Doh Guidelines

7/26/2019 Doh Guidelines

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ASSESSMENT TOOL FOR LICENSING AN

ACUTE-CHRONIC PSYCHIATRIC CARE FACILITY

Name of Health Facility :

Address of the Health Facility :

Republic of the Philippine!ep"#t$ent of He"lth

HEALTH FACILITIES AN! SER%ICES REGULATORY &UREAU

DOH-APC-LTORevision0!"#$"

'( GENERAL INFORMATION

O&ner :

'edical Director :

Classification : (overnment ) *National ) *

Local ) *

Others+ s,ecify

Private ) *in.le ) *Pro,rietorshi, ) *Partnershi, ) *Cor,oration ) *Civic Or.ani/ation ) *Reli.ios ) *Fondation ) *Others+ s,ecify

Chairman of the 1oard 23f :Cor,oration4

Athori/ed 1ed Ca,acity :

3m,lementin. 1ed Ca,acity :

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DOH-APC-LTO-Revision0!"#$"0

*( SER%ICE CAPA&ILITY

5#5 ervice Ca,a6ility of an Acte-Chronic Psychiatric Care Facility:

5#5#5 Provides medical service+ nrsin. care+ ,harmacolo.ical

treatment and ,sychosocial intervention for mentally ill,atients5

55 The health facility shall render 7ality health services a,,ro,riate to thelevel of care 6ein. ,rovided5

SER%ICE A%AILA&ILITY

2" if Availa6le4 REMAR+S

Gene#"l A,$init#"ti-e

Se#-ice

Clinic"l Se#-ice'edical and Psychiatricervices

Crisis 3ntervention

Nu#in. Se#-ice

Psychiatric Nrsin. Care

Ancill"#/ Se#-ice

Psychosocial ervices 8

Referral ervices

'edical-r.ical ervices

Dental ervicesClinical La6oratory

Radiolo.y

8 For ,sycholo.ical evalation of ,atients+ affiliation &ith a service ,rovider is allo&ed5 A memorandm of a.reement &ith the service ,rovider mst 6e secred as a ,rere7isite for licenseto o,erate5

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DOH-APC-LTORevisio0!"#$"

5$5 O,erations

5$5#5 Policies and Procedres

An or.ani/ational chart is ,laced in a location readily seen 6ythe ,6lic5 ) * 9es ) * No

The health facility has docmented ,olicies and standardo,eratin. ,rocedres for the follo&in.:(eneral Administrative ervice ) * 9es ) * No

Clinical ervice'edical and Psychiatric ervices ) * 9es ) * NoCrisis 3ntervention ) * 9es ) * Nose of Restraint ) * 9es ) * No3solation of Patient ) * 9es ) * NoPatient Trans,ort"Condction ) * 9es ) *No

Nrsin. ervice

Psychiatric Nrsin. Care ) * 9es ) *

No Ancillary ervicePsychosocial ervices ) * 9es ) * NoReferral ervices ) * 9es ) * No

5$55 (eneral Administrative ervice

Ne& ,ersonnel receive an orientation ,ro.ram that covers theessential com,onents of the service 6ein. ,rovided5

) * 9es ) * No

Dties and res,onsi6ilities of the ,ersonnel are identified and

docmented5 ) * 9es ) * No

5$5$5 Clinical ervice

Personnel to deliver care are availa6le for ! hors5) * 9es ) * No

All e7i,ment+ medicines and s,,lies necessary to ,rovidecare are availa6le5 ) * 9es ) * No

The se of restraint is covered 6y doctor;s order5) * 9es ) * No

Nrsin. care is ,rovided at all times5 ) * 9es ) * No

A Nrsin. Procedre 'anal and a ,ro,erly tili/ed <arde=are availa6le in all ,atient care nits5Nrsin. Procedre 'anal ) * 9es ) * NoPro,erly tili/ed <arde= ) * 9es ) * No

The delivery of nrsin. care tili/es the nrsin. ,rocess5

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) * 9es ) * No

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'edical dia.noses+ ,rocedres and"or o,erations ,erformedon ,atients are recorded sin. 3CD > #05

) * 9es ) * No

Records of medico > le.al cases are ,ro,erly and com,letelyfilled ,5 ) * 9es ) * No

Death certificate forms are ,ro,erly and com,letely filled ,5) * 9es ) * No

Confidentiality of ,atient information is maintained at all times5) * 9es ) * No

A Patient Lo.6oo? is ,ro,erly filled , in the follo&in. areas: Admission ) * 9es ) * NoDischar.e ) * 9es ) * No

Patient Charts are ,ro,erly and com,letely filled , andcontain ,-to-date information on the follo&in.:

Contents of 'edical Chart 3n-Patient Ot-Patient2" if

Availa6le4

2" if

Availa6le4

3dentification Data

Consent Form

Chief Com,laint " Referral

3nformation

History of Present 3llness or 3nterval History for Re-admittedPatients

Physical and Nerolo.ical

@=amination and 3nitial 'ental

tats @=aminationLa6oratory Reslts+ -rayReslts and all other Ancillary

Procedres

Dia.nosis"Admittin. Dia.nosis

Admittin."Attendin. Physician

Consltation"Referral Notes

Pro.ress Notes

Doctor;s Order heet

'edication"Treatment Record

Nrsin. Record

Bisitor;s Lo.

