice capabilityand usual case mix are availableand are performed and patients are properly identified before medications are administered before medications are administered verify orders from doctors prior to administration of medicines. OBSERVE How staffverifies the prescriptions or orders by qualifiedpersonnel
  3. Medicines are All medicines are CHART REVIEW ER administered in a administered observing Check patients charts for Wards timely, safe, the five (5) R's of the accuracy ofmedicine appropriate and medication which are: administration. controlled manner
  4. Right patient
  5. Right medication
  6. Right dose
  7. Right route
  8. Right time
  9. Only qualified All doctors, pharmacists INTERVIEW Wards personnel order, and nurses have updated Randomly check the Pharmacy prescribe, dispense licenses licenses of some doctors, ER prepare, and nurses and pharmacists if OPD administer drugs. they are updated.
  10. Prescriptions or Proof that prescriptions INTERVIEW Wards orders are verified or orders are verified Ask staff how they ER Revisionzo1 04/23/2018 Page 1 of 2 REMARKS

PART II HOSPITAL NURSING SERVICE the wards. CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS for medicines with the doctor’s order. . Patients are properly Proof that patients are INTERVIEW Wards identified before correctly identified prior Verify from patients if ER medicines are to administration of they were correctly administered medications identified prior to drug administration. OBSERVE if the staff verifies the identity ofpatient prior to administration of medications (patient should be the one to state his/her name.) . Medicine All charts have proper CHART REVIEW Medical administration is documentation of Medication sheet in records properly documented medicine administration. patient chart from office in the patient chart medical records or from wards II. SAFE PRACTICE AND ENVIRONMENT A. INFECTIONCONTROL Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcare- associated infections. . There are programs for prevention and treatment ofneedle stick injuries, and policies and procedures for the safe disposal ofused needles are documented and monitored Presence ofpolicies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles INTERVIEW Ask staff their policies on needle stick injury OBSERVE Use ofPPEs in doing minor surgeries, IV insertions, etc. ER Wards Standard: Cleaning, disinfecting, drying, packagingand sterilizing of equipment, and maintenance of associated requirements and codes of practice. environment,conform to relevant statutory . Policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies. Presence ofpolicies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies DOCUMENT REVIEW 0 Policies and procedures 0 Logbooks on packaging and sterilizing of equipment, instruments and supplies OBSERVE Designated areas for receiving, cleaning, disinfecting, drying packaging, sterilizing and releasing of sterilized equipment, instruments and supplies. CSSR DOH-HOS-LTO-ATPII Revision:01 04/23/2018 Page 2 of 2

DOH STANDARDS (Indicators) for HOSPITALS Instructions: PART III HOSPITAL PHYSICAL PLANT

In the appropriatebox, place a check mark (\l) ifthe hospital is compliant or X-mark ifnot compliant. 0 Interview at least 10 patients and 10 hospital staff members. 0 Conduct documentreview of at least 10 sample documents. needs (e.g. ramps) are available, clearly and prominently marked and free of any types of structure passagewaysfor patients with special needs. 0 They are prominently Other areas CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS I. PATIENT CARE A. ACCESS 1.A multi-levelramp Presence of ramp or OBSERVE shall have a minimum elevator clear width of 1.22 meters in one direction and slope is 1:12; an elevator which can accommodate at least a patient bed, provided if there is no ramp; Ramp is provided at the entrance if it is not at the same level with the inside 2. Entrances and exits Presence of entrances OBSERVE ER are clearly and and exits that are readily

With entrance and OPD prominentlymarked accessible.(Reference: exit signs. Check ER, Wards RA 6541 Building Code OPD and wards OR/RR/DR ofthe Philippines) 0 Entrances and exits Imaging are accessibleand free from any obstruction 3. Directional signs are Presence of directional OBSERVE ER prominently posted to signage to locate service Signage is easily seen OPD help locate service areas along comers, corridors, Wards areas within the lobby, clinic Lobby organization. 4. Alternative Entrance ramp is OBSERVE ER passagewaysfor provided, as required in Check: OPD patients with special AccessibilityLaw for all 0 Alternative Wards obstruction. marked 0 They are free from obstruction. 5. Corridors conform Corridors used as access OBSERVE with standard measurement for patients using bed or stretcher are at least 2.44 meters while in areas not commonly used for bed or stretcher are at least 1.83 meters o Corridors 2.44 meters wide can accommodate 2 wheeled stretchers alongside each other DOH-HOS-LTO-ATPIII Revision:01 04/23/2018 Page 1 of 6

PART III HOSPITAL PHYSICAL PLANT CRITERIA INDICATOR 7 EVIDENCE AREAS COMPLIED REMARKS o Wheeled stretcher can have a 360 degree turning radius B. SERVICES THAT MAY BE OUTSOURCED 6. Outsourcedservices Presence of all DOCUMENT Adminis- are within the facility outsourced services REVIEW trative within the hospital 0 Contracts/MOAfor Office outsourcedservices 0 Valid licensesof all providers 0 Check contracts/ job orders 1. ADMINISTRATIVE SERVICES A. Dietary There shall be provision DOCUMENT of safe, quality and REVIEW/ nutritious food to INTERVIEW patients. 0 Check policies and procedures in the Diet prescriptionor diet dietary. counselling is provided 0 Monthly menu for to patients patients B. Linen/ Laundry If not contractedout, DOCUMENT there shall be: ‘ REVIEW/ INTERVIEW

Sortingofsoiled and contaminatedlinens ChCCk POIiCiCS and in designated areas procedures on hOW . Systematicwashing soiled linens are 8 oflaundry with collected disinfectedand ES safeguard against washed. a spread of infection a; o Disinfectionof ‘5' laundry E E C. Security Policies and procedures DOCUMENT <1 on securityofpatients, REVIEW visitors and hospital staff Securitycheck for internal and external customers including use ofvisitor’s pass D. Housekeeping/ Janitorial There shall be provision and maintenanceof clean, safe and sanitary facilities and environment for hospital personnel, patients and clients OBSERVE Proof of implementation DOH-HOS-LTO—ATPIII Revision101 04/23/2018 Page 2 of 6

PART III HOSPITAL PHYSICAL PLANT CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS E. Proper Waste Policies and DOCUMENT Disposal procedures on proper REVIEW waste disposal. Proof of implementation ofpolicies and procedures on proper waste disposal. F. Maintenance Policies and procedures DOCUMENT Lobby (Equipment and on maintenance REVIEW ER / OPD Building) Wards and OBSERVE the rest of Proof of implementation the hospital II. SAFE PRACTICE AND ENVIRONMENT A. PATIENT AND STAFF SAFETY Standard: The organizationplans a safe and effective environment ofcare consistent with its mission, services, and with laws and regulations 7. Hospital has a valid license Presence of updated DOH license to operate DOCUMENT REVIEW 0 Updated DOH license 0 If facility has nuclear medicine, check certificate issued by PNRI Adminis- trative office 8. Building Maintenance Program is in place ensuring facilities are in state of good repair Policies and procedures DOCUMENT REVIEW Routine program of work for preventive maintenanceand record addressing safety 0 Safety policies and procedures of corrective maintenanceare available 9. Hospital is free from DOCUMENT Hospital undue noise, pollution REVIEW surroundings and from foul Odor

  • Checkpresence of Laboratory MSDS (Material Pharmacy Safety Data Sheet) in and other the laboratoryand part of the Engineering facility and 0 Record ofdisposalof Maintenance radiologic wastes INTERVIEW Ask staff at random: their manner of waste segregation and disposal; safe storage and disposal ofreagents, and disposal of wastewater 10.Presenceof a Presence of a DOCUMENT Adminis- management plan, management plan, REVIEW trative office policies and policies and procedures Maintenance procedures addressing: 0 Managementplan, Office, DOH-HOS-LTO-ATPIII Revision:01 04/23/2018 PageSofG

