of the Philippines

Republic
Department of Health
OFFICE OF THE SECRETARY

SEP 2020
ADMINISTRATIVE ORDER
36

No. 2020 —-
0047

SUBJECT: Rules and Regulations Governing the Licensure of Primary Care

Facilities in the Philippines

I. RATIONALE/BACKGROUND

Section 27.b of the Universal Health Care (UHC) Act or Republic Act (RA) No. 11223
states that, “The DOH shall
institute a licensing and regulatory system for stand-alone health
facilities, including those providing ambulatory and primary care services, and other modes
of health service provision.”

The Department of Health (DOH), through the Health Facilities and Services
Regulatory Bureau (HFSRB) and Center for Health Development Regulation Licensing and
Enforcement Divisions (CHD-RLEDs), already regulates stand-alone health facilities
providing ambulatory services such as birthing homes, infirmaries, medical facilities for
overseas workers and seafarers, ambulatory surgical clinics, and hemodialysis clinics.

As listed in the 2020 National Health Facility Registry, there are 2,592 rural health

units (RHUs) classified as primary care facilities (PCFs) and are currently not being
regulated by DOH. These PCFs shall deliver initial-contact, accessible, continuous,
comprehensive and coordinated care to the communities they serve, as envisioned in the
_
UHC Acct. Thus, to
fulfill the DHC goals in ensuring that only safe and quality primary care
services are being delivered to every Filipino, PCFs will now be regulated and henceforth
must comply with the licensing standards and requirements in this Order.

Hi. OBJECTIVE

This Order aims to set the guidelines and the minimum standards and requirements for
licensing primary care facilities.

Hil. SCOPE

This Order shall apply to all government and private primary care facilities, and not to
the outpatient departments of hospitals and infirmaries that deliver primary care services.

IV. DEFINITION OF TERMS

A. Applicant the natural or juridical person who is applying for a License to

—

Operate or Certificate of Accreditation of a hospital or any other health facility.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111, 1 11137
Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
Assessment Tool — tlie checklist which prescribes the minimum standards and
requirements for licensure or accreditation of health facilities.

Department of Health-License to Operate (DOH-LTO) — a formal authority

issued by DOH
to an individual, agency, partnership or corporation to operate a
hospital or other health facility.

Department of Health — Permit to Construct (DOH-PTC) — a permit issued by

DOH
through HFSRB to an applicant who will establish and operate a hospital
or other health facility, upon compliance with required documents prior to the
actual construction of the said facility. A DOH-PTC
is also required for hospitals
and other health facilities with substantial alteration, expansion, renovation,
increase in the number
ons) beyond their
of
service
beds, transfer of site, or for additional services (add-
capability. It is a prerequisite for License to Operate.

Health Facilities — refers to facilities or institutions, whether stationary or

mobile, land based or otherwise, that provides any of the following services:
diagnostics, therapeutic, rehabilitative, and other health care services except
medical radiation facilities and hospital-based or stand-alone pharmacies.

Individual-based health services — refer to services which can be accessed within

a health facility or remotely that can be definitively traced back to one (1)
recipient, has limited effect at a population level and does not alter the
underlying cause of illness such as ambulatory and inpatient care, medicines,
laboratory tests and procedures, among others (RA 11223).

Initial Applications — refer to applications by newly constructed health facilities,

or those with changes in the circumstances of the facility, such as, but not
limited to, change of ownership, transfer of site, and increase in bed and major
alterations or renovations.

One-Stop Shop (OSS) Licensing System — a strategy of the DOH to harmonize

the licensure of hospitals, their ancillary and other health facilities including, but
not limited to, the clinical laboratory, HIV testing, drinking water analysis and
drug testing; blood bank, blood collection unit and blood station; dialysis clinic;
ambulatory surgical clinic; pharmacy; and medical x-ray facility; but excluding
hospital-based Medical Facilities for Overseas Workers and Seafarers
(MFOWS), hospital-based Drug Abuse Treatment and Rehabilitation Center,
hospital-based Stem Cell Facility, facilities for kidney transplantation, and
facility using radioactive material that are currently regulated by the Philippine
Nuclear Research Institute (PNRI). The OSS shall also apply to non-hospital-
based Medical Facilities for Overseas Workers and Seafarers, non-hospital-
based Ambulatory Surgical Clinics, non-hospital-based Dialysis Clinics,
Infirmaries and Birthing Homes. |

Population-based health services — refer to interventions such as_ health

promotion, disease surveillance, and vector control which have population
groupsas recipients (RA 11223).

Primary Care — refers to initial-contact, accessible, continuous, comprehensive

ret
and coordinated care that is accessible at the time of need including a range of
services for all presenting conditions, and the ability to coordinate

1
 other health care providers in the health care delivery system, when necessary.
(RA 11223)

—
K. Primary Care Facility (PCF) — refers to the institution that primarily delivers
primary care services which shall be licensed or registered by the DOH (RA
11223 IRR).

L. Primary Care Provider Network (PCPN) — refers to a coordinated group of

public, private, or mixed primary care providers, which serve as the foundation
of a Health Care Provider Network (HCPN).
M. Primary Care Worker — refers to health care worker, who may be a health
professional or community health worker/volunteer, certified by DOH to provide
primary care services (RA 11223 IRR).

GENERAL GUIDELINES

A. All Primary Care Facilities (PCFs) shall secure a DOH-LTO and must be
compliant at all times with the licensing standards and requirements set forth by
HFSRB and FDA.

B. PCFs under the same management, but operating in separate premises, shall
secure separate DOH-LTOs.

C. A PCF can either

be government-owned or privately-owned. It can be a rural
health unit, urban health center, private medical clinic, among others.

D. All government PCFs shall provide both individual-based and population-based

primary care services.

E. All private PCFs shall provide individual-based primary care services, based on
the guidelines set forth by DOH and PhilHealth.

F, All PCFs shall follow the guidelines for individual and population based
services set by DOH and Philhealth.

G. PCFs shall provide medical consultations and minor surgical services within
their premises and shall not be allowed to outsource these services.

|.
Ancillary services of a PCF shall include the following:
H.
Clinical laboratory
2. Diagnostic radiologic services
3. Pharmacy
4. Birthing services
5. Dental services
6. Ambulance service (Type 1)

I. Ancillary services shall comply with licensing standards set by DOH and/or
FDA, asapplicable.

ee
J. If the ancillary services are owned by the PCF and located within its premises
such as, clinical laboratory, pharmacy, birthing services, diagnostic

|
 services, dental services, and ambulance service, the guidelines for the OSS
implementation based on AO No. 2018-0016, titled “Revised Guidelines in the
imipiementation of the One-Stop Shop Licensing System” shall be strictly

—
followed at the Center for Health Development — Regulatory Licensing and
Enforcement Divisions (CHD-RLEDs).