Dischar.e mmary

Others

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5!5 Pro.rams

5!5#5 Psychosocial Pro.ram

The health facility has a docmented ,sychosocial ,ro.ramfor ,atients+ delineatin.+ amon. others+ the ,ro.ramo6ectives+ activities and res,onsi6ilities of ,ersonnel5

) * 9es ) * No

5!55 Disaster 'ana.ement

The health facility has a docmented emer.ency and disaster mana.ement ,lan5 ) * 9es ) * No

5!5$5 Hman Resorce Develo,ment

The health facility im,lements a hman resorcedevelo,ment ,ro.ram that identifies+ ,lan+ facilitate andrecord trainin. and edcation for all ,ersonnel5

) * 9es ) * No

An a,,raisal system identifies and revie&s the effectivenessand a,,ro,riateness of the trainin. ,rovided5

) * 9es ) * No

5!5!5 ality 'ana.ement

The health facility has an esta6lished+ docmented andmaintained 7ality mana.ement ,ro.ram that reflectscontinos 7ality im,rovement ,rinci,les5

) * 9es ) * No

There is an e=ce,tion re,ortin. system that incldes therecordin.+ re,ortin.+ investi.ation+ analysis+ corrective actionand revie& ,rocess for adverse+ n,lanned+ or nto&ardevents sch as:

Accidents+ incidents+ near misses+ and adverse clinical events

Com,laints and s..estions))

* 9es* 9es

))

* No* No

3nfectios " Notifia6le diseases

ervice shortfalls

)

)

* 9es

* 9es

)

)

* No

* No

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0( PERSONNEL

$5#5 The health facility a,,oints and allocates ,ersonnel &ho are sita6ly7alified+ s?illed and"or e=,erienced to ,rovide the service and meet,atient needs5

$5#5#5 @ach ,ersonnel is 7alified+ s?illed and"or e=,erienced toassme the res,onsi6ilities+ athority+ acconta6ility and

fnctions of the ,osition5 ) * 9es ) * No

$5#55 Professional 7alifications are validated+ incldin. evidenceof ,rofessional re.istration"license+ &here a,,lica6le+ ,rior toem,loyment5 ) * 9es ) * No

$5#5$5 An or.ani/ed medical and nrsin. staff shall 6e res,onsi6lefor the 7ality of ,atient care and for the ethical condct and,rofessional ,ractices of its mem6ers5 ) * 9es ) * No

POSITION RE3UIREMENT COMPLIANCE

2" if Com,liant4

STATUS 2FT if

Fll Time4 2PT if

Part Time4

REMAR+S

Gene#"l

A,$init#"tie Se#-ice

Administrator #

Administrative Assistant #

Coo? (May becontracted out)E

#

Driver (On call and May be contracted out) F4

#

Landry Gor?er (May be contracted out)E

#

E A contract of service or memorandm of a.reement &ith a service ,rovider mst 6e secred as a

,rere7isite for license to o,erate5

F4 The Driver refers to the driver of the Patient Trans,ort Behicle5 3f the services of the Driver arecontracted ot+ there mst 6e a contract of service or memorandm of a.reement 6et&een the Driverand the health facility5

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POSITION RE3UIREMENT COMPLIANCE

2" if Com,liant4

STATUS 2FT if

Fll Time4 2PT if

Part Time4

REMAR+S

Clinic"l Se#-ice

Psychiatrist (On call and Board Certified) 8

#

Licensed Physician (Full

time) 8 #

8 A 1oard Certified Psychiatrist is a di,lomate or fello& of the Phili,,ine Psychiatric Association5

8 3f there is already a flltime Psychiatrist+ he"she may also act as the fll time Physician5 Ths+another flltime Physician is no lon.er re7ired5

