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PART IV - LEVEL 2 HOSPITALInstruction: In the appropriate box, place a check mark ( ) if the hospital is compliant or X-mark if not compliant.ATTACHMENT 2.A - PERSONNELPOSITIONQUALIFICATIONEVIDENCENUMBER /RATIOCOMPLIEDREMARKSTOP MANAGEMENT (Should be full-time)Chief ofHospital/MedicalDirector Licensed physician Have completed atleast twenty (20)units towards aMaster’s Degree inHospitalAdministration orrelated course(MPH, MBA, MPA,MHSA, etc.) ANDat least five (5)years hospitalexperience in asupervisory ormanagerial positionChief of Clinics /Chief MedicalProfessionalServices Licensed physician Fellow/diplomate ofa specialty/subspecialty society At least five (5)years hospitalexperience in aclinical supervisoryor managerialpositionDepartment Head(Specialty) Licensed physician Fellow / diplomatein a specialty /Subspecialty societyof the departmenthe/ she headsChief Nurse/Director of Nursing Licensed nurse Master’s Degree inNursing AND atleast five (5) yearsof clinicalexperience in aDOCUMENT REVIEW Diploma/Certificate ofunits earned Updated Physician PRClicense Certificates of Trainingsattended Proof of Employment/Appointment (notarized) ServiceRecord/Certificate ofEmployment (proof T REVIEW Diploma/Certificatefrom Specialty society Updated PRC license Certificates of Trainingsattended Proof of Employment /Appointment(notarized) ServiceRecord/Certificate ofEmployment (proof ofclinicalsupervisory/managerialexperience in hospital)1DOCUMENT REVIEW Diploma/Certificatefrom Specialty society Updated PRC license Certificates of Trainingsattended Proof of Employment /Appointment(notarized)DOCUMENT REVIEW Diploma Updated PRC license Certificates of Trainingsattended Proof of Employment /1 23/2018Page 1 of 18Page 1 of 1
tratorQUALIFICATIONEVIDENCEsupervisory ormanagerial positionin nursing(R.A. No. 9173)Appointment (notarized) ServiceRecord/Certificate ofEmployment (proof ofsupervisory/managerialexperience in nursing)DOCUMENT REVIEW Diploma/Certificate ofunits earned Updated PRC license Certificates of Trainingsattended Proof of Employment /Appointment (notarized) ServiceRecord/Certificate ofEmployment (proof ofhospitalsupervisory/managerialexperience)Have completed atleast twenty (20) Unitstowards Master’sDegree in HospitalAdministration orrelated course (MPH,MBA, MPA, MHSA,etc.) AND at least five(5) years hospitalexperience in asupervisory /managerial position.NUMBER /RATIOCOMPLIEDREMARKS1ADMINISTRATIVE SERVICESAccountantBilling OfficerBook keeperCertified PublicAccountant (may beoutsourced)With Bachelor’sDegree relevant to thejobBudget / FinanceOfficerDOCUMENT REVIEW Diploma/Certificate ofunits earned Updated PRC license(if applicable) Certificates of Trainingsattended Proof of Employment/Appointment (notarized)1111Cashier1Human ResourcesManagementOfficer / PersonnelOfficerEngineer (fulltime)1Supply Officer/StorekeeperLicensed EngineerWith appropriatetraining andexperienceLaundry WorkerMedical Recordsofficer Bachelor's Degree Training in ICD 10 Training in MedicalRecordsManagementDOCUMENT REVIEW Diploma Updated PRC license Proof of Employment /Appointment(notarized)DOCUMENT REVIEW Certificates of Trainingsattended Proof of Employment /Appointment(notarized)DOCUMENT REVIEW Diploma Certificates of Trainingsattended Proof of Employment /23/2018Page 2 of 18Page 1 of 1