K. If ancillary services are outsourced and located either within or outside the
premises of the PCF, a valid Memorandum of Agreement (MOA) with DOH-
or FDA-licensed facilities, as applicable, shall be required.

L. If the PCF and the

ancillary services (located outside the premises of the PCF),
have the same owner, a valid MOA or its
equivalent shall still be required.

M. Barangay Health Stations (BHS) shall be under the supervision of their

respective rural health units/urban health centers and shall not secure their own
DOH-LTO.
|

N. All applications, whether for initial or renewal, shall be processed manually or

through the Online Licensing and Regulatory System (OLRS), once the system
is fully functional.

O. PCFs shall strictly follow the standards, criteria and requirements prescribed in
the Assessment Tool for Licensing of Primary Care Facilities (ANNEX B).

VI. SPECIFIC GUIDELINES

A. Licensing Standards

PCFs shall follow the standards, criteria and requirements prescribed in the
Licensing Standards for Primary Care Facilities (ANNEX A).

B. Assessment Tool

An Assessment Tool for Licensing of Primary Care Facilities (ANNEX B) shall

be used by regulatory officers and other stakeholders to evaluate compliance of
PCFs to DOH standards and technical requirements for safety. This particular
tool shall also serve as the Self-Assessment Tool to be used by owners of PCFs
prior to inspection or monitoring visits by the CHD-RLEDs.

C. Asingle DOH-LTO shall be issued to the PCF, and shall include:

1. Category of health facility;

2. Ownership; and
3. Validity period

D. Every PCF may be monitored by CHD-RLEDs.

E. PCF shall have a contingency plan in case of suspension or revocation of the

DOH or FDA LTO of any of its
ancillary services, whether located within or
outside its premises.

al
F. PCFs shall have a Manual of Operations, which shall include, but not limited to,
the standard operating procedures being implemented in the facility,

\4
 guidelines and Manual of Procedures for primary care services, once available;
and copies of relevant laws and DOH issuances.

G. PCFs shall use only FDA

registered drugs and/or devices.

VII. PROCEDURAL GUIDELINES

A. Application for DOH-PTC

l. A DOH-PTC shall be required for construction of new PCFs and for

renovation or expansion of existing PCFs.

_—
2. A completely filled out application form for DOH-PTC, whether manual
or online, shall be submitted to the respective CHD-RLED.

3. The procedural guidelines for the processing of DOH-PTC shall be in

accordance with Administrative Order (AO) No. 2016-0042, also known
as, “Guidelines in the Application for Department of Health Permit to
Construct (DOH-PTC).”

B. Application For DOH-LTO

1. A completely filled out application form for DOH-LTO, whether manual

or online, shall be submitted to the respective CHD-RLED.

2. All applications, whether for initial or renewal, shall be processed

manually or through the OLRS, once the system is fully functional.

The licensing process, both for initial and renewal of DOH-LTO, shall be
in accordance with AO No. 2018-0016, also known as, “Revised
Guidelines in the Implementation of the One-Stop Shop Licensing
System.”

For ancillary services owned and located within the premises of the PCF,
the following documents shall be transmitted to CHD-RLED by the
following releasing offices either manually or through the OLRS, once
the system is fully functional:

Releasing Office Document

Food and Drug Administration - Certificate of Compliance for
Center for Device Regulation diagnostic radiology
-

Radiation Health Research (FDA-

CDRRHR)/ | |

FDA Regional Field Office

|

(FDA-RFO)
FDA
Regional Field Office Recommendation Letter/
Certificate of Compliance for
pharmacy
_

AA

74
 C. Validity of DOH-LTO
The DOH-LTO of PCF shall be valid for three (3) years. Renewal of DOH-

—
LTO shall follow the annual cut-off dates as prescribed in AO No. 2019-
0004, titled “Guidelines on the Annual Cut-off Dates for Receipt of Complete
Applications for Regulatory Authorizations Issued by the Department of
Health.”

D. Fees

1. The DOH-LTO fee shall follow the schedule of fees prescribed by DOH.
2. The applicant, upon filing the application, shall pay the corresponding
fee to the CHD Cashier.

Vii. VIGLATIONS AND SANCTIONS

A. Any violations relative to the existing laws, rules and regulations of PCF and
its ancillary services shall be subjected to the corresponding sanctions stated in
their respective existing laws, rules and regulations, and this Order. The
sanctions shall be borne by the PCF, regardless of location and ownership.

B. The following shall be considered as a violation of PCF:

1. Noncompliance to any of the licensing standards indicated in the

Assessment Tool for Licensing of Primary Care Facilities (ANNEX B)
beyond the compliance period provided by CHD-RLED.

2. Noncompliance of an ancillary service, regardless of location and

ownership, beyond the compliance period provided by CHD-RLED or
FDA. However, if the PCF has more than one (1) outsourced clinical
laboratory, diagnostic radiologic services, pharmacy, birthing services,
dental services, and ambulance service (Type 1), with a valid MOA, the
PCF will not be sanctioned if at least one ancillary facility of the
appropriate category is fully compliant with existing rules and
|

regulations.

C. The following sanctions shall be imposed on PCFs found with violations:

1. For violation to any of the licensing standards indicated in the

Assessment Tool for Licensing of Primary Care Facilities (ANNEX B)
beyond the compliance period provided by CHD-RLED:

Number of Incidence
First Offense
Sanction
Written Warning
Second Offense Thirty thousand pesos
oo | |

(Php 30,000)
Third Offense Fifty thousand pesos
(Php 50,000)
Fourth Offense Suspension of thirty days
— _

(30 days) or revocation of LTO

ap
Vy
 2. For noncompliance of an ancillary service, regardless of location and
ownership, beyond the compliance period provided by CHD-RLED or
FDA:

Number of
First Offense
Incidence Sanction
Written Warning
Second Offense Twenty thousand pesos
(Php 20,000)
Third Offense Additional twenty percent (20%)
of the previous fine
Fourth Offense and onwards Suspension of thirty days
(30 days) or revocation of LTO

D. The PCFs or the ancillary service/s shall be cleared of its violation after
complying with the necessary corrective actions and the prescribed sanction.

IX. APPEAL

Any PCF aggrieved by the decision

absence or unavailability or when delegated, the
of the Director IV of CHD, or in his/her
Director III of CHD, may, within ten (10)
days after receipt of the notice of decision file a notice of appeal to the Secretary of Health,
whose decision shall be absolute and executory. All pertinent documents and records of the
applicant shall then be elevated by the CHD.