Nu#in. Se#-ice

Re.istered Nrse #:! 6eds"shift 8

Nrsin. Attendant #:# 6eds"shift 8

8 For all ,ersonnel re7irements e=,ressed as a ratio 2e5.5 #:! 6eds4+ an e=cess of not more than

%0I of the nm6er of 6eds in the ratio &ill 6e allo&ed5 For e=am,le: if the health facility has # to !6eds+ one Re.istered Nrse ,er shift is re7ired5 3f the health facility has % to $J 6eds+ oneRe.istered Nrse ,er shift is re7ired5 3f the nm6er of 6eds is $K 2the e=cess nm6er of 6eds is

more than %0I of !4+ an additional Re.istered Nrse ,er shift is re7ired5

Ancill"#/ Se#-ice

Re.isteredPsycholo.ist (Full

#

E The Psycholo.ist mst have at least t&o 24 years of relevant e=,erience5

Others 2Please s,ecify4

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ASSESSMENT TOOL FOR LICENSING AN ACUTE-CHRONIC PSYCHIATRIC CARE FACILITY



1( E3UIPMENT6INSTRUMENT

!5#5 All e7i,ment and instrments necessary for the safe and effective,rovision of services are availa6le and are ,ro,erly maintained5

!5#5#5 Records of e7i,ment are maintained and ,dated re.larly5) * 9es ) * No

!5#55 A ,reventive maintenance ,ro.ram ensres that alle7i,ment are maintained and"or cali6rated to an a,,ro,riatestandard or s,ecification5 ) * 9es ) * No

ITEM RE3UIREMENT COMPLIANCE

2" if Com,liant4

CON!ITION2" if ervicea6le4

REMAR+S

Gene#"l

A,$init#"ti-e

Se#-ice

@mer.ency Li.ht #

Fire @=tin.isher #

Patient Trans,ortBehicle (Available for 24 hours) 8

#

ecred Filin. Ca6inet #

Ty,e&riter"Com,ter #

8 The Patient Trans,ort Behicle may 6e contracted ot5 3f contracted ot+ the vehicle mst 6e availa6lefor ! hors+ altho.h not necessarily &ithin the ,remises of the health facility+ and the health facilitymst have a Contract of ervice or 'emorandm of A.reement &ith the o&ner of the vehicle5

Clinic"l Se#-ice

Am6 1a. #

1eds"'attresses"'atsDe,ends on

A1C 8

Clinical Gei.hin.cale

#

O=y.en nit #

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ITEM RE3UIREMENT COMPLIANCE

2" if Com,liant4

CON!ITIONREMAR+S

,hy.momanometer #

tethosco,e #

Recreational",orts"@=ercise @7i,ment

#

Others 2Pleases,ecify4

8 A1C is Athori/ed 1ed Ca,acity5

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2( PHYSICAL PLANT

%5#5 All ,hysical facilities and tility systems necessary for the safe and effective,rovision of services are availa6le and are ,ro,erly maintained5

AREA COMPLIANCE

2" if Com,liant4

LIGHTING2" if Ade7ate4

%ENTILATION2" if Ade7ate4

REMAR+S

Gene#"l A,$init#"ti-eSe#-ice

Gaitin. Area

3nformation+ Rece,tion and1siness Office

Office of the Administrator

Toilet

Landryand Linen Area

(ara.e

,,ly tora.e Area

Gaste Holdin. Area

Dietary

Dinin. Area

Not re7ired if the service is contracted ot5

Clinic"l Se#-ice

Admission+ Dischar.e andFollo&-, nit

Admittin. and Records Area

Consltation Area

@=amination and Treatment Area

@7i,ment and ,,lytora.e Area

Nrsin. nit

Private " emi-PrivateRoom

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AREA COMPLIANCE

2" if Com,liant4

LIGHTING2" if Ade7ate4

%ENTILATION2" if Ade7ate4

REMAR+S

Gard

O6servation Room

Toilet

Nrse tation &ith Gor? Area and Lavatory"in?

Ancill"#/ Se#-ice

Psychosocial nit

3ndoor Activity Area

Otdoor Activity Area

%55 @nvironment

The health facility is:

Readily accessi6le to the commnity5 ) * 9es ) * No

Free from nde noise+ smo?e+ dst+ fol odor+ flood5) * 9es ) * No

Not located adacent to railroads+ frei.ht yards+ children;s ,lay.ronds+air,orts+ indstrial ,lants+ and &aste dis,osal ,lants5

) * 9es ) * No

%5$5 Occ,ancy

The location of the health facility com,lies &ith all local /onin.

ordinances5 ) * 9es ) * No

%5!5 afety

The health facility ,rovides and maintains a safe environment for,atients+ ,ersonnel and ,6lic5 ) * 9es ) * No

1ildin.s ,ose no ha/ards to the life and safety of ,atients+ ,ersonneland ,6lic5 ) * 9es ) * No

@=its are restricted to the follo&in. ty,es: door leadin. directly otside

the 6ildin.+ interior stair+ ram,+ and e=terior stair5) * 9es ) * No

A minimm of t&o 24 e=its+ remote from each other+ are ,rovided foreach floor of the 6ildin.5 ) * 9es ) * No

@=its terminate directly at an o,en s,ace to the otside of the 6ildin.5) * 9es ) * No