PART III HOSPITAL PHYSICAL PLANT CRITERIA INDICATOR EVIDENCE AREAS , 1 COMPLIED REMARKS OSecurity 0 Proof of ER ODisposal and control of Implementation Wards hazardousmaterials and biologic wastes INTERVIEW OEmergency and disaster ASk about the frequency preparedness Of the following: 0 Fire drill conductedin the past 12 months 0 Earthquake drill conducted in the past 12 months ll.Policies and Presence of policies and DOCUMENT ER procedures for the procedures for: REVIEW OPD safe and efficient use 0 QualityControl 0 Presence of operating Wards of medical equipment 0 Corrective and manuals of the DR according to Preventive medical equipment Laboratory specifications are MaintenanceProgram 0 Preventive and Pharmacy documented and for medical corrective Maintenance implemented. equipment maintenancelogbook Office 0 Film reject analysis 0 Qualitycontrol tests results OBSERVE How staff performs necessaryprecaution or safety procedures such as: red light is on while x-ray procedure is being done. Note: Look into their storage ofmercury containing devices which are no longer allowed to be used Other areas 12. Patient areas provide sufficient space for safety, comfort and privacy ofthe patient and for emergency care. I Presence of adequate space, lighting and ventilation in compliance with structural requirements(for patient safety and privacy) OBSERVE o Adequate space for patients in moving around the bed areas 0 Adequate lighting (lights are working, lighting is adequate enough for conduct of general activities) 0 Adequate ventilation o Segregationof sexes, in wards and clinical areas ER OPD Wards DR 13. A coordinated security arrangement in the organization assures protectionof Presence of an appointed personnel in charge of security. DOCUMENT REVIEW Contract or Appointment ofperson in charge of security. DOH-HOS-LTO—ATPIII Revision101 04/23/2018 Page 4 of 6

PART III HOSPITAL PHYSICAL PLANT CRITERIA INDICATOR EVIDENCE , AREAS COMPLIED REMARKS patients, staff and visitors. INTERVIEW Ask the personnel in charge of securitywhat the policies on security are. OBSERVE ' Securitymeasures ' 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 statutoryrequirementsand codes of practice. 14. Generator, emergency Presence ofgenerator, DOCUMENT Engineering/ light, water system, emergency light, water REVIEW Maintenance adequate ventilation system, adequate 0 Check result of water Other or air conditioning ventilationor air analysis for the last 6 Relevant conditioning. months. Areas 0 Preventive and corrective maintenance logbooks OBSERVE 0 Test if faucets and water closets are working 0 Functionalemergency lights and generators 15.Equipment are Presence of policies and DOCUMENT regularly maintained procedureson preventive REVIEW with plan for and corrective Records of preventive replacement maintenance and and corrective according to expected replacementifwarranted maintenanceand plan for life span or when no replacement longer serviceable. 16. Trainingof the staff Proof of training of the DOCUMENT Engineering/ who is in charge of staff who is in charge of REVIEW Maintenance the maintenanceof the maintenanceof the For in—house: Certificate Office the equipment equipment of trainingofservice Laboratory personnel or Certificate Imaging of training Other Areas For outsourcedservice: MOA/Contract INTERVIEW Ask about how equipment(generator, A/C, Medical and non- medical devices, etc.) are maintained DOH-HOS-LTO-ATPIH Revision201 04/23/2018 Page 5 of 6

PART III HOSPITAL PHYSICAL PLANT CRITERIA INDICATOR EVIDENCE AREAS COMPLIED reference and guidance in the operation and maintenance of plant and equipment. 17. Operating manualsof equipment Presence of operating manuals equipment DOCUMENT REVIEW Operating manual of Medical equipment, generators, air conditioners and other non-medical equipment. Engineering/ Maintenance Office Imaging, Laboratory C. ENERGY AND WASTE MANAGEMENT Standard: The handling, collection and disposal of waste conform with relevantstatutory requirementsand code of practice 18.Licenses/permits/ clearances from pertinent regulatory agencies Presence of licenses/permits/ clearances from pertinent regulatoryagencies, if applicable DOCUMENT REVIEW 0 Valid licenses/permitsfrom regulatoryagencies (LGU, DENR, etc.) 0 Proof of compliance i.e., generator permit, elevator permit, etc. Adminis- trative office 19. Policies and procedures on Waste Disposal Management Proof ofstrict implementationof policies and procedures on waste management DOCUMENT REVIEW 0 Issuances - memos, guidelines on waste segregation, collection,treatment and disposal. 0 Contractswith service providers waste handlers or disposal contractors (if applicable) OBSERVE o Segregationofwaste 0 Proper labellingof waste receptacles o Recyclable waste staging areas 0 Proper management oftemporary storage areas prior to hauling for disposal. INTERVIEW Ask staff regarding SOPs on actual procedure on waste disposal DOH-HOS—LTO-ATPIII Revision:01 04/23/2018 Page 6 of 6 REMARKS Standard: Current informationand scientific data from manufacturersconcerning their products are available for

PART IV - LEVEL 1 HOSPITAL Instruction: In the appropriate box, place a check mark (/) if the hospital is compliant or X—mark if not compliant. ATTACHMENT1.A - PERSONNEL TOP MANAGEMENT (Should be full-time) Chief of 0 Licensed physician DOCUMENT Hospital/Medical . Have completed at REVIEW Director least twenty (20) units a Diploma/Certificate of towards a Master’s units earned Degree in Hospital 0 Updated Physician Administration or PRC license related course (MPH, o Certificates of MBA, MPA, MHSA, Trainings attended etc.) O_R at least five 0 Proof of Employment/ (5) years hospital Appointment experience in a (notarized) supervisory or 0 Service managerial position Record/Certificate of Employment (proof of hospital supervisory/manageria 1 experience) Chief Nurse /Director 0 Licensed nurse DOCUMENT 0f Nursing 0 Master’s Degree in REVIEW Nursingfl at least ° Diploma five (5) years of 0 Updated PRC license clinical experience in a o Certificates of supervisory or Trainings attended managerial position in 0 Proof of Employment/ nursing Appointment (RA. No. 9173) (notarized) 0 Service Record/Certificate of Employment (proof of supervisory/manageria 1 experience in nursing) Chief Administrative Have completed at least DOCUMENT Officer/Hospital twenty (20) Units REVIEW Administrator towards Master’s Degree 0 Diploma/Certificate of in Hospital units earned Administration or related 0 Updated PRC license course (MPH, MBA» o Certificates of MPA, MHSA, etc.) Q Trainings attended at least five (5) years 0 Proof of Employment/ hospital experience in a Appointment supervisory/ managerial (notarized) position. . Service Record/Certificate of Employment (proof of hospital supervisory/manageria DOH-HOS-LTO-AT-L1-PIV Revision201 § 04/23/2018 Page1of19

exp nce ADMINISTRATIVE SERVICES Bachelor’s Degree in 1 Accountant Accountancy DOCUMENT (may be outsourced) REVIEW _ Billing Officer With Bachelor’s Degree ' Diploma/Cgrtificate 0f 1 . relevant to thejob umts earne Budget / Finance 0 Updated PRC license 1 Officer (ifapplicable) Cashier o Certificates of 1 Human Resources Trainings attended 1 Management Officer/ ' PFOOf 0f Employment/ Personnel Officer Appointment Book keeper (notarized) 1 Supply Officer/ With appropriate training DOCUMENT l Storekeeper and experience REVIEW 0 Certificates of Trainings attended 0 Proof of Employment/ Appointment (notarized) Medical Records 0 Bachelor's Degree DOCUMENT 1 officer 0 Training in ICD 10 REVIEW 0 Training in Medical 0 Diploma/Certificate of Records Management units earned 0 Certificates of Trainings attended 0 Proof of Employment/ Appointment (notarized) Medical Social Licensed social worker DOCUMENT 1 worker (Full Time) REVIEW Nutritionist-Dietician Licensed nutritionist o Diploma/Certificate of 1 (Full Time) units earned 0 Updated PRC license Certificates of Trainings attended 0 Proof of Employment/ Appointment (notarized) Utility Worker May be outsourced. DOCUMENT 1 per shift Security Guard REVIEW 1 per shift Laundry worker Security guard must be 0 Relevant Training 1 licensed. 0 License, if applicable 0 Proof of Employment/ Appointment (notarized) if employed by hospital 0 Notarized MOA if outsourced DOH—HOS-LTO-AT-L1-PIV Revision:01 04/23/2018 Page 2 of 19