POSITIONQUALIFICATIONMedical Socialworker (Full Time)Licensed SocialWorkerNutritionistDietician (FullTime)Licensed yWorkerSecurity Guard(licensed)May be outsourced.Security guard must belicensed.EVIDENCE(notarized)DOCUMENT REVIEW Diploma / Certificate ofunits earned Updated PRC licenseCertificates of Trainingsattended Proof of Employment /Appointment(notarized)NUMBER /RATIOCOMPLIEDREMARKS11DOCUMENT REVIEW Relevant Training License, if applicable Proof of Employment/Appointment(notarized) if employedby hospital Notarized MOA ifoutsourced1 per shiftDOCUMENT REVIEW Certificate fromSpecialty society, ifapplicable (for BoardCertified) Residency TrainingCertificate (for BoardEligible) Certificate ofResidency Training /Medical Specialists(*DOH MedicalSpecialist, last examwas in 1989) Updated PRC license Certificates ofTrainings attended Proof of Employment/Appointment(notarized)At least 50% ofthe consultantsper specialtyare boardcertified1 per shiftCLINICAL SERVICESConsultant Staff inOb-Gyn,Pediatrics,Medicine, Surgery,and Anesthesia Licensed physician Fellow/Diplomate ACLS certified (forSurgeons andAnesthesiologists)*Hospital may haveadditionalconsultants fromother specialties.Intensive CareUnit:MultidisciplinaryTeam composed of,but not limited to,board lmonologistPreferably OR anintensivistNeonatal IntensiveCare Unit:A multidisciplinaryteam composed of,but not limited iatric Licensed physician Fellow/Diplomate Licensed physician Fellow/DiplomateA teamcomposed of atleast 1 perspecialty(May be parttime or visitingconsultant/s)OR anintensivistA teamcomposed of atleast 1 perspecialty(May be parttime or visitingconsultant) ORa /2018Page 3 of 18Page 1 of 1
POSITIONpulmonologist ORa neonatologistHigh RiskPregnancy Unit:GeneralObstetricians,preferably with aPerinatologist, anda referral team ofIM specialistsResident Physicianon Duty (Shall notgo on duty formore than 48 hoursstraight).QUALIFICATIONEVIDENCENUMBER /RATIOCOMPLIEDREMARKSDOCUMENT REVIEW Licensed physician Fellow/DiplomateLicensed physician Certificate fromSpecialty society, ifapplicable (for BoardCertified) Residency TrainingCertificate (for BoardEligible) Certificate ofResidency Training /Medical Specialists(*DOH MedicalSpecialist, last examwas in 1989) Updated PRC license Certificates ofTrainings attended Proof of ans,preferably withaPerinatologist,and a referralteam of IMspecialists(May be parttime or visitingconsultant)DOCUMENT REVIEW Updated PRC license Certificates ofTrainings attended Proof of Employment/Appointment(notarized) Schedule of dutyapproved by MedicalDirector/Chief ofHospitalWards - 1:20beds at anygiven timePLUSER – at least 1at any giventimeDOCUMENT REVIEW Diploma/Certificate ofUnits Earned Updated PRC license Certificates ofTrainings attended Proof of Employment/Appointment(notarized) ServiceRecord/Certificate ofEmployment (proof ofsupervisory/managerial experiencein nursing)1:100 Beds*This ratio doesnot includeResidentPhysicians onDuty that shallbe required foradd-on servicessuch as dialysisfacility. It shallbe countedseparately.NURSING SERVICESAssistant ChiefNurse Licensed nurse At least twenty (20)units towardsMaster’s Degree inNursing At least three (3)years-experience insupervisory/managerial positionin age 4 of 18Page 1 of 1