X. TRANSITORY PROVISIONS

A. The requirement for DOH-PTC shall be waived for existing and operating PCFs
prior to the effectivity of this Order. In lieu of this requirement, an as-built plan
shall be submitted to the CHD-RLED.
B. The application fee for DOH-LTO and DOH-PTC for PCF shall be waived until
a new schedule of fees is issued by DOH.
C. Existing PCFs which cannot completely comply with the licensing standards of
ambulance service based on A.O. No. 2018-0001, also known as
and Regulations Governing the Licensure of Ambulances and Ambulance
“Revised Rules

Service Providers“, during initial application of DOH-LTO shall be given a

grace period until October 1, 2022. A DOH-registered Patient Transport Vehicle
shall serve as the transportation service of the PCF while complying with the
licensing standards of their ambulance service.
D. Furthermore, existing PCFs which cannot completely comply with the required
dental equipment and instruments in Annex B of this Order during initial
application of DOH-LTO shall be given a grace period until October 1, 2023, to
attain full compliance with the licensing standards set forth by this Order.

|
XI. REPEALING CLAUSE

Provisions from previous issuances that are inconsistent or contrary to

provisions of this Order are hereby rescinded and modified accordingly. py
XII. SEPARABILITY CLAUSE

In the events that any provision or part of this Order is declared unconstitutional
or null and void or rendered invalid by any court of law of competent authority, those
provisions not affected by such declaration shall remain valid and effective.

XI. EFFECTIVITY

This order shali take effect fifteen (15) days after publication in the Official
Gazette or in a newspaperof general circulation. Copies of this Order shall be filed with the
U.P. Law Center pursuant to Book VII, Chapter 2, Sec. 3 of E.O. 292.

Secretary of Health
 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

-
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

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

Pagel of4
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.

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

Page 2 of 4
 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

7
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

]
Page 3 of 4
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.
OO
There shall be a “No smoking policy” and that the same shall be strictly enforced.

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

Page 4 of 4
 A.O. No. 2020 - 0047
ANNEX B

Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

ASSESSMENT TOOL FOR LICENSING A PRIMARY CARE FACILITY

INSTRUCTIONS:
I. To properly fill-out this tool, the Licensing Officer shall make use of: INTERVIEWS, REVIEW OF
DOCUMENTS, OBSERVATIONS and VALIDATION of findings.
2. If the corresponding items are present, available or adequate, place (/) on each of the appropriate spaces
under the FINDINGS column or space provided alongside each corresponding item. If not, put an (X)
instead.
The REMARKS column shall document relevant observations.
to
|

vee Make sure fill-in the blanks with the needed information. Do not leave any items blank.
The Team Leader shall ensure that all team members write down their printed names, designation and
affix their signatures and indicate the date of inspection/monitoring, all at the last page of the tool.
The Team Leader shall make sure that the Head of the facility or, when not available, the next most senior
or responsible officer likewise affix his/her signature on the same aforementioned pages, to signify that
the inspection/monitoring results were discussed during the exit conference and a duplicate copy also
received.

GENERAL INFORMATION:

Name of Primary Care Facility:

Address:
(Number and Street) (Barangay/District) (Municipality/City)

(Province/Region)

Telephone/Fax No. E-mail Address:

Initial: Renewal:

Existing License No: Date Issued: Expiry Date:

Name of Owner or Governing Body (if corporation):

Name
of Head of Primary Care Facility:
Classification:

Ownership: Government Private

___ __

DOH-PCF-LTO-AT-Annex
B Revision:00
09/30/2020
Page 1 of 17
8
ath
de

PART I. SERVICE CAPABILITY, PERSONNEL AND PHYSICAL PLANT

L PATIENT
|

1.
RIGHTS AND ORGANIZATION ETHICS —

quality care and their responsibilities in that care.

|

Informed consent Document Review

ee
|
ae .

2 Standard: Organizational Policies and procedures which respect and‘support patients’ rights to

is obtained from e All patient charts have signed

patients prior to consent for procedures
procedures. (example: minor surgery,
immunization).
2. Policies which Observe
identify and e Posted patients’ rights in
address patients’ conspicuous places.
rights and
responsibilities are
documented.
TL. PATIENT CARE | 5

Pos Standard: ‘The organization iinforms the s

community about the services.sitit providesand the hours
_ of their availability.

3. Clinical
_
Observe
services :

are appropriate to e List of services and schedule

patients' needs and of operation posted in a
the former's conspicuous area.
availability is e DOHLTO (updated, valid
consistent with the and original) posted in a
organization's conspicuous area.
service capability
and role in the
community.
4. Population-based Document Review
Primary Care - Written policies and procedures
Services based on DOH issued
(Government PCFs guidelines:
only) e Health promotion
Epidemiologic surveillance
Health protection (vector
control, environmental
health, occupational safety,
and food safety measures)
e Emergency preparedness and
response
5. Individual-based Document Review
Primary Care - Written policies and procedures
Services based on DOH guidelines and
Manual of Procedures:
Maternal and Newborn Care
Family Planning Services
Nutrition Services
Dental Services (may be
outsourced and/or located Ly

fi)DOH-PCF-LTO-AT-Annex
B Revision:00
09/30/2020
Page 2 of 17
__
outside PCF through a valid
MOA. Outsourced dental
services shall comply with
the licensing standards
Assessment Tool)
in this

Referral services* to:

—_
o Community-based
Rehabilitation Services
(example: physical therapy,
occupational therapy,
speech therapy)
o Developmental and mental
health evaluation
o Substance abuse services
*May be provided by PCF
6. Minor Surgeries Document Review
Written policies and procedures in
conducting minor surgical procedures:
Suturing of superficial
lacerations
e Circumcision
e Incision and Drainage
e Debridement
e Excision of small cysts
7. Administrative Document Review
Services Written policies and procedures on:
Issuance of certificates
(Government PCFs (medical certification, death
only) certification, and medico-
legal certification)
Sanitation inspection and
issuance of sanitary permit
8. Supervisory Document Review
Services Written policies and procedures on:
Patient navigation in its
primary care provider
network
Supervision of barangay
health stations (Government
PCFs only)
Supervision of health
workers (Government PCFs
only)

each patient that is readily accessible to authorized personnel. _

9. Ail patients are Document Review
—
t

ne r
Standard: Theorganization uniquely identifies all patients and creates a specific patient record for
|

correctly The contents of patient's records are

identified by their the following:
patient records. Doctor's order
An appropriate

Det
DOH-PCF-LTO-AT-Annex
B Revision:00
09/30/2020
Page 3 of 17
__
history and Informed Consent, if
physical applicable
examination _is e Complete history and physical
performed on examination (may use SOAP
every patient. The method for follow-up check-
history includes ups)
present illness, e Medication and/or treatment
past medical, record
family, social and e Dental records (May be stored
personal history. separately if dental facility is
outsourced and located outside
the PCF)
e Laboratory and X-ray reports,
if any
e Record of referral or transfer of
patient to other
facility/service/doctor
including notes
__ Standard: The
care plan addresses patient's relevant clinical needs.
10. Coordinated plan Document Review
of care with goals. e Proof of implementation of
adopted/developed protocols,
and DOH approved CPGs,

|
once available.
TL. LEADERSHIP AND MANAGEMENT
:
1 |
vs - | : :

Standard: The PCF’s management team provides leadership, acts according to the organization’ Ss.

ee ee
~ policies and has
for the organization’ s Operation, and the quality of its services |
overall responsibilityfo
11.
‘and its resources
Organizational
~

Observe
28 . ©
ee

ee ees

oe
Be oe

Structure/Chart e Observe
ifthe organizational
structure/chart is posted in
conspicuous area.
12.The organization Document Review
and its services e® Written vision and mission
develop their
vision and Observe
mission. Posted vision and mission in
e
a conspicuous area
14.Evaluation and Document Review
monitoring e Accomplishment reports or
activities to assess other annual reports, as
management and applicable.
organizational
performance
(Required for
government-
owned PCFs.
Recommended
only for privately-
owned PCFEs.)