CLINICALSERVICES Consultant Staff in 0 Licensed physician DOCUMENT A11 Ob-Gyn, Pediatrics, . Fellow/Diplomate REVIEW consultants Medicine, Surgery, . ACLS certified (for 0 Certificate from must be at and Anesthesia. Surgeons and Specialty society, if least board AnestheSiologists) applicable (for eligible. *HOSPilal may have Board Certified) At least one additional consultants . Residency Training consultant from other specialties. Certificate (for must be Board Eligible) board 0 Certificate of certified per Residency Training/ specialty. Medical Specialists (*DOH Medical Specialist, last exam was in 1989) 0 Updated PRC license 0 Certificates of Trainings attended 0 Proof of Employment] Appointment (notarized) Resident Physician Licensed physician DOCUMENT Wards - 1:20 on Duty (Shall not go REVIEW beds at any on duty for more than 0 Updated PRC given time 48 hours Straight). license PLUS 0 Certificates of ER — at Trainings attended leastl at any 0 Proof of given time Employment/ *This ratio Appointment does '10! (notarized) indl‘de 0 Schedule of duty R6514?“ Physzczaris on approved by Duty that Medlcal shallbe Director/Chief of requiredf0,. Hospital add—0n services such as dialysis facility. It shallbe counted separately. NURSING SERVICES Supervising 0 Licensed nurse DOCUMENT 1:50 Beds Nurse/Nurse 0 With at least nine (9) REVIEW Office hours Managers units ofMaster's 0 Diploma/Certificate only (8am Degree in Nursing of Units Earned to 5pm) 0 At least two (2) years— 0 Updated PRC experience in general license nursing service 0 Certificates of administration. Trainings attended Proof of Employment/ DOH-HOS-LTO-AT-L1-PIV Revision:01 ’ 04/23/2018 i Page 3 of 19

Apporntment (notarized) 0 Service Record/Certificate of Employment (Proof of general nursing service administration experience) Head Nurse/Senior . Licensed nurse DOCUMENT 1:15 staff Nurse 0 With at least 2 years- REVIEW nurses hospital experience 0 Diploma o BLS certified 0 Updated PRC license 0 Certificate of trainings attended 0 Proof of employment (notarized) o If nursing staffing is outsourced: Validity of the contract of Staff Nurse 0 Licensed nurse employment should be Ward - 1:12 o BLS certified at least one (1) year Beds at any and within the validity given time period of the (plus 1 hospital’s LTO. reliever for 0 Schedule of duty CVCI'Y 3 approved by Chief RNS) Nurse Nursing Attendant . Highschool graduate DOCUMENT 1:24 beds at 0 With relevant health- REVIEW any given related training 0 Certificates of time (P1113 1 (may be in house Trainings attended reliever for training) 0 Proof of Employment/ every 3 Appointment NAS) (notarized) Operating Room 0 Licensed nurse DOCUMENT 1 SN and 1 Nurses: 0 Training in OR REVIEW CN per -Scrub Nurse (SN) Nursing functioning -Circu1ating Nurse . Training in BLS and o Diploma OR per shift (CN) ACLS . Updated PRC license (plus 1 0 Certificate oftrainings reliever for attended every 3 0 Proof of employment nurses) Delivery Room Nurse 0 Licensed nurse (notarized) 1 per 3 ' Training in Maternal 0 If nursing staffing is delivery and Child Nursing outsourced: Validity table per (may be in house ofthe contract of Shlft training or training in employment should be (Plus 1 Essential Integrated at least one (1) year reliever for Newborn Care and within the validity every 3 [EINCD period of the nurses) 0 Training in BLS and hospital’s LTO, ACLS 0 Schedule of duty DOH-HOS-LTO-AT-L1-PIV Revision:01 5 04/23/2018 Page4of19

Emergency Room Licensed nurse Training in Trauma Nursing, ACLS and other relevant training Licensed nurse Training in BLS Department Nurse Nurse approved by Chief 1:3 beds per shift (plus 1 reliever for every 3 nurses) 1 DOH-HOS—LTO-AT—L1-PIV

ATTACHMENT1.B - PHYSICALPLANT 2. DOH Approved Floor Plan 3. Checklist for Review of Floor Plans (accomplished) OBSERVATIONS/FINDINGS (may use separate additional sheets if needed): DOH-HOS-LTO-AT-L1-PIV 3 Revision:01 04/23/2018 Page60f 19

ATTACHMENT1.C — EQUIPMENT/INSTRUMENT EQUIPMENT/INSTRUMENT (Functional) QUANTITY AREA COMPLIED REMARKS ADMINISTRATIVE SERVICE Ambulance o If owned by hospital, available 24/7 and h sicall resent if not bein used . Sui/mg tithep of inspection/moiitoring 1 Parking 0 If outsourced, shall be on call but able to respond within reasonable time. Computer with Internet Access 1 Admgéglreatlve Lobby, hallway, . nurses' station, Emergency nght office/unit and stairways lobby, hallway, . ' . . 1 er unit or nurses' station, F1re Extinguishers P area office/unit and stairways Generator set with Automatic Transfer 1 Genset house Switch (ATS) KITCHEN/DIETARY Exhaust fan 1 Food Conveyor or equivalent (closed- 1 type) Food Scale 1 Blender/Osteorizer 1 Oven 1 Kitchen Stove 1 Refrigerator/Freezer 1 Utility cart 1 Garbage Receptacle with Cover (color— 1 for each coded) color EMERGENCYROOM 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 Delivery set, multigravid 2 sets ECG Machine with leads 1 EENT Diagnostic Set with 1 Ophthalmoscope and Otoscope Emergency Cart (for contents, refer to 1 ER separate list). Examining table 1 Examining table (with Stirrups for OB— 1 Gyne Glucometer with strips Gooseneck lamp/Examining Light 1 DOH-HOS-LTO-AT—L1-PIV Revision:01 : 04/23/2018 Page 7 of19

EQUIPMENT/1N STRUMENT , (Functional) QUANTITY AREA COMPLIED REMARKS Instrument/Mayo Table 1 Minor Instrument Set (May be used for Tracheostomy, Closed Tube 2 sets Thoracostomy, Cutdown, etc.) Nebulizer 1 Negatoscope 1 Neurologic Hammer 1 OR Light (portable or equivalent) 1 Oxygen Unit Tank is anchored/chained/ strapped or 2 with tank holder if not from pipeline Pulse Oximeter 1 ER Sphygmomanometer, Non-mercurial

  • Adult Cuff 1
  • Pediatric Cuff 1 Stethoscope 1 Suction Apparatus l Suturing Set 2 sets Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 Vaginal Speculum Different Sizes .1 for each ’ different Size Wheelchair 1 Wheeled Stretcher with guard/side rails 1 and wheel lock or anchor. OUT- PATIENTDEPARTMENT Clinical Height and Weight Scale 1 EENT Diagnostic Set with 1 ophthalmoscope and otoscope Gooseneck lamp/Examining Light 1 Examining table with wheel lock or 1 anchor Instrument/Mayo Table 1 Minor Instrument Set 1 Neurologic Hammer 1 Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder ifnot pipeline Peak flow meter
  • Adult 1 CPD
  • Pediatric 1 Sphygmomanometer, Non-mercurial — Adult cuff 1
  • Pediatric cuff 1 Stethoscope 1 Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 Suture Removal Set 1 Wheelchair / Wheeled Stretcher 1 DOH-HOS-LTO-AT-L1-PIV Revision:01 fl 04/23/2018 Page 8 of 19

EQUIPMENT/INSTRUMENT . , ' . (Functional) QUANTITY AREA COMPLIED REMARKS OPERATINGROOM Air conditioning Unit l/OR Anesthesia Machine l/OR Cardiac Monitor with Pulse Oximeter l/OR Caesarian Section Instrument 1 Defibrillator with paddles 1 Electrocautery machine 1 Emergency Cart (for contents, refer to 1 separate list) Glucometer with strips Instrument / Mayo Table 1 Laparotomy pack (Linen pack) 1 set per OR OR Laparotomy / Major Instrument Set 1 set per OR Laryngoscopes with different sizes of 1 blades Operating room light 1 per OR Operating room table 1 per OR Oxygen Unit Tank is anchored/chained/ strapped or 1 per OR with tank holder if not pipeline Rechargeable Emergency Light (in case 1 per OR generator malfunction) Sphygmomanometer, Non—mercurial OR

