A.O. No.

2020- 0047
ANNEX A

Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
LICENSING STANDARDS FOR PRIMARY CARE FACILITIES

PERSONNEL

There shall be an adequate number of

qualified, trained and competent staff to ensure
efficient and effective delivery of quality primary care services.

A. Every PCF shall have a duly licensed physician, as head of the facility, to oversee
the clinical and administrative operations of the health facility.
B. For rural health units and urban health centers, the head of the facility shall also
oversee the clinical and administrative operations of barangay health stations
within their jurisdiction.
C. The minimum staffing standards such as staff composition and number/ratio
shall be set by DOH. Adjustments in the staffing pattern shall depend on the
workload and services being provided, using applicable workload assessment
tools.
D. The staff must be competent and shall have the appropriate learning and
development interventions and certification prescribed by DOH
worker.
asa primary care

E. There shall be staff development and continuing education program at all levels
of organization to upgrade the knowledge, attitude and skills of staff.

II. PHYSICAL FACILITIES.

Every PCF shall have physical facilities with adequate and appropriate areas to safely,
effectively, and efficiently provide health services to patients. As such, it shall:

A. Conform to applicable national and local regulations for the construction,

renovation, maintenance and repair of the same.
B. Conform to the required space for the conduct of its
activities depending on
workload and the services being provided, as stated in the Checklist for Review
its

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of Floor Plans for Primary Care Facility (ANNEX C).
C. Have an approved DOH Permit to Construct (DOH-PTC) in
accordance with the
planning and design guidelines prepared by DOH (ANNEX C).

Ill. EQUIPMENT AND INSTRUMENTS

Every PCF shall have available and operational equipment, instruments, materials and
supplies consistent with the services it will provide. As such, it
shall:

A. Adequately equipped based on the primary care services it

provides.
B. Have an updated inventory, program for calibration, preventive maintenance and

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repair of equipment.
C. Have a contingency plan in case of equipment breakdown and matron,

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IV. SERVICE DELIVERY

Every PCF shall ensure that the services being delivered to patients comply with the
standards in the Assessment Tool for Licensing of PCF (ANNEX B) and other related
relevant issuances.

A. Primary care services, both individual- and population-based, shall be defined

and set into guidelines by DOH and PhilHealth.
B. All government PCFs shall provide both individual-based and population-
based primary care services.
C. All private PCFs shall provide individual-based primary care services.
D. Ancillary services of PCF include the following:
1. Clinical laboratory
2. Diagnostic radiologic services
3. Pharmacy
4. Birthing services
5. Dental services
6. Ambulance service (Type 1)
E. Ancillary services may be outsourced and located outside the premises of PCF,
through a valid Memorandum of Agreement with DOH or FDA-licensed health
facilities or services within the primary care provider network.
F. Clinical laboratory services, either provided within the PCF or outsourced from
one or more DOH-licensed clinical laboratories, shall include the following:
Complete blood count with platelet count
WN
Urinalysis
Fecalysis
Fecal occult blood test
Lipid profile (total cholesterol, HDL, LDL, triglycerides)
Fasting blood sugar
RPNAYMAS

Oral glucose tolerance test

Pap smear
CO Creatinine
10. Blood
typing
11. Screening for hepatitis B, syphilis, and HIV
12. Sputum microscopy or Nucleic acid amplification test
13. Dengue rapid test
G. In DOH-identified endemic areas, additional appropriate diagnostic test/s shall
be provided, either within the PCF or outsourced from one or more DOH-
licensed clinical laboratories (example: Kato Katz Schistosomiasis, Malaria
smear, Filaria smear, slit-skin smear, and rapid plasma reagin for Syphilis).
H. Every PCF shall have documented administrative Standard Operating
Procedures (SOP) for the provision of its services.
I. Every PCF shall have documented technical policies and procedures for
individual-based and/or population-based primary care services, based on
policies, guidelines, and Manual of Procedures issued by DOH and PhilHealth.
J. Every PCF shall have documented policies and .procedures on the
establishment and/orits participation in the primary care provider network.

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K. PCFs that provide primary care services through digital technologies for health
and mobile health services, shall adhere to the existing or

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 telemedicine guidelines issued by DOH Knowledge Management and
Information Technology Service (KMITS).

V. QUALITY IMPROVEMENT (QI) ACTIVITIES

Every PCF shall establish and maintain a system for continuous quality improvement
activities.

A. Each shall have policies and procedures on Quality Assurance Program

PCF

(QAP) and continuous quality improvement.

B. The Quality Assurance Program shall have a written plan and its
implementation shall be continuous with period reviews.

VI. INFORMATION MANAGEMENT

Every PCF shall maintain a system of communication, recording and reporting and
releasing of patient’s results, in adherence to Republic Act (RA) No. 10173 also known
as the “Data Privacy Act of 2012” and RA No. 11332 also known as the “Mandatory
Reporting of Notifiable Diseases and Health Events of Public Health Concern Act.”

A. Medical Records
B. Validated Electronic Medical Records (EMR)
C. Proof of submission of data to National Database of Human Resources for Health
Information System (NDHRHIS)
D. Technical records/logbooks of:
1. Sentinel/adverse events
2. Navigation, coordination and referrals of patients through the Primary Care
Provider Network and Health Care Provider Network
E. Administrative records of:
Minutes of the Meeting
WN
Attendance logbook
201 Personnel Staff files
Reports of DOH inspection and monitoring activities
ANP
Preventive and corrective maintenance of equipment
. Maintenance and monitoring of health facility
F. Records Management
1. There shall be documented policies and procedures on access to and
confidentiality of patient’s information. Likewise, the right of the patient to

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obtain records of treatment and other relevant medical information shall be
observed.
2. Retention and disposal of medical records and other relevant information
whether paper-based or electronic media shall be in accordance with the
standards promulgated by DOH or by competent authorities for such

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Vil. ENVIRONMENTAL MANAGEMENT

PCF shall ensure that the environment is safe for its patients and staff, including the
general public.

A. There shall be a program of proper maintenance and monitoring of physical

facilities.
B. There shall be procedures for the proper disposal of infectious wastes and toxic
and hazardous substances in accordance with RA 6969, also known as “Toxic
and Hazardous Substances and Nuclear Wastes Act’ and other related policy
guidelines and/or issuances.
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There shall be a “No smoking policy” and that the same shall be strictly enforced.

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There shall be a contingency plan in case of accidents and emergencies.

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