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: Iv. HUMAN RESOURCE MANAGEMENT
oe
c
Standard: Workload is monitored and appropriate guidelines consulted to ensure that |

appropriate staffnumbersand skill mix areavailable to achieve desired patient and organizational
- outcomes.
_

15. The organization Document Review

|

documents and e Policies and procedures for

follows policies and hiring and credentialing of

§=6
procedures for hiring staff
and credentialing of
its staff. Interview
e Administrative Officer or
Head of PCF

Standard: There are relevant activities related to orientation of new ersonnel.

16. New personnel, Document Review
new graduates and e Documentation of
external contractors- orientation conducted
are adequately
supervised by
qualibed
staff
Standard: Thereshall be an adequate numberof qualified, trained and competent staff to ensure
“efficient and effective delivery of quality primarycare services. es
|
|

The staff ‘composition and number/ratio shall depend on the workload. and services being provided, -
_ adjusted based on applicable workload assessment tools set by DOH.
__

17.Physician Document Review

(Full time) e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings
o Proof of
Employment/Appointment
18. Nurse (Full Time) Document Review
e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings
o Proof of
Employment/Appointment
19. Midwife Document Review
(Full Time) e Proof of qualifications
o Resume
oPRC ID and Certificate
o Primary Care Worker
Certificate
o Proof of relevant trainings

We
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=
o Proof of
Employment/Appointment
20. Dentist Document Review
e Proof of qualifications
o Resume
oPRC ID and Certificate
o Proof of
Employment/Appointment,
if applicable
o Valid Memorandum of
Agreement (MOA),
outsourced
if
21. Sanitation Document Review
Inspector e §=Proof of qualifications

(Government PCFs o Resume

only) OPRC ID and Certificate
o Proof of
Employment/Appointment
22. Information Document Review
Technology Officer e Proof of qualifications
o Resume
*may be allowed to o Proof of
handle two Employment/Appointment
administrative roles
at a time
23. Records Officer Document Review
e of qualifications
§=©Proof

*may be allowed to o Resume

handle two Medical Records
oO

administrative roles Management Training

at a time Certificate
oICD-10 Training
Certificate
o Proof of
Employment/Appointment
24. Administrative Document Review
Officer e Proof of qualifications
o Resume
*may be allowed to o Proof of
handle two Employment/Appointment
administrative roles
at a time

25. Utility Worker Document Review

e Proof of qualifications
o Resume
o Proof of
Employment/Appointment
V. INFORMATION MANAGEMENT 2
¢

i
-

Standard: Relevant, accurate, quantitative and qualitative data are collected and used inatimely

fu
and efficient manner for delivery of patient care and management of services _f f£

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26. Records are Document Review
stored, retained and
disposed of in
¢ Logbooks on record storage,
retention and disposal
accordance with the
guidelines set by Observe
National Archives of e Proper storage of records
the Philippines
(NAP)
27. The organization Document Review
defines data sets, data e Policies and procedures on
generation, collection record storage, safekeeping
and aggregation and maintenance, retention
methods and the and disposal.
qualified staff who
are involved in each
stage.
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential
and safe, and comply with all relevant statutory requirements and codes of practice. ~
28. Patient records Observe
documenting any e Patient records are easily
previous care can be retrievable within 10-15
quickly retrieved for minutes
review, updating and
concurrent use.
29.The organization Document Review
has policies and e Logbooks for borrowing and
procedures, and retrieval of records
devotes resources,
including Observe
infrastructure, to e Access to records
protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access
or use. Only
authorized
individuals make
entries in the patient
records
30. Validated Observe
Electronic Medical e EMR implementation
Records includes, but is not limited
to, primary care benefits,
maternal and neonatal
deaths, injury, and confirmed
cases of diagnosis
31. National Document Review
Database of Human e Proof of submission of data
Resources for Health to NDHRHIS
He
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 )

‘Information System
(NDHRHIS)
VIL SAFE PRACTICE AND ENVIRONMENT
|
|
Standard: The organization plans a safe aca effectiveenvironment ofcare consistent with its
_mission, services, and with laws and regulations ~ t

32. An incident Document Review

reporting system e Record of incident reports
identifies potential
harms, evaluates
causal and
contributing factors
for the necessary
corrective and
reventive action
33. Presence of a Document Review
management plan, e Management plan, policies
policies and and procedures on safety
procedures e Proof of implementation of
addressing safety the following:
e Fire drill conducted in the
past 12 months
e Earthquake drill
conducted in the past 12
months
34. Building Document Review
Maintenance e Routine program of work for
Program is in place preventive maintenance and
ensuring facilities are record of corrective
in state of good repair maintenance are
available
35. Policies and Document Review
procedures for the e Presence of operating
safe and efficient use manuals of the medical
of medical equipment equipment
according to e Preventive and corrective
specifications are maintenance logbook and
documented and plan for replacement
implemented.
37. A coordinated Document Review
security arrangement e Designation of person in
in the organization charge of security.
assures protection of
patients and staff
Interview
e Ask the personnel in charge
of security what the policies
on security are.

Observe

ee
e Security measures

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 su a
Standard: ‘Emergency light and/or power supply, water and ventilation systems are provided for, irin
_keeping with relevant statutory requirements and codes of practice. _
38. Generator, Document Review:
emergency light, e Bacterial water analysis done
water system, every 6 months.
adequate ventilation e Proof of corrective measures
or air conditioning done for failed bacterial
water analysis.
e Preventive and corrective
maintenance logbooks of
generator, emergency light,
ventilation and conditioning

Observe:
e Test if faucets and water
closets are working
e Functional emergency lights
and generators
39, Non-medical Document Review:
equipment are e Records of preventive and
regularly maintained corrective maintenance and
with plan for plan for replacement
replacement
according to expected
life span or when no
longer serviceable
40. Operating Document Review:
manuals of non- e Operating manuals of
medical equipment equipment, generators, air
conditioners and other non-
medical equipment
Standard: The
~ handling, | collection
= requirements and code of practice and disposal, of waste conform with relevant statutory
41. Policies and Document Review:
procedures on Waste e Issuances — laws, memos,
Disposal guidelines on waste
Management segregation, collection,
treatment and disposal
e Contracts with service
providers, waste handlers or
(if
disposal contractors
applicable)