  • Adult cuff 1 per OR
  • Pediatric cuff 1 per OR Spinal Set 1 Stethoscope 1 Suction Apparatus 1 Thermometer, non—mercurial
  • Oral 1
  • Rectal 1 Wheeled Stretcher with guard/side rails 1 and wheel lock or anchor. POST ANESTHESIACARE UNIT / RECOVERYROOM Air conditioning Unit 1 Cardiac Monitor 1 1 (if separate Defibrillator with paddles from the OR Complex) Eerggffenfiytfart(for contents, refer to ggisffifgg Complex) Glucometer with. strips . PACU/RR Mechanical / patlent bed, w1th guard 1 side rails and wheel lock or anchored Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Pulse Oximeter Sphygmomanometer, Non-mercurial
  • Adult cuff 1
  • Pediatric cuff 1 DOH-HOS-LTO-AT—L1-PIV Revision:01 04/23/2018 Page90f19

EQUIPMENT/INSTRUMENT , (Functional) QUANTITY AREA COMPLIED REMARKS Stethoscope 1 Thermometer, non-mercurial 1 LABORROOM Fetal Doppler 1 Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Patient Bed 1 Labor Room Pulse Oximeter 1 Sphygmomanometer, Non-mercurial 1 Stethoscope 1 Thermometer, Non-mercurial 1 DELIVERYROOM Air-conditioning Unit 1 Bag valve mask unit (Adult and 1 pediatric) Bassinet Clinical Infant Weighing Scale 1 1 (if DR is Defibrillator with paddles 561°32‘83“ Complex ) Delivery set, primigravid 1 set Delivery set, multigravida 2 sets Delivery room light 1 Delivery room table 1 Dilatation and Curettage Set 1 set 1 Emergency Cart (for contents, refer to (ifDR is DR separate list) separate from OR Complex) Instrument/Mayo Table 1 Kelly Pad or equivalent 1 Laryngoscope with different sizes of 1 blades Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder ifnot pipeline Rechargeable Emergency Light (In case . 1 of generator malfunctions) Sphygmomanometer -Non-mercurial 1 Stethoscope 1 Suction Apparatus 1 Wheeled Stretcher 1 NURSING UNIT/WARD Bag-Valve-Mask Unit — Adult 1 — Pediatric 1 NURSING Clinical Height and Weight Scale 1 UNIT/WARD Nursing units located on the Defibrillator with paddles 1 same floor may share the defibrillator and the E-cart, DOH-HOS-LTO-AT-L1-PIV Revision:01 j 04/23/2018 Page100f19

EQUIPMENT/INSTRUMENT (Functional) QUANTITY AREA COMPLIED REMARKS provided that they are not more than 50 meters away from each other. Emergency cart or equivalent (refer to 1 separate list for the contents) EENT Diagnostic Set with 1 ophthalmoscope and otoscope Laryngoscope with different sizes of 1 blades Mechanical/Patient bed with lock, if ABC wheeled; with guard or side rails Bedsxde Table ABC NURSING Nebuhzer 1 UNIT/WARD Neurologic Hammer 1 Oxygen Unit 1 tank is anchored/chained if not pipeline Sphygmomanometer, Non— Mercurial

  • Adult cuff 1 — Pediatric cuff 1 Stethoscope 1 Suction Apparatus 1 Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 CENTRAL STERILIZING & SUPPLY ROOM Autoclave/Steam Sterilizer 1 CSSR CADAVER HOLDINGAREA/ROOM CADAVER Bed or stretcher for cadaver 1 HOLDING AREA DOH-HOS-LTO-AT—L1-PIV Revisionzo1 04/23/2018 Page 1 1 of 19 §

ATTACHMENT 1.D - EMERGENCYCART CONTENTS FOR LEVEL 1 HOSPITAL EMERGENCYCARTCONTENTS ER 0R DR NSl st N83 N84 Nss N86 N57 N88 NS9 510 11 512 REMARKS Adenosine 6 Vial Amiodarone 1 mL ule Anti—tetanus serum (either equine-based antiserum or human antiserum irin USP 325 let ine 1 ml nists i.e. Salbutamol 2 Benzodiazipine (Diazepam 10mg/2m1 ampule and/or Midazolam in ' alert box Calcium (usually calcium gluconate 10% solution in 10 mL Cl ' l 75 tablet D5W 250 mL D50W 0.5 mL ' henh ' Dobutamine 5mL e 200 5mL ule/Vial hrine 1 ml Furosemide 2 ule Hal 'dol mL 6 H ' 2 vial Lidocaine 10% in 50mL Lidocaine 2% solution via] 1 50ml sulfate 1 mL Mannitol 20% solution in 500ml/bottle DOH-HOS-LTO-AT—L1-PIV ~ Revision:01 04/23/2018 Page 12 of 19

EMERGENCYCART CONTENTS ER OR DR N81 N82 N83 N84 N85 N86 N87 N88 N89 NS 10 NS 11 N8 12 REMARKS Methylprednisolone 4mg/tablet Metoclopramide 10mg/2mLampule Morphine sulfate 10mg/mLampule (in high alert box ) Nitroglycerin inj. 10 mg/10mL ampule or Isosorbide dinitrate 5mg SL tablet or 10 mg/10mL ampule Noradrenaline 2mg/2mL ampule Paracetamol 300mg/ampule (IV preparation) Phenobarbital 120mg/m1 ampule IV or 30mg tablet (in high alert box ) Phenytoin 100mg/capsuleor 100 mg/ZmL ampule Plain LRS 1L/bottle Plain NSS 1L/bottle — 0.9% Sodium Chloride Potassium Chloride 40mEq/20mL vial (in high alert box ) Vitamin B1/6/12 vial (1g B1,1g B6, 0.01gB12 in 10 mL vial) Sodium bicarbonate 50mEq/50mL ampule Verapamil 5 rug/2 ml ampule EQUIPMENT/SUPPLIES Airway adjuncts Airway / Intubation Kit ( with stylet and bag valve masks ) Alcohol disinfectant Aseptic bulb syringe Calculator Capillary Blood Glucose (CBG ) Kit Cardiac Board Endotracheal Tubes, all sizes DOH—HOS—LTO-AT-L1-PIV Revision:01 E 04/23/2018 2 Page 13 of19

EMERGENCYCARTCONTENTS ER OR DR N81 N52 N83 NS4 NSS NS6 NS7 NS8 NS9 NS 10 NS 11 NS 12 REMARKS Flashlights or Pen lights Gloves, sterile Gloves, non-sterile Laryngoscope with different sizes ofblades Nasal cannula Protective face shield or mask or goggles Standard face mask Sterile gauze ( pre—foldedand individually packed ) Syringes (different volumes) Urethral catheter Urine collection bag Waterproof aprons *Notes: ER — Emergency Room OR — Operating Room DR — Delivery Room NS — Nurses’ Station DOH-HOS-LTO-AT—L1-PIV Revision:01 04/23/2018 Page 14 of 19

ASSESSMENT TOOL FOR LEVEL 1 HOSPITAL ATTACHMENT1.E — ADD-ON SERVICES CHECKLIST Level 1 hospitals applyingfor thefollowing add-on services must comply first with the licensing standards for thefollowing:

  1. Physical plant ofthe desired add-on service by securing an approved DOHPermit to Construct; and
  2. Licensing standards for the required ancillary and support units (e.g. tertiary clinical laboratory, Level 2 x-rayfacility, board certified specialists, and respiratory therapy unit). Thus, it is still strongly recommended to upgrade to a higher level ofhospital. A. INTENSIVE CARE UNIT (ICU) Multidisciplinary 7‘ I by Licensed physrcian i team Team composed of, . Fellow/Diplomate DOCUMENT REVIEW composed of but not limited to, 0 Diploma/Certificate at least 1 per board certified from Specialty society specialty Cardiologist, 0 Updated PRC license (May be part Pulmonologist, o Certificates of Trainings time or Neurologist, attended visiting Pulmonologist 0 Proof of Employment / consultant/s) 0_R an Intensivist Appointment (notarized) 1‘ an intensivist Nurse 0 Licensed nurse DOCUMENT REVIEW 1:3 beds at 0 Certificate of 0 Diploma any time per Training in Critical 0 Updated PRC license Shift (plus 1 Care Nursing, ACLS 0 Certificate of trainings reliever for attended every 3 RNS) 0 Proof of employment (notarized) 0 Ifnursing staffing is outsourced: Validity of the contract of employment should be at least one (1) year and within the validity period of the hospital’s LTD. 0 Schedule of duty approved by Chief Nurse Nursing Attendant o Highschool DOCUMENTS REVIEW graduate 0 Certificates of Trainings 1312 beds at 0 With relevant attended any time (plus health-related . Proof of Employment 1 reliever for training ( notarized ) every 3 (may be in house NA/MWs) training) DOH-HOS-LTO-AT-L1-PIV Revision:01 04/23/2018 Page 15 of 1 5

Air Conditioning Unit 1 Bag-valve-mask Unit

  • Adult 1
  • Pediatric 1 Cardiac Monitor with Pulse Oximeter 1 Defibrillator with paddles 1 EENT Diagnostic Set with 1 set ophthalmoscope and otoscope Emergency Cart (for contents, refer to 1 separate list). Infusion pump 1 Laryngoscope with different sizes of 1 blades Depending on Mechanical Bed the number of beds applied Mechanical Ventilator (May be 1 outsourced) Minor Instrument Set (May be used for Tracheostomy, Closed Tube 1 set Thoracostomy, Cutdown, etc.) Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Sphygmomanometer, Non-mercurial
  • Adult Cuff l
  • Pediatric Cuff 1 Stethoscope l Suction Apparatus 1 Thermometer, Non-mercurial l B. NEONATAL INTENSIVE CARE UNIT W1CU) Multidisciplinary 0 Licensed physician A team team composed of, o Fellow/Diplomate DOCUMENT REVIEW composed of but not limited to,
  • Diploma / Certificate at least 1 per pediatric from Specialty society specialty cardiologist,
  • Updated PRC license (May be part pediatric
  • Certificates ofTrainings time or nephrologist, attended visiting pediatric
  • Proof of Employment / consultant) pulmonologist% Appointment (notarized) O_R a a neonatologist neonatologii DOH-HOS-LTO-AT-L1-PIV Revision:01 04/23/2018 Page 16 of 19

7».>:"?'l‘3>.-,.lni 1;. 7 1:3 bassinets/ Nurse 0 Licensed nurse DOCUMENT REVIEW 0 Certificate of

  • Diploma incubator/ Training in Critical
  • Updated PRC license warmer Care Nursing, ACLS
  • Certificate of trainings (1 reliever for attended every 3 RNs)
  • Proofof employment (notarized)
  • If nursing staffing is outsourced: Validity of the contract of employment should be at least one (1) year and within the validity period of the hospital’s LTO.
  • Schedule of duty approved by Chief Nurse Nursing 0 Highschool DOCUMENTS REVIEW 1.12 Attendants/ graduate o Certificates ofTrainings b. .

. assmets/ M1dw1fe 0 With relevant attended incubator/ health-related 0 Proofof Employment warmer “'31;qu h ( notarized ) (1 reliever for 32331;? ouse every 3 NAs) Air Conditioning Unit ' ‘ 1 Bassinet 1 Bilirubin Light / Phototherapy machine or equivalent Cardiac Monitor with Pulse Oximeter 1 Clinical Infant Bag-valve mask unit 1 Clinical Infant weighing scale 1 Defibrillator with paddles l BENT Diagnostic Set with 1 ophthalmoscope and otoscope Emergency Cart (for contents, refer to 1 separate list) Glucometer 1 Depending on Incubator the number of beds applied Infusion pump 1 DOH-HOS-LTO-AT-L1-PIV Revision:01 04/23/2018 Page 17 of 19

Laryngoscope with neonatal blades of 1 different sizes Mechanical Ventilator (May be 1 outsourced) Neonatal Stethoscope 1 Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Refrigerator for Breast milk storage 1 Sphygmomanometer, Non-mercurial

  • Neonate 1 Suction Apparatus 1 Thermometer, Non-mercurial l Umbilical Cannulation set 1 set C. HIGH RISKPREGNANCY UNIT (HRPLD General 0 Licensed physician DOCUMENT Y General Obstetricians, o Fellow/Diplomate REVIEW Obstetricians, preferably with a o Diploma/Certificate Perinatologist, Perinatologist, and a from Specialty society and IM specialists referral team of IM 0 Updated PRC license (May be part time specialists . Certificates of or visiting Trainings attended consultant) 0 Proofof Employment/ Appointment (notarized) Nurse 0 Licensed nurse DOCUMENT REVIEW 1:3 beds at any n Certificate of o Diploma given time Training in Critical 0 UpdatedPRC license (plus 1 reliever Care Nursing, 0 Certificateof trainings for every 3 RNs) ACLS attended 0 Proofofemployment (notarized) 0 If nursingstaffing is outsourced: Validity of the contract of employment should be at least one (1) year and within the validity DOH-HOS-LTO-AT—L1-PIV Revlsion:01 04/23/2018 Page18 of19

period of the hospital’s LTO. 0 Schedule of duty (may be in house training) approvedby Chief Nurse Nursing Attendants/ o Highschool DOCUMENTS 1:12 beds at any MidWife graduate REVIEW given time 0 With relevant 0 Certificates of (P1115 1 reliever health-related Trainings attended for every 3 training 0 Proofof Employment NAS/MWS) ( notarized ) Cardiac Monitor with Pulse Oximeter 1 Cardiotocography (CTG) Machine 1 Fetal doppler 1 Oxygen Unit Tank is anchored/chained/ strapped or with tank 1 holder if not pipeline . . . . Refer to Patient bed With s1de ra11s approved PTC Sphygmomanometer, Non-mercurial l Suction Apparatus 1 D. AMBULATORYSURGICAL CLINICS (ASC) Refer to assessment toolfor ASCs E. DIALYSIS CLINICS Refer to assessment toolfor Dialysis Clinics DOH-HOS-LTO-A ; Revision:01 04/23/2018 Page190f19

PART IV - LEVEL 2 HOSPITAL Instruction: In the appropriate box, place a check mark (\I) if the hospital is compliant or X—mark if not compliant. ATTACHMENT2.A - PERSONNEL TOP MANAGEMENT (Should be full-time) Chief of I Licensed physician DOCUMENT REVIEW 1 Hospital/Medical 0 Have completed at o Diploma/Certificate of Director least twenty (20) units earned units towards a 0 Updated Physician PRC Master’s Degree in license Hospital 0 Certificates ofTrainings Administration or attended related course 0 Proof ofEmployment/ (MPH, MBA’ MFA, Appointment (notarized) MHSA, etc.)fl]; . SCI'VlCC at least five (5) Record/Certificate of years hospltal Employment (proof of experience in a hospital superv1soryor . . supervisory/managerial managerlal pos1tlon experience) Chief of Clinics / 0 Licensed physician DOCUMENT REVIEW 1 Chief Medical 0 Fellow/diplomate of o Diploma/Certificate Professional a specialty/ from Specialty society Services subspecialty society 0 Updated PRC license 0 At least five (5) _ . _ years hospital 0 Certificates ofTrainlngs experience in a attended clinical supervisory 0 Proof of Employment/ or managerial Appointment position (notarized) 0 Service Record/Certificate of Employment (proof of clinical supervisory/managerial experience in hospital) Department Head 0 Licensed physician DOCUMENT REVIEW 1 per (Specialty) o Fellow/ diplomate o Diploma/Certificate department in a specialty / . from Specialty society Subspeclalty soc1ety

