Vian Family Hospital - Ugong

SUMMARY OF FINDINGS
INFIRMARY
VIAN FAMILY HOSPITAL
4048 Que Grande St., Ugong, Valenzuela City
Date of Monitoring: April 24, 2018 FULL COMPLIANCE DATE: _____________________
Date Prepared: August 15, 2018
Violation: Inadequate personnel complement in the nursing service.
To submit proofs of compliance to the following:
I. Patient Care
 Present copy of coordinated plan of care with goals (CPGs)
 Copy of all PRC ID of medical personnel
 Copy of discharge plan
II. Leadership and Management

 Photo of updated organizational chart including all personnel
 Submit copy of the following:
- Credentialing & privileging – committees and minutes of the meeting
- Waste management - committees and minutes of the meeting
- Patient safety - committees and minutes of the meeting
- Infection control - committees and minutes of the meeting
- Emergency and disaster preparedness - committees and minutes of the meeting
- Continuous quality improvement – committees, policy and minutes of the meeting
- Grievance - committees, policy and minutes of the meeting
- Selection and promotions - committees, policy and minutes of the meeting
- Copy of hospital accomplishment report - committees, policy and minutes of the meeting
 Copy of annual hospital accomplishment report
 Copy of policy including monthly menu for patients
 Policy for disinfecting soiled linens
 Copy of memorandum of agreement for security guard
 Policy for housekeeping
 MOA for waste management service
 MOA for transport vehicle / Memorandum of agreement with a DOH licensed ambulance service provider
III. Human resource management

 Annual plan on training activities
 Proof of orientation conducted for newly hired personnel
IV. Information Management

 Present own compilation of annual stat report
 Policy for proper disposal of records
 Copy of logbook for borrowing and retrieval of chart
V. Safe practice and environment

 Proof of implementation of preventive maintenance of equipment
 Copy of logbook for sentinel event
 Certificate of training of service personnel for maintenance of equipment or certification from the provider
 To present user’s manual of equipment
 Proof of designation of doctor & nurse for infection control
 Policy on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies
 Policy in reporting notifiable diseases
 MOA with management service
 Continuous quality improvement program (policy)
 Copy of sample survey results and photo of suggestion box with lock
 Proof of better patient outcome as a result of CQI activities
 Proof of certification for mother baby friendly hospital or letter of intent for accreditation received by the
program managers from DOH-Mother baby friendly
 Hospital order for the designation of hems coordinator
 Proof of conduct of drill exercises
 Policy for emergency preparedness, response and recovery plan
 Policy for newborn who were tested for hearing and logbook for referral of newborn for screening on hearing
 Logbook for FP acceptors
 Logbook for TB referral
VI. Personnel
Submit the following:
- Medical director – PRC license, training certificate and proof of employment/appointment
- Administrative Officer/Personnel officer – bachelor’s degree
- Accountant or accountant clerk – diploma(accountant), trainings attended, proof of employment
- Medical records – bachelor’s degree, training in ICD 10 and medical records management, proof of
employment
- Billing/cashier – certificate of training, proof of employment
- Clerk - certificate of training, proof of employment
- Supply officer - certificate of training, proof of employment
- Building maintenance or utility worker - n certificate of training, proof of employment
- Laundry worker - proof of employment
- Driver – professional driver’s license, proof of employment
- Cook - proof of employment
- Security guard - proof of employment
- Physicians – diploma, PRC license, certificate of training, proof of employment
- Nurses – all nurses – diploma, PRC ID, proof of employment, atleast 1 nurse with 9 units of masters degree
in nursing and training in ACLS
- TO HIRE ADDITIONAL 4 REGULAR NURSES AND 3 RELIEVERS
PHYSICAL PLANT REQUIREMENT

 Provision of PWD toilet
 To utilize pantry – submit photo as proof
 Provision of cadaver holding area
Recommendation: Re-Plan delivery service facility. Required to upgrade delivery room, to apply permit to construct
from DOH-NCRO before proceeding with its construction
EQUIPMENT/INSTRUMENT
Submit photo and official receipt of the following:
ADMINISTRATIVE SERVICE
 Memorandum of agreement with a DOH licensed ambulance service provider
 Emergency light
KITCHEN
 Exhaust Fan
 Food conveyor or equivalent
 Food scale
 Stove
 Refrigerator
 Utility cart
 Garbage receptacle with cover color coded
EMERGENCY ROOM
 Defibrillator
 Emergency cart
 Wheeled stretcher with guard/side rails and wheel lock or anchor
EMERGENCY ROOM
 Skin retractor
DELIVERY ROOM
 RECHARGEABLE EMERGENCY LIGHT
NURSING UNIT/WARD
 Patient bed with guard rails
CADAVER HOLDING AREA

 Bed stretcher for cadaver
EMERGENCY CART CONTENTS

 D50W 50mg/vial
 Amiodarone 150mg/ampule
 Anti-rabies vaccine (passive)
 Aspirin USP grade (325mg/tablet)
 Calcium gluconate 10mg/ampule
 Digoxin 0.5mg/ampule
 Diphenhydramine 50mg/ampule
 Dopamine 20mg/vial
 Haloperidol 50mg/ampule
 Hyoscine N-butyl-bromide 20mg/vial
 Magnesium sulphate 1g/ampule
 Methylprednisolone 4mg/tablet
 Metoclopramide 10mg/ampule
 Noradrenaline 2mg/ampule
 Phenobarbital 30mg/ml or 30mg tablet
 Potassium chloride 40mEq/vial
 Pyridoxine 1g/ampule
 Sodium bicarbonate 50mEq/ampule
 Verapamil 5mg/2ml ampule
 Biomedical refrigerator
 Cardiac board
 Elastic bandages in different sizes
BASIC ER SUPPLIES
 Gloves
 Hydrogen peroxide
 Nasal canula
 Povidone iodine
 Face mask
 PFT
 Spine board with straps
 Splinting devices
 Protective face shield
 Syringes
 Urethral catheter
 Urine collection bag
 Waterproof aprons
 X-ray reading lamp or negatoscope
Monitored by: Signature
1. Dr. Alberto Ponce Belarmino MO III ________________________

2. Arch. Oliver Santos LO III ________________________
3. Ruby Anne Ruiz, RPh LO III ________________________
4. Carol Anne Casihan, RN ADAS III ________________________
Renewal Period: October to December 15 only

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SUMMARY OF FINDINGS

Date of Monitoring: April 24, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 15, 2018

Violation: Inadequate personnel complement in the nursing service.

To submit proofs of compliance to the following:

II. Leadership and Management

III. Human resource management

IV. Information Management

V. Safe practice and environment

PHYSICAL PLANT REQUIREMENT

CADAVER HOLDING AREA

EMERGENCY CART CONTENTS

Monitored by: Signature

1. Dr. Alberto Ponce Belarmino MO III ________________________

Renewal Period: October to December 15 only

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