Observe:
e Location of waste holding
area
e Segregation of waste (use of

fl
color coded garbage plastic
and/or bins)
AAT

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 Proper labelling of waste
receptacles
Proper management of
temporary storage areas prior
to hauling for disposal
Standard: An interdisciplinary infection, control program ensures the Prevention and control of
¢
_
infection in allservices. oe Coa See ee
_

ir |
s
2

42. Infection Document Review

Prevention and e IPC Manual
Control (IPC)
Program
43. Policies and Document Review
procedures on e Policies and procedures on
cleaning, cleaning, disinfecting,
disinfecting, drying, drying, packaging and
packaging and sterilizing of equipment,
sterilizing of instruments and supplies
equipment,
instruments and
supplies.
Standard: The organization uses
‘healthcare- associated infections.
44. “Organization Document Review
a
| t
a coordinated system-wide approach to reduce therisks of BS

takes steps to prevent Validate PCF policies on

and control outbreaks infection control such as use
of healthcare of PPEs, isolation
associated infections. precautions and hand
washing.
Written policies and
procedures in
accordance
with DOH issuances.

Observe
Use of gloves, surgical
masks, etc., as needed
Sinks or lavatories or
designated areas for hand
washing or dispenser for
sanitizers
Ask a PCF staff to
demonstrate hand washing.
45. There are Document Review
programs for Reports of needle stick
prevention and injuries
treatment of needle
stick injuries, and Interview
policies and staff their policies on
Ask
procedures for the needle stick injury
safe disposal of used
needles are Observe 4
AEE
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documented and e Use of PPEs in doing minor
monitored surgeries, handling patients
with infectious diseases etc.

] Standard:
ee ee
Whenneeded, the organization reportsinformation
about infections to personnel and
public health agencies. ee |

46. Policies and Document Review

procedures in e Copies of reports submitted
reporting notifiable to PIDSR and other
diseases (Refer to AO applicable DOH recording
No. 2008-0009 and and notification systems.
AO No. 2020-0013). |

ho oo
as
VIL. IMPROVING PERFORMANCE. # Be
:

has. planned systematic organization- wide approach,to process:

“e__ Standard: The organization
- a
design and performance measurement, assessment and improvement. e
:
a7.Continuous Document Review
Quality Improvement e CQI plan and proof of
(CQIT) Program implementation

Interview
e Ask about their activities on
CQI.

48. Customer
The.
- Standard:
“@improvement

satisfaction survey
activities
Document Review
e
EUS; E

See
Domains of the survey form
used.
:
a
organization. Brovides better. care service as result. of continuous quality:
fe cos

e Survey results and how

complaints/comments are
acted upon.

VII PHYSICAL
and
49. Entrances
PLANT.
Observe
sy
exits are clearly and e Posted entrance and exit
prominently marked, signs.
free of any e Entrances and exits are
obstruction and accessible and free from any
readily accessible. obstruction

Note: Exit signs should be luminous

or illuminated and prominently
marked. There should be exit signs in
major areas of the hospital and all
doors leading to the
outside. (Reference: RA 6541 Building
Code of the Philippines)
50. Directional signs Observe
are prominently e Directional signs are
posted to help locate prominently posted.
service areas within
the organization.

. Ate
Nn

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51. Ramps for Observe
patients with special @
Ramps for patients with
needs are available, special needs.
clearly and © Prominently marked
prominently marked o Free from obstruction
and free of any
obstruction.

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PART IT. EQUIPMENT AND INSTRUMENTS

_
nctional
MEDICAL EQUIPMENT AND INSTRUMENTS INPCF
Autoclave, 20 L
BP apparatus, non-mercurial, with adult and pediatric cuffs
Cervical Inspection Set/Vaginal Speculum Set
Small size
Medium size
Large size
Dressing set (minor surgical set)
Surgical scissors straight
Surgical scissors curved
Bandage scissors
Pick up (ovum) forceps
Mosquito forceps
Tissue forceps with teeth
Tissue forceps without teeth
Suture removal scissors
EENT Diagnostic Set
Ophthalmoscope
Otoscope
Emergency light
Examining light
Examining table
Foot stool
Instrument table
IV stand
Nebulizer
Neurohammer
Non-mercurial thermometer
Salter scale
Safety/Sharps collector box
Snellen’s Chart, Visual Acuity Chart

et
Stethoscope Z

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 Weighing scale with height measuring stick, adult
Weighing scale, infant
Wheelchair
Wheeled stretcher
Vaccine carrier with cold dog
Vaccine carrier thermometer
Vaccine refri gerator

‘(OutsourcedHoxial se
- DENTAL EQUIPMENT AND INSTRUMENTS ~
complywith thefollowing
service.locatedoutside PCF shall still be Inspectedand
licensing requirements) pe

Autoclave, 20 L
Dental Unit and chair with compressor and complete
accessories, with high and low speed hand pieces
Dental prophylaxis instrument set:
Universal scaler, non-magnetic hollow handle
Peri Curette, non-magnetic hollow handle
Periodontal probe
Gracey curette, set of 6 different tips, non-magnetic
hollow handle
Dental instruments: mouth mirror, cotton plier, explorer,
spoon excavator (1 set)
Basic Dental Surgery Set
Extraction forcep, #16 with cross serration (for
better grip)
Ergonomic for better comfort designed instrument
Extraction forcep, #17
Extraction forcep, #18L
Extraction forcep, #18R
Extraction forcep, #44
Extraction forcep, #69
Extraction forcep, #150
Extraction forcep, #151
Pedo forcep, #150
Pedo forcep, #151
Pedo forcep, #17S
Pedo forcep, #16S
Pedo forcep, #18R
Pedo forcep, #18L
Aspirating syringe (2), stainless steel, with locking
mechanism

Aa
LA

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q¢

Minnesota retractor, stainless steel

Bone file, stainless steel
Dental instrument cabinet
Instrument table
Sterilizing unit, table top
unit
Sharp waste disposal
e
“NON-MEDICAL EQUIPMENT AND INSTRUMENTS ——™”
Computer/laptop with internet connection
(mobile data, Ethernet)
Printer
Mobile phone/cellphone
Fire extinguisher
Standby generator set

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 Republic of the Philippines
Department Healthof
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Name
of Primary Care Facility:
Date of Inspection:

RECOMMENDATIONS:
A. For Licensing Process
[ ] For Issuance of License To Operate as PRIMARY CARE FACILITY

Validity from to

[ Issuance depends upon compliance to the recommendations given and submission of the
following within days from the date of inspection

[ Non-issuance. Specify reason/s:

Inspected by:
Printed name Signature Position/Designation

Received by:
Signature:
Printed Name:
Position/Designation:
Date:

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 Republic of the Philippines
Department Healthof
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Name of Primary Care Facility:

Date of Monitoring:

RECOMMENDATIONS:
B. For Monitoring Process
[ ] Issuance of Notice of Violation

[ | Non-issuance of Notice of Violation

[ Others. Specify:

Monitored by:
Printed name Signature. Position/Designation

Received by:
Signature:
Printed Name:

Position/Designation:
Date:

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 Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

ANNEX —- C1
A.O. 2020- 0047

PLANNING AND DESIGN GUIDELINES FOR PRIMARY CARE FACILITY

This Planning and Design Guidelines applies to all new construction and renovation of
primary care facilities (PCF) as defined and classified under this Administrative Order. The
following provisions and requirements shall be applied in the planning and design process
the construction, addition, alteration and renovation of a PCF.
of
1. General Requirements:
1.1 Location. The Primary Care Facility (PCF) shall be situated in an area or location
that is conveniently accessible both to clients and staff via available means
transportation.
of
public

1.2 Access. Separation and access shall be maintained, regardless the classification of
PCF and whether the PCF is freestanding or is part of another facility. Building
entrance should be at grade level, clearly marked, and located so that patients need
not go through other activity areas. Design shall preclude unrelated traffic within the
facility.

1.3 Privacy. The design shall ensure appropriate levels of patient audible and visual
privacy and dignity throughout the care process, from the interviews, examinations,
treatment, counselling and other testing procedures and related activities.

1.4 Parking. A PCF shall provide a minimum of one (1) parking space for every one
hundred (100) square meters of gross floor area (GFA) and the fraction thereof.
Aside from this, the PCF shall also provide a designated parking slot for an
ambulance and/or patient transport vehicle.

1.5 The PCF shall conform to all applicable local and national regulation for the
construction, renovation, maintenance and repair of its facilities.

2. Space Requirements

2.1 The PCF shall have adequate space or area provided for its various space/room
requirements in order to attain the effective and efficient operation of its activities
and functions.

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 2.2 PCF shall provide have the following zones, if applicable:
2.2.1 General Administrative Services and Public Areas:
2.2.2 Clinical Services Area:
2.2.3 Ancillary Services Area;
2.2.4 Support Services Area.
2.3 The General Administrative and Public Areas shall be comprised of the following
spaces:
2.3.1. Main Lobby, provided with:

2.3.1.1 A Reception and information counter or desk.

2.3.1.2 Sufficient waiting area for clients, an area of 1.4 square meters
shall be allocated per person. Consideration should be given to
special needs of specific patient groups, such as of person with
disabilities (PWD), infants, pregnant women, etc., such as
dedicated seats for PWD, presence of ramps in the entrance,
handrails, diaper changing and breastfeeding room, and alike.

2.3.1.3 Conveniently accessible toilet for the public. Provision of one (1)
toilet for every eight (8) patient shall be applied. A separate toilet
for male and female is preferred, and shall be PWD-accessible.

2.3.1.4 Conveniently accessible wheelchair storage.

2.3.2. Office for Staff. General or individual office(s) for the staff, business
transactions, and clerical and administrative functions shall be provided, with
sufficient space for the staff and the activity involved therein, to attain
effective and efficient operation of its activities and function.

2.3.2.1 A separate toilet for the staff, Provision of one (1) toilet for every
fifteen (15) personnel shall be applied.

2.3.2.2 Other spaces for staff such as conference room, staff pantry and
the like, are optional.

2.3.3. Sufficient Storage for Records and Supplies.

2.4 The Clinical Services Area shall be composed of the following spaces:
2.4.1 Physician Office(s)/ Consultation Room(s);

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 2.4.2 Medical Examination Room, which shall have a minimum floor area of 7.43
square meters per examination table / bed, exclusive of ante-room and toilet
(if any). Room arrangement should permit of at least 850 mm clearance at
the side and foot of the examination table / bed. A space for handwashing
and a counter/shelf space for writing shall be provided.

2.4.3 Minor surgical room shall have a minimum floor area of twelve (12) square
meters, excluding vestibule and toilet (if any). The minimum room dimension
shall be three (3) meters. A hand washing station and a counter
writing shall be provided.
or
shelf for
A space for handwashing shall be provided.
2.5 The Ancillary Services Area(s) shall be composed of the following spaces:
2.5.1 Clinical Laboratory, which shall be composed ofthe
following:
2.5.1.1 Extraction Area, separate from the Clinical work area;
2.5.1.2 Clinical Work Area with Sink (minimum of 20.00 square meters
floor area);
in
2.9.1.3 A Pathologist Area ( may be a separate room or be a part of the
Clinical Work Area);
2.5.1.4 Access to Toilet and waiting area.

2.9.2 Diagnostic Radiology Facility. The Medical X-ray Facility (Chest X-ray for
Heart and Lungs) shall meet the requirements set by the FDA-CDRRHR,
and shall comprise of the following spaces:

2.5.2.1 X-ray room (with a minimum width of 2.50 m. and minimum length
of 3.00 m as required by the DOH-CDRRHR), and a control booth
and dressing area;
|

2.5.2.2 Darkroom (with a minimum dimension of 2.00 m by 1.50 m as

,

required by the DOH-CDRRHR);

2.5.2.3 Film Reading Room and Film file Storage;
2.5.2.4 Accessto Toilet and waiting area;

2.5.3 Birthing Facility (must comply with the requirements provided in the Annex
C- Planning and Design Guidelines for Birthing Home of Administrative
Order No. 2016-0042 of the Guidelines in the Application for the DOH-
Permit-to-Construct (PTC)).

2.5.4 Pharmacy, with a minimum floor area of fifteen (15) square meters, provided
with work counter and sink.

2.5.5 Dental Clinic. Provide at least 8.63 square meters per dental chair that
includes space for one (1) dental chair, space for movement of person, and
space for passage of equipment.
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 2.5.6 Designated Parking Area for Ambulance and/or Patient Transport Vehicle.
2.6 The Support Services Area(s) shall be composed of the following spaces:

2.6.1 Waste Holding Room/Area, for temporary and sanitary storage of

segregated waste which includes infectious waste such as contaminated
sharps and needles and non-infectious waste or general waste;
2.6.2 Janitor’s Closet, with slop sink and housekeeping cabinet;
2.6.3 Designated Sputum Collection Area.

. Functional Requirements

3.1 The different areas of the PCF shall be functionally related to each other.
3.2 Main entrance of the PCF directly accessible from public road and should be located
at ground level with sufficient ramps compliant to BP 344 (with a clear width of 1.2
meters and minimum slope of 1:12) to accommodate person with disabilities (PWD)
and groups with special needs.

3.3 There shall be a ramp for clinical and ancillary services located on the upper floor (if
any).

3.4 The Reception and information counter or desk shall be located in such a manner
that it
will afford visual control of the main entry to the PCF. Its layout shall allow the
staff to see and acknowledge incoming clients/patients and at the same time
facilitate their transaction activities.

it
3.5 The waiting area shall be planned in such a way that is easily accessible from the
main entry and located adjacent to the Reception and information counter or desk.
Furthermore, the waiting are shall have a pleasing environment for the clients and
patients and shall be adequately spaced and provided with appropriate furniture.
3.6 office, shall be located adjacent to the lobby and both shall be located near the
The
main entrance of the PCF.