  • Updated PRC license of the department _ . . he/ she heads 0 Certlficates of Traimngs attended 0 Proof of Employment/ Appointment (notarized) Chief Nurse/ 0 Licensed nurse DOCUMENT REVIEW 1 Director ofNursing 0 Master’s Degree in 0 Diploma Nursing m). at least five (5) years of clinical experience in a 0 Updated PRC license 0 Certificates of Trainings attended 0 Proof of Employment / DOH-HOS-LTO-AT-LZ-PIV Revision101 04/23/2018 Page 1 of 18

superv1soryor managerial position in nursing Appointment (notarized) 0 Service Record/Certificate of (RA. No. 9173) Employment (proof of supervisory/managerial experience in nursing) Chief Have completed at DOCUMENT REVIEW Administrative least twenty (20) Units 0 Diploma/Certificate 0f Officer/Hospital towards Master’s umts earned . Administrator Degree in Hospital . Updated PRC hcense Administration or o Certlficates of Trainings tt (1 d related course (MPH, a en e 0 Proof of Employment/ MBA? MPA’ MHSA’ Appointment (notarized) etc.) AND at least five . Service (5) years hospital Record/Certificate of experience in a Employment (proof of supervisory / hospital _ managerial position. SLIpCI’VlSOI'y/manager1a1 experience) ADMINISTRATIVE SERVICES A t t Certified Public DOCUMENT REVIEW CCOlll'l an Accountant (may be 0 Diploma/Certificate Of outsourced) units earned

, 0 Updated PRC license Billing Officer W1th Bachelor s (if applicable) Degree relevant to the . . . . o CertIficates of Trainings Book keeper 10b attended Budget / Finance 0 Proof of Employment/ Officer Appointment (notarized) Cashier Human Resources Management Officer / Personnel Officer Engineer (full Licensed Engineer DOCUMENT REVIEW time) o Diploma 0 Updated PRC license 0 Proof of Employment/ Appointment (notarized) Supply Officer/— With appropriate DOCUMENT REVIEW Storekeeper training and o Certificates ofTrainings experience attended Laundry Worker 0 Proof-of Employment/ Appomtment (notarized) Medical Records 0 Bachelor's Degree DOCUMENT REVIEW officer 0 Training in ICD 10 o Diploma 0 Training in Medical Records Management 0 Certificates ofTrainings attended 0 Proof of Employment/ Appointment DOH-HOS-LTO-AT—LZ-PIV Revision101 04/23/2018 Page 2 of 18

(notarized) Medical Social Licensed Social DOCUMENT REVIEW 1 worker (Full Time) Worker 0 Diploma / Certificate of units earned 0 Updated PRC license Nutritionist- Licensed Nutritionist- certificates0fTrainings 1 Dietician (Full Dietician attended Time) 0 Proof of Employment / Appointment (notarized) Building May be outsourced. DOCUMENT REVIEW 1 per shift Maintenance 0 Relevant Training Man/Utility Security guard must be 0 License, if applicable Worker licensed. 0 Proof of Employment/ Security Guard aifgfiggirii employed 1 per Shift (llcensed) by hospital 0 Notarized MOA if outsourced CLINICAL SERVICES Consultant Staff in 0 Licensed physician DOCUMENT REVIEW At least 50% of Ob-Gyn, o Fellow/Diplomate 0 Certificate from the consultants Pediatrics, 0 ACLS certified (for Specialty society, if per specialty Medicme, Surgery, Surgeons and applicable (for Board are board and Anesthesia Anesthesiologists) Certified) certified 0 Residency Training *Hosl’imlmay have Certificate (for Board additional Eligible) consultantsfrom . Certificate 0f Other Sfyecmmes' Residency Training / Intenswe Care 0 Licensed physician . . . A team . . Medical Spec1a11sts Unit: 0 Fellow/Dlplomate (*DOH Medical composed of at Multidisciplinary Specialist, last exam least‘ llper Team composed of, was in 1989) 8112;013th rt but not limited to, Updated PRC license iimZyor:i::ting board certified Certificates of Cardiologist, Trainings attended consultant/s) Pulmonologist, 0 Proof of Employment/ O_R an . Neurologist Appointment 1ntens1v1st ’. (notarized) Pulmonologlst PreferablyQ an intensivist Neonatal Intensive 0 Licensed physician A team Care Unit: 0 Fellow/Diplomate composed of at A multidisciplinary least'l per team composed of, spec1alty (May be part but not limited to, pediatric cardiologist, pediatric nephrologist, pediatric time or visiting consultant)Q a neonatologist Revision:01 04/23/2018 Page 3 of18

__ i s pulmonologist O Master’s Degree in Nursing 0 At least three (3) years-experience in supervisory/ managerial position in nursing Certificates of Trainings attended Proof of Employment/ Appointment (notarized) Service Record/Certificate of Employment (proof of supervisory/ managerial experience in nursing) a neonatologist DOCUMENT REVIEW High RiSk 0 Licensed physician . General Pregnancy Unit: 0 Fellow/Diplomate . Certrficate from . Obstetricians, General Specialty somety, 1f preferably with . . applicable (for Board a Obstetnc1ans, Certified) Perinatologist, preferably Wlth a 0 Residency Training and a referral Perinatologist, and Certificate (for Board team of IM a referral team of Eligible) specialists IM specialists ’ certificate0f (May be part Residency Training / time or visiting Medical Specialists consultant) (*DOH Medical Specialist, last exam was in 1989) Updated PRC license Certificates of Trainings attended 0 Proof ofEmployment/ Appointment (notarized) Resident Physician Licensed physician DOCUMENT REVIEW Wards - 1:20 on Duty (Shall not 0 Updated PRC license beds at any go on duty for . certificatesOf given time more than 48 hours Trainings attended PLUS straight). 0 Proof ofEmployment/ ER — at. least 1 Appointment at any given (notarized) time ° Schedule Of duty *This ratio does approved by Medical not include Director/Chief of Resident Hospital Physicians on Duty that shall be requiredfor add-on services such as dialysis facility. It shall be counted separately. NURSING SERVICES Assistant Chief o Licensed nurse DOCUMENT REVIEW 1:100 Beds Nurse . At least twenty (20) 0 Diploma/Certificate of units towards Umts Earned . Updated PRC license DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 4 of 18

QUALIFICATION PQ§1TION EVIDENCE

COMPLIED., REMARKS Supervising 0 Licensed nurse DOCUMENT REVIEW 1 per Nurse/Nurse 0 With at least nine I Diploma/Certificate of Department — Managers (9) units of Master's Units Earned Office hours Degree in Nursing Updated PRC license only (8am — 0 At least two (2) Certificates of 5pm) years-experience in Trainings attended general nursing 0 Proof of Employment/ service Appointment administration. (notarized) 0 Service Record/Certificate of Employment (Proof of general nursing service administration experience) Head Nurse/Senior 0 Licensed nurse DOCUMENT REVIEW 1 per shift per Nurse 0 With at least 2 clinical years-hospital ' Diploma department experience 0 Updated PRC license 0 BLS certified 0 Certificate of trainings Staff Nurse o Licensed nurse attended Ward - 1:12 o BLS certified ' PFOOf 0f employment beds at any (notarized) . time (1 reliever o If nursmg staffingis for every 3 outsourced: Validity of RNs) the contract of Staff Nurse in 0 Licensed nurse employment should be 1:3 beds at any every Critical Unit 0 Certificate of at 1635i one (1) year and time per shift (CCU, ICU, NICU, Training in Critical within the validity (plus 1 reliever PICU, SICU, Care Nursing, ACLS Eerrgd of the hospital’s per 3 CCU HRPU etc.) 0 Schedule of duty RNS) approved by Chief Nurse Nursing Attendants o Highschool DOCUMENTS REVIEW 1:24 beds at in wards graduate 0 Certificates ofTrainings any time(1 0 With relevant attended reliever for health-related 0 Proof of Employment every 3 NAs) training ( notarized ) Nursing Attendant (my. be in house 1: 12 beds at training) in CCUs any time (plus 1 reliever for every 3 NA/MWS) Operating Room 0 Licensed nurse DOCUMENT REVIEW 1 SN and 1 CN Nurses: 0 Training in OR per functioning -Scrub Nurse (SN) Nursing ' Diploma OR per shift -Circulating Nurse ' Training in BLS and ' Updated PRC “961356 (plus 1 reliever (CN) ACLS

