April 12, 2017

FRANCISCO V. MATEO, MD
Regional Director
Department of Health Region XII
Cotabato City

Dear Regional Director Mateo:

We would like to say thank you for scheduling the monitoring team headed by Dr. Leonora A. Lozana to conduct a very fruitful monitoring
inspection in this facility. This opportunity helped us to be more equipped and maintain the standard in providing safe quality care among our
clients. Respectfully submitting to your good office the action plan and immediate intervention of this facility based on the results and findings
of the monitoring team headed by Dr. Leonora A. Lozana last March 23, 2017.

FINDINGS EXPLANATION SOLUTION OFFERED EXPECTED OUTPUT

Non-availability of Atropine
ampule
Use of BCG vaccine and Tetanus
Toxoid that is not FDA approved
and without certificate of product
registration and certificate of
distributorship
Atropine ampule was expired
dated November 2016.
We can not ask for BCG vaccine
and Tetanus Toxoid allocation
from our Rural Health Unit due to
DOH protocol as stated by the
Public Health Nurse. And this
facility admitted that we do not
know that we need to secure from
our agent the necessary
documents before we will going
to purchase the vaccines.
1.To purchase of Atropine ampule
2.Quarterly inventory of all clinic
supplies, equipment and drugs
3.Formulation of inventory form
1.We communicated to the IPHO
last 2015 and 2016 with regards
to this problem. The response was
to wait for guidelines and policy
for allocation of vaccines from
private hospital and birthing clinic
2.We received a communication
letter from the IPHO inviting us
to join in a meeting regarding
vaccine allocation for private
Purchased Atropine ampule
OR number
Formulated a facility based
inventory form
The Department of Health is very
much appreciated in addressing
the need of the private health care
institution in vaccine allocation.
We are very happy that we do not
need to buy expensive vaccines
and we are now oriented to secure
certificate of product registration
and certificate of distributorship

Incorrect plotting of women labor
progress in the partograph form
Fix door of CR for staff and OPD
clients
Remove clatter inside the
sterilization
Provide cabinet/shelves for
scrub,gowns outside the birthing
area
Update organizational chart
Due to information overload we
mistakenly adopt a unacceptable
way of plotting the progress of
labor in the partograph form. And
this facility would like to thanks
Dr. Leonora A. Lozana for giving
us a brief but very concise lecture
on partograph plotting during her
monitoring visit last March 23,
2017.
The door was not functional a day
before the visit of the monitoring
team (March 22,2017) due to
unavoidable circumstances
Due to insufficient space and
availability of cabinet we
admitted that we place some of
our office supply in the
sterilization area
This clinic admitted that the
boots, slippers and gown was
place inside the birthing area (at
the back of the door) because of
the availability of space
People may come and go, some of
the staff of this facility resigned
due to health problem and job
opportunity
hospital and birthing center
1.Scheduled a mentoring session The staff of this facility is now
to all staff midwife and nurses on adopting the correct way of
the proper plotting of progress of plotting the progress of labor in
labor in the partograph form. the partograph form
2.Short course workshop was
scheduled.
1.Hired a carpenter who can fix The door now is functional
the door to make it functional
1.Review the floor plan of the To secure approval to Engr. Lopez
facility with regards to a minor
renovation of the facility
2.Communicate to Engr. Lopez
about the suggested floor plan To purchase additional cabinet
revision and ask for her comment
and approval
3.Purchase additional cabinet
1.Provide hanging cabinet for the To secure hanging cabinet and to
gowns maximize the available space
2.Maximize the space below the
scrub up sink for the slippers
To update the organizational chart Updated organizational chart
with the present clinic personnel
Submit updated facility policies
and procedure in spiral binder
Availability of Personnel
credential (201 File)
Very truly yours,
CHARIS JOY R. DOONG, RN, RM
Clinic Manager and Owner
Before the visit of the monitoring
team this facility tried to enhance
the files of all personnel that will
make DOH and PhilHealth very
comfortable to
1.To revisit the existing manual of To submit a updated manual of
procedure procedure in spiral binder
2.Enhance the policies based on
the suggestion and
recommendation of the
monitoring team
1.To apply all the Provide a folder for each
recommendation of Maam personnel and to secure pertinent
Jocelyn T. Factora on the proper credentials
management of personnel
credential
1.1 each personnel should have a
one folder where all of their
pertinent papers be place
1.2 Secure all documents in a safe
place
1.3 Make the documents available
at all times