eManagers Licensed nurse With at least nine(9) units of Master'sDegree in Nursing At least two (2)years-experience ingeneral nursingserviceadministration.Head Nurse/SeniorNurse Licensed nurse With at least 2years-hospitalexperience BLS certified Licensed nurse BLS certifiedDOCUMENT REVIEW Diploma/Certificate ofUnits Earned Updated PRC license Certificates ofTrainings attended Proof of Employment/Appointment(notarized) ServiceRecord/Certificate ofEmployment (Proof ofgeneral nursingservice administrationexperience)DOCUMENT REVIEWStaff NurseStaff Nurse inevery Critical Unit(CCU, ICU, NICU,PICU, SICU,HRPU etc.) Licensed nurse Certificate ofTraining in CriticalCare Nursing, ACLSNursing Attendantsin wards Highschoolgraduate With relevanthealth-relatedtraining(may be in housetraining)Nursing Attendantin CCUsOperating RoomNurses:-Scrub Nurse (SN)-Circulating Nurse(CN) Licensed nurse Training in ORNursing Training in BLS andACLSDelivery RoomNurse Licensed nurse Training inMaternal and ChildNursing (may be inhouse training or Diploma Updated PRC license Certificate of trainingsattended Proof of employment(notarized) If nursing staffing isoutsourced: Validity ofthe contract ofemployment should beat least one (1) year andwithin the validityperiod of the hospital’sLTO. Schedule of dutyapproved by ChiefNurseDOCUMENTS REVIEW Certificates of Trainingsattended Proof of Employment( notarized )NUMBER /RATIOCOMPLIEDREMARKS1 perDepartment –Office hoursonly (8am –5pm)1 per shift perclinicaldepartmentWard - 1:12beds at anytime (1 relieverfor every 3RNs)1:3 beds at anytime per shift(plus 1 relieverper 3 CCURNs)1:24 beds atany time(1reliever forevery 3 NAs)1:12 beds atany time (plus1 reliever forevery 3NA/MWs)DOCUMENT REVIEW Diploma Updated PRC license Certificate of trainingsattended Proof of employment(notarized) If nursing staffing isoutsourced: Validity ofthe contract of1 SN and 1 CNper functioningOR per shift(plus 1 relieverfor every 3nurses)1 per 3delivery tableper shift(plus 1 relieverfor every 3DOH-HOS-LTO-AT-L2-PIVRevision:0104/23/2018Page 5 of 18Page 1 of 1
POSITIONEmergency RoomNurseOutpatientDepartment NurseDentist – MOA ifoutsourced but thedental serviceshould be withinthe vicinity Etraining in EssentialIntegrated NewbornCare [EINC]) Training in BLS andACLSemployment should beat least one (1) year andwithin the validityperiod of the hospital’sLTO. Schedule of dutyapproved by ChiefNurse Licensed nurse Training in TraumaNursing, ACLS andother relevanttraining Licensed nurse Training in BLSLicensed dentistLicensed respiratorytherapist or licensednurse with respiratorytherapy trainingDOCUMENT REVIEW Diploma Updated PRC license Certificates ofTrainings attended Proof of Employment/Appointment(notarized) If outsourced: Validityof the contract ofemployment should beat least one (1) yearand within the validityperiod of thehospital’s LTO.NUMBER /RATIOCOMPLIEDREMARKSnurses)1:3 beds pershift(plus 1 relieverfor every 3nurses)1Office hoursonly(8am – 5pm)1Office hoursonly(8am – 5pm)1 per e 6 of 18Page 1 of 1
ATTACHMENT 2.B - PHYSICAL PLANTDOCUMENTS1.DOH -Approved PTC2.DOH Approved Floor Plan3.Checklist for Review of Floor DINGS (may use separate additional sheets if Page 7 of 18Page 1 of 1
ATTACHMENT 2.C onal)QUANTITYAREACOMPLIEDREMARKSADMINISTRATIVE SERVICEAmbulance Available 24/7 Physically present if not being usedduring time of inspection/monitoring1Computer with Internet Access1Emergency LightFire ExtinguishersGenerator set with Automatic TransferSwitch (ATS)1 per unit orarea1ParkingAdministrativeOfficelobby, hallway,nurses' station,office/unit andstairwayslobby, hallway,nurses' station,office/unit andstairwaysGenset houseKITCHEN/DIETARYExhaust fanFood Conveyor or equivalent (closedtype)11Food reezer1Utility cart1Garbage Receptacle with Cover (colorcoded)1 for eachcolorEMERGENCY ROOMBag-valve-mask Unit- Adult- Pediatric11Calculator for dose computation1Clinical Weighing scale1Defibrillator with paddles1Delivery set, primigravid2 setsDelivery set, multigravid2 setsECG Machine with leadsEENT Diagnostic Set withOphthalmoscope and OtoscopeEmergency Cart (for contents, refer toseparate list)KitchenER11 set1DOH-HOS-LTO-AT-L2-PIVRevision:0104/23/2018Page 8 of 18Page 1 of 1