  • Certificate of tramings for every 3 attended . 0 Proof of employment nurses) Delivery Room 0 Licensed nurse (notarized) 1 per 3 Nurse ' Training in o If nursing staffing is dellvery table Maternal and Child outsourced: Validity of per Shlft . Nursing (may be in the contract of (plus 1 reliever house training or for every 3 DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 5 of 18

rammg 1n ssen 1a Integrated Newborn Care [EINC]) 0 Training in BLS and ACLS emp oymen s on e at least one (1) year and within the validity period of the hospital’s LTO. nurses 0 Schedule of duty Emergency Room 0 Licensed nurse approved by Chief 1:3 beds per Nurse 0 Training in Trauma Nurse Shift ‘ Nursing, ACLS and (P1115 1 reliever other relevant for every 3 training nurses) Outpatient 0 Licensed nurse 1 Department Nurse 0 Training in BLS Office hours only (8am — 5pm) Dentist — MOA if Licensed dentist DOCUMENT REVIEW 1 outsourced but the o Diploma Office hours dental service . Updated PRC license only should be within . Certificates of (8am — 5pm) the vicinity 0f Trainings attended hospital 0 Proof of Employment/ Respiratory Licensed respiratory Appointment 1 per shift Therapist therapist or licensed (notarized) nurse with respiratory therapy training If outsourced: Validity of the contract of employment should be at least one (1) year and within the validity period of the hospital’s LTO. DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 6 of 18

ATTACHMENT2.B - PHYSICALPLANT 1. DéH -Ap’prav'éd fife 2. DOH Approved Floor Plan 3. Checklist for Review of Floor Plans (accomplished) OBSERVATIONS/FINDINGS (may use separate additional sheets if needed): DOH-HOS-LTO-AT-LZ-PIV Revision101 04/23/2018 Page 7 of18

ATTACHMENT2.C —EQUIPMENT/INSTRUMENT EQUIPMENT/IFSTRUMENT QUANTITY AREA COMPLIED REMARKS (Functional) ADMINISTRATIVE SERVICE Ambulance 0 Available 24/7 1 Parkin

  • Physically present if not being used g during time of inspection/monitoring . Administrative Computer w1th Internet Access 1 Office lobby, hallway, . nurses‘ station, Emergency nght office/unit and stairways lobby, hallway, . . . 1 per unit or nurses‘ station, Fire Extlnguishers area office/unit and Stairways Generator set with Automatic Transfer 1 Genset house Switch (ATS) KITCHEN/DIETARY Exhaust fan 1 Food Conveyor or equivalent (closed— 1 type) Food Scale 1 Blender/Osteorizer 1 Oven 1 Kitchen Stove 1 Refrigerator/Freezer 1 Utility cart 1 Garbage Receptacle with Cover (color- 1 for each coded) color EMERGENCYROOM 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, multigravid 2 sets ECG Machine with leads 1 BENT Diagnostic Set with 1 t Ophthalmoscope and Otoscope se Emergency Cart (for contents, refer to 1 separate list) DOH-HOS-LTO-AT-LZ-PIV Revision101 04/23/2018 Page 8 of 18

EQUIPMENT/INSTRUMENT (Functional) QUANTITY Examining table 1 Examining table (with Stirrups for OB- 1 Gyne) Glucometer with strips Gooseneck lamp/Examining Light 1 Instrument/Mayo Table 1 Minor Instrument Set (May be used for Tracheostomy, Closed Tube 2 sets Thoracostomy, Cutdown, etc.) Nebulizer 1 Negatoscope 1 Neurologic Hammer 1 OR Light (portable or equivalent) 1 Oxygen Unit Tank is anchored/chained/ strapped or 2 with tank holder if not pipeline Pulse Oximeter 1 Sphygmomanometer, Non-mercurial l

  • Adult Cuff 1 — Pediatric Cuff 1 Stethoscope 1 Suction Apparatus 1 Suturing Set 2 sets Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 Vaginal Speculum Different Sizes 1 for caCh ’ different size Wheelchair l Wheeled Stretcher with guard/side rails 1 and wheel lock or anchor. AREA ER COMPLIED REMARKS OUT- PATIENTDEPARTMENT Clinical Height and Weight Scale 1 EENT Diagnostic Set with 1 set ophthalmoscope and otoscope Gooseneck lamp/Examining Light 1 Examining table with wheel lock or 1 anchor Instrument/Mayo Table 1 Minor Instrument Set 1 set Neurologic Hammer 1 OPD DOH-HOS-LTO-AT-LZ-PIV Revisionzo1 04/23/2018 Page 9 of l 8

EQUIPMENT/INSTRUMENT . QUANTITY AREA COMPLIED REMARKS (Functional) Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Peak flow meter

  • Adult 1 — Pediatric l OPD Sphygmomanometer, Non-mercurial — Adult cuff 1
  • Pediatric cuff 1 Stethoscope 1 Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 Suture Removal Set 1 set Wheelchair / Wheeled Stretcher l OPERATINGROOM Air conditioning Unit 1 Anesthesia Machine 1 Cardiac Monitor with Pulse Oximeter l Ceasarian Section Instrument l Defibrillator with paddles 1 Electrocautery machine 1 Emergency Cart (for contents, refer to 1 separate list) Glucometer with strips Instrument / Mayo Table l 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 Oxygen Unit Tank is anchored/chained/ strapped or 1 per OR OR with tank holder ifnot pipeline Rechargeable Emergency Light (in case 1 per OR generator malfunction) Sphygmomanometer, Non-mercurial
  • Adult cuff 1 per OR
  • Pediatric cuff 1 per OR Spinal Set 1 set Stethoscope 1 Suction Apparatus 1 Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 Wheeled Stretcher with guard/side rails and wheel lock or anchor. 1 DOH-HOS-LTO-AT—LZ—PIV Revision:01 04/23/2018 Page 10 of 18

EQUIPMENT/INSTRUMENT QUANTITY AREA COMPLIED REMARKS (Functional) POST ANESTHESIA CARE UNIT / RECOVERYROOM Air conditioning Unit 1 Cardiac Monitor 1 1 (ifseparate Defibrlllator With paddles from the OR PACU/RR Complex ) 1 (ifseparate imiregfenlciztfart (for contents, refer to from the OR p Complex ) Mechanical / patient bed, with guard side 1 rails and wheel lock or anchored Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Sphygmomanometer, Non-mercurial PACU/RR

  • Adult cuff 1
  • Pediatric cuff 1 Stethoscope 1 Thermometer, non-mercurial 1 LABORROOM Fetal Doppler 1 Oxygen Unit Tank is anchored/chained/ strapped 0r 1 with tank holder if not pipeline Patient Bed 1 Labor Room Pulse Oximeter 1 Sphygmomanometer, Non-mercurial 1 Stethoscope 1 Thermometer, Non—mercurial 1 DELIVERYROOM Air-conditioning Unit 1 Bag valve mask unit (Adult and 1 pediatric) Bassinet 1 Clinical Infant Weighing Scale 1 1 ( ifDR is . . separate from DR Defibrillator With paddles the OR Complex ) Delivery set, primigravid 1 set Delivery set, multigravid 2 sets Delivery room light 1 Delivery room table 1 Dilatation/Curettage set 1 set 1 Emergency Cart (for contents, refer to (ifDR is separate list). separate from OR Complex) DOH-HOS-LTO-AT—LZ—PIV Revisionzo1 04/23/2018 Page 1 1 of 1 8