3.7 The design and planning of the PCF shall also consider important factors such as
medical equipment to be accommodated (especially those of the diagnostic
radiological and clinical laboratory facilities), proper office/clinic layout/s which
include/s furniture, fixtures and equipment, provision of client-friendly transaction
windows and counter where necessary, comfortable seats for waiting and
appropriate signage.

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 3.8 The General Administrative Service and Public Areas namely the Lobby, The Office,
and Records Storage shall be planned contiguous to one another as
they are closely
related in terms of function, providing easy accessibility between these areas.

3.9 The Consultation and Examination Rooms shall be planned adjacent or easily
accessible from the main lobby.

3.10 The Minor Surgical Room and Birthing Room shall be located away from the main
traffic and access shall be limited to authorized personnel and patient only.

3.11 The Ancillary Zone for diagnostic services, namely the Clinical Laboratory and
Medical X-ray Facility, shall also be planned contiguous or adjacent to one another.
Appropriate waiting areas for these rooms should be provided.

3.12 Ancillary Services Areas shall be located and arranged to prevent non-related traffic
through the room.

3.13 Support Service areas shall be planned in such a way that

they are accessible to
both clients and staff but concealed from the direct view or zoned away from the rest
of the major areas of the PCF for aesthetic purposes. These rooms may be clustered
in a service zone or perhaps located at corridor ends.

3.14 Sputum Collection Area shall be located in an open air environment away from the
main flow of patients and staff in the facility, but should be not too far away from the
point where the patient can deliver the soutum sample, and shall be provided with
partitions on both side for privacy and lavatory/sink for handwashing.

. Specific Technical Requirements

4.1 Fire Safety. The PCF shall conform to the Division 11 of Chapter 2 and applicable
provisions of the 2019 Revised Implementing Rules and Regulations (IRR) of
Republic Act (RA) 9514 or the Fire Code of the Philippines. There shall be a
minimum of two (2) exits, as remote from each other for each floor of the building,
which terminates directly at an open public space to the outside of the building. Exits
shall be restricted to the following permissible types: Doors leading directly outside
the building; stairs and smoke-proof enclosures, ramps, horizontal exits and exit
passageways.
4.2 Patient Movement. The recommended minimum width for public corridor for PCF
shall be at least but not limited to 1.80 meters or six (6) feet. Wider corridors shall
be provided if waiting areas along the corridor will be accommodated. Width of
service corridors may be reduced to 1.20 meters. Rooms shall be properly labelled
and identified for ease of way finding.
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4.3 Lighting. The entire facility shall be well-lighted for the comfort of patients and staffs.
4.4 Ventilation. There shall be provision of natural ventilation (if applicable) for
comfortable environment of patient and staff. Nonetheless, the facility may opt for
artificial ventilation if natural ventilation is not possible. Areas requiring a controlled
environment, such as the laboratory, diagnostic radiological facility and areas
handling temperature sensitive supplies and equipment, shall be artificially
ventilated to attain specific HVAC requirements.

In compliance with the Building Code requirements, floor to ceiling height of all
rooms of the PCF shall be at least but not limited to 2.40 meters for artificially
ventilated rooms and 2.70 meters for naturally ventilated rooms. However, for
radiographic and other rooms containing tall and ceiling-mounted equipment, the
ceiling shall be of sufficient height in order to accommodate the equipment and/or
fixtures.

4.5 Water Supply. A water supply from an approved public water supply system
whenever available shall be provided. However, other sources may be tapped
provided that the water supply has under gone thorough treatment to make safe
for human consumption. Water tank shall also be installed if it necessary just to
it
ensure that the water supply required for the efficient function of the facility is
maintained.

4.6 Flooring. Floor finishes to be used for various rooms and areas of the PCF shall be
readily cleanable and appropriately wear-resistant. Floors subject to traffic while wet
(i.e. entrance porch and toilet facilities) shall have a non-slip surface.

4.7 Walls and Partitions. All walls of the Clinical Laboratory in general shall be
structurally sound, safe, and sturdy with minimum fire resistant rating as prescribed
by the Fire Code of the Philippines for this type of occupancy. Wall finishes shall be
washable and in the proximity of plumbing fixtures shall be smooth and moisture
resistant.
The outlying walls housing the examination rooms, minor surgical room, diagnostic
radiological facility (with special enclosures as specified by the Center for Device
Regulation, Radiation Health and Research (CDRRHR)), Clinical Working Area of
the Clinical Laboratory, Birthing Facility and toilet facilities shall be constructed from
floor to ceiling to ensure a safe and secured environment with audio and visual
privacy for patients undergoing procedures.

The interior walls enclosing the clinical services areas shall concave at
the base of
the wall towards the floor to create a seamless finish to prevent the accumulation of
dirt and dust.
/4f )
?
DOH-PDG-PTC-PCF
: Revision:00
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Page 6 of 7
 Cubicle curtains and draperies if used for the PCF shall be non-combustible or
flame-retardant.
4.8 Doors. The minimum clear opening for the main door for the PCF shall be at least
but not limited to 0.90 meters to easily accommodate patients regardless of the type
of movement. Installing vision panels to control doors and doors leading to clinical
and ancillary services rooms is recommended,
if applicable.
The recommended door width of rooms of the PCF that will accommodate patients
for consultation, examination, and treatment purposes shall be at least but not limited
to 860 millimeters for convenient access of both users and equipment.

Windows. The minor surgical room and birthing room (if birthing facility is on-site)
may have windows for natural light and cross ventilation of natural air especially
during routine decontamination or cleaning, provided that such windows shall be at
least 1.60 meters from the finished floor up to the windowsill to ensure privacy.

5. References:

A. Relevant Laws and Standards

a) Batas Pambansa Blg. 344. An Act to Enhance the Mobility of Disabled

Persons.
b) Presidential Decree (PD) 1096.The National Building Code with its revised
Implementing Rules and Regulations.
c) 2019 Revised Implementing Rules and Regulations of RA 9514 Fire Code
the Philippines.
of
d) 1999 National Plumbing Code
Plumbing Law.
of
the Philippines of the RA 1378 or the

B. DOH Issuances and Manuals

a) A.O. 2016-0042- Guidelines in the Application for Department of Health
Permit to Construct (PTC). Department of Health. Manila. 2016.
b) Manual on Healthcare Waste Management. 4% Edition. Department of Health.
2020.

C. Books and Publication

a) Guidelines for Design and Construction of Hospital and health Care Facilities.
American Institute of Architects. 2001.
b) De Chiara, Joseph. (2001). Time-Saver Standards for Building Types (4th
edition). McGraw-Hill Book Company.
c) Fajardo (2002). Planning and Designers Handbook, Second Edition. Quezon

ad
City. 5138 Merchandising.