EQUIPMENT/INSTRUMENT(Functional)QUANTITYExamining table1Examining table (with Stirrups for OBGyne)1AREACOMPLIEDREMARKSGlucometer with stripsGooseneck lamp/Examining Light1Instrument/Mayo Table1Minor Instrument Set (May be used forTracheostomy, Closed TubeThoracostomy, Cutdown, etc.)2 setsNebulizer1NegatoscopeNeurologic HammerOR Light (portable or equivalent)Oxygen UnitTank is anchored/chained/ strapped orwith tank holder if not pipeline111Pulse Oximeter1Sphygmomanometer, Non-mercurial- Adult Cuff- Pediatric Cuff111Stethoscope1Suction Apparatus1Suturing SetThermometer, non-mercurial- Oral- RectalVaginal Speculum, Different SizesER22 sets111 for eachdifferent sizeWheelchair1Wheeled Stretcher with guard/side railsand wheel lock or anchor.1OUT- PATIENT DEPARTMENTClinical Height and Weight ScaleEENT Diagnostic Set withophthalmoscope and otoscope11 setGooseneck lamp/Examining Light1Examining table with wheel lock oranchor1Instrument/Mayo Table1Minor Instrument Set1 setNeurologic 18Page 9 of 18Page 1 of 1
EQUIPMENT/INSTRUMENT(Functional)Oxygen UnitTank is anchored/chained/ strapped orwith tank holder if not pipelinePeak flow meter- Adult- PediatricSphygmomanometer, Non-mercurial- Adult cuff- Pediatric cuffStethoscopeThermometer, non-mercurial- Oral- RectalSuture Removal SetWheelchair / Wheeled StretcherAir conditioning UnitAnesthesia MachineCardiac Monitor with Pulse OximeterCeasarian Section InstrumentDefibrillator with paddlesElectrocautery machineEmergency Cart (for contents, refer toseparate list)Glucometer with stripsInstrument / Mayo TableLaparotomy pack (Linen pack)Laparotomy / Major Instrument SetLaryngoscopes with different sizes ofbladesOperating room lightOperating room tableOrthopedic Instrument SetOxygen UnitTank is anchored/chained/ strapped orwith tank holder if not pipelineRechargeable Emergency Light (in casegenerator malfunction)Sphygmomanometer, Non-mercurial- Adult cuff- Pediatric cuffSpinal SetStethoscopeSuction ApparatusThermometer, non-mercurial- Oral- RectalWheeled Stretcher with guard/side railsand wheel lock or anchor.QUANTITYAREACOMPLIEDREMARKS111OPD111111 set1OPERATING ROOM111111111 per OR1 per OR11 per OR1 per OR11 per OROR1 per OR1 per OR1 per OR1 Page 10 of 18Page 1 of 1
EDREMARKSPOST ANESTHESIA CARE UNIT / RECOVERY ROOM111 (if separateDefibrillator with paddlesfrom the ORPACU/RRComplex )1 (if separateEmergency Cart (for contents, refer tofrom the ORseparate list)Complex )Mechanical / patient bed, with guard side1rails and wheel lock or anchoredOxygen UnitTank is anchored/chained/ strapped or1with tank holder if not pipelineSphygmomanometer, Non-mercurialPACU/RR- Adult cuff1- Pediatric cuff1Stethoscope1Thermometer, non-mercurial1LABOR ROOMFetal Doppler1Oxygen UnitTank is anchored/chained/ strapped or1with tank holder if not pipelinePatient Bed1Labor RoomPulse Oximeter1Sphygmomanometer, Non-mercurial1Stethoscope1Thermometer, Non-mercurial1DELIVERY ROOMAir conditioning UnitCardiac MonitorAir-conditioning Unit1Bag valve mask unit (Adult andpediatric)1Bassinet1Clinical Infant Weighing ScaleDefibrillator with paddles11 ( if DR isseparate fromthe ORComplex )Delivery set, primigravid1 setDelivery set, multigravid2 setsDelivery room light1Delivery room table1Dilatation/Curettage setEmergency Cart (for contents, refer toseparate list).DR1 set1(if DR isseparate fromOR Page 11 of 18Page 1 of 1