EQUIPMENT/INSTRUMENT AREA DR COMPLIED REMARKS HIGH RISK PREGNANCY UNIT (Functional) QUANTITY Instrument/Mayo Table 1 Kelly Pad or equivalent 1 Laryngoscope with different sizes of 1 blades Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder ifnot pipeline Rechargeable Emergency Light (In case 1 of generator malfunctions) Sphygmomanometer -Non-mercurial 1 Stethoscope 1 Suction Apparatus 1 Wheeled Stretcher 1 Cardiac Monitor with Pulse Oximeter 1 Cardiotocography (CTG) Machine 1 Fetal doppler 1 Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder ifnot pipeline Patient bed with side rails 1 Suction Apparatus 1 Sphygmomanometer -Non—mercurial 1 HRPU NEONATAL INTENSIVE CARE UNIT (NICU) Air conditioning unit 1 Bassinet 1 Bilirubin Light / Phototherapy machine 1 or equivalent Cardiac Monitor with Pulse Oximeter 1 Clinical Infant Bag—valvemask unit 1 Clinical Infant weighing scale 1 Defibrillator with paddles 1 EENT Diagnostic Set with ophthalmoscope and otoscope 1 set Emergency Cart (for contents, refer to 1 separate list) Glucometer 1 Incubator 1 Infusion pump / Syringe pump 1 Laryngoscope with neonatal blades of 1 different sizes Mechanical Ventilator (May be 1 outsourced) Neonatal Stethoscope 1 Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder ifnot pipeline Refrigerator for Breast milk storage 1 NICU DOH-HOS-LTO-AT-LZ—PIV Revision:01 O4l23I2018 Page 12 of18

EQUIPMENT/INSTRUMENT . QUANTITY . AREA COMPLIED REMARKS (Functional) Sphygmomanometer, Non-mercurial 1

for neonate Suction apparatus 1 Thermometer, Non-mercurial 1 Umbilical Cannulation set 1 set INTENSIVE CARE UNIT (ICU) — For all types of ICU (PICU, SICU, Medical ICU, etc.) Air conditioning unit 1 Bag-valve-mask Unit

  • Adult 1
  • Pediatric 1 Cardiac Monitor with Pulse Oximeter 1 Defibrillator with paddles 1 Emergency Cart (for contents, refer to 1 separate list) EENT Diagnostic Set with 1 set ophthalmoscope and otoscope Infusion pump 1 Laryngoscope with different sizes of 1 blades Depending on Mechanical Bed the number of beds declared ICU Mechanical Ventilator / Respirator (May 1 be outsourced) Minor Instrument Set (May be used for Tracheostomy, Closed Tube 1 set Thoracostomy, Cutdown, etc.) Oxygen Unit Tank is anchored/chained/ strapped or 1 with tank holder if not pipeline Sphygmomanometer, non—mercurial (reserved for sudden breakdown of cardiac monitor)
  • Adult cuff for adult unit 1
  • Pediatric cuff for pediatric unit 1 Stethoscope 1 Suction Apparatus 1 NURSING UNIT/WARD Bag—Valve-Mask Unit — Adult 1
  • Pediatric 1 Clinical Height and Weight Scale 1 Nursing units located on the same floor may share Defibrillator with paddles 1 NURSING zgzdgffgggaofhg‘zhtf; Ere UNIT/ WARD not more than 50 meters away from each other. Emergency cart or equivalent (refer to 1 separate list for the contents) EENT Diagnostic Set with 1 set ophthalmoscope and otoscope Laryngoscope with different sizes of 1 blades DOH-HOS-LTO-AT-LZ-PIV Revision201 04/23/2018 Page 13 of 18

EQUIPMENT/INSTRUMENT . QUANTITY AREA COMPLIED REMARKS (Functional) Mechanical/Patient bed with look, if ABC wheeled; with guard or side rails Bedside Table ABC Nebulizer 1 Neurologic Hammer 1 Oxygen Unit 1 tank is anchored/chained if not pipeline Sphygmomanometer, Non— Mercurial

  • Adult cuff 1
  • Pediatric cuff 1 Stethoscope 1 Suction Apparatus l Thermometer, non-mercurial
  • Oral 1
  • Rectal 1 RESPIRATORY/PULMONARYUNIT ABG Machine 1 Pulmonary Function Test (PFT) or Peak Expiratory Flow Rate (PEFR) Tube Respiratory / Spirometer 1 Pulmonary Unit Nebulizer 1 DENTAL CLINIC Air compressor Autoclave Bone file, stainless Cotton pliers Cowhom Forceps Dental Chair unit Explorer, double-end Forceps, No. 8 Forceps, No. 17 Upper molar Forceps, No. 18 Upper molar Forceps, No. 150 Maxillary Universal Forceps, No. 150 S Primary Teeth DENTAL Forceps, No. 151 Lower Universal CLINIC Forceps, No. 151 Mandibular Pre-molar Forceps, No. 151 S Lower Primary Teeth Gum separator High speed handpiece with Burr remover Low speed handpiece, Angled head Mouth mirror explorer Periosteal elevator No. 9, double-end Rongeur Root elevator Scaler Jacquettes Set No. 1, 2, and 3 Surgical Chisel H—Ij—lj—lp—‘Hfl—IHHHj—Iflp—‘Hp—Ip—IHp—ly—lp—IHflp—I DOH-HOS-LTO-AT-LZ-PIV Revisionzo1 04/23/2016 Page 14 of 18

EQUIPMENT/INSTRUMENT (Functional) ' QUANTITY Surgical Malette 1 AREA COMPLIED REMARKS CENTRAL STERILIZING & SUPPLY ROOM Autoclave/Steam Sterilizer 1 CSSR CADAVER HOLDINGAREA/ROOM Bed or stretcher for cadaver l CADAVER HOLDING AREA DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 15 of 18

ATTACHMENT 2.D - EMERGENCY CART CONTENTS FOR LEVEL 2 HOSPITAL EMERGENCY CART CONTENTS ER 0R DR ICU HRPU s1 N32 N83 N84 N55 N86 N87 Adenosine 6 vial Amiodarone 1 mL e Anti-tetanusserum (either equine-based antiserumor human antiserum ' USP 325 let 1 ml e 'c ' i.e. Salbutamol2 ml Benzodiazipine(Diazepam 10mg/2ml ampule and/or Midazolam in hi alert box Calcium(usuallycalciumgluconate 10% solution in 10 mL e Cl ' 75 tablet D5W 250 mL DSOW vial Di xin 0.5 ule Di ' mL Dobutamine2 5mL e 200 5mL e/vial 1 ml e Furosemide 2 ml ule Hal ' 1 mL e H ' vial Lidocaine 10% in 50mL Lidocaine2% solution vial l 50ml sulfate 1 e Mannitol 20% solution in 500ml/bottle Meth ' lone 4 et Metocl 'de 1 mL 6 M hine sulfate 1 mL 6 in hi DOH-HOS-LTO-AT-LZ-PIV Revisionzo1 04/23/2018 Page 16 of 18

EMERGENCY CART CONTENTS ER 0R DR ICU NICU HRPU N81 N82 NS3 NS4 NSS N86 N87 orrmzxs mums REMARKS alert box ) Nitroglycerininj. 10 mg/10mL ampule or Isosorbidedinitrate 5mg SL tablet or 10 mg/l OmL ampule Noradrenaline2mg/2mLampule Paracetamol300mg/ampule(IV preparation) Phenobarbital 120mg/ml ampule IV or 30mg tablet (in high alert box ) Phenytoin lOOmg/capsule or 100 mg/2mL ampule Plain LRS lL/bottle Plain NSS lL/bottle — 0.9% Sodium Chloride Potassium Chloride40mEq/20mLvial (in high alert box ) Vitamin Bl/6/12 vial (1g B1,1g B6, 001an in 10 mL vial) Sodiumbicarbonate50mEq/50mLampule Verapamil 5 mg/2 ml ampule EQUIPMENT misurrmas

Airway adjuncts Airway/ IntubationKit ( with stylet and bag valve masks ) Alcohol disinfectant Aseptic bulb syringe Calculator CapillaryBlood Glucose(CBG ) Kit Cardiac Board EndotrachealTubes, all sizes Flashlights or Pen lights Gloves , sterile Gloves, non—sterile DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 17 of 18

EMERGENCY CART CONTENTS OTHERS arms REMARKS Laryngoscopewith different sizes ofblades Nasal cannula Protectiveface shield or mask or goggles Standardface mask Sterilegauze (pre-foldedand individually packed ) Syringes (different volumes) Urethral catheter Urine collectionbag Waterproofaprons *Notes: ER — Emergency Room OR — OperatingRoom DR — Delivery Room NS — Nurses’ Station DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 18 of 18

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