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Protective devices are sed on doors and &indo&s:Gard ) * 9es ) * NoO6servation Room ) * 9es ) * NoNrse tation ) * 9es ) * No

%5%5

Toilet

ecrity

) * 9es ) * No

The health facility ensres the secrity of ,erson and ,ro,erty &ithinthe facility5 ) * 9es ) * No

%5J5 Li.htin. and Bentilation

Areas sed 6y ,atients and ,ersonnel are ade7ately li.hted andventilated5 ) * 9es ) * No

%5K5 Patient 'ovement

Ade7ate s,ace is ,rovided to allo& ,atients and ,ersonnel to move

safely arond ,atient 6ed areas5 ) * 9es ) * No

Patients &ho se mo6ility aids are a6le to safely manever &ith theassistance of their aid &ithin their 6ed area5 ) * 9es ) * No

%55 Aditory and Bisal Privacy

Ade7ate ,rivacy for ,atients is ,rovided sch that sensitive or ,rivatediscssion+ e=amination+ and"or ,rocedre are condcted in a manner or environment &here these cannot 6e o6served or the ris? of 6ein.overheard 6y others is minimi/ed5 ) * 9es ) * No

%5M5 Po&er ,,ly

The health facility has an a,,roved ,o&er s,,ly system5

) * 9es ) * No

%5#05 Gater ,,ly

The health facility has an a,,roved &ater s,,ly system5

) * 9es ) * No

%5##5 Gaste 'ana.ement

%5##5#5 Li7id Gaste

Li7id &aste is dischar.ed into a mlti-cham6er se,tic tan?5) * 9es ) * No

%5##55 olid Gaste

olid &aste is collected+ treated and dis,osed of inaccordance &ith the Health Care Gaste 'ana.ement 'analof the De,artment of Health+ 00!5 ) * 9es ) * No

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The health facility o6serves se.re.ation+ codin. and la6elin.of &aste51lac? Trash 1a.2(eneral > Non-3nfectios > Dry4 ) * 9es ) * No(reen Trash 1a.

2(eneral > Non-3nfectios > Get4har, Container

) * 9es ) * No

2har,s4 ) * 9es ) * No

Protective e7i,ment and clothin. a,,ro,riate to the ris?sassociated &ith the handlin.+ stora.e+ and dis,osal of &astesare ,rovided to and sed 6y ,ersonnel5 ) * 9es ) * No

%5#5 anitation

The health facility o6serves ,est and vermin control:3n-Hose ) * 9es ) * NoContractor ) * 9es ) * NoCom,any Name 55555555555555555555555555555555555555555555555555555

Records are availa6le and ,dated5 ) * 9es ) * NoFre7ency 55555555555555555555555555555555555555555555555555555

%5#$5 'aintenance

A 6ildin."facility inventory is maintained and ,dated re.larly5) * 9es ) * No

Fre7ency 55555555555555555555555555555555555555555555555555555

%5#!5 'aterial ,ecification

Floors+ &alls and ceilin. are made of strdy materials that allo&dra6ility+ ease of cleanin. and fire resistance5 ) * 9es ) * No

%5#%5 i.na.e

There are visal aids and devices for:3nformation and Orientation ) * 9es ) * NoDirection ) * 9es ) * No3dentification ) * 9es ) * No

%5#J5 Permits

A Permit to Constrct is availa6le for:Constrction of Ne& Health Facility 2if a,,lica6le4 ) * 9es ) * No

Alteration"@=,ansion"Renovation of @=istin. Health Facilitylica6le4 ) * 9es ) * No

Chan.e in Classification 2if a,,lica6le4

3ncrease in 1ed Ca,acity 2if a,,lica6le4

)

)

* 9es

* 9es

)

)

* No

* No

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http://slidepdf.com/reader/full/doh-guidelines 15/16DOH-APC-LTO-AT

Revision:0


Date of 3ns,ection:

RECOMMEN!ATIONS9A( Fo# Licenin. P#oce9) * For issance of License as Acte-Chronic Psychiatric Care Facility5

Balidity from to

) * 3ssance de,ends ,on com,liance to the recommendations .iven and s6mission of thefollo&in. &ithin days from the date of ins,ection:

) * Non-3ssance: ,ecify reason"s5

Inpecte, b/9

Printed Name i.natre Position"Desi.nation

Receie, b/9

i.natrePrinted NamePosition"Desi.nationDate





DOH-APC-LTORevision0!"#$"


Date of 'onitorin.:

RECOMMEN!ATIONS9&( Fo# Monito#in. P#oce9) * 3ssance of Notice of Biolation

) * Non-issance of Notice of Biolation

) * Others 2,ecify4

Monito#e, b/9

Printed Name i.natre Position"Desi.nation

Receie, b/9

i.natrePrinted NamePosition"Desi.nationDate

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