/Mayo Table1Kelly Pad or equivalent1Laryngoscope with different sizes ofbladesOxygen UnitTank is anchored/chained/ strapped orwith tank holder if not pipelineRechargeable Emergency Light (In caseof generator r -Non-mercurial1Stethoscope1Suction Apparatus1Wheeled Stretcher1DRHIGH RISK PREGNANCY UNITCardiac Monitor with Pulse Oximeter1Cardiotocography (CTG) Machine1Fetal doppler1Oxygen UnitTank is anchored/chained/ strapped or1HRPUwith tank holder if not pipelinePatient bed with side rails1Suction Apparatus1Sphygmomanometer -Non-mercurial1NEONATAL INTENSIVE CARE UNIT (NICU)Air conditioning unit1Bassinet1Bilirubin Light / Phototherapy machine1or equivalentCardiac Monitor with Pulse Oximeter1Clinical Infant Bag-valve mask unit1Clinical Infant weighing scale1Defibrillator with paddles1EENT Diagnostic Set with1 setophthalmoscope and otoscopeNICUEmergency Cart (for contents, refer to1separate list)Glucometer1Incubator1Infusion pump / Syringe pump1Laryngoscope with neonatal blades of1different sizesMechanical Ventilator (May be1outsourced)Neonatal Stethoscope1Oxygen UnitTank is anchored/chained/ strapped or1with tank holder if not pipelineRefrigerator for Breast milk Page 12 of 18Page 1 of 1
EDREMARKSSphygmomanometer, Non-mercurial1for neonateSuction apparatus1Thermometer, Non-mercurial1Umbilical Cannulation set1 setINTENSIVE CARE UNIT (ICU) – For all types of ICU (PICU, SICU, Medical ICU, etc.)Air conditioning unit1Bag-valve-mask Unit- Adult1- Pediatric1Cardiac Monitor with Pulse Oximeter1Defibrillator with paddles1Emergency Cart (for contents, refer to1separate list)EENT Diagnostic Set with1 setophthalmoscope and otoscopeInfusion pump1Laryngoscope with different sizes of1bladesDepending onMechanical Bedthe number ofICUbeds declaredMechanical Ventilator / Respirator (May1be outsourced)Minor Instrument Set (May be used forTracheostomy, Closed Tube1 setThoracostomy, Cutdown, etc.)Oxygen UnitTank is anchored/chained/ strapped or1with tank holder if not pipelineSphygmomanometer, non-mercurial(reserved for sudden breakdown ofcardiac monitor)- Adult cuff for adult unit1- Pediatric cuff for pediatric unit1Stethoscope1Suction Apparatus1NURSING UNIT/WARDBag-Valve-Mask Unit- Adult1- Pediatric1Clinical Height and Weight ScaleDefibrillator with paddlesEmergency cart or equivalent (refer toseparate list for the contents)EENT Diagnostic Set withophthalmoscope and otoscopeLaryngoscope with different sizes ofblades11NURSINGUNIT/ WARDNursing units located onthe same floor may sharethe defibrillator and the Ecart, provided that they arenot more than 50 metersaway from each other.11 set1DOH-HOS-LTO-AT-L2-PIVRevision:0104/23/2018Page 13 of 18Page 1 of 1