DOH-PDG-PTC-PCF
Revision:00
09/30/2020
Page 7 of 7
 Republic of the Philippine=
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Annex C2
A.O. No. 2020-0047
CHECKLIST FOR REVIEW OF FLOOR PLANS
PRIMARY CARE FACILITY (PCF)

Name
Address:
of Health Facility:
Date: Review: 1 2nd
3
1. PHYSICAL PLANT
1.1 General Administrative Services and Public areas
1.1.1 Lobby
1.1.1.1. Waiting Area / Multi-purpose Area (commensurate 1.4 m? per pax)
1.1.1.2 Reception and Information Counter / Desk
1.1.1.3. Toilet (Separate for Male and Female, PWD-accessible)
ed Nh
Office |

ed ®W
Staff Toilet
ek BR
Staff Areas / Conference Room (Optional)
me Om
Records Storage Area /Room
Supply Storage Area / Room
1.2 Clinical Services
1.2.1 Minor Surgical Room with Lavatory/Sink (min. of 12 m? in floor area)
1.2.2 Physician Office / Consultation Room/Area
1.2.3 Examination Room with Lavatory/Sink
1.3. Ancillary Services
1.3.1 Birthing Area*
PPE 1.3.1.1. Birthing Room (commensurate 10.5 m? per birthing table)
1.3.1.2. Ward (commensurate 7.43 m? per bed)
1.3.1.3. Clean-up and Sterilization Room
1.3.1.4. Scrub-up Area
1.3.1.5. Toilet
1.3.2 Clinical Laboratory*
1.3.2.1. Clinical Work Area with Lavatory/Sink (min. of 20 m? in floor area)
1.3.2.1. Pathologist Area
1.3.2.2. Extraction Area
1.3.2.3. Access to Toilet
1.3.2.4. Reception / Waiting area
1.3.3 Radiology (Chest X-ray for Heart and Lungs) *
1.3.3.1. X-Ray Room with Control Booth and Dressing Area
1.3.3.2. Dark Room
1.3.3.3. Film Reading Room and Film File Storage
1.3.3.4. Access to Toilet
1.3.4 Pharmacy* with work counter and sink (min. of 15.00 m? in floor area)
1.3.5 Dental Clinic* with Lavatory/Sink (commensurate 8.26 m? per dental chair)
PEELETE
1.3.6 Parking Area for Ambulance / Patient Transport Vehicle
1.4 Support Services
1.3.7 Waste Holding Area / Room
1.3.8 Janitor’s Closet / Maintenance and housekeeping Area / room

oy
1.3.9 Sputum Collection Area with Lavatory/Sink |

=<
2 ® * When the services are outsourced and/or located outside the premises of the PCF, these areas are
not required. However, a contract of service or Memorandum of with a service
provider should be secured as a prerequisite for License to Operate (LTO).
PCF-PTC-CR
4
'
: Revision:00
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Page 1 of 3
Note: For ancillary services (regulated health facility) outsourced and/or located outside the premises of the
PCF, please refer to their respective Checklist for Review of Floor plans in the DOH-AO 2016-0042 or
the “Guidelines in the Application for DOH-Permit-to-Construct(PTC)”.

2. PLANNING AND DESIGN

2.1. Floor plans properly identified and completely labelled.
2.2 Conforms to the applicable codes as part of professional service.
2.2.1 Exits shall be restricted to the following permissible types: Doors leading
directly outside the building; stairs and smoke-proof enclosures, ramps,
horizontal exits and exit passageways.
2.2.2 Minimum of two (2) exits of the above types, as remote from each other for
each floor of the building.
2.2.3 Exits terminate directly at an open public space to the outside of the
building.
2.2.4 The plans shall conform to the provisions of Batas Pambansa (BP) 344 —

Accessibility Law.
2.2.5 Provision of Ramp for wheelchair access with a clear width of 1.2 meters
and minimum slope of 1:12 (Ramp is provided at the entrance ifit is not at
the same level with the inside, and if clinical and ancillary services are
located on the upper floor).
2.3 Meets prescribed functional programs:
2.3.1. Main entrance of the PCF directly accessible from public road.
2.3.2. Ramp
or
(if any).
elevator for clinical and ancillary services located on the upper floor

2.3.3. Provide sufficient area for the office based on the number and the workflow
of the staff.
2.3.4. Main lobby and Business Office located near the main entrance of the PCF.
2.3.5. Minor operating room, Birthing Room’, Clinical Laboratory* and Radiology*
shall be located and arranged to prevent non-related traffic through the room.

COMMENTS:

PCF-PTC-CR
Revision:00
09/30/2020
Page 2 of 3
 Republic of the Philippinam
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Name of Health Facility:

Address:
Date:

COMMENTS:

HEALTH FACILITIES EVALUATION AND REVIEW COMMITTEE (HFERC)

[ ] Approved [ ] Disapproved

Chairperson, HFERC

Vice-Chairperson, HFERC

Member Member Member

Member Member Member

ft PCF-PTC-CR
Revision:00
09/30/2020
Page 3 of 3
 ANNEX C-3a

floor eee COLLECTION AREA

|

if
\
=
AO 2020- 004-7

1300

4000

AREA

SPUTUM

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COLLECTION

5300.

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aa

|
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4 SCALE 1:75m GROSS FLOOR AREA: 72.2 m? (9.5 m x 7.6 m)

PLAN
2 4 8

Republic of the Phifppines

TITLE / SHEET CONTENT: APPROVED BY: SHEET NO. 1 OF
1
DEPARTMENT OF REVISION 0.0
HEALTH SAMPLE FLOOR PLAN FOR VERGEIRE,
09/30/2020
MARIA - CESOIV
CENTRAL OFFICE PRIMARY CARE FACILITY ROSARIO SING MD. MPH, BY:
PREPARED
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila City
HFSRB-SDD
 ANNEX C-3b

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2000
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SAMPLE FLOOR PLAN

SCALE 1:425 m GROSS FLOOR AREA: 248.3 m? (26.7 m x 9.3 m)
|

——_
;
3 ®

setae Patpoes
TITLE OF HEALTH CARE FACILITY: SHEET CONTENTS: } APPROVED BY: SHEET NO. 1 OF
1
<-> DEPARTMENT OF
oe
REVISION 0.0
SAMPLE FLOOR PLAN FOR
SAMPLE PLAN FOR
:

=”
HEALTH FLOOR 09/30/2020
CENTRAL OFFICE PRIMARY CARE FACILITY WITHALLANGKTARY SERVices) NA**ROSRIOSNG eteareemeam CEO" PREPARED BY
~__Santazare Compound Rizal Avenue, Ste Cruz, Maria Cly (
HEALTH
REGULATION
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HFSRB-SDD

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