Part I Evidence Needed Remarks
to include mandatory services for level 1
List of services with indicated
3 hospitals eg, surgery, pharmacy, secondary
time of availability
clinical laboratory, blood station
4 Contents of patient's charts to submit copy of advance directive form
Proof of monitoring of
implementation of the policies to submit copy of calibration report of X-ray
9
and procedures on quality machines expired validity-NOV 17, 2023
control of diagnostic
examinations
to include pertinent DOH issuances relative to
14 Committees
blood services
to include specific time for infectious wastes
and sharps collection from the different areas
to Central Waste Storage
for revision of policy on buying of medicines
by relatives from outside pharmacy
to enhance evacuation plan procedures and
policies-order and prioritization on evacuation
of patients, IC in the absence of TOP
management; staff in-charge for oxygen tank
and other supplies; identification of the
specific evacuation area
22 Logbooks on record storage, to submit picture of logbook
retention and disposal
to submit copy of Occupational Health and
Safety Program for employees
Occupational Health and Safety Immunization
30
Program for employees
Occupational Health and Safety
30
Program for employees Pre-employment Health Assessment and
Annual Physical Exam
Mental Health
Occupational Health Training/Seminar
Proof of implementation of to submit copy of MOA with a NB Hearing
38
Newborn Hearing Screening provider
MBFHI Certificates:
39 MBF Hospital to submit status update and notarized MOU
MBF Workplace
47 Policies and procedures on to submit policies
handling cases of patients for
discharge but with unpaid
hospital bills are aligned with
the provisions in R.A. No. 9439.
Logbooks showing proof of Logbooks showing proof of submission of
50 submission of accomplished accomplished birth and death certificates to
birth and death certificates to local civil registry
local civil registry
Responsible Person Status
Admin
Medical/Nursing for Legal
Radio
Engineering
Blood Transfusion
Healthcare Waste
Management-
Pharmacologic and
Therapeutic-
Emergency and Disaster
Preparedness-
Medical Records
IPCC
Admin
Psychologist
Engineering
Nursing/Mam Jam MOA for legal
MOU signed by Dr.
Silva; for review and
signing of Dra Julie;
Dra. Poti
Status update c/o Dra
Poti
Admin
Medical Records
PART II
HOSPITAL NURSING SERVIC
COMPLIANT
HOSPITAL PH
CRITERIA EVIDENCE
DOCUMENT REVIEW/ INTERVIEW
B. Linen/ Laundry Check policies and procedures on how
soiled linens are collected disinfected and
washed.
Ask about the frequency of the following:
10.Presence of a management
Fire drill conducted in the past 12 months
plan, policies and procedures
Earthquake drill conducted in the past 12
addressing safety
months
DOCUMENT REVIEW Check result of
14.Generator, emergency light,
water analysis for the last 6 months.
water system, adequate
Preventive and corrective maintenance
ventilation or air conditioning
logbooks
DOCUMENT REVIEW
16.Training of the staff who is
For in-house: Certificate of training of
in charge of the maintenance of
service personnel or Certificate of training
the equipment
For outsourced service: MOA/Contract
DOCUMENT REVIEW
18.Licenses/permits/ clearances Valid licenses/permits from regulatory
from pertinent regulatory agencies (LGU, DENR, etc.)
agencies Proof of compliance i.e., generator
permit, elevator permit, etc
PART III
HOSPITAL PHYSICAL PLANT
REMARKS Person Responsible STATUS
To include systematic washing and
Engineering
disinfection of laundry
Submit latest Fire and Earthquake
Engineering
Drill Certificate
To submit latest water analysis
result
n-house - Christian Bobis
DENR
x ECC
x Discharge Permit
x Permit to Operate
BFP
x FSIC
to submit progress report
PART IV - LEVEL 1 HOSPITAL
ATTACHMENT 1.A - PERSONNEL
POSITION
Chief Nurse /Director of Nursing
Chief Administrative
Officer/Hospital Administrator
Supply Officer/ Storekeeper
Medical Records officer
Consultant Staff in Ob-Gyn,
Pediatrics, Medicine, Surgery, and
Anesthesia. *Hospital may have
additional consultants from other
specialties.
REMARKS STATUS
submit proof of at least five (5) years of clinical
experience in a supervisory or managerial position in
nursing (R.A. No. 9173) for submission
Ongoing Masterals in Management at Phil Christian
University OR at least five (5) years hospital
experience in a supervisory/ managerial position.
submit certificates of trainings
submit training certificates in Medical Records
management
DR MARIA PATRICIA BENEDICTOR-ANTONIO
(MS)- submit specialty board certficate
DR DIANNE DELA CRUZ(MO)- submit PRC ID,
appointment
R CARLA DENISSE CRISTOBAL-BACIAS (MO)-
submit specialty board certificate
DR PAULA DEL FIN (MS) - submit PRC ID,
appointment, specialty board certificate
DR MARIA GLENDA ZILMAR PT (MS)- submit
specialty board certificate, ACLS
DR REAGAN SANGALANG (MS) FP- submit
specialty board certificate, ACLS
DR JEMBURT TAN (MO)- submit ACLS
DR JOANNA LYN ALEJANDRO (MS) PT- submit
ACLS