/Patient bed with lock, ifwheeled; with guard or side railsABCBedside TableABCNebulizer1Neurologic Hammer1Oxygen Unittank is anchored/chained if not pipelineSphygmomanometer, Non- Mercurial- Adult cuff- Pediatric cuffAREACOMPLIEDREMARKS111Stethoscope1Suction Apparatus1Thermometer, non-mercurial- Oral- Rectal11RESPIRATORY/PULMONARY UNITABG Machine1Pulmonary Function Test (PFT) or PeakExpiratory Flow Rate (PEFR) TubeRespiratory /Pulmonary UnitSpirometer1NebulizerAir compressorAutoclaveBone file, stainlessCotton pliersCowhorn ForcepsDental Chair unitExplorer, double-endForceps, No. 8Forceps, No. 17 Upper molarForceps, No. 18 Upper molarForceps, No. 150 Maxillary UniversalForceps, No. 150 S Primary TeethForceps, No. 151 Lower UniversalForceps, No. 151 Mandibular Pre-molarForceps, No. 151 S Lower Primary TeethGum separatorHigh speed handpiece with Burr removerLow speed handpiece, Angled headMouth mirror explorerPeriosteal elevator No. 9, double-endRongeurRoot elevatorScaler Jacquettes Set No. 1, 2, and 3Surgical Chisel1DENTAL LTO-AT-L2-PIVRevision:0104/23/2018Page 14 of 18Page 1 of 1
EQUIPMENT/INSTRUMENT(Functional)Surgical MaletteQUANTITYAREACOMPLIEDREMARKS1CENTRAL STERILIZING & SUPPLY ROOMAutoclave/Steam SterilizerBed or stretcher for cadaver1CSSRCADAVER HOLDING evision:0104/23/2018Page 15 of 18Page 1 of 1
ATTACHMENT 2.D - EMERGENCY CART CONTENTS FOR LEVEL 2 HOSPITALEMERGENCY CART CONTENTSERORDRICU NICU HRPU NS 1 NS 2 NS 3 NS 4 NS 5 NS 6 NS 7OTHERS OTHERSREMARKSAdenosine 6 mg/2mL vialAmiodarone 150mg/3mL ampuleAnti-tetanus serum (either equine-basedantiserum or human antiserum)Aspirin USP grade (325 mg/tablet)Atropine 1mg/ml ampuleΒ-adrenergic agonists (i.e. Salbutamol 2mg/ml)Benzodiazipine (Diazepam 10mg/2ml ampuleand/or Midazolam) (in high alert box )Calcium (usually calcium gluconate 10%solution in 10 mL ampule)Clopidogrel 75 mg tabletD5W 250 mLD50W 50mg/vialDigoxin 0.5mg/2mL ampuleDiphenhydramine 50mg/mL ampuleDobutamine 250mg/5mL ampuleDopamine 200 mg/5mL ampule/vialEpinephrine 1mg/ml ampuleFurosemide 20mg/2ml ampuleHaloperidol 50mg/mL ampuleHydrocortisone 250mg/2mL vialLidocaine 10% in 50mL sprayLidocaine 2% solution vial 1g/50mlMagnesium sulfate 1g/2mL ampuleMannitol 20% solution in 500ml/bottleMethylprednisolone 4mg/tabletMetoclopramide 10mg/2mL ampuleMorphine sulfate 10mg/mL ampule (in highDOH-HOS-LTO-AT-L2-PIVRevision:0104/23/2018Page 16 of 18Page 1 of 1
EMERGENCY CART CONTENTSERORDRICU NICU HRPU NS 1 NS 2 NS 3 NS 4 NS 5 NS 6 NS 7OTHERS OTHERSREMARKSalert box )Nitroglycerin inj. 10 mg/10mL ampule orIsosorbide dinitrate 5mg SL tablet or 10mg/10mL ampuleNoradrenaline 2mg/2mL ampuleParacetamol 300mg/ampule (IV preparation)Phenobarbital 120mg/ml ampule IV or 30mgtablet (in high alert box )Phenytoin 100mg/capsule or 100 mg/2mLampulePlain LRS 1L/bottlePlain NSS 1L/bottle – 0.9% Sodium ChloridePotassium Chloride 40mEq/20mL vial (in highalert box )Vitamin B1/6/12 vial (1g B1, 1g B6, 0.01gB12in 10 mL vial)Sodium bicarbonate 50mEq/50mL ampuleVerapamil 5 mg/2 ml ampuleEQUIPMENT/SUPPLIESAirway adjunctsAirway / Intubation Kit ( with stylet and bagvalve masks )Alcohol disinfectantAseptic bulb syringeCalculatorCapillary Blood Glucose (CBG ) KitCardiac BoardEndotracheal Tubes, all sizesFlashlights or Pen lightsGloves , sterileGloves, 018Page 17 of 18Page 1 of 1
EMERGENCY CART CONTENTSERORDRICU NICU HRPU NS 1 NS 2 NS 3 NS 4 NS 5 NS 6 NS 7OTHERS OTHERSREMARKSLaryngoscope with different sizes of bladesNasal cannulaProtective face shield or mask or gogglesStandard face maskSterile gauze (pre-folded and individuallypacked )Syringes (different volumes)Urethral catheterUrine collection bagWaterproof aprons*Notes:ER – Emergency RoomOR – Operating RoomDR – Delivery RoomNS – Nurses’ age 18 of 18Page 1 of 1
DOH-HOS-LTO-AT-L2-PIV Revision:01 04/23/2018 Page 1 of 1 Page 1 of 18 PART IV - LEVEL 2 HOSPITAL Instruction: In the appropriate box, place a check mark ( ) if the hospital is compliant or X-mark if not compliant.
